Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature

Severe intraventricular hemorrhage caused by extension from subarachnoid he morrhage or intracerebral hemorrhage leads to hydro-cephalus and often to p oor outcome. We conducted a systematic review to compare conservative treat ment, extraventricular drainage, and extraventricular drainage combined wit h fibrinolysis. We carried out a search in Medline of the literature betwee n January 1966 and December 1998 and an additional hand-search from January 1990 to December 1998. Pharmaceutical companies were contacted to gather u npublished data. We reviewed the reference lists of all relevant articles. Two authors independently assessed eligibility of the studies and extracted data on characteristics of study design, patients, and treatment. Patients with primary intraventricular hemorrhage were excluded. Main outcome measu res were death and poor outcome (defined as death or dependency) at the end of follow-up. No randomized clinical trial has yet been conducted so far, and we therefore reviewed only observational studies. The case fatality rat e for conservative treatment (ten studies) was 78%. For extraventricular dr ainage (seven studies) it was 58% [relative risk versus conservative treatm ent (RR) 0.74; 95% confidence interval (CI) 0.55-0.99]. For extraventricula r drainage with fibrinolytic agents (five studies) the case fatality rate w as 6% (RR 0.08; 95% CI 0.02-0.24). The poor outcome rate for conservative t reatment was 90%, that for extraventricular drainage 89% (RR 0.98; 95% CI 0 .75-1.30) and that for extraventricular drainage with fibrinolytic agents 3 4% (RR 0.38; 95% CI 0.21-0.68). All RR values remained essentially the same after adjusting for age, sex, World Federation of Neurological Surgeons sc ale, study design, and year of publication for the studies that provided th ese data. Outcome is thus poor in patients with intraventricular extension of subarachnoid or intracerebral hemorrhage. This meta-analysis suggests th at treatment with ventricular drainage combined with fibrinolytics may impr ove outcome for such patients, although this impression is derived only fro m an indirect comparison between observational studies. A randomized clinic al trial is warranted.