External Ventricular Drainage for Intraventricular Hemorrhage

Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.     

Intraventricular Fibrinolysis for Intracerebral Hemorrhage with Severe Ventricular Involvement

Intraventricular hemorrhage (IVH) has been associated with poor prognosis in patients with spontaneous intracerebral hemorrhage. Several factors contribute to the deleterious effects of IVH, including direct mass effects of the ventricular blood clot on ependymal and subependymal brain structures, mechanical and inflammatory impairment of the Pacchioni granulations by blood and its breakdown products, and disturbance of physiological cerebrospinal fluid (CSF) circulation. Acute obstructive hydrocephalus represents a major life-threatening complication of IVH and is usually treated with an external ventricular drainage (EVD). However, treatment with EVD alone is frequently not sufficiently effective due to obstruction of the catheter by blood. In the past two decades, intraventricular fibrinolysis (IVF) has been increasingly used for maintenance of EVD functionality and acceleration of ventricular clot resolution in such patients. Unfortunately, there is no prospective, randomized controlled trial addressing the effect of IVF on clinical outcome. The available data on IVF consist of small retrospective case series, case reports, and a few prospective case–control studies, which are the subject of the present review article. All these studies, when considered in their entirety, suggest that IVF has a positive impact on mortality and functional outcome, and could be considered as a treatment option for selected patients.     

单、双侧脑室引流治疗重度脑室出血的对比研究

目的探讨两种不同脑室引流方法治疗重度脑室出血的疗效。方法对35例重度脑室出血患者采用双侧侧脑室引流加终池置管持续引流脑脊液置换术(双侧引流组)治疗,另对32例重度脑室出血患者采用单侧侧脑室引流加腰穿放液脑脊液置换术(单侧引流组)治疗。结果双侧引流组总有效率、死亡率、脑室出血清除时间、生活能力评分与单侧引流组比较有显著差异(P<0.01)。结论双侧侧脑室引流加终池置管持续引流脑脊液置换术操作简便,疗效好,适合于重度脑室出血患者的治疗。     

重症脑室出血的临床救治

目的 探讨重症脑室出血的救治方法，以期降低重症脑室出血的死亡率。方法 早期采用双侧脑室交替或同时尿激酶灌注引流及早期改善脑血液循环等综合措施治疗。结果 本组救治50例重症脑室出血病人(GRAEB评分＞5分)，存活率72％(36／50)，死亡率28％(14／50)，36例存活患中5例因脑积水行脑室—腹腔分流术。结论 尽早疏通脑室梗阻，改善脑脊液循环与脑微循环是重症脑室出血救治成功的关键，脑室引流、尿激酶灌注治疗重症脑室出血是一种安全、可行、有效的方法。     

Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage

Background

The American Academy of Neurology (AAN) has established a core curriculum of topics for residency training in neurocritical care. At present there is limited data evaluating neurology residency education within the neurological intensive care unit. This study evaluates learner concerns with the neurological intensive care unit.

Methods

The Communication Committee and Resident & Fellow Taskforce within the Neurocritical Care Society (NCS) developed an online survey that consisted of 20 selection and free-text based questions. The survey was distributed to NCS members and then to neurology residency program directors. Statistical analysis of neurocritical care exposure were completed with t or Fisher exact test with p-value <0.05 considered significant.

Results

A total of 95 individuals from 32 different residency programs (36.5 % response rate) responded to the questionnaire. Most individuals train with neurocritical care attendings, fellows and advanced practitioners and have neurocritical care exposure during multiple years of residency training. 54 % of responders cite improvement in education as a means to improve neurocritical care training. Those that raised concern had no difference in time in the neurocritical care unit (9.4 weeks vs 8.8 weeks), exposure to trained neurointensivists, neurocritical care fellows or advanced providers (p value 0.53, 0.19, 0.83, respectively).

Conclusions

There is significant learner concern regarding education within the neurointensive care unit. Although there are educational guidelines and focused neurocritical care educational materials, these alone do not satisfy residents’ educational needs. This study demonstrates the need for educational changes, but it does not assess best strategies nor curricular content.

