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