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Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial.

TitlePermanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial.
Publication TypeJournal Article
Year of Publication2017
AuthorsMurthy SB, Awad I, Harnof S, Aldrich F, Harrigan M, Jallo J, Caron J-L, Huang J, Camarata P, Lara LRivera, Dlugash R, McBee N, Eslami V, Hanley DF, Ziai WC
Corporate AuthorsCLEAR III Trial Investigators
JournalNeurology
Volume89
Issue4
Pagination355-362
Date Published2017 Jul 25
ISSN1526-632X
KeywordsCerebral Hemorrhage, Cerebral Ventricles, Cerebrospinal Fluid Shunts, Disability Evaluation, Double-Blind Method, Drainage, Emergency Treatment, Female, Fibrinolytic Agents, Humans, Intracranial Pressure, Logistic Models, Male, Middle Aged, Multivariate Analysis, Odds Ratio, Severity of Illness Index, Socioeconomic Factors, Tissue Plasminogen Activator, Treatment Outcome
Abstract

OBJECTIVE: To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH).

METHODS: Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days.

RESULTS: Among the 500 patients with IVH, CSF shunting was performed in 90 (18%) patients at a median of 18 (interquartile range [IQR] 13-30) days. Patient demographics and IVH characteristics were similar among patients with and without shunts. In the multivariate analysis, black race (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.18-3.34), duration of EVD (OR 1.10; CI 1.05-1.15), placement of more than one EVD (OR 1.93; CI 1.13-3.31), daily drainage CSF per 10 mL (OR 1.07; CI 1.04-1.10), and intracranial pressure >30 mm Hg (OR 1.70; CI 1.09-2.88) were associated with higher odds of permanent CSF shunting. Patients who had CSF shunts had similar odds of 180-day mortality, while survivors with shunts had increased odds of poor functional outcome, compared to survivors without shunts.

CONCLUSIONS: Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion.

DOI10.1212/WNL.0000000000004155
Alternate JournalNeurology
PubMed ID28659429
PubMed Central IDPMC5574677