Tissue plasminogen activator for the treatment of intraventricular hematoma: the dose-effect relationship

The role of cell-free DNA in fibrinolysis for intraventricular hemorrhage

OBJECTIVE

Tissue plasminogen activator (tPA) fibrinolysis did not improve functional outcomes of patients with intraventricular hemorrhage (IVH), largely because of the unsatisfactory clot clearance. The presence of neutrophil extracellular traps (NETs) within the clot has been confirmed to impair tPA fibrinolysis, but the mechanism has been unclear. The authors hypothesized that cell-free DNA (cfDNA), the main framework of NETs, might be the important reason for the fibrinolysis resistance, and they validated the hypothesis, hoping to provide a new target to promote intraventricular fibrinolysis.

METHODS

First, cfDNA was detected in IVH clots by immunofluorescence staining in a rat model of IVH. Second, after blood (with or without exogenous cfDNA) intraventricular injection, IVH rats were given intraventricular infusion of 2 μl of saline, tPA, or tPA + DNase1 randomly. Then, the ventricular volume, animal behavior, and reactive astrocyte proliferation were assessed. Third, the IVH clots were collected for fibrinolysis assay in vitro. Finally, the effects of exogenous cfDNA in IVH were evaluated.

RESULTS

The presence of cfDNA in clots was observed as early as 1 hour after IVH. Compared with the whole-blood model, blood + cfDNA caused more severe ventricular dilation (day 7: blood 32.47 ± 2.096 mm3 vs blood + DNA 40.09 ± 2.787 mm3, p < 0.05), increased fibrinolysis resistance to tPA (day 7: tPA + DNA 26.04 ± 1.318 mm3 vs tPA 22.15 ± 1.706 mm3, p < 0.05), and further deteriorated the functional defects in rats (blood vs blood + DNA, p < 0.05). Degradation of cfDNA by DNase1 further enhanced the fibrinolysis effects on relieving the ventricular dilation (day 7: tPA + DNase1 11.67 ± 2.023 mm3 vs tPA, p < 0.05), improving the functional outcome (tPA vs tPA + DNase1, p < 0.05) and reducing periventricular astrocyte proliferation.

CONCLUSIONS

cfDNA impaired tPA fibrinolysis for IVH, and degradation of cfDNA may be a new target to improve this condition.

Novel therapeutics for hydrocephalus: Insights from animal models

Hydrocephalus is a cerebrospinal fluid physiological disorder that causes ventricular dilation with normal or high intracranial pressure. The current regular treatment for hydrocephalus is cerebrospinal fluid shunting, which is frequently related to failure and complications. Meanwhile, considering that the current nonsurgical treatments of hydrocephalus can only relieve the symptoms but cannot eliminate this complication caused by primary brain injuries, the exploration of more effective therapies has become the focus for many researchers. In this article, the current research status and progress of nonsurgical treatment in animal models of hydrocephalus are reviewed to provide new orientations for animal research and clinical practice.

Safety and Efficacy of Transcatheter Administration of Tissue Plasminogen Activating Factor as Adjuvant Therapy for Intraventricular Hemorrhage

Objective

Stroke is the fifth leading cause of death in the United States and the leading cause of disability. Hemorrhagic stroke has higher risks of mortality and neurologic deficit. Higher still, acute intraventricular hemorrhage (IVH) has mortality between 50% and 80% while complicating subarachnoid hemorrhage in 15% of cases and intracerebral hemorrhage in 40% of cases. We sought to demonstrate that early adjuvant intraventricular recombinant tissue plasminogen activating factor (rt-PA) improved outcomes.

Methods

Retrospective chart review was performed on patients aged 18-95 years with external ventricular drain (EVD) and intraventricular rt-PA for clot evacuation in IVH between 2005 and 2015. In total, 22 patients met the inclusion criteria. Generalized linear modeling was performed with factorial analysis using the Glasgow Coma Score (GCS) on arrival, GCS at EVD placement, EVD day of onset of rt-PA administration, GCS at onset of rt-PA administration, total duration of EVD, necessity of ventriculoperitoneal (VP) shunt, occurrence of ventriculitis, day of ventriculitis, GCS after rt-PA, length of stay (LOS) in the intensive care unit (ICU), and hospital disposition.

Results

Presenting GCS affected LOS significantly. Ventriculitis only significantly affected ICU LOS. GCS after rt-PA only significantly affected discharge GCS. EVD day of rt-PA protocol commencement demonstrated significant effects on EVD duration and cerebrospinal fluid (CSF) diversion requirement. Age affected ICU and hospital LOS.

Conclusion

These findings argue for larger prospective trials of EVD day two rt-PA protocol inception in acute IVH. Reported ventriculitis rates with EVDs are 8.8%, while we demonstrated a rate of 18% without significant effects except in ICU LOS. Transcatheter intraventricular rt-PA is safe and effective as an adjuvant in acute spontaneous intraventricular hemorrhage with the greatest benefit of rt-PA protocol at EVD day two.

