Jürgen Bardutzky

Hypothermia Reduces Perihemorrhagic Edema After Intracerebral Hemorrhage

Background and Purpose— The prognosis of spontaneous intracerebral hemorrhage (sICH) is poor because of the mass effect arising from the hematoma and the associated peri-hemorrhagic edema, leading to increased intracranial pressure. Because the efficacy of surgical and anti-edematous treatment strategies is limited, we investigated the effects of mild induced hypothermia in patients with large sICH. Methods— Twelve patients with supratentorial sICH >25 mL were treated by hypothermia of 35°C for 10 days. Evolution of hematoma volume and perifocal edema was measured by cranial CT. Functional outcome was assessed after 90 days. These patients were compared to patients (n=25; inclusion criteria: sICH volume >25 mL, no acute restriction of medical therapy on admission) from the local hemorrhage data bank (n=312). Side effects of hypothermia were analyzed. Results— All patients from both groups needed mechanical ventilation and were treated in a neurocritical care unit. All hypothermic patients (mean age, 60±10 years) survived until day 90, whereas 7 patients died in the control group (mean age, 67±7 years). Absolute hematoma size on admission was 58±29 mL (hypothermia) compared to 57±31 mL (control). In the hypothermia group, edema volume remained stable during 14 days (day 1, 53±43 mL; day 14, 57±45 mL), whereas edema significantly increased in the control group from 40±28 mL (day 1) to 88±47 mL (day 14). ICH continuously dissolved in both groups. Pneumonia rate was 100% in the hypothermia group and 76% in controls (P=0.08). No significant side effects of hypothermia were observed. Conclusions— Hypothermia prevented the increase of peri-hemorrhagic edema in patients with large sICH.

Influence of intraventricular fibrinolytic therapy with rt‐PA on the long‐term outcome of treated patients with spontaneous basal ganglia hemorrhage: a case–control study

Over the recent years, fibrinolytic agents have been tested for intraventricular clot fibrinolysis (IVF). Compared with patients who did not receive IVF, administration of rt‐PA induces rapid resorption of intraventricular blood and normalization of cerebrospinal fluid (CSF) circulation resulting in a reduced 30‐day mortality and beneficial short‐term outcome after 3 months. Our objective was to analyze possible influences of IVF on the long‐term outcome after 12 months. Based on a prospective data base, patients with ganglionic supratentorial hematoma with additional intraventricular hemorrhage and occlusive hydrocephalus (n = 135) were isolated. Twenty‐seven patients received IVF. To design a case–control study, we carefully matched 22 controls without IVF with regard to hematoma volume, Graeb score, Glasgow Coma Scale on admission and age (five patients remained unmatchable). We determined clinical and imaging parameters by reviewing the medical records and CT scans of all included patients. Outcome after 12 months was evaluated using the modified Rankin scale (mRS). One multivariate regression analysis was performed to determine predisposing factors for outcome. IVF significantly reduced Graeb score during treatment (eight on admission, three after IVF, one prior to discharge in the treated group versus 8/6/2 in patients without IVF). In patients with IVF requirement, a second external ventricular drainage (EVD) and a ventriculoperitoneal (VP) shunt were reduced (P = 0.08) and the incidence of a lumbar drainage was significantly higher (P < 0.01), whilst the overall time of extra‐corporal CSF drainage was comparable. EVD associated complications were equal in both groups. Overall long‐term outcome was poor but no significant differences were found between patients with and without IVF (mRS 4–6: 12/22 (54%) in patients with and 13/22 (59%) in patients without IVF; P = 0.81). The five excluded patients with IVF were similar to the 22 included ones with respect to imaging findings and outcome. The multivariate analysis revealed age and baseline hematoma volume, but not IVF to significantly impact the outcome. In accordance with previous studies, IVF hastened clot lysis and reduced the need for repeated EVD exchanges and permanent shunting. However, despite these advantages, IVF did not influence long‐term outcome after 12 months. The results of the prospective randomized trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) need to be awaited.

Lumbar drainage for communicating hydrocephalus after ICH with ventricular hemorrhage.

