Intra-ventricular hemorrhage (IVH) is a critical condition with high rate of morbidity and mortality due to acute hydrocephalus and secondary brain injury. Mechanisms underlying the clinical deterioration are not only related to the appearance of an acute hydrocephalus but also to blood-clot mass effect and the inflammatory effects of blood break-down products which impede local blood flow and exert a direct toxic effect on the peri-ventricular structures leading to chronic hydrocephalus. An effective treatment strategy should aim at IVH fast removal and reduction of blood-clot mass effect. Although external ventricular drainage placement is an intuitive treatment for obstructive hydrocephalus this treatment does not address in total the aforementioned pathophysiological mechanisms underlying secondary brain damage. Intra-ventricular fibrinolysis, with tissue plasminogen activator or urokinase, is a level of evidence B, class IIB treatment which has proved to be beneficial in lowering the mortality rates. Its effectiveness on functional outcome has been assessed on three large meta-analysis and a recent large randomized control trial (CLEAR III). Results from the CLEAR III multicenter trial suggest that a routine extra-ventricular drain, irrigation with alteplase reduced mortality but did not substantially improve functional outcomes compared with irrigation with saline. Protocol-based use of alteplase with extra-ventricular drain seemed safe, therefore such approach may be a potential option in individual cases. Currently no consensus has been reached and extrapolation of data from the literature does not permit to identify a uniform therapeutic approach but merely to outline some rational procedural modalities. Further research and studies are needed to compare the efficacy of the different fibrinolytic agents and protocols on functional outcome.

译文

:脑室内出血(IVH)是一种由于急性脑积水和继发性脑损伤而导致高发病率和高死亡率的严重疾病。临床恶化的潜在机制不仅与急性脑积水的出现有关,而且还与血块质量效应和血液分解产物的炎症作用有关,这些物质阻碍局部血流并直接对脑室周围产生毒性作用导致慢性脑积水的结构。一种有效的治疗策略应以IVH快速清除和减少血块效应为目标。尽管外部脑室引流是阻塞性脑积水的一种直观治疗方法,但这种治疗方法并未完全解决继发性脑损伤背后的上述病理生理机制。带有组织纤维蛋白溶酶原激活剂或尿激酶的脑室内纤维蛋白溶解是证据水平B,IIB类治疗,已被证明对降低死亡率是有益的。已通过三项大型荟萃分析和一项近期的大型随机对照试验(CLEAR III)评估了其对功能结局的有效性。 CLEAR III多中心试验的结果表明,常规的心室外引流,阿替普酶冲洗可降低死亡率,但与盐水冲洗相比,并不能显着改善功能结局。基于协议的阿替普酶伴室外引流的使用似乎是安全的,因此,在个别情况下,这种方法可能是一种潜在的选择。当前,尚未达成共识,并且从文献中推断数据还不能确定统一的治疗方法,而仅是概述一些合理的程序方式。需要进行进一步的研究以比较不同纤溶剂和方案对功能结局的功效。

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