Challenges for intraventricular hemorrhage research and emerging therapeutic targets

INTRODUCTION

Intraventricular hemorrhage (IVH) affects both premature infants and adults. In both demographics, it has high mortality and morbidity. There is no FDA approved therapy that improves neurological outcome in either population highlighting the need for additional focus on therapeutic targets and treatments emerging from preclinical studies. Areas covered: IVH induces both initial injury linked to the physical effects of the blood (mass effect) and secondary injury linked to the brain response to the hemorrhage. Preclinical studies have identified multiple secondary injury mechanisms following IVH, and particularly the role of blood components (e.g. hemoglobin, iron, thrombin). This review, with an emphasis on pre-clinical IVH research, highlights therapeutic targets and treatments that may be of use in prevention, acute care, or repair of damage. Expert opinion: An IVH is a potentially devastating event. Progress has been made in elucidating injury mechanisms, but this has still to translate to the clinic. Some pathways involved in injury also have beneficial effects (coagulation cascade/inflammation). A greater understanding of the downstream pathways involved in those pathways may allow therapeutic development. Iron chelation (deferoxamine) is in clinical trial for intracerebral hemorrhage and preclinical data suggest it may be a potential treatment for IVH.

Efficacy and safety of combined intraventricular fibrinolysis with lumbar drainage for prevention of permanent shunt dependency after intracerebral hemorrhage with severe ventricular involvement: A randomized trial and individual patient data meta-analysis

OBJECTIVE

Intraventricular hemorrhage (IVH) is a negative prognostic factor in intracerebral hemorrhage (ICH) and is associated with permanent shunt dependency in a substantial proportion of patients post-ICH. IVH treatment by intraventricular fibrinolysis (IVF) was recently linked to reduced mortality rates in the CLEAR III study and IVF represents a safe and effective strategy to hasten clot resolution that may reduce shunt rates. Additionally, promising results from observational studies reported reductions in shunt dependency for a combined treatment approach of IVF plus lumbar drains (LDs). The present randomized, controlled trial investigated efficacy and safety of a combined strategy-IVF plus LD versus IVF alone-on shunt dependency in patients with ICH and severe IVH.

METHODS

This randomized, open-label, parallel-group study included patients aged 18 to 85 years, prehospital modified Rankin Scale ≤3, ICH volume < 60ml, Glasgow Coma Scale of <9, and severe IVH with tamponade of the third and fourth ventricles requiring placement of external ventricular drainage (EVD). Over a 3-year recruitment period, patients were allocated to either standard treatment (control group receiving IVF consisting of 1mg of recombinant human tissue plasminogen activator every 8 hours until clot clearance of third and fourth ventricles) or a combined treatment approach of IVF and-upon clot clearance of third and fourth ventricles-subsequent placement of an LD for drainage of cerebrospinal fluid (CSF; intervention group). The primary endpoint consisted of permanent shunt placement indicated after a total of three unsuccessful EVD clamping attempts or need for CSF drainage longer than 14 days in both groups. Secondary endpoints included IVF- and LD-related safety, such as bleeding or infections, and functional outcome at 90 and 180 days. Conducted endpoint analyses used individual patient data meta-analyses. The study was registered at clinicaltrials.gov (NCT01041950).

RESULTS

The trial was stopped upon predefined interim analysis after 30 patients because of significant efficacy of tested intervention. The primary endpoint was analyzed without dropouts and was reached in 43% (7 of 16) of the control group versus 0% (0 of 14) of the intervention group (p = 0.007). Meta-analyses were based on overall 97 patients, 45 patients receiving IVF plus LD versus 42 with IVF only. Meta-analyses on shunt dependency showed an absolute risk reduction of 24% for the intervention (LD, 2.2% [1 of 45] vs no-LD, 26.2% [11 of 42]; odds ratio [OR] = 0.062; confidence interval [CI], 0.011-0.361; p = 0.002). Secondary endpoints did not show significant differences for CSF infections (OR = 0.869;CI, 0.445-1.695; p = 0.680) and functional outcome at 90 days (OR = 0.478; CI, 0.190-1.201; p = 0.116), yet bleeding complications were significantly reduced in favor of the intervention (OR = 0.401; CI, 0.302-0.532; p < 0.001).

INTERPRETATION

The present trial and individual patient data meta-analyses provide evidence that, in patients with severe IVH, as compared to IVF alone, a combined approach of IVF plus LD treatment is feasible and safe and significantly reduces rates of permanent shunt dependency for aresorptive hydrocephalus post-ICH. ANN NEUROL 2017;81:93-103.

Pharmacokinetics and Pharmacodynamics of Tissue Plasminogen Activator Administered Through an External Ventricular Drain

BACKGROUND

Intraventricular hemorrhage (IVH) frequently complicates spontaneous intracerebral or subarachnoid hemorrhage (SAH). Administration of intraventricular tissue plasminogen activator (TPA) accelerates blood clearance, but optimal dosing has not been clarified. Using a standardized TPA dose, we assessed peak cerebrospinal fluid (CSF) TPA concentrations, the rate at which TPA clears, and the relationship between TPA concentration and biological activity.