IntroductionOur objective was to investigate the feasibility of lumbar drainage (LD) as a new therapeutic approach for the treatment of communicating hydrocephalus in patients with supratentorial intracerebral hemorrhage (ICH) and ventricular extension (IVH) who initially required an external ventricular drain (EVD).MethodsThree consecutive patients with ICH and severe IVH were treated with EVD immediately after admission due to acute obstructive hydrocephalus. Each patient received intraventricular fibrinolysis (IVF) starting 12 hours after admission (4mg rtPA every 12 hours up to a maximum cumulative dose of 20 mg). Although complete clearing from blood of the third and fourth ventricles was achieved in all patients after IVF, branching off the EVD failed because of increasing intracranial pressure (ICP). Assuming a communicating, malresorptive hydrocephalus was present, a lumbar drain was placed (to allow extracorporal CSF drainage through outer CSF space).ResultsIn all patients, the EVD could be branched off without raising ICP (while the LD remained open), resulting in the opportunity to remove the EVD in all patients after another 24 hours (mean duration of EVD was 115±4 hours). Clamping the LD was performed every second day and development of hydrocephalus was monitored by CT. After a mean duration of 6 (5–7) days after placement, the LD could be removed. None of the patients required a VP-Shunt.ConclusionOur preliminary data suggest that LD is a simple and reasonable alternative for treating communicating hydrocephalus after ICH and IVH. The combination of IVF to enhance clot resolution and to clear the third and fourth ventricle followed by LD may represent a new and promising approach in the therapy of hydrocephalus following severe ventricular hemorrhage.

Predictors for good functional outcome after neurocritical care

IntroductionThere are only limited data on the long-term outcome of patients receiving specialized neurocritical care. In this study we analyzed survival, long-term mortality and functional outcome after neurocritical care and determined predictors for good functional outcome.MethodsWe retrospectively investigated 796 consecutive patients admitted to a non-surgical neurologic intensive care unit over a period of two years (2006 and 2007). Demographic and clinical parameters were analyzed. Depending on the diagnosis, we grouped patients according to their diseases (cerebral ischemia, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), meningitis/encephalitis, epilepsy, Guillain-Barré syndrome (GBS) and myasthenia gravis (MG), neurodegenerative diseases and encephalopathy, cerebral neoplasm and intoxication). Clinical parameters, mortality and functional outcome of all treated patients were analyzed. Functional outcome (using the modified Rankin Scale, mRS) one year after discharge was assessed by a mailed questionnaire or telephone interview. Outcome was dichotomized into good (mRS ≤ 2) and poor (mRS ≥ 3). Logistic regression analyses were calculated to determine independent predictors for good functional outcome.ResultsOverall in-hospital mortality amounted to 22.5% of all patients, and a good long-term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of ICH, GBS/MG, and inoperable cerebral neoplasm as well as Therapeutic Intervention Scoring System (TISS)-28 on Day 1 were independently associated with functional outcome after one year.ConclusionsThis investigation revealed that age, LOV and TISS-28 on Day 1 were strongly predictive for the outcome. The diagnoses of hemorrhagic stroke and cerebral neoplasm leading to neurocritical care predispose for functional dependence or death, whereas patients with GBS and MG are more likely to recover after neurocritical care.

Clinical severity predicts time to hospital admission in patients with spontaneous intracerebral hemorrhage.

Background: In this study we analyzed whether demographic, clinical and neuroradiological parameters are associated with time to hospital admission in patients with spontaneous intracerebral hemorrhage (ICH). We a priori hypothesized that the earlier a patient was admitted to hospital, the worse the clinical status would be. Methods: Demographic, clinical and neuroradiological parameters of consecutive patients with spontaneous ICH directly admitted to 2 neurological university departments were subjected to correlation, trichotomization and logistic regression analyses for prediction of (i) early hospital admission, and (ii) favorable clinical presentation at admission [dichotomized Glasgow Coma Scale (GCS) score ≧9]. Results: We analyzed 157 patients with a median age of 66 (39–93) years. Patient trichotomization according to the GCS revealed a significant difference (p < 0.001) between all groups with regard to the time from symptom onset to hospital admission: patients with a GCS score of 3–5 were admitted after 105 (40–300) min (mean: 113 ± 53), those with a GCS score of 6–9 after 180 (45–420) min (mean: 184 ± 95) and those with a GCS score of 10–15 after 300 (60–1,560) min (mean: 324 ± 367). There were significant correlations between (i) hematoma volume and GCS (r = –0.632; p < 0.001); (ii) time to admission and GCS (r = 0.596; p < 0.001), and (iii) Graeb scores for intraventricular hemorrhage and hematoma volume (r = 0.348; p < 0.001). In the multivariate regression model for prediction of time until hospital admission, presence of intraventricular hemorrhage and the GCS score on admission were significant. In the multivariate regression model for prediction of a GCS score of ≧9 on admission, hematoma volume and time until hospital admission were significant parameters. Conclusions: Clinically more severely affected patients were admitted to hospital earlier. This highlights the importance of most rapid diagnosis of ICH. Efforts should be made to get less severely affected patients admitted earlier as they might be ideal candidates for emerging innovative treatments.

