Division of Neurosciences Critical Care, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
Neurocrit Care. 2013 Jun;18(3):354-61. doi: 10.1007/s12028-013-9826-1.
In severe spontaneous intraventricular hemorrhage (IVH), intraventricular (IVR) administration of tissue plasminogen activator (rtPA) clears blood from the ventricles more rapidly than with external ventricular drainage (EVD) alone. However, experimental studies suggest tPA may be neurotoxic in compromised brain tissue and may exacerbate perihematomal edema.
We used computerized volumetrics to assess change in intracerebral hemorrhage (ICH), IVH, ventricular, and perihematomal edema (PHE) volumes at 2-4 (T1) and 5-9 (T2) days following diagnostic CT scans (T0) of 24 patients (12 tPA-treated; 12 controls) with IVH requiring EVD. Controls from a hospital registry were matched by IVH and ICH volume to tPA-treated patients who came from a multicenter trial involving 52 patients with IVH.
There were no significant differences between matched pairs in admission ICH and IVH volumes. IVR tPA resulted in more rapid clearance of IVH as determined by T2-T0 decrease in median IVH volume (tPA: -18.7 cc, iqr 14.9; control:-6.9 cc, iqr 6.4; P = 0.002). Median ratios of PHE to ICH volume were not significantly different in control versus tPA-treated patients at T1 and T2 [control:tPA = 0.55:0.56 (T1); P = 0.84 and 0.81:0.71 (T2); P = 1.00]. Total ventricular volume was significantly larger in the control group at T2 (mean: 57.57 ± 10.32 vs. tPA: 24.80 ± 2.67 cc; P = 0.01). Bacterial ventriculitis was more frequent in the control group (5 vs. 1 episodes; P = 0.06) as was shunt dependence (4 vs. 0 cases; P = 0.03).
For case matched large IVH with small ICH volume, IVR tPA enhances lysis of intraventricular blood clots and has no significant impact on PHE.
在严重自发性脑室内出血（IVH）中，与单纯使用外部脑室引流（EVD）相比，脑室内（IVR）给予组织型纤溶酶原激活物（rtPA）可更快地清除脑室中的血液。然而，实验研究表明 tPA 在受损脑组织中可能具有神经毒性，并可能加重血肿周围水肿。
我们使用计算机容积测量法评估了 24 例需要 EVD 的 IVH 患者（12 例 tPA 治疗组；12 例对照组）在诊断性 CT 扫描（T0）后 2-4 天（T1）和 5-9 天（T2）时的颅内出血（ICH）、IVH、脑室和血肿周围水肿（PHE）体积的变化。对照组来自医院登记处，通过与 tPA 治疗组的 IVH 和 ICH 体积相匹配，tPA 治疗组来自一项涉及 52 例 IVH 患者的多中心试验。
在入院时 ICH 和 IVH 体积方面，匹配对之间没有显著差异。IVR tPA 导致 IVH 更快清除，T2-T0 时 IVH 体积中位数下降（tPA：-18.7 cc，四分位距 14.9；对照组：-6.9 cc，四分位距 6.4；P = 0.002）。对照组和 tPA 治疗组患者在 T1 和 T2 时 PHE 与 ICH 体积的比值没有显著差异[对照组：tPA = 0.55:0.56（T1）；P = 0.84 和 0.81:0.71（T2）；P = 1.00]。在 T2 时，对照组的总脑室体积明显大于 tPA 治疗组（平均值：57.57 ± 10.32 vs. tPA：24.80 ± 2.67 cc；P = 0.01）。对照组中细菌性脑室炎更常见（5 例 vs. 1 例；P = 0.06），分流依赖性也更高（4 例 vs. 0 例；P = 0.03）。
对于病例匹配的大 IVH 和小 ICH 体积，IVR tPA 可增强对脑室内血凝块的溶解作用，对 PHE 无明显影响。
