Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial

Natalie L. Ullman, Pouya Tahsili-Fahadan, Carol Thompson, Wendy C Ziai, Daniel F Hanley

Research output: Contribution to journalArticle

Abstract

Introduction: The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions. Methods: ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4–6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment. Results: Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01–3.47) and mortality at 180 days (OR 2.73, CI 1.27–5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4–6 (OR 3.20, CI 1.30–7.88) and higher mRS at 180 days (OR 2.33, CI 1.24–4.35), while obstruction by IVH was not. Conclusions: Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.

Original languageEnglish (US)
JournalNeurocritical Care
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Third Ventricle
Cerebral Hemorrhage
Tissue Plasminogen Activator
Hemorrhage
Cerebrovascular Circulation
Glasgow Coma Scale
Mortality
Hydrocephalus
Logistic Models
Tomography
Regression Analysis

Keywords

  • Alteplase
  • Computed tomography
  • Functional outcomes
  • Intracerebral hemorrhage
  • Intraventricular hemorrhage
  • Modified Rankin
  • Neuroimaging
  • Stroke
  • Thalamus
  • Thrombolytic
  • Ventricular system

ASJC Scopus subject areas

  • Clinical Neurology
  • Critical Care and Intensive Care Medicine

Cite this

@article{0d532e4dc8234121bd918b2dc9e8548a,
title = "Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial",
abstract = "Introduction: The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions. Methods: ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4–6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment. Results: Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01–3.47) and mortality at 180 days (OR 2.73, CI 1.27–5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4–6 (OR 3.20, CI 1.30–7.88) and higher mRS at 180 days (OR 2.33, CI 1.24–4.35), while obstruction by IVH was not. Conclusions: Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.",
keywords = "Alteplase, Computed tomography, Functional outcomes, Intracerebral hemorrhage, Intraventricular hemorrhage, Modified Rankin, Neuroimaging, Stroke, Thalamus, Thrombolytic, Ventricular system",
author = "Ullman, {Natalie L.} and Pouya Tahsili-Fahadan and Carol Thompson and Ziai, {Wendy C} and Hanley, {Daniel F}",
year = "2018",
month = "1",
day = "1",
doi = "10.1007/s12028-018-0610-0",
language = "English (US)",
journal = "Neurocritical Care",
issn = "1541-6933",
publisher = "Humana Press",

}

TY - JOUR

T1 - Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial

AU - Ullman, Natalie L.

AU - Tahsili-Fahadan, Pouya

AU - Thompson, Carol

AU - Ziai, Wendy C

AU - Hanley, Daniel F

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Introduction: The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions. Methods: ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4–6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment. Results: Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01–3.47) and mortality at 180 days (OR 2.73, CI 1.27–5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4–6 (OR 3.20, CI 1.30–7.88) and higher mRS at 180 days (OR 2.33, CI 1.24–4.35), while obstruction by IVH was not. Conclusions: Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.

AB - Introduction: The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions. Methods: ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4–6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment. Results: Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01–3.47) and mortality at 180 days (OR 2.73, CI 1.27–5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4–6 (OR 3.20, CI 1.30–7.88) and higher mRS at 180 days (OR 2.33, CI 1.24–4.35), while obstruction by IVH was not. Conclusions: Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.

KW - Alteplase

KW - Computed tomography

KW - Functional outcomes

KW - Intracerebral hemorrhage

KW - Intraventricular hemorrhage

KW - Modified Rankin

KW - Neuroimaging

KW - Stroke

KW - Thalamus

KW - Thrombolytic

KW - Ventricular system

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U2 - 10.1007/s12028-018-0610-0

DO - 10.1007/s12028-018-0610-0

M3 - Article

C2 - 30251074

AN - SCOPUS:85053829851

JO - Neurocritical Care

JF - Neurocritical Care

SN - 1541-6933

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