     

Severe Symptomatic Vasospasm following Intraventricular Hemorrhage from Arteriovenous Fistula

The authors present a rare case of severe vasospasm following the rupture of arteriovenous fistula. On initial CT scan, hematoma in the corpus callosum and left inferior frontal region with surrounding cerebromalacia and all ventricles without apparent subarachnoid hemorrhage were seen. Angiograms showed arterivenous fistula but did not show cerebral vasospasm. Thirteen days after admission the neurological state of patient suddenly deteriorated and bilateral motor weaknesses developed. Following angiograms revealed severe narrowing on the supraclinoid portion of bilateral internal carotid arteries, bilateral anterior cerebral arteries and bilateral middle cerebral arteries. Transluminal angioplasty and intra-arterial papaverine infusion were performed. The patient remained stable with moderate neurologic deficits.     

Ommaya囊联合侧脑室外引流治疗高血压脑室出血

目的探讨高血压脑室出血的治疗方法并评价其临床疗效。方法对17例高血压脑室出血患者采用Ommaya囊联合侧脑室外引流并早期注入尿激酶治疗。结果存活14例，死亡3例。有效随访14例，随访时间3-6月，其中恢复良好4例，中残6例，重残3例，植物生存1例。结论Ommaya囊联合侧脑室外引流并早期注入尿激酶治疗高血压脑室出血具有操作简单、并发症相对较少的优点．是治疗高血压脑室出血的一种新的有效方法。     

并置双管引流在肝胆管结石行肝叶切除术中的临床应用

对70例肝胆管结石行肝叶切除术中,应用腹腔引流管进行临床研究,其中85～89年间,34例肝叶切除放置双套管引流(套管组),90～92年,36例肝叶切除放置并置双管引流(双管组)。二组比较结果:双管组并发症明显少于套管组,尤其膈下感染、肝断面感染等严重感染并发症发生率明显减少(P<0.01),为临床推广应用提供依据。     

Antibiotic-Impregnated Versus Silver-Bearing External Ventricular Drainage Catheters: Preliminary Results in a Randomized Controlled Trial

Background

Evaluation of antibiotic-impregnated (AI) and ionized silver particle coated external ventricular drainage catheters (EVD) in patients with subarachnoid (SAH) or intracranial hemorrhage (ICH).

Methods

Between February 2011 and June 2012, 40 patients with acute hydrocephalus due to SAH, ICH or intraventricular hemorrhage were enrolled in a prospective, randomized, mono-center pilot study. Primary endpoints were defined as: number of events of cerebrospinal fluid (CSF) infections. Secondary endpoints were defined as: neurosurgical complications following the placement of the EVD, number of revisions of EVD catheters, and cost effectiveness.

Results

Sixty-one EVD placements in 40 patients, 32 antibiotic-coated (Bactiseal^®), 29 silver-bearing catheters (VentriGuard^®), have been performed. Confirmed or high suspicion of CSF infections occurred in 11 out of 61 events (confirmed infection: p = 0.71, probable infection: p = 0.90). Revisions of EVD were needed in 13 cases (22 %) due to CSF infection, dysfunction, impaired healing, or malplacement (p = 0.37).

Conclusion

Regarding CSF infection rate and dysfunction, no statistical significant differences between the two EVD catheters Bactiseal^® versus VentriGuard^® were found. The silver-bearing catheter might offer a safe and cost-conscious alternative to the AI catheter.     

White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage

Background: Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location. Methods: Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates. Results: Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages. Conclusions: Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.     

Spontaneous Intraventricular Hemorrhage Associated with Prolonged Diosmin Therapy

Background  

The prevalent use of anticoagulation in a growing elderly population has led to an increasing incidence of intracerebral hemorrhage. Furthermore, the understanding of the interactions and adverse effects of oral anticoagulants when used with non-FDA approved drugs is limited. Diosmin is one such non-FDA approved drug which is a semisynthetic, phlebotropic supplement with multiple microcirculatory effects. We report a case of a patient on oral anticoagulation and diosmin, who presented with spontaneous intraventricular hemorrhage, and discuss the possible etiology behind this rare event.     

