| Background:Intraventricular hemorrhage(IVH)is defined as the cerebral ventricular system is broken.It is classified as a spontaneous and posttraumatic.Spontaneous intraventricular hemorrhage: intracranial vascular rupture caused by non traumatic factors,blood into the ventricular system,divided into primary intraventricular hemorrhage and secondary ventricular hemorrhage.Primary intraventricular hemorrhage is defined as bleeding from the choroid plexus,the ventricles of the brain and the ventricles of the brain and the periventricular area(Within 1.5cm),Secondary intraventricular hemorrhage is defined as hemorrhage from cerebral ventricle(beyond 1.5cm)rupture of the cerebral parenchyma hemorrhage,hematoma into the ventricular system.Secondary intraventricular hemorrhage more common on clinic,about 70% of the intraventricular hemorrhage is SIVH,common in hypertensive cerebral hemorrhage,intracranial arteriovenous malformation(AVM),ruptured intracranial aneurysm,coagulation disorders,brain tumor,etc.As the name implies,posttraumatic intraventricular hemorrhage: refers to the brain trauma caused by cerebral vascular rupture,blood into the ventricular system.IVH is one of the most dangerous disease in Department of Neurosurgery,especially in the middle and severe have poor prognosis,mortality and disability rate is high,It has been reported for first years,the survival rate is only 38%.IVH death and the main reason for high morbidity associated with consideration of the following aspects:(1)intraventricular hematoma caused by obstruction of the ventricular system,cerebrospinal fluid circulation disorder,caused by ventricular expansion,increased intracranial pressure,compression and stimulation of the hypothalamus and brainstem,caused by high fever,respiratory and circulatory dysfunction and hemorrhage of digestive tract;(2)red blood cells the decomposition of toxic substances released together in the subarachnoid CSF,cerebral vasospasm,caused by cerebral ischemic necrosis;(3)blood products will stimulate the brain parenchyma and arachnoid,serious toxic effects,cause periventricular edema,neuronal death,and ultimately can also cause fibrosis and tubular membrane the arachnoid chamber,leading to severe hydrocephalus,endanger patient life.Therefore,as soon as possible to remove intraventricular hemorrhage,especially in third and fourth haematocele,prevent the occurrence of obstructive hydrocephalus brain,relieve the oppression of the brain stem,normal CSF circulation is the key to successful rescue.Reported that the ventricular self absorption is relatively slow,usually takes 12 to 3 weeks or longer time,1982,Yamamoto months after the autopsy found that patients with IVH are still the blood.At present,the clinical treatment of intraventricular hemorrhage,including surgical treatment and conservative treatment,conservative treatment due to poor prognosis,clinical application.Surgical treatment includes craniotomy hematoma removal,drainage(external ventricular,EVD)and endoscopic hematoma removal.Craniotomy evacuation of hematoma,due to its large trauma,complications,third,fourth ventricle hematoma removal difficult,less clinical application.The nerve endoscope is highly demanding and expensive to operate,and is limited to the use of large hospitals which are responsible for teaching tasks in China.EVD because of its simple operation,small trauma,intraventricular hematoma drainage thoroughly,is widely used in clinical,especially EVD combined with fibrinolytic agents(Intraventricular fibrinolysis IVF)perfusion therapy,rapid ventricular drainage,treatment is often used.However,the efficacy of EVD combined with IVF in the treatment of IVH has been controversial.The results reported in literature are not the same,some of the reported EVD combined with IVF and EVD alone can reduce the mortality of patients with IVH,improve neurological function,it has been reported that two kinds of treatment methods have no difference in reducing the mortality and improve the nervous function.In view of this situation,this study was conducted to study the effect of EVD on IVH.This study is divided into two parts:Part? Retrospective analysis of the discharge outcome of external ventricular drainage and conservative treatment in patients with severe intraventricular hemorrhage.Part II Comparative analysis of the treatment of Intraventricular hemorrhage by external ventricular drainage combined with urokinase perfusion or rtPA perfusion.Part? Retrospective analysis of the discharge outcome of external ventricular drainage and