METHODS

Twelve patients with aneurysmal SAH and IVH, treated with endovascular coiling and ventricular drainage, were randomized to receive either 2 mg intraventricular TPA or placebo every 12 h (five doses). CT scans were performed 12, 48, and 72 h after initial administration, and blood was quantified using the SAH Sum and IVH Scores. CSF TPA and fibrin degradation product (D-dimer) concentrations were measured at baseline and 1, 6, and 12 h after the first dose using ELISA assays.

RESULTS

Median CSF TPA concentrations in seven TPA-treated patients were 525 (IQR 352-2129), 323 (233-413), and 47 (29-283) ng/ml, respectively, at 1, 6, and 12 h after drug administration. Peak concentrations varied markedly (401-8398 ng/ml). Two patients still had slightly elevated levels (283-285 ng/ml) when the second dose was due after 12 h. There was no significant correlation between the magnitude of CSF TPA elevation and the rate of blood clearance or degree of D-dimer elevation. D-dimer peaked at 6 h, had declined by 12 h, and correlated strongly with radiographic IVH clearance (r = 0.82, p = 0.02).

CONCLUSIONS

The pharmacokinetics of intraventricular TPA administration varies between individual patients. TPA dose does not need to exceed 2 mg. The optimal administration interval is every 8-12 h.

Successful intracavitary tissue plasminogen activator treatment of gastrocnemius intramuscular hematoma in a patient following anticoagulant therapy with warfarin: case report

Warfarin is an anticoagulant used in a variety of clinical indications and may rarely cause severe bleeding that can be life-threatening. Although intramuscular bleeding frequently occurs, secondary to trauma, it can be induced in cases with bleeding tendency. Hematoma is often treated with conventional methods. However, surgical decompression can also be applied. In this article, we report a case of gastrocnemius intramuscular hematoma, which was successfully treated with intracavitary tissue plasminogen activator that was recently used in the treatment of abdominal and pelvic abscess.

Intraventricular fibrinolysis with tissue plasminogen activator is associated with transient cerebrospinal fluid inflammation: a randomized controlled trial

Locally administered tissue plasminogen activator (TPA) accelerates clearance of intraventricular hemorrhage (IVH), but its impact on neurologic outcomes remains unclear and preclinical research suggests it may have pro-inflammatory effects. We randomly allocated patients with ruptured cerebral aneurysms and IVH, treated with endovascular coiling and ventricular drainage, to receive either 2-mg intraventricular TPA or placebo every 12 hours. Cerebrospinal fluid (CSF) and serum cytokine and white blood cell (WBC) concentrations were measured before drug administration and daily for 72 hours. Cerebrospinal fluid D-dimer levels were assessed 6 and 12 hours after administration to quantify fibrinolysis. Six patients were randomized to each group. Patients treated with TPA developed higher CSF cytokine concentrations compared with placebo-treated patients (P<0.05 for tumor necrosis factor-α, interferon-γ, interleukin (IL)-1α, IL-1β, IL-2, IL-4, and IL-6), as well as higher CSF WBC counts (P=0.03). Differences were greatest after 24 hours and decreased over 48 to 72 hours. The magnitude of the inflammatory response was significantly associated with peak CSF D-dimer concentration and extent of IVH clearance. We conclude that intraventricular TPA administration produces a transient local inflammatory response, the severity of which is strongly associated with the degree of fibrinolysis, suggesting it may be induced by release of hematoma breakdown products, rather than the drug itself.

Urokinase versus Alteplase for intraventricular hemorrhage fibrinolysis

Intraventricular hemorrhage (IVH) is the most severe form of stroke with intraventricular fibrinolysis (IVF) as a hopeful treatment. Urokinase (uPA) and tissue-type plasminogen activator (tPA) are used for IVF in Human. No clinical trial has evaluated the differential impact of these two fibrinolytics for IVF. Thus, we decided here to compare the use of these two fibrinolytics in a pre-clinical study. IVH was induced in rats by injection of collagenase type VII within the brain parenchyma followed by an IVF. Rats were randomized to receive uPA, tPA or saline within the ventricle, and cerebrospinal fluid was aspirated. Hematoma and ventricular volumes, brain water contents, inflammation and neurological deficits were measured at day three post-treatments. We also performed in vitro studies, in which neuronal cultures were subjected to an excitotoxic paradigm in the presence of either uPA or tPA. In the IVH model, we showed that although both uPA and tPA led to reduced ventricular volumes, only uPA significantly improved functional recovery. These results could be explained by the fact that uPA, in contrast of tPA, fails to promote inflammatory processes and neurotoxicity. Our study provides evidence supporting the use of uPA for fibrinolysis of IVH. A clinical trial could be warranted if tPA failed to improve outcomes in human IVH.

Clearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage

PURPOSE OF REVIEW

Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments.

RECENT FINDINGS

Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial.

SUMMARY

IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.

[Management of intracerebral hemorrhage: can we still learn something?]

