Intraventricular Thrombolysis for Intracerebral Hemorrhage with Ventricular Extension

Pathophysiology and Problematic

Intraventricular hemorrhages (IVH) occur in approximately 45% of patients with spontaneous intracerebral hemorrhages (ICH) and are an independent factor for poor prognosis 1
The mortality rate increases from 20% in ICH without IVH to 51% in ICH with IVH 1
Secondary IVH is particularly common in hypertensive bleeding in the basal ganglia and thalamus 1
The sole placement of a ventricular drain (VD) is often insufficient, as catheters can become clogged with clotted blood and removal of intraventricular blood occurs slowly 2

Intraventricular fibrinolytics like tPA accelerate the dissolution of the blood clot and removal of blood 1, 3
This leads to reduced hydrocephalus development 1

Several studies show that IVH with tPA resolves faster (1-3 days) than with urokinase (5-8 days) 4
Compared to sole ventricular drainage, mortality rates could be reduced from 60-90% to approximately 5% 4
A meta-analysis of 4 randomized and 8 observational studies demonstrated a significant reduction in mortality from 47% to 23% in patients with IVH treated with ventricular drainage plus intraventricular fibrinolysis 2
The CLEAR-IVH study investigated the safety of intraventricular tPA in 52 IVH patients and showed a 30-day mortality rate of 17% 3

The most common complications are infections and bleeding 4
In the CLEAR-IVH study, symptomatic bleeding occurred in 4% and bacterial ventriculitis in 2% of patients 3

According to the American Heart Association/American Stroke Association guidelines (2015), intraventricular administration of tPA for IVH appears to have a relatively low complication rate 1
The effectiveness and safety of this treatment are still uncertain and are considered experimental (Class IIb, Evidence Grade B) 1, 3
Ventricular drainage for hydrocephalus is recommended for patients with decreased consciousness (Class IIa, Evidence Grade B) 3