conservative treatment in patients with severe intraventricular hemorrhageObjective:Retrospective analysis of the discharge outcome of external ventricular drainage(EVD)and conservative treatment in patients with severe intraventricular hemorrhage(SeIVH).Methods:From January 2011 to December 2016,patients with SeIVH admitted to the General Hospital of the PLA Rocket Force and the Army General Hospital received EVD treatment and were classified as the treatment group.According to intraventricular hemorrhage volume and age,patients received conservative treatment were pair matched and classified as control group.Then we compared the clinical outcome of moderate disability or less degree of discharge(mRS ?3)and death incidence(mRS 6)between two groups.Results:A total of 361 patients with IVH were treated during these six years.Among them,75 cases were chosen as treatment group.Another 75 cases were pair matched as control group from 286 cases.At the time of admission,the ventricular hemorrhage volume of two groups were(55.77 ± 22.69)ml and(53.63 ± 23.29)ml(P=0.569)respectively.Cerebral hemorrhage volume were(23.56 ± 5.28)ml and(23.97 + 5.43)ml(P=0.631).And the median Glasgow coma score(GCS)were 4[IQR(3,7)]and 5[IQR(4,7)](P=0.131).At the discharge time,there were 16%(12/75)patients scored mRS?3 in treatment group,while 2.7%(2/75)in control group(P<0.005).The absolute risk reduction(ARR)was 13.3%,and the number needed to treat(NNT)was 7.5.The mortality rate of treatment group was 13.3%(10/75),much lower than that of the control group 41.1%(31/75),P<0.001).ARR was 27.8% and NNT was 3.6.Conclusion:Although the prognosis of SeIVH was poor,compared with conservative treatment,EVD treatment significantly improved the outcome of these patients.Randomized controlled trials are needed to validate the efficacy of EVD.Part II Comparative analysis of the treatment of Intraventricular hemorrhage by external ventricular drainage combined with urokinase perfusion or rtPA perfusion Objective:To compared the effect of two kinds of treatment of patients with intraventricular hemorrhage by external ventricular drainage(EVD)combined with urokinase(UK)or alteplase(rtPA)for perfusion.Methods:51 patients with Intraventricular hemorrhage accorded with the inclusion criteria from January 2011 to March 2015 were chosen,who were from the rockets army general hospital PLA,they were divided into two groups by different drugs in the intraventricular.With 26 cases in control group(rtPA)and 25 cases in observation group(UK).Two groups of patients were given EVD placement within 24 hours,catheter tip position was corrected after operation by head CT,control group injected rtPA,observation group injected UK.The primary observation index were the observation of hematoma clearance rate,short-term outcome and long-term neural function,hematoma clearance rate by 5 mGS score achieved,short-term outcomes and long-term nerve function by 30 d GOS and 180 d m RS score achieved,respectively,The secondary observation index were the observation of the complications,EVD indwelling time,ICU stay time and drug expenses.Results: Hematoma removal rate of observation group and control group were compared,with no statistical difference(P>0.05),5d mGS median score of two groups were compared,with no statistical difference(P>0.05).There were no significant differences of the short-term outcome and long-term neurological function(P>0.05),30 d GOS score and 180 d m RS score of two groups were compared,with no statistical difference(P>0.05).Within 30 days of control group with 1 cases died(3.8%),observation group with 2 cases(8.0%)died,compared the two groups with no statistical difference(P>0.05).EVD indwelling time and ICU stay time had no significant difference in the two groups(P>0.05).control group thrombolytic drugs cost significantly more than observation group,compared the two groups with statistical difference(P>0.05).Within 30 days,control group had 2 cases of intracranial infection,1 cases of epilepsy,observation group had 2 cases of intracranial infection,1 cases of re bleeding,1 cases of traffic hydrocephalus.There was no significant difference in the incidence of complications between the two groups(P>0.05).Conclusion: EVD combine intraventricular fibrinolysis(IVF)in the treatment of IVH can quickly clean the ventricular hematocele(especially the third and the fourth ventricle),rtPA and UK can do for intraventricular injections of drugs,cost of UK is significantly more less than that of rtPA. |
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