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。     

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.

     

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.     

Determinants of External Ventricular Drain Placement and Associated Outcomes in Patients with Spontaneous Intraventricular Hemorrhage

Background

External ventricular drain (EVD) usage in patients with intraventricular hemorrhage (IVH) is variable in current practice and in clinical trials, and its impact on outcome remains controversial. The objective of this study was to identify the clinical predictors of EVD utilization, and associated outcome in adults with spontaneous IVH with or without intracerebral hemorrhage (ICH).

Methods

Retrospective review of 183 consecutive IVH patients admitted to a University Hospital between 2003 and 2010. Clinical and radiographic data were analyzed for associations between EVD placement and mortality, poor outcome, and improvement in Glasgow Coma Scale score (GCS) using multivariate logistic regression models.

Results

Average age was 62 ± 15.6 years, and average ICH and IVH volumes were 35.8 ± 40.9 cc and 19.7 ± 25.3 cc, respectively. Independent predictors of EVD placement within first 5 days of admission were GCS ≤ 8 (OR 11.5; P < 0.001), Graeb score >5 (OR 4.6; P = 0.001), and non-lobar ICH ≤ 30 cc (OR 9.7; P < 0.001). Median GCS increased from 5 (IQR 3–7) 48 h post-EVD (P < 0.001). EVD placement was an independent predictor of reduced mortality (OR 0.31; P = 0.04) and modified Rankin score 0–3 (OR 15.7; P = 0.01) at hospital discharge. In patients with hydrocephalus on presentation, EVD was associated with reduced mortality for patients with GCS > 3 after controlling for ICH and IVH severity (OR 0.02; P = 0.01).

Conclusions

Patients with lower GCS, higher IVH severity, and lower ICH volume are more likely to have an EVD placed. EVD placement is associated with reduced mortality and improved short-term outcomes in patients with IVH after adjusting for known severity factors. EVD use should be protocolized in clinical trials of ICH management where IVH is included.     

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。     

Drainage Efficiency with Dual Versus Single Catheters in Severe Intraventricular Hemorrhage

Background

Little is known about the efficacy of single versus dual extraventricular drain (EVD) use in intraventricular hemorrhage (IVH), with and without thrombolytic therapy.

Methods

Post-hoc analysis of seven patients with dual bilateral EVDs from two multicenter trials involving 100 patients with IVH, and spontaneous intracerebral hemorrhage (ICH) volume <30?ml requiring emergency external ventricular drainage. Seven ??control?? patients with single catheters were matched by IVH volume and distribution and treatment assignment. Head CT scans were obtained daily during intraventricular injections for quantitative determination of IVH volume.

Results

Median [min?Cmax] age of the 14 subjects was 56 [40?C73] years. Median duration of EVD was 7.9 days (single catheter group) versus 12.2 days (dual catheter group) (P?=?0.34). Baseline median IVH volume was not significantly different between groups (75.4?ml [22.4?C105.1]??single EVD vs. 84.5?ml [42.0?C132.0]??dual EVD; P?=?0.28). Comparing the change in IVH volume on time-matched CT scans during dual EVD use, the median decrease in IVH volume in dual catheter patients was significantly larger (52.1 [31.7?C81.1]?ml) versus single catheter patients (34.5 [13.1?C73.9]?ml) (P?=?0.004). There was a trend to greater decrease in IVH volume during dual EVD use in both rt-PA (P?=?0.9) and placebo-treated (P?=?0.11) subgroups.

Conclusion

The decision to place dual EVDs is generally reserved for large IVH (>40?ml) with casting and mass effect. The use of dual simultaneous catheters may increase clot resolution with or without adjunctive thrombolytic therapy.     

Safety of Intraventricular Hemorrhage (IVH) Thrombolysis Based on CT Localization of External Ventricular Drain (EVD) Fenestrations and Analysis of EVD Tract Hemorrhage

Background

The purpose of the study is to review the CT findings associated with ventriculostomy placement in regards to the safety of an EVD plus recombinant tissue plasminogen activator (rt-PA) for IVH.

