J Korean Neurosurg Soc.  2023 May;66(3):263-273. 10.3340/jkns.2022.0258.

Fibrinolytic (Thrombolytic) Therapy for Post Intraventricular Hemorrhagic Hydrocephalus in Preterm Infants

• Park YS

• KMID: 2542011
• DOI: http://doi.org/10.3340/jkns.2022.0258

Abstract

While the survival rate of preterm infants has increased dramatically over the last few decades, intraventricular hemorrhage and subsequent hydrocephalus remain major unsolved problems in neonatal intensive care. Once intraventricular hemorrhage occurs, severe neurological sequelae are inevitable. Treatment of this complicated pathology and achievement of favorable neurofunctional outcomes in fragile infants are crucial challenges for pediatric neurosurgeons. Fibrinolytic therapy, which chemically dissolves hematoma, is a promising and useful treatment method. In this paper, the historical background of fibrinolytic therapy for postintraventricular hemorrhagic hydrocephalus in preterm infants is reviewed and a recent method of fibrinolytic therapy using urokinase is introduced.

Keyword

Preterm infant; Intraventricular hemorrhage; Hydrocephalus; Fibrinolysis

Figure

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  Fig. 1. The direction of irrigation and drainage of the ventricular system during DRIFT (drainage, irrigation, and fibrinolytic therapy). Modified from the illustration provided by Whitelaw et al [42] with permission. CSF : cerebrospinal fluid, tPA : tissue plasminogen activator.

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  Fig. 2. Fibrinolytic (thrombolytic) treatment. A : A very thin catheter is used for external ventricular drainage (indicated by the arrow). A urokinase (UK) infusion syringe pump was connected to a three-way cock. B and C : Dissolution of the hematoma by UK injection and drainage of bloody cerebrospinal fluid (CSF). D : Protocol of UK intraventricular injection. CSF : cerebrospinal fluid.

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  Fig. 3. Changes in bloody cerebrospinal fluid resulting from fibrinolytic therapy. A : Before starting treatment. B : Day 1 of treatment. C : Day 2. D : Day 4. E : Day 6. F : Day 10.

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  Fig. 4. A : A 24-gauge catheter (0.63 mm in diameter, PI catheter kit, ArgyleTM; Cardinal Health, Tokyo, Japan). B : Percutaneous ventricular puncture with a venous access needle. C : Insertion of a very thin catheter into the lateral ventricle.

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  Fig. 5. A : Subcutaneous tunnel of 4 cm or more and minimal surgical wounds. B : Surgical wounds are tightly covered with surgical film dressings.

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  Fig. 6. A : Ultrasonography on day 2 showing bilateral intraventricular hemorrhage (IVH) mainly in the right lateral ventricle (yellow arrows). B : A massive hematoma is confirmed after several hours post-onset (red arrows). Day 8 (C), Day 12 (D) : IVH and intracerebral hemorrhage dissolve effectively and rapidly. Day 200 (E) : T2-weighted magnetic resonance imaging revealing only mild white matter damage around the right lateral ventricle (blue arrows) without requiring permanent ventriculoperitoneal shunt placement.

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  Fig. 7. A : Ultrasonography on day 4 showing bilateral intraventricular hemorrhage. The hematomas are very large (red arrows). Day 10 (B), Day 15 (C) : hematomas are significantly dissolved, and ventricular dilatation improves rapidly. Day 195 (D) : T2-weighted imaging revealed minimal white matter damage around the right lateral ventricle (blue arrows) without requiring permanent ventriculoperitoneal shunt placement.

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  Fig. 8. The ideal treatment strategy for post intraventricular hydrocephalus in preterm infants. Tx : therapy, EVD : external ventricular drainage, VAD : ventricular access device, V-Sg : ventriculosubgaleal, VP : ventriculoperitoneal.

Reference

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