Huttner H B, Tognoni E, Bardutzky J, Hartmann M, Köhrmann M, Kanter I-C, Jüttler E, Schellinger P D, Schwab S
Department of Neurology, University of Erlangen, Erlangen, Germany.
Eur J Neurol. 2008 Apr;15(4):342-9. doi: 10.1111/j.1468-1331.2008.02077.x. Epub 2008 Feb 26.
Over the recent years, fibrinolytic agents have been tested for intraventricular clot fibrinolysis (IVF). Compared with patients who did not receive IVF, administration of rt-PA induces rapid resorption of intraventricular blood and normalization of cerebrospinal fluid (CSF) circulation resulting in a reduced 30-day mortality and beneficial short-term outcome after 3 months. Our objective was to analyze possible influences of IVF on the long-term outcome after 12 months. Based on a prospective data base, patients with ganglionic supratentorial hematoma with additional intraventricular hemorrhage and occlusive hydrocephalus (n = 135) were isolated. Twenty-seven patients received IVF. To design a case-control study, we carefully matched 22 controls without IVF with regard to hematoma volume, Graeb score, Glasgow Coma Scale on admission and age (five patients remained unmatchable). We determined clinical and imaging parameters by reviewing the medical records and CT scans of all included patients. Outcome after 12 months was evaluated using the modified Rankin scale (mRS). One multivariate regression analysis was performed to determine predisposing factors for outcome. IVF significantly reduced Graeb score during treatment (eight on admission, three after IVF, one prior to discharge in the treated group versus 8/6/2 in patients without IVF). In patients with IVF requirement, a second external ventricular drainage (EVD) and a ventriculoperitoneal (VP) shunt were reduced (P = 0.08) and the incidence of a lumbar drainage was significantly higher (P < 0.01), whilst the overall time of extra-corporal CSF drainage was comparable. EVD associated complications were equal in both groups. Overall long-term outcome was poor but no significant differences were found between patients with and without IVF (mRS 4-6: 12/22 (54%) in patients with and 13/22 (59%) in patients without IVF; P = 0.81). The five excluded patients with IVF were similar to the 22 included ones with respect to imaging findings and outcome. The multivariate analysis revealed age and baseline hematoma volume, but not IVF to significantly impact the outcome. In accordance with previous studies, IVF hastened clot lysis and reduced the need for repeated EVD exchanges and permanent shunting. However, despite these advantages, IVF did not influence long-term outcome after 12 months. The results of the prospective randomized trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) need to be awaited.
近年来，已对纤溶药物用于脑室内血凝块纤溶治疗（IVF）进行了测试。与未接受IVF治疗的患者相比，给予rt-PA可使脑室内血液快速吸收，脑脊液（CSF）循环恢复正常，从而降低30天死亡率，并在3个月后带来有益的短期预后。我们的目的是分析IVF对12个月后长期预后的可能影响。基于前瞻性数据库，筛选出患有神经节幕上血肿并伴有脑室内出血和梗阻性脑积水的患者（n = 135）。27例患者接受了IVF治疗。为设计一项病例对照研究，我们根据血肿体积、Graeb评分、入院时格拉斯哥昏迷量表和年龄，精心匹配了22例未接受IVF治疗的对照患者（5例患者无法匹配）。我们通过查阅所有纳入患者的病历和CT扫描来确定临床和影像学参数。使用改良Rankin量表（mRS）评估12个月后的预后。进行了一项多因素回归分析以确定预后的 predisposing因素。IVF治疗期间显著降低了Graeb评分（治疗组入院时为8分，IVF治疗后为3分，出院前为1分，而未接受IVF治疗的患者为8/6/2分）。在需要IVF治疗的患者中，二次体外脑室引流（EVD）和脑室腹腔（VP）分流减少（P = 0.08），腰大池引流的发生率显著更高（P < 0.01），而体外CSF引流的总时间相当。两组EVD相关并发症相同。总体长期预后较差，但接受IVF治疗和未接受IVF治疗的患者之间未发现显著差异（mRS 4 - 6：接受IVF治疗的患者中为12/22（54%），未接受IVF治疗的患者中为13/22（59%）；P = 0.81）。5例被排除的接受IVF治疗的患者在影像学表现和预后方面与22例纳入患者相似。多因素分析显示年龄和基线血肿体积而非IVF对预后有显著影响。与先前的研究一致，IVF加速了血凝块溶解，减少了重复进行EVD置换和永久性分流的需求。然而，尽管有这些优势，IVF并未影响12个月后的长期预后。前瞻性随机试验（血凝块溶解：评估脑室内出血的加速溶解）的结果有待期待。
