TREATMENT OF INTRAVENTRICULAR HEMORRHAGE WITH TISSUE-PLASMINOGEN ACTIVATOR

TEN PATIENTS WITH intraventricular hemorrhage (IVH) were treated with recombinant tissue plasminogen activator (rt-PA) injected directly int o the lateral ventricles, followed by ventricular drainage. All had a decreased level of consciousness before treatment (Glasgow Coma Scale score 10 +/-3.4). A total dose between 2 and 12 mg of rt-PA (6.4 +/- 3 .3) was administered. For eight patients with aneurysmal IVH, treatmen t with rt-PA began with two patients the same day as the aneurysm clip ping, and the day after with six patients. For a patient with an excis ion of a ruptured arteriovenous malformation and a patient with IVH re sulting from a lateral ventricular catheterization during posterior fo ssa tumor surgery, treatment with rt-PA started 24 hours after surgery . After an injection of rt-PA, the ventricular drain was closed for 1 hour, followed by alternate-hourly drainage and intracranial pressure (ICP) monitoring. Five patients received a second injection of rt-PA o n the second postoperative day, and one patient received a third dose on the third day. Among the eight patients given rt-PA the day after s urgery, the volume of external cerebrospinal fluid (CSF) drainage for 24 +/- 8 hours before treatment was 61 +/- 57 ml, and the mean ICP was 22 +/- 5 mm Hg during this same time. Younger age and poorer neurolog ical condition correlated with higher ICP before treatment. After the initiation of rt-PA treatment, daily CSF drainage increased significan tly (P < 0.005) and daily ICP decreased significantly (P < 0.005) as f ollows: 179 +/- 66 ml and 16 +/- 6 mm Hg during the first post-treatme nt day; and 168 +/- 84 ml and 13 +/- 6 mm Hg during the second post-tr eatment day. The number of days from IVH until the majority of clot cl eared from the various ventricles (as determined by computed tomograph y) were as follows: lateral ventricles, 4.6 +/- 1.8 days; third ventri cle, 3 +/- 0.5 days; and fourth ventricle, 3.5 +/- 1.4 days. There wer e no hemorrhagic, infectious, or other complications resulting from tr eatment, and no catheter became obstructed with blood clot. Four patie nts ultimately required ventriculoperitoneal shunting. Outcome was sev ere disability in one patient, moderate disability in three, and no di sability in six. Combined with early surgery to obliterate the source of bleeding and overall aggressive management of selected poor-grade p atients suffering from IVH, intraventricular fibrinolysis with rt-PA a ppears to facilitate the rapid resolution of IVH, the continuous paten cy of the ventricular drainage catheter, and the normalization of ICP, and it may have a favorable effect on outcome.