EBS: Intraventricular thrombolysis for intraventricular haemorrhage secondary to spontaneous supratentorial ICH

Anthony Chau, Oct 2015

Clinical case• 66M b/g gunshot wounds req trauma surgery• Found unconscious, hypoxic and tachycardic, E1V1M4 on arrival, PEARL

PICO question• P: adults with IVH secondary to spontaneous supratentorial

ICH• I: EVD + intraventricular TPA• C: EVD alone• O: mortality, functional outcomes, LoS, complications

(bleeding, ventriculitis)

QUESTION:“In adults with IVH secondary to spontaneous supratentorial ICH,

is intraventricular thrombolysis superior to external ventriculostomy alone?”

Search Strategy

• RCTs• Databases– Medline (via OVID)– Clinical trials registries

• Hand searching – Scopus bibliographies/ citation history

MeSH terms (P)

Other terms: intraventricular, haemorrhage

MeSH terms (I)

Other terms: tissue-type plasminogen activator, urokinase

Oct 2015

PRISMA flow chart

Medline 169 articlesTrials registries 2 studies Handsearched 10 articles

164 abstracts reviewed

9 full text articles retrieved

Excluded:- Full RCT results not yet available: 1 (CLEAR-III), prelim results available- Aneurysmal/ AVM IVH: 4- Separate clinical question: 146- Non-RCT: 12- Posterior fossa: 1

Excluded:- Meta-analysis: 1

6 studies for qualitative review (multiple publications)

Summary of RCTs

Sample protocol

Intraventricular fibrinolysis for IVH

Study Year Country Pts Comments

CLEAR III Dey Ziai

2015-16 2015 2012

USA 500 250 100

Ongoing, main results TBA rtPA does not increase bleeding or ventriculitis rtPA faster clot resolution

CLEAR IVH Webb Naff

?ongoing 2012 2011

USA 64 48

rtPA faster clot resolution in a dose-dependent mannerrtPA does not increase bleeding or ventriculitis

King 2012 Singapore 16 Uk faster clot resolution

Gubucz 2004 Hungary 27 Uk lower mortality and infection

Naff 2004 USA 12 Uk faster clot resolution

Tung 1998 Singapore 21 Uk lower mortality and VP shunting, higher ventriculitis

Summary of Literature

Mortality

Mortality

Good functional outcome, 3mo

Shunting

Bleeding

Ventriculitis

Events

Clot reduction

Length of EVD placement

Hematoma reduction by site + dose

Case selection

Abstract

Study dates: 2002-2011

Temporal trend

CLEAR-III trial