Sir,
The incidence of intracerebral hemorrhage (ICH) is increasing worldwide in young individuals due to early-onset hypertension, drugs, aneurysm, and arteriovenous (AV) malformation. Intraventricular hemorrhage (IVH) occurs in 10% of ICH. Spontaneous hemorrhage into the corpus callosum with intraventricular extension is rare and only few cases have been reported.[1]The mortality in IVH patients is reported to be >50%, and <20% have good functional outcome. This could be improved with intraventricular thrombolysis.[2]In the present article, we report a case of massive spontaneous corpus callosal hemorrhage with intraventricular extension successfully treated with intraventricular alteplase.
A 40-year-old female presented to the emergency department with a history of two episodes of projectile vomiting which was followed by loss of consciousness of 3 h duration. She was not a known case of hypertension or diabetes. At the time of examination in the emergency room, her blood pressure was 160/100 mm/Hg. She was in altered sensorium (Glasgow Coma Scale score was E1V2M4), pupils were unequal (right pupil 4 mm and left pupil 2 mm), and sluggishly reacting to light. Blood investigations including coagulation profile were within normal range.
Her computed tomography (CT) scan plain axial images showed acute intraparenchymal bleed in the body and genu of corpus callosum with intraventricular extension in lateral, third, and fourth ventricles with mild hydrocephalus and ooze (modified Grabe score 20), basal cisterns, and cortical sulci were effaced, suggestive of cerebral edema [Figure 1].
Figure 1.
Computed tomography scan plain axial and coronal images showing acute intraparenchymal bleed in body and genu of corpus callosum with intraventricular extension in lateral, third, and fourth ventricles
A right and left frontal external ventricular drain (EVD) was placed in the Intensive Care Unit. As she had chances of developing acute obstructive hydrocephalus due to blood clot leading to poor drainage of cerebrospinal fluid (CSF), to prevent this, intraventricular alteplase was considered to the patient. A discussion was held with the patient's family regarding intraventricular instillation of alteplase. The increased risk of bleeding but chances of improved neurological recovery was explained to the family members. After getting consent from the family member, we proceeded for intraventricular alteplase treatment. The protocol used was according to CLEAR III trial with a plan of a total of 12 doses and each dose to be repeated at every 8 h. Each access of the EVD was done under fully sterile conditions. For each dose, 1 mg of alteplace and 2 ml of normal saline mixed and half of the amount were instilled to both sides of the EVD and it was clamped for 60 min after instillation.
The patient tolerated the instillations well without any untoward effects. She developed fever after six doses of alteplace instillation. There was concern for possible central nervous system infection, CSF and blood cultures were sent, and broad-spectrum antibiotics were started. Her all body fluid cultures were sterile. Repeat head CT after 12 doses showed a significant decrease in IVH (modified Grabe score 6) [Figure 2].
Figure 2.
Repeat computed tomography scan plain axial images after 12 doses of alteplase showing significant decrease in blood in the third and fourth ventricles
She started opening her eyes spontaneously, localizing to noxious stimuli with both upper extremities. Her EVD was removed after 24 h of alteplase dose completion. She underwent CT angiography 7 days after admission which showed no evidence of aneurysm or arteriovenous malformation (AVM) with a significant reduction of intraventricular bleed and hydrocephalus [Figure 3].
Figure 3.
Computed tomography brain with angiography 7 days after alteplase instillation showing significant decrease in bleed and hydrocephalus with no evidence of aneurysm
IVH in adults is caused by a variety of conditions, including ruptured intracranial aneurysms, AVMs, hypertension, intraventricular tumors, bleeding diatheses, cerebral venous thromboses, Moyamoya disease, drug abuse, and infections.
A systematic review and meta-analysis suggested that removal of IVH improves survival and long-term functional outcome by relieving acute obstructive hydrocephalus and reducing neurotoxicity.[3]
Recombinant t-PA was thought to enhance normal fibrinolytic process within CSF pathways and hence was thought to be more physiological.[4]
The results of the CLEAR-III trial showed that intraventricular rt-PA administration via surgical catheter did not significantly improve the primary end point of good functional outcome (i.e. modified Rankin Scale score 0-3). The study did suggest an overall reduction in mortality by 10% in the interventional arm. Subgroup analysis revealed that in patients with larger volume clots who underwent removal of 20 mL of blood, there was a significant 10% increase in patients achieving good functional outcome.[5]
Our patient presented with a primary parenchymal hemorrhage with panventricular extension, and CT angiography did not reveal a vascular malformation. She was treated urgently with placement of an EVD and intraventricular alteplase for clot lysis as she had high modified Grabe score. Without the use of rt-PA, this situation was thought to be potentially fatal. Compassionate use of rt-PA was attempted which led to rapid clearance of the ventricular hematoma with ultimate removal of the EVD. No rebreeding was noted. She also improved clinically and had spontaneous eye opening after 6 doses of alteplase, and repeat CT brain showed significant removal of ventricular blood and hydrocephalus.
Fibrinolytic therapy with alteplase may be life-saving in severe cases of IVH. Our case report suggests that early EVD and alteplase thrombolysis reduce patient's mortality with early good outcome as IVH itself has a high mortality rate.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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