Methods

A retrospective review was conducted for patients receiving intraventricular rt-PA for IVH from January 2004 to September 2009. Safety was assessed by the presence of EVD tract hemorrhage by CT at baseline after EVD placement, worsening hemorrhage after rt-PA, and CSF infection. IVH volumetrics were assessed by the Le Roux score and outcomes by Glasgow Outcome Scale and modified Rankin Scale.

Results

Twenty-seven patients received rt-PA for IVH. Median dose was 2 mg (range 0.3–8) and a median of two doses (range 1–17) were given. Worsening EVD catheter tract hemorrhage after rt-PA was 46.7 %, with a significantly higher incidence of worsening tract hemorrhage seen with incorrectly placed EVDs (p = 0.04). IVH hematoma burden decreased by a median Le Roux score of 10 (range 3–16) prior to rt-PA to 4 (range 0–16) after rt-PA. There were no central nervous system bacterial infections.

Conclusion

Intraventricular rt-PA appears to be relatively safe especially when all EVD fenestrations are within the ventricle and reduces IVH burden similar to other studies. We describe a CT-based EVD tract hemorrhage grading scale to evaluate EVD tract hemorrhage before and after thrombolysis, and a bone-window technique to evaluate EVD fenestrations prior to IVH thrombolysis. Further research is needed evaluating these imaging techniques in regard to intraventricular thrombolytic safety and EVD tract hemorrhage.     

Management of Intraventricular Hemorrhage

Brain hemorrhage is the most fatal form of stroke and has the highest morbidity of any stroke subtype. Intraventricular extension of hemorrhage (IVH) is a particularly poor prognostic sign, with expected mortality between 50% and 80%. IVH is a significant and independent contributor to morbidity and mortality, yet therapy directed at ameliorating intraventricular clot has been limited. Conventional therapy centers on managing hypertension and intracranial pressure while correcting coagulopathy and avoiding complications such as rebleeding and hydrocephalus. Surgical therapy alone has not changed the natural history of the disease significantly. However, fibrinolysis in combination with extraventricular drainage shows promise as a technique to reduce intraventricular clot volume and to manage the concomitant complications of IVH.     

Hemorrhage Rate After External Ventricular Drain Placement in Subarachnoid Hemorrhage: Time to Heparin Administration

Objective

The use of antiplatelet or anticoagulants has previously been shown to increase hemorrhagic complications of ventricular catheterization. Although heparin use 24 h after ventriculostomy appears safe, the safety of heparin immediately (within 4 h) after ventriculostomy is unknown. The objective of this study was to assess the safety of heparin immediately (within 4 h) after ventriculostomy in subarachnoid hemorrhage (SAH) patients undergoing endovascular treatment.

Patients and Methods

This is a retrospective cohort study of 46 patients with aneurysmal SAH secondary to aneurysm rupture who required ventriculostomy. Post-ventriculostomy imaging was carefully reviewed for tract hemorrhaging. Timing of heparinization was noted. Early heparinization was within 4 h after ventriculostomy, and intermediate heparinization was between 4 and 24 h after ventriculostomy.

Results

Overall, the tract hemorrhage rate was 26.1% for the study cohort—mostly grade I tract hemorrhages—consistent with the existing literature. The tract hemorrhage rate in the early (<4 h) heparin group was a remarkable 58.8%. The hemorrhages were also notably larger in the early (<4 h) heparin group.

Conclusion

Although heparin appears to be safe after 4 h, immediate heparinization (within 4 h) after ventriculostomy significantly increases the odds of tract hemorrhage. Additional time should be afforded between ventriculostomy and heparinization to avoid potentially devastating external ventricular drain tract hemorrhage. It is advisable to wait a sufficient time (at least 4 h) after ventriculostomy before embarking on endovascular treatment of ruptured aneurysms.