No Exacerbation of Perihematomal Edema with Intraventricular Tissue Plasminogen Activator in Patients with Spontaneous Intraventricular Hemorrhage

Introduction

In severe spontaneous intraventricular hemorrhage (IVH), intraventricular (IVR) administration of tissue plasminogen activator (rtPA) clears blood from the ventricles more rapidly than with external ventricular drainage (EVD) alone. However, experimental studies suggest tPA may be neurotoxic in compromised brain tissue and may exacerbate perihematomal edema.

Methods

We used computerized volumetrics to assess change in intracerebral hemorrhage (ICH), IVH, ventricular, and perihematomal edema (PHE) volumes at 2–4 (T1) and 5–9 (T2) days following diagnostic CT scans (T0) of 24 patients (12 tPA-treated; 12 controls) with IVH requiring EVD. Controls from a hospital registry were matched by IVH and ICH volume to tPA-treated patients who came from a multicenter trial involving 52 patients with IVH.

Results

There were no significant differences between matched pairs in admission ICH and IVH volumes. IVR tPA resulted in more rapid clearance of IVH as determined by T2–T0 decrease in median IVH volume (tPA: ?18.7 cc, iqr 14.9; control:?6.9 cc, iqr 6.4; P = 0.002). Median ratios of PHE to ICH volume were not significantly different in control versus tPA-treated patients at T1 and T2 [control:tPA = 0.55:0.56 (T1); P = 0.84 and 0.81:0.71 (T2); P = 1.00]. Total ventricular volume was significantly larger in the control group at T2 (mean: 57.57 ± 10.32 vs. tPA: 24.80 ± 2.67 cc; P = 0.01). Bacterial ventriculitis was more frequent in the control group (5 vs. 1 episodes; P = 0.06) as was shunt dependence (4 vs. 0 cases; P = 0.03).

Conclusions

For case matched large IVH with small ICH volume, IVR tPA enhances lysis of intraventricular blood clots and has no significant impact on PHE.     

69例继发性脑室出血临床分析

目的分析69例继发性脑室出血患者的临床特点和CT表现,探讨其预后.方法回顾性分析69例继发性脑室出血病人的临床表现,通过死亡、存活及4-5周后ADL评分情况来判定预后.结果伴意识障碍、呕吐、瞳孔不等大、白细胞计数增高、血压显著升高者预后差,而原发出血部位、破入脑室范围是判断预后的重要参数;存活者ADL评分显示恢复满意率达71.4%.结论继发性脑室出血急性期病死率高;存活者恢复良好,致残率低.     

Autonomic Effects of Intraventricular Extension in Intracerebral Hemorrhage

Background  

Autonomic dysfunction after stroke is common and relates to unfavorable outcome. The pathophysiology of autonomic impairment after intracerebral hemorrhage (ICH) is unknown. This study examined the relationship between intraventricular hemorrhage extension (IVH) and autonomic dysregulation after ICH.     

Risk of Thromboembolic Events with Endovascular Cooling Catheters in Patients with Subarachnoid Hemorrhage

Introduction

Endovascular cooling is currently used for hypothermia treatment and fever reduction therapy. At the same time, little is known about the risks associated to endovascular cooling in patients treated with an endovascular cooling catheter (ECC).

Methods

A retrospective chart review of 122 patients with subarachnoid hemorrhage (SAH) treated with an ECC either for therapeutic hypothermia or for fever reduction was performed. ECC-associated thromboembolic events (TEE) such as pulmonary embolism and thrombosis were recorded and compared between patients treated with an ECC and patients treated only with a central venous line (CVL). Additionally, various laboratory parameters were recorded to determine if they might be related to the frequency of TEE’s.

Results

43 Patients were treated with an ECC and 79 with a CVL. Patients in the ECC group suffered more frequently from TEE (37 %) than those with a CVL (5 %). None of the laboratory parameters was associated with an increased TEE risk. The treatment with an ECC alone was a risk factor for a TEE, independent from age as well as from Hunt and Hess grade.

Conclusion

Our data show that the treatment with ECC increases the risk of TEE in SAH patients. Therefore, especially when considered for fever reduction, non-invasive devices for surface cooling should be the first choice.     

