Philippine Journal of Surgical Specialties Vol. 74, No. 2, July-December, 2019, pp 33-43

Technique of External Ventricular Drainage with Intraventricular Administration of Recombinant Tissue Plasminogen Activator for Patients with Secondary Intraventricular Hemorrhage – Case Series in a Single Institution

Author(s): Kevin Paul B. Ferraris, MD, MBA, Alain James R. Salloman, MD, Kenny S. Seng, MD, FAFN, and Joseph Erroll V. Navarro, MD, FAFN



Intraventricular hemorrhage (IVH) as an extension of spontaneous intracerebral hemorrhage is an independent predictor of mortality. The Clot Lysis: Evaluating Accelerated Resolution of IVH phase 3 (CLEAR III) trial is a randomized, double-blinded, placebo controlled, multiregional trial recently conducted to determine whether external ventricular drainage (EVD) plus intraventricular recombinant tissue plasminogen activator (rtPA, alteplase) improved outcome, in comparison to EVD plus saline. This study is an application of the rationale and principles of management in CLEAR III trial and related literature.

There are five patients described in this case series. Report followed the PROCESS guidelines.

30-day mortality in this series is 2 out of 5 while actual all-cause mortality is 4 out of 5. Modified Graeb scores and IVH scores of all subjects have decreased after the intervention. However, good functional status defined as modified Rankin scale (mRS) score of 0-3 has not been achieved with the intervention. Efficacy of completely resolving IVH and hydrocephalus has been achieved in 2 out of 5 which translated to a benefit of survival to one of the two. Shunt dependence has been avoided by the subjects except for the one with the caudate intracerebral hemorrhage. Complications related to the intervention have been noted and discussed

In this single-institution study, patients for which rtPA was used for intraventricular fibrinolysis of IVH clot in addition to EVD as surgical treatment for hydrocephalus resulted to a 30-day survival of 3 out of 5 in this series, while actual survival is 1 out of 5. The intervention was efficacious in decreasing the Modified Graeb scores and IVH scores of all study subjects at end of treatment. Functional status of mRS 5 is the highest score achieved among survivors.

Key words: intraventricular hemorrhage, fibrinolysis, external ventricular drainage