Thrombolytic evacuation of intracerebral and intraventricular hemorrhage

Use of fibrinolytics for percutaneous drainage of intrabdominal hematoma: a case report

Background

Intrabdominal hematoma can be managed with angioembolization, surgical drainage, or percutaneous drainage depending on the patient factors, underlying pathology, and size and stability of hematoma. During the past decades, advancements have been made in the percutaneous management of intrapleural fluid collections using fibrinolytics. However, intrabdominal hematoma resolution with the help of fibrinolytic-assisted percutaneous drainage has not been as widely studied as intrapleural fibrinolytics. Our case presents a scenario where effective percutaneous drainage of abdominal fluid collection using fibrinolytics avoided an operative intervention in a patient with a history of multiple abdominal surgeries. This case report in essence can help navigate future studies into exploring non-operative management options in patients with a history of multiple abdominal surgeries.

Case Description

In this report, we present a 51-year-old female status post hiatal hernia repair with jejunostomy tube (J-tube) exchange complicated by walled off intraabdominal hematoma who presented with persistent abdominal pain and leakage around her J-tube. Due to her past history of multiple abdominal surgeries including multiple hiatal hernia repairs, distal esophagectomy with Roux-en-Y, and revision of the said Roux-en-Y complicated by wound dehiscence, surgical drainage was deferred in favor of trialing fibrinolytic administration via catheters. For this purpose, we employed the protocol for fibrinolytic administration used by the Second Multicenter Intrapleural Sepsis Trial (MIST2).

Conclusions

Use of tissue plasminogen activator (t-PA) and deoxyribonuclease (DNase) as per MIST2 protocol was safely replicated for intrabdominal walled off hematoma and resulted in a near complete resolution of the hematoma in 1 week. The patient was eventually discharged with no complications. This case highlights safe and efficacious use of fibrinolytics for non-operative management of intrabdominal hematomas.

Outcomes of Combined Endoscopic Surgery and Fibrinolytic Treatment Protocol for Intraventricular Hemorrhage: A Randomized Controlled Trial

BACKGROUND

Intraventricular fibrinolysis (IVF) and endoscopic surgery (ES) are the new promising treatment strategies to enhance the rate of hematoma clearance, which might improve functional outcome. This study investigated and compared the outcomes among these interventions.

METHODS

A randomized (1:1) double-blinded trial was carried out between August 2018 and December 2021. The intervention and control groups comprised patients receiving IVF and/or ES and external ventricular drainage (EVD), respectively. All participants had experienced primary or secondary intraventricular hemorrhage (IVH) from spontaneous intracerebral hemorrhage with obstructive hydrocephalus complications. The primary outcome was modified Rankin Scale score 180 days post treatment. Interim assessments were planned for every 50 participants enrolled to ensure safety and efficacy.

RESULTS

After enrollment of 110 participants (55 participants in each group), there was a difference in 30-day mortality (2 [3.6%] vs. 13 [32.7%] in the EVD group, P = 0.002), reaching the predetermined boundaries for termination of the trial. We demonstrated a better favorable outcome (modified Rankin Scale score 0-3) at 180 days in the intervention group, compared with the control group (35 [63.6%] vs. 24 [43.6%], P = 0.04). Participants in the intervention group experienced a higher IVH removal rate (91% [9.0] vs. 69.5% [38.0], P < 0.01) and had lower shunt conversion (1 [1.8%] vs. 16 [29.3%], P < 0.01). Treatment complications were comparable between the two groups.

CONCLUSIONS

This study demonstrated that combined ES and IVF is safe and effective for the treatment of IVH. In addition, it concluded that aggressive but safe procedures used to remove IVH could improve clinical outcome in patients with IVH.

