Modified ventricular puncture combined with urokinase in the treatment of secondary intraventricular cast hemorrhage

Most patients with IVH continue to fare very poorly. It was once believed that the poor prognosis was because of elevated intracranial pressure because of impaired CSF circulation-i.e., the occurrence of obstructive hydrocephalus. In addition to this mechanism, it is now known that the blood clot itself exerts a mass effect on the ventricular walls, and may also cause damage by means of an inflammatory reaction. CT scans may give the false impression that intraventricular blood has resolved, when in actuality it has only become isodense to the CSF normally contained within the ventricles.

Traditionally, treatment of IVH has entailed the placement of one or more external ventricular drains (EVDs) for drainage of blood and CSF from the ventricular system and normalization of intracranial pressure. However, this approach alone is often not sufficiently effective in improving the poor prognosis for severe IVH [9, 10]. Patency of the EVD may be difficult to maintain. In an effort to keep the EVD open, and to expedite the resolution of the ventricular blood, clinicians have administered fibrinolytic agents directly into the ventricular system. Removal and/or dissolution of the intraventricular hematoma would be expected to decrease intracranial pressure, increase cerebral perfusion, and minimize the chance of IVH-induced hydrocephalus. In selected cases, surgical evacuation of intraparenchymal and intraventricular hematoma has been employed, either through craniotomy or an endoscopic approach.

While the prognosis for IVH is not as dismal as once believed, most patients continue to fare poorly, and improved treatments need to be developed. The morbidity and mortality of patients with IVH depend on: 1) the underlying pathology, 2) the location of the intracranial hematoma (in secondary IVH), and 3) the extent of the intraventricular bleeding [3, 6, 7]. Survival of primary IVH is common, but accompanied by considerable morbidity. Patients with secondary IVH fare more poorly than those with primary IVH [2, 7]. When an intracerebral hematoma extends into a portion of the ventricular system, the mortality has been reported to be 32 to 44 %. When hemorrhage extends into all four ventricles, the mortality has been 60 to 91 % [4, 7, 11, 12]. With respect to the location of the hematoma causing the IVH, patients with hematomas located in the thalamus fare the worst [2].

Among the prognostic factors associated with negative outcome in patients with IVH, the volume of intraventricular blood is certainly one of the most relevant [13]. Therefore, efficient and rapid removal of intraventricular blood is the primary goal in the management of IVH, because it will reduce ventricular dilation and a allow re-equilibration of the CSF circulation. IVH severity influences the occurrence of acute hydrocephalus and the initial level of consciousness, which is significantly associated with prognosis. Priority treatment of IVH should be given to those ICH patients with IVH with Graeb score of 6 or more [13]. Animal studies have demonstrated IVH causes inflammatory response in epidermal and subepidermal tissue layers, as well as inflammation and fibrosis of the arachnoidal villi surface [14]. Therefore, fast removal of ventricular and subarachnoid blood may prevent prolonged irritation of the Pacchioni granulations and ongoing inflammatory response caused by the blood and its breakdown products. This may result in faster recovery of the granulation and avoid persistent hydrocephalus. In our series, the modified ventricular puncture (MVP) group had higher Graeb scores, but the VP shunt rate is lower than in the EVD group. This may have occurred because our procedure can remove the intraventricular blood faster, reduce ventricular dilatation, and reequilibrate the CSF circulation, resulting in the avoidance of persistent hydrocephalus. The main differences between MVP and control method are the puncture point and puncture direction. The MVP’s puncture point:eyebrow up 2.5 cm, midline next to 1.5 cm. Puncture direction:parallel to the baseline direction. This point lies between anterial frontal venous and middle frontal venous. This is just the lack of blood vessels. So it is safe. Through this direction, the drainage tube can enter the hematoma along the long axis of the lateral ventricle, and we can suck out the maximum hematoma.

Compared with the traditional EVD, there are many advantages of MVP method. Such as, it’s simple and easy to operate, and is conducive to the popularization. It can be carried out in the setting of small local hospitals. It can quickly clear the hematoma and significantly shorten the time with a pipe through MVP method. This would also help reduce the incidence of complications.