Influence of Bleeding Pattern on Ischemic Lesions After Spontaneous Hypertensive Intracerebral Hemorrhage with Intraventricular Hemorrhage

Background

Concomitant acute ischemic lesions are detected in up to a quarter of patients with spontaneous intracerebral hemorrhage (ICH). Influence of bleeding pattern and intraventricular hemorrhage (IVH) on risk of ischemic lesions has not been investigated.

Methods

Retrospective study of all 500 patients enrolled in the CLEAR III randomized controlled trial of thrombolytic removal of obstructive IVH using external ventricular drainage. The primary outcome measure was radiologically confirmed ischemic lesions, as reported by the Safety Event Committee and confirmed by two neurologists. We assessed predictors of ischemic lesions including analysis of bleeding patterns (ICH, IVH and subarachnoid hemorrhage) on computed tomography scans (CT). Secondary outcomes were blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 180 days.

Results

Ischemic lesions occurred in 23 (4.6%) during first 30 days after ICH. Independent risk factors associated with ischemic lesions in logistic regression models adjusted for confounders were higher IVH volume (p = 0.004) and persistent subarachnoid hemorrhage on CT scan (p = 0.03). Patients with initial IVH volume ≥ 15 ml had five times the odds of concomitant ischemic lesions compared to IVH volume < 15 ml. Patients with ischemic lesions had significantly higher odds of death at 1 and 6 months (but not poor outcome; mRS 4–6) compared to patients without concurrent ischemic lesions.

Conclusions

Occurrence of ischemic lesions in the acute phase of IVH is not uncommon and is significantly associated with increased early and late mortality. Extra-parenchymal blood (larger IVH and visible subarachnoid hemorrhage) is a strong predictor for development of concomitant ischemic lesions after ICH.

     

尼莫地平对高血压性脑出血破入脑室患者脑循环动力学参数的影响

目的 探讨尼莫地平治疗高血压性脑出血破入脑室的疗效和作用机制.方法 用尼莫地平治疗高血压性脑出血破入脑室患者,比较治疗组与对照组的脑循环动力学参数、治疗有效率、头颅CT片上的血肿量和水肿面积大小.结果 治疗组用药后脑循环动力学参数中的平均血流速度(Vmean)、平均血流量(Qmean)值较对照组用药后有明显的增高(P＜0.05),外周血管阻力(R)、临界压力(CP)较对照组明显下降(P＜0.01),其中Vmean、Qmean、R与CP值在治疗组治疗后双侧无明显差异;治疗组的治疗好转例数明显较对照组高;治疗组治疗前后的水肿面积积分差、血肿量积分差与对照组没有明显差异.结论 尼莫地平治疗高血压性脑出血破入脑室者具有增加脑血流量、降低脑血管阻力、调节脑血管功能、减少可能的广泛脑血管痉挛、提高近期治疗效果作用,但对血肿量和水肿面积无作用.     

Cerebral Vasospasm and Delayed Cerebral Ischemia in Intraventricular Hemorrhage

Background

Intracerebral hemorrhage (ICH) with intraventricular extension (IVH) is a devastating disease with a particular high mortality. In some aspects, IVH may resemble subarachnoid hemorrhage. The incidence and role of cerebral vasospasm in ICH with IVH are poorly understood. Here, we aimed to analyze the incidence and relationship of cerebral vasospasm to clinical characteristics, in-hospital mortality, and functional outcome at 3 months in patients suffering ICH with IVH.

Methods

Patients with ICH and IVH treated on a neurological intensive care unit were prospectively enrolled in a single-center observational study. Vasospasm was defined using established ultrasound criteria. Delayed cerebral ischemia (DCI) was defined as a new hypodensity on follow-up cranial CT. Functional outcome at 3 months was assessed using the modified Rankin Scale.

Results

129 patients with ICH and IVH were screened for the study. 62 patients entered the final analysis. The incidence of significant vasospasm was 37 %. A strong trend was found for the association between all cerebral vasospasm and DCI (P = 0.046). Early (up to 48 h) vasospasm was significantly associated with a DCI (P = 0.033). Overall mortality and outcome after 3 months did not differ between the groups.

Conclusion

Cerebral vasospasm seems to be a frequent complication after ICH with IVH and might be associated with DCI. Larger studies are warranted to confirm this hypothesis.