Intracerebral hemorrhage (ICH) is the most devastating form of stroke. It affects approximately 2 million people worldwide every year and is a major cause of mortality and morbidity. Despite the focus of intensive scientific research on ICH for decades there is still no proven treatment strategy for this disease. Advances in knowledge on the underlying pathomechanisms of ICH and the clinical impact have contributed to the development of novel treatment approaches. Currently, surgical treatment, aggressive blood pressure management and intraventricular fibrinolysis in patients with additional severe intraventricular hemorrhage are being investigated in large scale phase III clinical trials.

Intraventricular fibrinolysis does not increase perihemorrhagic edema after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Additional intraventricular hemorrhage leads to higher mortality and worse functional outcome after intracerebral hemorrhage (ICH). Intraventricular fibrinolysis (IVF) with recombinant tissue plasminogen activator (rtPA) is an emerging treatment strategy for such patients. However, experimental studies suggest that rtPA may exert proedematous effects and lead to increased perihemorrhagic edema (PHE) after ICH. We aimed to compare the course of PHE after ICH between patients who received IVF with rtPA and controls matched for ICH volume.

METHODS

Patients were identified retrospectively from our institutional ICH database. Sixty-four patients with ICH and intraventricular hemorrhage who were treated with IVF were compared with 64 controls, who did not receive IVF, matched for ICH volume. The course of PHE was assessed on computed tomography scans (day 1, days 2 and 3, days 4-6, 7-9, and 10-12) using a threshold-based semiautomatic volumetric algorithm. Relative PHE was calculated as a ratio of PHE volume and initial ICH volume.

RESULTS

The matching algorithm resulted in similar mean ICH volumes in both groups (20.01 ± 17.5 mL, IVF vs 20.08 ± 17.1 mL, control). Intraventricular hemorrhage volume was larger in the IVF group (26.8 ± 19.2 mL vs 9.2 ± 13.4 mL). The mean total rtPA dose used for IVF was 8 ± 6 mg. PHE increased over time in both groups until day 12. At all investigated time points, there was no significant difference in relative PHE between the IVF group and controls (F=0.39; P=0.844).

CONCLUSIONS

IVF with rtPA did not lead to a relevant increase in PHE after ICH. rtPA doses used in the current study seem to be safe regarding PHE.

Management of non-traumatic intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is defined as the eruption of blood in the cerebral ventricular system and is mostly secondary to spontaneous intracerebral hemorrhage and aneurysmal and arteriovenous malformation rupture. IVH is a proven risk factor of increased mortality and poor functional outcome. Its seriousness is correlated not only with the amount of blood but also with the involvement of the third and fourth ventricles. There are four mechanisms that explain the pathophysiology of this event: acute obstructive hydrocephalus, the mass effect exerted by the blood clot, the toxicity of blood-breaking products on the adjacent brain parenchyma, and, lastly, the development of a chronic hydrocephalus. It is thus obvious that the clearance of blood from the ventricles should be a therapeutic goal. In cases of acute hydrocephalus, external ventricular drainage is a mandatory step, but proven often insufficient. The concomitant use of intraventricular fibrinolytics such as recombinant tissue plasminogen activator or urokinase seems to be beneficial at least in the context of spontaneous intracerebral hemorrhage, in which their use is now accepted but not yet validated by a randomized trial. Given the potential neurotoxicity of these agents, further research is needed in order to identify the best treatment for intraventricular fibrinolysis (IVF). The endoscopic retrieval of intraventricular blood was also described recently and seems to be as efficient as IVF, but its use is limited to specialized centers. IVH represents a therapeutic challenge for neurosurgeons, neurologists, and intensivists. Thus, a better understanding of this dramatic event will help in better tailoring the treatment strategies.

[New treatment strategies for intraventricular hemorrhage]

The presence of additional intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH) is associated with a much higher mortality and worse functional outcome. Although evidence-based specific treatment options for this entity are still lacking, knowledge about the pathophysiology of IVH has grown in recent decades, leading to the development of promising treatment strategies. Intraventricular fibrinolysis (IVF) accelerates IVH resolution and removal from the ventricular system. The additional usage of lumbar drains probably reduces the incidence of permanent posthemorrhagic hydrocephalus. The influence of these treatment modalities on functional outcome is currently being investigated in ongoing studies. The present article gives an overview of pathophysiological and clinical aspects of IVH, emphasizing novel treatment options.

Factors affecting clot lysis rates in patients with spontaneous intraventricular hemorrhage

BACKGROUND AND PURPOSE

In the treatment of severe intraventricular hemorrhage (IVH), thrombolytic use and clot size are known to influence clot lysis rates. We evaluated the effect of other variables on IVH clot lysis rates among patients treated with recombinant tissue-type plasminogen activator or placebo.

METHODS

One hundred patients with IVH and intracerebral hemorrhage volume <30 mL requiring emergency external ventricular drainage from 2 multicenter trials were treated with intraventricular administration of recombinant tissue-type plasminogen activator (n=78; 53 males, 25 females) or placebo (n=22; 7 males, 15 females). IVH volume was quantified daily by head CT. A segmented linear regression using an optimized spline knot for each patient was fit. Random effects linear regression was used to estimate the effect of prespecified patient characteristics on clot lysis rates over the first 6 days.