Intrahematomal catheter placement with connection to the ventricular system allows more effective thrombolysis of combined intracerebral and intraventricular hematomas

Intracerebral hematomas (ICH) with intraventricular hemorrhage (IVH) are associated with high morbidity. Catheter-based thrombolysis with recombinant tissue plasminogen activator (rtPA) allows a faster hematoma resolution compared to conservative treatment. However, simultaneous thrombolysis of ICH and IVH is not achievable because the ependyma hinders ICH-lysis if rtPA is given into the ventricles and inversely. We evaluated if the thrombolysis efficacy is enhanced by placing an intrahematomal catheter reaching the ventricle. Patients with ICH plus IVH treated with catheter-based thrombolysis were retrospectively analyzed. Group 1 included patients with an intrahematomal catheter reaching the ventricles and group 2 patients with a catheter placed exclusively in the ICH. The relative hematoma volume reduction (RVR) of ICH and IVH within 3 days was calculated. Furthermore, the patients' outcome, the hydrocephalus incidence, and the infection rate were evaluated. A total of 74 patients were analyzed, of whom 49% had a catheter reaching the ventricle. The mean ICH-RVR (68% vs. 58%, p = 0.0001) and IVH-RVR were significantly higher in group 1 compared to group 2. In group 1, infections occurred more often compared to group 2 (31% vs. 6%, p = 0.005). There was no difference in outcome and in hydrocephalus incidence between both groups. The catheter reaching the ventricles allows simultaneous and more effective thrombolysis of ICH and IVH. We assume that the fibrinolytic property of cerebrospinal fluid itself and a washout effect contribute to these findings. In patients with ICH plus IVH, catheter positioning through the hematoma into the ventricle, and subsequent fibrinolytic therapy should be considered.

Intracranial haemorrhage: therapeutic interventions and anaesthetic management

Intracranial haemorrhage (ICH) is a devastating cause of stroke. Although the total incidence of ICH has remained stable worldwide, the proportion associated with the use of anticoagulant medications is increasing. Innovative interventions developed to improve patient outcomes often require peri-procedure anaesthetic management. This non-systematic review examines the pathophysiology of ICH at a clinical level, reports on novel therapeutic interventions, many of which are currently in clinical trials, and reviews the current published recommendations for the management of patients with ICH.

The use of TPA in combination with alcohol in the treatment of the recurrent complex hydrocele

A hydrocele is an abnormal collection of serous fluid in the space between the parietal and visceral layers of the tunica vaginalis. Hydrocele is the most common cause of painless scrotal swelling which affects about 1% of men. Generally, adult hydroceles are idiopathic in origin; however, inguinal surgery, varicocelectomy, infection, trauma and a patent processus vaginalis are each associated with the subsequent development of a hydrocele. Surgical removal of hydroceles is the gold standard of care. However, multiple cases have reported high success rates (ranging from 85% to 96%) using a combination of aspiration and sclerotherapy. We present a case of a patient with recurring complex hydrocele and effective treatment utilizing a combination of thrombolytic therapy, catheter drainage and subsequent alcohol ablation.

Transcranial MR-guided focused ultrasound sonothrombolysis in the treatment of intracerebral hemorrhage

Intracerebral hemorrhage remains a significant cause of morbidity and mortality. Current surgical therapies aim to use a minimally invasive approach to remove as much of the clot as possible without causing undue disruption to surrounding neural structures. Transcranial MR-guided focused ultrasound (MRgFUS) surgery is an emerging technology that permits a highly concentrated focal point of ultrasound energy to be deposited to a target deep within the brain without an incision or craniotomy. With appropriate ultrasound parameters it has been shown that MRgFUS can effectively liquefy large-volume blood clots through the human calvaria. In this review the authors discuss the rationale for using MRgFUS to noninvasively liquefy intracerebral hemorrhage (ICH), thereby permitting minimally invasive aspiration of the liquefied clot via a small drainage tube. The mechanism of action of MRgFUS sonothrombolysis; current investigational work with in vitro, in vivo, and cadaveric models of ICH; and the potential clinical application of this disruptive technology for the treatment of ICH are discussed.