TREATMENT OF INTRAVENTRICULAR HEMORRHAGE WITH TISSUE-PLASMINOGEN ACTIVATOR
TREATMENT OF INTRAVENTRICULAR HEMORRHAGE WITH TISSUE-PLASMINOGEN ACTIVATOR
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DOI：
10.1227/00006123-199306000-00010
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发表时间：
1993-06-01
期刊：
影响因子：
4.8
通讯作者：
SAWAYA, R
中科院分区：
文献类型：
--
作者：
FINDLAY, JM;GRACE, MGA;SAWAYA, R
用重组组织型纤溶酶原激活剂（rt-PA）直接侧脑室注射，脑室引流治疗10例脑室出血（IVH）。治疗前所有患者的意识水平均下降（格拉斯哥昏迷量表评分10 +/-3.4）。给予的rt-PA总剂量为2 - 12 mg（6.4 +/- 3.3）。对于8名患有动脉瘤性IVH的患者，2名患者在动脉瘤夹闭术当天开始rt-PA治疗，6名患者在夹闭术后第二天开始治疗。对于切除破裂动静脉畸形的患者和在后颅窝肿瘤手术期间因侧脑室导管插入术导致IVH的患者，在手术后24小时开始rt-PA治疗。注射rt-PA后，关闭脑室引流1小时，然后每小时交替引流并监测颅内压（ICP）。5例患者在术后第二天接受了第二次rt-PA注射，1例患者在第三天接受了第三次注射。在术后第二天给予rt-PA的8名患者中，治疗前24 +/- 8小时的脑脊液（CSF）外引流量为61 +/- 57 ml，同一时间内的平均ICP为22 +/- 5 mm Hg。年龄较小和神经系统状况较差与治疗前较高的ICP相关。开始rt-PA治疗后，每日CSF引流量显著增加（P < 0.005），每日ICP显著降低（P < 0.005），如下所示：治疗后第一天为179 +/- 66 ml和16 +/- 6 mm Hg;治疗后第二天为168 +/- 84 ml和13 +/- 6 mm Hg。从IVH到大部分血凝块从各脑室清除（通过计算机断层扫描确定）的天数如下：侧脑室，4.6 +/- 1.8天;第三脑室，3 +/- 0.5天;第四脑室，3.5 +/- 1.4天。没有出血、感染或治疗引起的其他并发症，也没有导管被血块阻塞。4例患者最终需要脑室腹腔分流术。结果是1例患者严重残疾，3例中度残疾，6例无残疾。结合早期手术以闭塞出血源和对患有IVH的选定的低级别患者进行全面积极的管理，rt-PA脑室内纤溶似乎有助于IVH的快速消退、脑室引流导管的持续通畅和ICP的正常化，并且可能对结局产生有利影响。
TEN PATIENTS WITH intraventricular hemorrhage (IVH) were treated with recombinant tissue plasminogen activator (rt-PA) injected directly into the lateral ventricles, followed by ventricular drainage. All had a decreased level of consciousness before treatment (Glasgow Coma Scale score 10 +/-3.4). A total dose between 2 and 12 mg of rt-PA (6.4 +/- 3.3) was administered. For eight patients with aneurysmal IVH, treatment with rt-PA began with two patients the same day as the aneurysm clipping, and the day after with six patients. For a patient with an excision of a ruptured arteriovenous malformation and a patient with IVH resulting from a lateral ventricular catheterization during posterior fossa tumor surgery, treatment with rt-PA started 24 hours after surgery. After an injection of rt-PA, the ventricular drain was closed for 1 hour, followed by alternate-hourly drainage and intracranial pressure (ICP) monitoring. Five patients received a second injection of rt-PA on the second postoperative day, and one patient received a third dose on the third day. Among the eight patients given rt-PA the day after surgery, the volume of external cerebrospinal fluid (CSF) drainage for 24 +/- 8 hours before treatment was 61 +/- 57 ml, and the mean ICP was 22 +/- 5 mm Hg during this same time. Younger age and poorer neurological condition correlated with higher ICP before treatment. After the initiation of rt-PA treatment, daily CSF drainage increased significantly (P < 0.005) and daily ICP decreased significantly (P < 0.005) as follows: 179 +/- 66 ml and 16 +/- 6 mm Hg during the first post-treatment day; and 168 +/- 84 ml and 13 +/- 6 mm Hg during the second post-treatment day. The number of days from IVH until the majority of clot cleared from the various ventricles (as determined by computed tomography) were as follows: lateral ventricles, 4.6 +/- 1.8 days; third ventricle, 3 +/- 0.5 days; and fourth ventricle, 3.5 +/- 1.4 days. There were no hemorrhagic, infectious, or other complications resulting from treatment, and no catheter became obstructed with blood clot. Four patients ultimately required ventriculoperitoneal shunting. Outcome was severe disability in one patient, moderate disability in three, and no disability in six. Combined with early surgery to obliterate the source of bleeding and overall aggressive management of selected poor-grade patients suffering from IVH, intraventricular fibrinolysis with rt-PA appears to facilitate the rapid resolution of IVH, the continuous patency of the ventricular drainage catheter, and the normalization of ICP, and it may have a favorable effect on outcome.