RESULTS

Stability IVH volumes were larger in males (N=60; 54 ± 5 mL) than females (N=40; 36 ± 5 mL; P=0.01). Intraventricular thrombolytic treatment was associated with an increase in clot lysis rate of 14.6% of stability IVH volume/day before the spline knot compared with the placebo group (P<0.001). After adjustment for thrombolytic, higher baseline serum plasminogen and lower baseline platelet count were independently associated with an increase in clot lysis of 1.28%/day per 10-g/dL increase (P<0.001) and 0.70% /day per 10×10(3)/uL decrease (P<0.001) before the knot, respectively.

CONCLUSIONS

Although thrombolysis remains the major determinant of IVH clot lysis rate, higher baseline serum plasminogen and lower platelet count also predict faster clot lysis. Further studies are needed to confirm whether plasminogen availability and thrombus structure impact IVH clot removal. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00650858.

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.

Inflammatory response to intraventricular hemorrhage: time course, magnitude and effect of t-PA

BACKGROUND

In 45% of cases of intracerebral hemorrhage (ICH) the hematoma extends into the ventricles (IVH). Intraventricular inflammation may be one mechanism by which IVH exerts deleterious effects. Tissue plasminogen activator instillation into the ventricles (IVT) has been studied for the treatment of IVH; however, its effect on IVH-induced inflammation is unknown. The purpose of this work was to describe the inflammatory response in the CSF following IVH and compare it in patients treated or not treated with IVT.

METHODS

Consecutive patients diagnosed with IVH and treated with ventriculostomy were selected from our prospective stroke registry from November 2004 to July 2007. CSF protein, glucose, and WBC (corrected for RBC number) from samples collected up to 19 days after IVH were captured. Patients with evidence of CSF infection were excluded.

RESULTS

29 patients were identified: 18 in the IVT group and 11 in the non-IVT group. The two groups were comparable in terms of stroke severity and IVH volume. A brisk cellular inflammatory reaction developed around day 2, lasted 5 days and then subsided. IVT seemed to attenuate this response. There were no differences in clinical outcomes between groups.

CONCLUSIONS

IVH induces intrathecal inflammatory response that peaks at day 5. IVT appears to modify this inflammation. Further work is needed to study the relationship between the intraventricular inflammatory response and patient outcome.

Dose effect of intraventricular fibrinolysis in ventricular hemorrhage

BACKGROUND AND PURPOSE

The aim of the current study was to investigate the dose-dependent efficacy of intraventricular fibrinolysis (IVF) in patients with severe intraventricular hemorrhage (IVH).

METHODS

Patients with intracerebral hemorrhage, severe IVH, and obstructive hydrocephalus with the need for external ventricular drainage were treated with IVF through external ventricular drainage. The time course of IVH resolution and the safety profile were compared between patients treated with high-dose IVF (4 mg alteplase every 12 hours, maximum 20 mg; n=32) and low-dose IVF (1 mg alteplase every 8 hours, maximum 12 mg; n=22). CT scans on Days 1 to 4, 7 ± 1 and 10 ± 1 after admission, were analyzed volumetrically. Outcome was assessed after 3 months.

RESULTS

The overall effect of IVF dosage was not significantly different between the 2 groups (F=1.3, P=0.25). The course of IVH volume in the third and fourth ventricles was similar with high- and low-dose IVF. High-dose IVF resulted in lower total IVH volumes on Days 7 (4.4 ± 4.2 mL versus 8.8 ± 8.1 mL; P=0.01) and 10 (1.4 ± 2.8 mL versus 4.9 ± 65.8 mL; P=0.005). Total clot half-life was 78 ± 43 hours in the low-dose and 56 ± 25 hours in the high-dose group (P=0.02). One asymptomatic ventricular bleeding, 2 cases of ventriculitis, and 1 death due to pulmonary embolism occurred in the high-dose group. There was no difference in outcome at 3 months.

CONCLUSIONS

Low-dose IVF (3 mg alteplase/day) has a similar effect on IVH clearance from the third and fourth ventricles and a similar safety profile when compared with high-dose IVF (8 mg alteplase/day).

Novel approaches to the treatment of intracerebral haemorrhage

Intracerebral haemorrhage is the most devastating subtype of stroke. It affects approximately two million patients worldwide every year and is a major cause of morbidity and mortality. After decades of research, we still face the fact that there is no evidence-based treatment strategy for this disease. However, research has contributed to a better understanding of the pathophysiology of intracerebral haemorrhage and also to the identification of new treatment targets. Several novel aspects of treatment of spontaneous intracerebral haemorrhage are reviewed in the present article.

Exacerbation of perihematomal edema and sterile meningitis with intraventricular administration of tissue plasminogen activator in patients with intracerebral hemorrhage

OBJECTIVE

Intraventricular hemorrhage (IVH) is associated with a poor outcome. External ventricular drainage together with clot lysis through intrathecal tissue plasminogen activator (IT-tPA) has been proposed as a promising therapy. However, recent experimental work has implicated tissue plasminogen activator (tPA) in the pathogenesis of cerebral edema.

