Wang Deren, Liu Junfeng, Norton Casey, Liu Ming, Selim Magdy
Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China; Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
World Neurosurg. 2017 Nov;107:1016-1024.e1. doi: 10.1016/j.wneu.2017.07.135. Epub 2017 Aug 1.
The safety and efficacy of intraventricular fibrinolysis (IVF) in patients with intraventricular hemorrhage (IVH) are unclear. We aimed to determine these issues and to evaluate whether there are differences between recombinant tissue-plasminogen activator (rt-PA) and urokinase according to subgroup analyses.
A meta-analysis was undertaken of randomized controlled trials in patients with IVH that compared the administration of rt-PA or urokinase through extraventricular drainage (EVD) with normal saline through EVD or EVD placement alone.
Six randomized controlled trials involving 607 patients with IVH were included; 2 trials investigated urokinase and 4 rt-PA. IVF reduced death from any cause at the end of follow-up (risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.83), which was driven mostly by rt-PA (RR 0.65, 95% CI 0.48-0.86). Urokinase did not reduce mortality (RR 0.30, 95% CI 0.06-1.53). However, rt-PA did not reduce the proportion of survivors with poor functional outcome (RR 1.36, 95% CI 1.04-1.77), or the composite endpoint of death and poor functional outcome (RR 0.96, 95% CI 0.83-1.11). IVF neither reduced the need for shunt placement (RR 1.06, 95% CI 0.75-1.49) nor increased ventriculitis (RR 0.57, 95% CI 0.35-0.93) and rebleeding (RR 1.65, 95% CI 0.79-3.45).
Although the use of IVF in patients with IVH appears generally safe, its benefit is limited to a reduction in mortality at the expense of an increased number of survivors with moderately-severe to severe disability. Subgroup analyses do not suggest an advantage of IVF with urokinase over rt-PA.
脑室内出血（IVH）患者进行脑室内纤溶治疗（IVF）的安全性和有效性尚不清楚。我们旨在确定这些问题，并通过亚组分析评估重组组织型纤溶酶原激活剂（rt-PA）和尿激酶之间是否存在差异。
对IVH患者的随机对照试验进行荟萃分析，比较通过脑室外引流（EVD）给予rt-PA或尿激酶与通过EVD给予生理盐水或仅行EVD置管的效果。
纳入了6项涉及607例IVH患者的随机对照试验；2项试验研究尿激酶，4项研究rt-PA。IVF降低了随访结束时任何原因导致的死亡（风险比[RR]0.63，9５%置信区间[CI]0.47-0.83），这主要由rt-PA驱动（RR 0.65，95%CI 0.48-0.86）。尿激酶未降低死亡率（RR 0.30，95%CI 0.06-1.53）。然而，rt-PA并未降低功能预后不良的幸存者比例（RR 1.36，95%CI 1.04-1.77），也未降低死亡和功能预后不良的复合终点（RR 0.96，95%CI 0.83-1.11）。IVF既未减少分流置管的需求（RR 1.06，95%CI 0.75-1.49），也未增加脑室炎（RR 0.57，95%CI 0.35-0.93）和再出血（RR 1.65，95%CI 0.79-3.45）。
尽管IVH患者使用IVF总体上似乎安全，但其益处仅限于降低死亡率，代价是中度至重度残疾的幸存者数量增加。亚组分析未显示尿激酶IVF优于rt-PA。
