Treatment of intraventricular hemorrhage with active exchange of cerebrospinal fluid: a case series

Introduction: Intraventricular hemorrhage (IVH) as primary presentation or due to extension of intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) is a devastating disease process with high mortality (50-80%). External ventricular drains (EVD) are frequently used in management of IVH to drain CSF, decrease intracranial pressure (ICP), and prevent hydrocephalus. Intrathecal (IT) administration of tissue plasminogen activator (tPA) via EVD can additionally facilitate resolution of IVH. Using active cerebrospinal fluid (CSF) exchange (IRRAflow®) to continuously irrigate the ventricles with or without tPA may serve as a means to treat extensive blood clots from the ventricular system.

Methods: We present six cases of IVH that were treated using active CSF exchange through the dual-catheter system. Clinical presentation, findings of imaging studies, type of hemorrhage, and treatment details were retrospectively reviewed. Duration of treatment with active CSF exchange without or with tPA, and outcomes of treatment were reported.

Results: Duration of time necessary for resolution of IVH and associated hematomas was 2.8 days. tPA was administrated in 4 patients. The average number of days spent in hospital and EVD duration length was 38 and 18.8 days, respectively. No complications were encountered due to use of the IRRAS device.

Conclusion : The timely clearance of IVH is crucial for improving outcomes and preventing chronic sequelae of IVH. This case series showed that active CSF exchange stand alone or with intrathecal tPA can promote the rapid resolution of intraventricular blood. This might be due to the continuous bidirectional flow of CSF and additional benefit of tPA administration. Results of present series promotes necessity for further randomized controlled studies to to determine the efficacy of active CSF exchange for treatment of IVH.