Treatment of intraventricular hemorrhage and hydrocephalus

Most cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuing treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.ZusammenfassungDie intraventrikuläre Blutung (IVB) – meist sekundär im Anschluss an eine spontane intrazerebrale Blutung oder Subarachnoidalblutung – birgt als Hauptgefahr die Entwicklung eines Hydrozephalus, der mit einer schlechten Prognose assoziiert ist. In den letzten Jahren sind verschiedene Therapieoptionen zur Akutbehandlung der IVB beschrieben worden, jedoch basiert bislang kein Therapieansatz auf prospektiven Studien. Diese Übersichtsarbeit stellt die einzelnen Therapiemöglichkeiten der IVB vor, einschließlich der externen Ventrikeldrainage (EVD), der intraventrikulären Fibrinolyse, der Lumbaldrainage und der neuroendoskopischen Verfahren. Schwerpunkt wird die Darstellung der kombinierten Behandlung des – sich aufgrund intraventrikulärer Blutanteile entwickelnden – initialen okklusiven Hydrozephalus mittels einer EVD und der intraventrikulären Fibrinolyse mit rt-PA sein sowie die Erläuterung der weiterführenden Therapie des malresorptiven, kommunizierenden Hydrozephalus mittels Lumbaldrainage.SummaryMost cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuative treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.

Behandlung von intraventrikulären Blutungen und Hydrozephalus

Most cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuing treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.ZusammenfassungDie intraventrikuläre Blutung (IVB) – meist sekundär im Anschluss an eine spontane intrazerebrale Blutung oder Subarachnoidalblutung – birgt als Hauptgefahr die Entwicklung eines Hydrozephalus, der mit einer schlechten Prognose assoziiert ist. In den letzten Jahren sind verschiedene Therapieoptionen zur Akutbehandlung der IVB beschrieben worden, jedoch basiert bislang kein Therapieansatz auf prospektiven Studien. Diese Übersichtsarbeit stellt die einzelnen Therapiemöglichkeiten der IVB vor, einschließlich der externen Ventrikeldrainage (EVD), der intraventrikulären Fibrinolyse, der Lumbaldrainage und der neuroendoskopischen Verfahren. Schwerpunkt wird die Darstellung der kombinierten Behandlung des – sich aufgrund intraventrikulärer Blutanteile entwickelnden – initialen okklusiven Hydrozephalus mittels einer EVD und der intraventrikulären Fibrinolyse mit rt-PA sein sowie die Erläuterung der weiterführenden Therapie des malresorptiven, kommunizierenden Hydrozephalus mittels Lumbaldrainage.SummaryMost cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuative treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.

Behandlung von intraventrikulären Blutungen und Hydrozephalus@@@Treatment of intraventricular hemorrhage and hydrocephalus

Most cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuing treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.ZusammenfassungDie intraventrikuläre Blutung (IVB) – meist sekundär im Anschluss an eine spontane intrazerebrale Blutung oder Subarachnoidalblutung – birgt als Hauptgefahr die Entwicklung eines Hydrozephalus, der mit einer schlechten Prognose assoziiert ist. In den letzten Jahren sind verschiedene Therapieoptionen zur Akutbehandlung der IVB beschrieben worden, jedoch basiert bislang kein Therapieansatz auf prospektiven Studien. Diese Übersichtsarbeit stellt die einzelnen Therapiemöglichkeiten der IVB vor, einschließlich der externen Ventrikeldrainage (EVD), der intraventrikulären Fibrinolyse, der Lumbaldrainage und der neuroendoskopischen Verfahren. Schwerpunkt wird die Darstellung der kombinierten Behandlung des – sich aufgrund intraventrikulärer Blutanteile entwickelnden – initialen okklusiven Hydrozephalus mittels einer EVD und der intraventrikulären Fibrinolyse mit rt-PA sein sowie die Erläuterung der weiterführenden Therapie des malresorptiven, kommunizierenden Hydrozephalus mittels Lumbaldrainage.SummaryMost cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuative treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.

Contents Vol. 25, 2008

S 13th Meeting of the European Society of Neurosonology and Cerebral Hemodynamics and 5th National Congress of the Italian Society of Neurosonology and Cerebral Hemodynamics Genova, Italy, May 10–13, 2008 Editors: M. Del Sette (Genova); C. Gandolfo (Genova); K. Niederkorn (Graz); D. Russell (Oslo)