METHODS

We reviewed the records of all patients with IVH caused by primary supratentorial intracerebral hemorrhage who underwent external ventricular drainage without surgical evacuation between January 2001 and June 2008. Of these 30 patients, we identified 13 who received IT-tPA. The remaining 17 patients served as controls. Hemorrhage, edema volume, and IVH score were determined on admission and by follow-up computed tomographic scans for 96 hours after admission. Discharge outcome was evaluated using the modified Rankin Scale.

RESULTS

There were no significant differences between the treatment and controls in terms of age, Glasgow Coma Scale score, Graeb and LeRoux IVH scores, or intracerebral hemorrhage volume on admission. IT-tPA resulted in more rapid clearance of IVH as determined by the 96-hour decrease in both the Graeb IVH score (tPA, 3.00 +/- .55; control, 1.00 +/- 0.57; P = .05) and the LeRoux IVH score (tPA, 6.2 +/- 0.80; control, 2.25 +/- 1.32; P = .05). Patients treated with IT-tPA demonstrated significantly larger peak ratios of edema to intracerebral hemorrhage volume (1.24 +/- 0.14 vs 0.70 +/- 0.08 in controls; P = .002). Additionally, increased rates of sterile meningitis (46% vs 12%; P = .049) and a trend toward shunt dependence (38% vs 6%; P = .06) were observed in the tPA cohort. Nevertheless, no significant differences in outcome at discharge or length of hospital stay were observed between cohorts.

CONCLUSION

Although IT-tPA hastens the resolution of IVH, it may worsen perihematomal edema formation. Larger prospective studies are required to confirm these findings and to determine whether outcome is adversely affected by IT-tPA administration.

Management of acute intracranial and intraventricular hemorrhage

OBJECTIVE

Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage.

DATA SOURCES

PubMed search and review of the relevant medical literature.

SUMMARY

The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery.

CONCLUSIONS

Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.

Tissue type plasminogen activator regulates myeloid-cell dependent neoangiogenesis during tissue regeneration

Ischemia of the heart, brain, and limbs is a leading cause of morbidity and mortality worldwide. Treatment with tissue type plasminogen activator (tPA) can dissolve blood clots and can ameliorate the clinical outcome in ischemic diseases. But the underlying mechanism by which tPA improves ischemic tissue regeneration is not well understood. Bone marrow (BM)-derived myeloid cells facilitate angiogenesis during tissue regeneration. Here, we report that a serpin-resistant form of tPA by activating the extracellular proteases matrix metalloproteinase-9 and plasmin expands the myeloid cell pool and mobilizes CD45(+)CD11b(+) proangiogenic, myeloid cells, a process dependent on vascular endothelial growth factor-A (VEGF-A) and Kit ligand signaling. tPA improves the incorporation of CD11b(+) cells into ischemic tissues and increases expression of neoangiogenesis-related genes, including VEGF-A. Remarkably, transplantation of BM-derived tPA-mobilized CD11b(+) cells and VEGFR-1(+) cells, but not carrier-mobilized cells or CD11b(-) cells, accelerates neovascularization and ischemic tissue regeneration. Inhibition of VEGF signaling suppresses tPA-induced neovascularization in a model of hind limb ischemia. Thus, tPA mobilizes CD11b(+) cells from the BM and increases systemic and local (cellular) VEGF-A, which can locally promote angiogenesis during ischemic recovery. tPA might be useful to induce therapeutic revascularization in the growing field of regenerative medicine.

Neuroprotective effect of diazoxide on brain injury induced by cerebral ischemia/reperfusion during deep hypothermia

OBJECT

The purpose of this study was to determine the effects of diazoxide on apoptosis and the relative mechanisms in a model of brain injury induced by cerebral ischemia/reperfusion (I/R) during deep hypothermia.

METHODS

Three-week-old Sprague-Dawley male rats were randomly and equitably divided into sham-operated group, placebo-treated group and diazoxide-treated group respectively. Specific examination of the regional cerebral blood flow (rCBF) was measured in the three groups continuously during the operation by laser Doppler flowmetry. Terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) was showed DNA fragmentation. The mRNA expressions of cytochrome c and full-length caspase-3 were determined by RT-PCR, while the protein expressions of cytochrome c and cleaved caspase-3 were determined by immunohistochemistry at 1 h, 6 h, 24 h, 72 h and 7 days after I/R, respectively. Cytosolic release of cytochrome c at 24 h after I/R was also confirmed by Western blot.

RESULTS

rCBF was significantly decreased in both of placebo-treated and diazoxide-treated group just after ischemia in the time interval 0-5 min, and had no obvious changes in all the time intervals during the operation. Diazoxide preconditioning significantly decreased the percentage of TUNEL-positive staining cells. The mRNA expressions of cytochrome c and full-length caspase-3 in diazoxide-treated group were significantly decreased. In addition, diazoxide provided a significant reduction in the protein expressions of cytochrome c and cleaved caspase-3.

CONCLUSION

These results suggested that the neuroprotective effects of diazoxide against cerebral I/R injury during deep hypothermia correlated with the reduction of DNA fragmentation, prevention of mitochondrial cytochrome c release and inhibition of caspase-3 activation.

