This document summarizes a study on the use of intraventricular thrombolysis (IVT) for intraventricular haemorrhage (IVH) secondary to spontaneous supratentorial intracerebral haemorrhage (ICH). It outlines the PICO question, search strategy and results. Six randomized controlled trials involving over 500 patients in total were reviewed. IVT was found to result in faster clot resolution compared to external ventricular drainage alone. IVT did not increase the risk of bleeding or ventriculitis. Mortality and the need for ventriculoperitoneal shunting were lower with IVT in some studies. Larger and ongoing trials like CLEAR-III may provide more definitive evidence

1. EBS: Intraventricular thrombolysis for intraventricular
haemorrhage secondary to spontaneous supratentorial ICH
Anthony Chau, Oct 2015

2. Clinical case
• 66M b/g gunshot wounds req trauma surgery
• Found unconscious, hypoxic and tachycardic, E1V1M4 on arrival, PEARL

3. 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?”

4. Search Strategy
• RCTs
• Databases
– Medline (via OVID)
– Clinical trials registries
• Hand searching
– Scopus bibliographies/ citation history

5. MeSH terms (P)
Other terms: intraventricular, haemorrhage

6. MeSH terms (I)
Other terms: tissue-type plasminogen activator, urokinase

7. Oct 2015

9. PRISMA flow chart
Medline 169 articles
Trials 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)

10. Summary of RCTs

11. Sample protocol

12. 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 manner
rtPA 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

13. Summary of Literature

15. Mortality

16. Mortality

17. Good functional outcome, 3mo

18. Shunting

19. Bleeding

20. Ventriculitis

22. Events

23. Clot reduction

24. Length of EVD placement

26. Hematoma reduction by site + dose

28. Case selection

29. Abstract
Study dates: 2002-2011

30. Temporal trend

31. CLEAR-III trial