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, 11 (9), e5785

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

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

Mark Krel et al. Cureus.

Abstract

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.

Keywords: cerebral hemorrhage; cerebrovascular accident; intracranial hemorrhage; intraventricular hemorrhage; intraventricular injections; tpa.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Mean length of stay in hospital by intake Glasgow Coma Scale (GCS)
This graph demonstrates a bimodal distribution of length of stay in hospital with longest stays noted at Glasgow Coma Scale four and seven at intake and shortest stay noted at GCS eight at intake. Abbreviations: Glasgow Coma Scale (GCS), Length of Stay (LOS)
Figure 2
Figure 2. Mean length of stay in the Intensive Care Unit (ICU) by ventriculitis occurrence
This graph demonstrates that mean length of stay in the Intensive Care Unit is very increased in the event of occurrence of ventriculitis. Abbreviations: Intensive Care Unit (ICU), Length of Stay (LOS)
Figure 3
Figure 3. External Ventricular Drain (EVD) Day of Recombinant Tissue Plasminogen Activator (rt-PA) protocol onset by need for cerebrospinal fluid diversion
Notably, patients who required ultimate Ventriculoperitoneal Shunt placement were begun on Recombinant Tissue Plasminogen Activator protocol later in their hospital course than were the patients who did not require VPS placement. Abbreviations: External Ventricular Drain (EVD), tPA (Tissue Plasminogen Activator), Ventriculoperitoneal Shunt (VPS)
Figure 4
Figure 4. Mean length of stay in the Hospital by patient age
Generally, there is a trend that older patients have longer hospital stays. The clear exception to this, however, is the 43-49 age bin that had the longest overall mean hospital stay. This is multifactorial and not strictly attributable to medical problems but also is accounted for by social and economic factors. Abbreviations: Length of Stay (LOS)
Figure 5
Figure 5. Mean length of stay in the Intensive Care Unit (ICU) by patient age
Generally, there is a trend that older patients have longer intensive care unit (ICU) stays, and this trend was found to be statistically significant. Abbreviations: Abbreviations: Length of Stay (LOS), Intensive Care Unit (ICU)

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