Thrombolytics in intraventricular hemorrhage

Intraventricular hemorrhage (IVH) may occur as an isolated event from primary ventricular bleeding or as a complication of brain hemorrhage from another etiology. It is associated with high mortality and morbidity. Recent translational and clinical studies demonstrate that thrombolytic drugs administered intraventricularly through an external ventricular drain to lyse an IVH clot are safe and may reduce morbidity and mortality. The ongoing, prospective, randomized clinical trial known as Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR IVH) offers new hope for patients with this devastating disease. Preliminary data show marked reduction in time to clot lysis as well as a potential reduction in mortality associated with IVH lysis. A large, phase III, randomized prospective trial to ascertain the true clinical efficacy of this treatment is currently in the planning stages. A review of the use of thrombolytics for treatment of IVH related to other secondary causes is also provided.

Effects of tissue plasminogen activator on cerebral microvessels of rats during focal cerebral ischemia and reperfusion

The time window in the treatment of ischemic stroke with tissue plasminogen activator (tPA) is narrow, arbitrarily within 3 hours after the onset of symptom. Hemorrhagic transformation resulting from cerebral ischemia may be related to damage of the microvascular basal lamina of the brain, which may in turn cause microvascular fibrin deposition and aggravate cerebral ischemia. Here, we investigated the effect of tPA on the microvascular tissue changes during cerebral ischemia/reperfusion. Sprague-Dawley rats were subjected to focal cerebral ischemia by ligation of the right middle cerebral artery and bilateral common carotid arteries for 90 minutes. Sixty minutes after the onset of ischemia, escalated dosages of tPA from 2.5 to 10 mg/kg or saline were intravenously infused for 60 minutes. Twenty-four hours after reperfusion, the animals were allowed to be killed for examination. Low dosage of tPA (2.5-7.5 mg/kg) reduced post-ischemic brain infarction, suppressed metalloproteinase 2 (MMP-2) activity and restored blood-brain barrier (BBB) integrity. In contrast, high dose of tPA (10 mg/kg) aggravated brain infarction, increased MMP-2 activity and exacerbated BBB disruption. Cerebral ischemia/reperfusion decreased the immunoreactivity of both collagen type IV- and laminin-positive microvessels, whereas the low dosage of tPA (2.5-7.5 mg/kg) attenuated the reduction. When these molecules in whole cortical tissues were analysed, tPA dosage-dependently decreased the total content of collagen type IV, laminin and fibronectin. Although the detailed mechanisms regarding the action of tPA are yet to be investigated, our findings demonstrate that the detrimental effect of tPA was mediated, at least in part, through the destruction of the basal lamina in the cerebral microvessels by activating MMP-2.

The use of intraventricular thrombolytics in intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is associated with a high mortality and morbidity. Patients with this disorder may now be offered the possibility of treatment. This treatment comes in the form of intraventricular thrombolytics. At present a large randomized trial is testing the efficacy of intraventricular rt-PA in IVH in the setting of intracranial hemorrhage (ICH) . Preliminary data suggests that it may be successful in patients with IVH in this setting. This trial is the accumulation of animal and human trials completed over the last 20 years.

Current Updates in Perioperative Management of Intracerebral Hemorrhage

Spontaneous ICH remains a formidable disease that continues to disable and kill the majority of its victims. Treatment of the disease continues to be controversial and without any proved success, such as improvement in the disease mortality or the resulting disability in survivors. Primary prevention is the most effective medical intervention. Nevertheless, as the population continues to age and patients remain undertreated for hypertension, the incidence of ICH likely will increase, resulting in significant socioeconomic impact on society in the coming years. It is imperative that more research be conducted to improve treatment and outcomes of patients who have ICH. Unlike ischemic stokes or other causes of hemorrhagic stroke, such as SAH, where major advancement of treatment has led to improved outcomes, the increased incidence of ICH has not been matched with any considerable improvement in treatment. This burden to improve therapeutic interventions for patients who have ICH should be shared by all neurosurgeons, stroke neurologists, and critical care physicians who care for these patients on a regular basis. It is hoped that early diagnosis and resuscitation, prevention of hematoma growth, selective surgery or minimally invasive clot evacuation, and judicious critical care and rehabilitation will combine to lessen the burden of this disease.

Intraventricular administration of rt-PA in patients with intraventricular hemorrhage

OBJECTIVE

Intraventricular hemorrhage (IVH) represents a clinicopathologic entity with a dismal prognosis. The associated mortality rate has been reported as high as 80%; the morbidity is also quite high. The use of various fibrinolytic agents (streptokinase, urokinase, and recombinant tissue-type plasminogen activator [rt-PA]) has been reported in a small number of clinical series with a very limited number of participants, yielding significant variability regarding inclusion criteria, treatment protocol, and outcome analysis.

METHODS

In our prospective study, we report our experience using rt-PA in 21 patients with IVH. Patients with IVH of aneurysmal or arteriovenous malformation origin were excluded. Intraventricular administration of rt-PA was initiated within 24 hours after the ictal event (dose, 3 mg every 24 hours) through a ventricular catheter. The patients' intracranial and cerebral perfusion pressures, cerebrospinal fluid (CSF) cell count, and head CT scans with emphasis to frontal horn dimension and inner cranium diameter at the same level ratio were collected and analyzed.