     

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。     

Intraventricular Nicardipine for Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage

Introduction  Delayed ischemic deficit from vasospasm is a leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Although several treatment modalities have been used to reverse the deleterious effects of vasospasm, alternative therapies are needed, as conventional therapies are often ineffective or contraindicated. Intrathecal nicardipine has been suggested for the prevention of vasospasm. We report our clinical experience with intraventricular nicardipine for refractory vasospasm in eight patients in whom conventional therapies were ineffective, contraindicated, or technically not feasible. Method  Retrospective case series performed at a tertiary care university hospital. Results  Eight patients (median Hunt-Hess grade = 2, median Fisher score = 4) with refractory vasospasm received intraventricular nicardipine (4 mg every 12 h) for a total of 5–17 days. One patient died in the intensive care unit. Seven patients had moderate to good outcomes with 6 being discharged to home (median Rankin Score = 2). Intraventricular nicardipine was well tolerated with minimal side effects. Conclusion  Our preliminary observations suggest that intraventricular nicardipine could be considered as a safe and effective treatment modality to treat vasospasm refractory to conventional management. A randomized, controlled trial to verify the efficacy and safety of intrathecal nicardipine in the prevention and treatment of cerebral vasospasm is warranted.     

Prediction of Shunt Dependency After Intracerebral Hemorrhage and Intraventricular Hemorrhage

Background

Spontaneous intracerebral hemorrhage is a disease with high morbidity and mortality. Extension of the hemorrhage into the ventricles is associated with the development of acute hydrocephalus and a poor outcome. Although it can be managed by external ventricular drainage (EVD), a subset of these patients require placement of permanent ventricular shunts. This study aimed to examine the factors on admission that can predict shunt dependency after EVD management.

Methods

Seventy-two patients who underwent EVD were included in this study. Seventeen of these patients underwent placement of a ventriculoperitoneal shunt. Variables analyzed included age, intraventricular hemorrhage (IVH) score, bicaudate index, acute hydrocephalus, initial Glasgow Coma Scale scores, and blood volume in each ventricle.

Results

In univariate analysis, IVH score (p?=?0.020), bicaudate index (p?<?0.001), blood volume in lateral ventricles (p?=?0.025), blood volume in the fourth ventricle (p?=?0.038), and the ratio of blood volume in lateral ventricles to that in third and fourth ventricles (p?=?0.003) were significantly associated with persistent hydrocephalus. The best multiple logistic regression model included blood volume parameters and bicaudate index as predictors with the area under a receiver operating characteristic curve of 0.849. The variance inflation factor (VIF) showed that collinearity was not found among predictors. Patients diagnosed with acute hydrocephalus had less blood volume in the lateral ventricles (OR?=?0.910) and had more blood volume in the third ventricle (OR?=?3.174) and fourth ventricle (OR?=?2.126).

Conclusions

These findings may promote more aggressive monitoring and earlier interventions for persistent hydrocephalus after intraventricular hemorrhage in patients at risk.

     

原发性脑室出血的病因、治疗与预后(附35例报告)

35例经CT证实的原发性脑室出血(PIVH)患者。病因是高血压、烟雾病、动静脉畸形、动脉瘤。PIVH分为三型:Ⅰ型室管膜下出血、Ⅱ型部分脑室出血、Ⅲ型全脑室出血。对Ⅰ型非手术治疗。对Ⅱ、Ⅲ型合并意识障碍手术治疗。多数病人生存下来(35例生存29例),但记忆力减退持续存在。     

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.     

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.     

Impact of Intraventricular Hemorrhage upon Intracerebral Hematoma Expansion

Background  

The purpose of this study is to determine whether intraventricular hemorrhage (IVH) exerts a “decompressive” effect that limits intracerebral hemorrhage (ICH) enlargement.     

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.