CASE PRESENTATION-IVH

Dr Surendra PatelFellow-CCM

RTIICS Kolkata

20/11/14

31 year female presented on 11/9/14 at 9.30 am

• Sudden onset of headache with vomiting f/b loss of consciousness with right side hemiparesis since 4am.

• Transfer from local hospital where she receive inj-diazepam i/m ---? For convulsion

• She had undergone IVF n embryo implant one day back—f/b inj progesterone 100 mg i/m for 3 days and given inj enoxaparin 40 mg s/c. on regular folic acid. [NO Record available]

• No h/o HTN,DM, coagulopathy , epilepsy• Menstrual h/o- ovulation induction, embryo transfer-

O/E in emg…….• Gcs- E1V1M2 pupil- b/l small size n sluggish reactive, rt hemiparesis, ? Diazepam effect• Vitals-– pulse- 85/min– Rr -18/min– Bp- 130/80 mmhg– Temp- 101 f– Spo2- 100% in room air Rbs-134

• Airway- patent bt not protective• Breathing –laboured• Abg-ph-7.447, pco2-28.2 po2-197, hco3-19, be-5.0,

Cont….

• Cns- could not be assessed properly. GCS-E1V1M2 - ? diazepam

• Chest-b/l clear, no added sounds• Cvs- S1S2, no murmur• P/A – soft, IPS present• P/V- no bleeding ….wnl• Urgent Intubation• CT scan urgent

investigation

• Ct brain- large acute intracerebral hemorrhage with perifocal edema in perietal region with IVE [GRAEB SCORE-11]

• given– Inj mannitol 300ml + inj lasix 20 mg stat n TDS– INJ LEVIPIL 500 BD

• CT-angio- wnl • Hb-12.8/tc-18.9-N86%/pc-304 /inr-1.19• Cxr-wnl• Cr-0.9/bun-7/na-136/k-4.1/• Lft-wnl• Neurosurgical opinion taken

Graeb scoreIntraventricular hematoma

• Components• Each lateral ventricle

– 1 = trace of blood– 2 = less than 50% filled– 3 = more than 50% filled– 4 = completely filled and expanded

• 3th and 4th ventricles– 0 = no blood– 1 = blood present, size normal– 2 = filled with blood and expanded

• Calculation Graeb score = righ ventricular score + left ventricular score + 3th

ventricular score + 4th ventricular scoreHwang BY, Bruce SS, Appelboom G, Piazza MA, Carpenter AM, Gigante PR, et al. Evaluation of intraventricular hemorrhage assessment methods for predicting outcome following intracerebral hemorrhage. J Neurosurg 2012; 116:185-192.

11/09/14

Modified graeb score

• The mGS is thus based on the fourth ventricle (maximum score 4), third (maximum score 4), right and left lateral ventricles (maximum score 4 for each), right and left occipital horns (maximum score 2 for each), and the right and left temporal horns (maximum score 2 for each).

• An additional score of +1 is given to each compartment if it is expanded beyond normal anatomic limits attributable to Clot.

• The maximum possible score is 32, in which every compartment is filled with blood and expanded. A score

• of zero denotes no intraventricular blood.(Stroke. 2013;44:635–641.)

mGRAEB score

• The CLEAR B study included 360 scans from 36 subjects. – The mGS score and IVH volume were highly correlated (R = 0.80,

P<0.0001, R2 0.65).– Baseline mGS was predictive of poor outcome (area under

receiving operating characteristic curve 0.74, 95% confidence interval, 0.57–0.91), whereas the original Graeb scale was not.

• The VISTA study included 399 participants. – Each unit increase in the mGS led to a 12% increase in the odds of a

poor outcome (odds ratio, 1.12; 95% confidence interval, 1.05–1.19).

• Measures of reliability (intra- and inter- reader) were good in both studies

(Stroke. 2013;44:635–641.)

Day-2 ------12/09

• Neurosurgical opinion• Plan next--- EVD insetion• GCS- E3M4-5VT

• Inj cefuroxime 500 mg iv bd

Repeat CT on14/09/14

14/09----20/09

• Plan to give inj alteplase 1 mg f/b 4 ml flush with sterile NS through left EVD

• Clamp for 1 hr then release• Repeat 8 hourly------remaining discard• Right EVD removed ON 16/09/14

• CSF sent for exam on 20/09/14 shows low sugar-34, high protien-334, cell count 150…. 75% neutrophils

• Inj ceftriaxone 2g iv bd + inj amikacine 500 mg iv bd

• Extubated on 21/09/14 • CSF c/s received on 24/09----no growth

• Left EVD removed on 24/09/14• CSF sent for exam----sugar-n/protein-70/cells-

45• Shifted in HDU on24/09/14• Discharge on 5/10/14 along with Ryles tube

and Foleys catheter• With GCS---E4M6V2

Before discharge

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

• AHA Recommendation Although intraventricular administration of

recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational (Class IIb; Level of Evidence: B).

Stroke. 2010;41:2108-2129

CLEAR IVH trial- phase 2More Than a Glimmer of Hope

• Naff et al report the results of a phase II trial to clear blood from the ventricles in patients with small supratentorial ICH (30 Ml) and massive IVH.

• All patients had an EVD

• were randomized within 24 hours to receive 3 mg/3 mL of recombinant tissue-type plasminogen activator (rtPA) or 3 mL of normal saline injected via the extraventricular drainage into the ventricular spaces every 12 hours until CT evidence of clot resolution was sufficient to remove the catheter.

• With 18% /day, the blood clot resolution was significantly higher in the rtPA– treated pts compared to 8% / day for the placebo (P0.001),

• treatment duration was shorter.

• Mortality and complications such as bleeding events were similar in both treatment arms,

• Mortality was 19% in the rtPA–treated group and 23% in the placebo group.

• Ventriculitis occurred among 8% and 9%, respectively,

• symptomatic bleeding was reported for 23% of the rtPA– treated group and 5% of the placebo group.

• also a trend toward better clinical outcome at 30 days.

• The prespecified functional outcome measures were all improved in the rtPA group.

Naff N, Williams M, Keyl PM, Tuhrim S, Bullock MR, Mayer S, et al. Low-dose recombinant tissue-type plasminogen activator enhances clot resolution in brain hemorrhage: the Intraventricular Hemorrhage ThrombolysisTrial. Stroke. 2011;42:3009 –3016.

CLEAR -3 TRIAL

• A pivotal phase III study (Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with rtPA III [CLEAR III]) of the effect of thrombolytic based removal of ventricular blood on functional outcome is underway.

• Results may came in 2015

THANK YOU