RESULTS

Good outcome was observed in 47.5% of our patients, whereas 28.5% died and 24.0% survived with severe disability. The development of rt-PA-associated complications was as follows: new hemorrhage in 19%, infection in 14.3%, and CSF pleocytosis in 100% of patients. Permanent CSF shunt was required in 40%. The intermediate (3-month) follow up of our survivors showed no significant outcome changes compared with the immediate (1-month) follow up.

CONCLUSIONS

Intraventricular administration of rt-PA appears to be beneficial in cases of IVH even though it is occasionally associated with serious complications. Further multi-institutional studies are required for validating this treatment modality and standardizing its parameters.

Endovascular Management of a Patient after SAH

Treatment of acute aneurysmal subarachnoid hemorrhages consists of occluding the aneurysm to prevent rebleed, attempting to prevent vasospasm, and maintaining blood flow to the brain through vessels in vasospasm. Endovascular treatment has been shown to be as safe as, or safer, than surgical clipping for patients with SAH. Engineering solutions to our clinical problems continue to improve endovascular outcomes. This article reviews the current state of endovascular therapy.

Treatment of intraventricular hemorrhage with intraventricular administration of recombinant tissue plasminogen activator A clinical study of 18 cases

OBJECTIVE

Intraventricular hemorrhage is associated with a very poor outcome. Simple external ventricular drainage alone has not resulted in a decline of mortality. The aim was to study the effect of direct intraventricular administration of recombinant tissue plasminogen activator (rtPA).

PATIENTS AND METHODS

A retrospective series of eighteen adult patients with severe intraventricular hemorrhage, admitted to our university hospital, was studied for the effect of direct intraventricular administration of recombinant tissue plasminogen activator (rtPA). rtPA was administered in a dosage of 2mg. The injection was repeated at 12h intervals until serial CT scans showed a substantial reduction of intraventricular blood.

RESULTS

The total of rtPA doses per patient ranged from 2 to 32mg. Seven out of 18 patients showed good neurological recovery, 4 died. Only one patient had a complication which could be directly attributed to the intraventricular thrombolytic therapy.

CONCLUSION

We conclude that the procedure of intraventricular administration of a thrombolytic agent, i.e. rtPA, seems effective in lysis of the intraventricular hematoma and may, therefore, improve outcome.

Lower dose intraventricular t-PA fibrinolysis

BACKGROUND

Recombinant tissue plasminogen activator (rtPA) intraventricular fibrinolysis has been demonstrated to be efficacious in clearing blood from the ventricular system. Preliminary studies indicate it may improve survival. There have also been reports of adverse affects from intraventricular fibrinolysis. Optimal dosing of rtPA has not been established.

METHODS

A 40-year-old patient with intraventricular hemorrhage extension secondary to a ruptured aneurysm was treated with a one-time infusion of 1 mg of rtPA through a right ventriculostomy.

RESULTS

Computed tomography scans demonstrated excellent resolution of intraventricular blood and improvement in cerebral spinal fluid flow after fibrinolysis. Fibrinolysis was most marked in the third and fourth ventricles. There were no adverse effects noted.

CONCLUSIONS

Intraventricular fibrinolysis is effective at a lower dose than previously used. Lower doses may have fewer adverse affects.

Recombinant tissue plasminogen activator in the treatment of intraventricular hemorrhage secondary to periventricular arteriovenous malformation before surgery: case report

OBJECTIVE AND IMPORTANCE

Intraventricular hemorrhage (IVH) is known to cause acute obstructive hydrocephalus, refractory elevated intracranial pressures (ICPs), and lowered cerebral perfusion pressures, leading to cortical ischemia. Frequent obstruction of external ventricular drains as a result of thrombus is a recurring theme. We present a case of IVH secondary to periventricular arteriovenous malformation (AVM) that was not visible at admission angiography and was treated by intraventricular infusion of recombinant tissue plasminogen activator before surgical intervention.

CLINICAL PRESENTATION

An 11-year-old boy presented with acute onset of headache followed by two seizures, loss of consciousness, decerebration, right temporal hematoma, IVH, and acute obstructive hydrocephalus.

INTERVENTION

A right external ventricular drain was placed but functioned poorly. ICP could not be controlled by conventional methods. Five milligrams of recombinant tissue plasminogen activator was injected into the ventricular system via the external ventricular drain. This was repeated daily for 4 days. This treatment resulted in progressive improvement in ICP and clinical status. Once the clot partially cleared, magnetic resonance imaging and magnetic resonance angiography suggested the presence of a right periventricular arteriovenous malformation, which was confirmed by angiography and subsequently resected.

CONCLUSION

Recombinant tissue plasminogen activator is effective in resolving IVH causing obstructive hydrocephalus and uncontrollable ICP posing a life-threatening situation, secondary to ruptured arteriovenous malformation, before surgical intervention.