Role of external ventricular drainage in spontaneous intraventricular haemorrhage patients in cileungsi district hospital

Background: Intraventricular haemorrhage (IVH) worsen the prognosis of Intracerebral hematoma (ICH). External Ventricular Drain (EVD) is inserted to reduce intracranial pressure that resulted from the progression of IVH. However, EVD is still an optional procedure because it is not always proven effective. This study was aimed to demonstrate prognostic factors of IVH and whether EVD insertion might improve the outcome. Methods: This cross-sectional retrospective study included IVH patients and concomitant ICH-IVH that required or not EVD in Cileungsi Hospital from January to December 2018. We made comparisons between EVD insertion group and non-EVD group based on sex, age, pulse pressure, Glasgow Coma Scale (GCS), bleeding volume, score of bleeding volume in ventricle lateral, third and fourth based on CT scan, Charlson Comorbid Index (CCI) and modified Rankin Scale (mRS). To determine factors contributing to the good prognosis of EVD, Spearman Correlation test was used with STATA 15 software. Results: 100 patients were diagnosed with ICH, five patients IVH, 16 patients ICH and IVH. Blood in the fourth ventricle made a significant difference between EVD and non-EVD groups in the concomitant ICHIVH group (p=0.035). GCS score (p=0.034) correlated significantly with the prognosis of concomitant ICHIVH patients that had EVD insertion with correlation coefficient 0.671. EVD did not improve the outcome in IVH patients nor patients with ICH-IVH. Conclusion: EVD did not improve the prognosis of spontaneous concomitant ICH-IVH or spontaneous IVH patients, but it still needs to be inserted in case of developing obstructive hydrocephalus that might be lethal. (Health Science Journal of Indonesia 2020;11(1):1-8)

Intraventricular haemorrhage (IVH), a collection of blood in the ventricular system, occurs in up to 45% of patients as an extension of spontaneous intracranial hematoma (ICH) or primary IVH, which the bleeding source in the ventricle chamber. 1,2 It is correlated with lower GCS and as a predictor of poor outcome. 3 In animal models such as canine and porcine IVH models, the increased amount of blood clot in the ventricle, the likelihood death of animals. 4 The same pathological process happened when blood clots expose to the ventricles leads to a decrease of cerebrospinal fluid (CSF) flow and later, inflammation, fibrosis, and hydrocephalus happened at the tissue level. 5 ICH accompanying IVH in a patient is predicted to reach a mortality rate of 50%-80%. Isolated or primary IVH patients are twice more likely to die, compared to a non-IVH group based on the modified Rankin Scale (mRS) when discharged from hospitals. 6 Placement of ventricular catheter is increased nowadays for monitoring of intracranial pressure (ICP) and also as an adjunct to drainage CSF in acute hydrocephalus. 7 However, EVD or ventriculostomy or ventricular drain has its disadvantages; mechanical complications such as dislodgement and blockade are common findings. 8 These complications result in ventriculitis and meningitis that increase morbidity, hospital costs and are also difficult to treat. 7 Even though many papers indicate the benefits of EVD in reducing intracranial pressure, this procedure is not adopted universally. The reasons behind this fact because several studies showed that the benefits are not seen. 9,10 Some authors have opinions that it needs to determine the first benefits of EVD such as control high ICP, reduce ventricular dilatation, or drainage the blood clot from the ventricular system. Nevertheless, some agreed that EVD should be done; otherwise, the prognosis of the patients might have been worst. 2 EVD is indicated for patients with massive intraventricular haemorrhage, hydrocephalus, or elevated ICP. 11 Based on the uncertainty of the benefits of EVD in IVH patients, this study was done to evaluate whether EVD insertion may improve the outcome and demonstrate factors influencing the prognosis of IVH patients. The incidence of spontaneous IVH patients was low, as shown by Arboix, 12 primary intraventricular haemorrhage is accounted for 0.31% of all cases of stroke and 3.3% of intracerebral hemorrhages. Different clinical series of ICH showed the prevalence of primary IVH varied greatly from 2% in the series of Hameed 13 to 7% in the series of Ara. 14 There was a study that reports of 551 and only 15 of them were diagnosed with primary IVH (2.7%). 15 Due to the small number of IVH cases, this study included concomitant ICH cases that extend with IVH. This paper aims to evaluate the role of EVD in primary IVH and concomitant ICH cases that extend with IVH.

METHODS
All patients diagnosed with ICH (ICD-9 code 431) in Cileungsi Hospital, Bogor Regency, West Java Province, Indonesia, from January to December 2018 were included as samples of the study. This hospital was a referral hospital in Bogor Regency and with a growing population of 5,131,798 people in 2014. This hospital is equipped with a comprehensive stroke unit, and it is seeing almost 500 stroke patients in a year. 16 This hospital was chosen because one neurosurgeon works and EVD was the standard of care to manage spontaneous IVH patients. Exclusion criteria were patients having craniotomy procedures, subarachnoid haemorrhage patients, traumatic ICH patients, ICH due to tumor or aneurysms, and patients with coagulation disorders. Independent variables were age, sex, pulse pressure, GCS scores, bleeding volume, scores of bleeding volume in lateral ventricles, third ventricle and fourth ventricle based on CT scan, and Charlson Comorbid Index scores (CCI). We divided each lateral ventricle with a score of 0 (no blood or a small amount of layering), 1 (up to one third filled with blood), 2 (one to two-thirds filled with blood), or 3 (mostly or completely filled with blood). The third and fourth ventricles scored 0 for no blood or 1 if they were partially or entirely filled with blood. 17 The dependent variable was the modified Rankin Score (mRS). The two groups: IVH patients; ICH-IVH patients, were divided based on having EVD procedures or not. The independent variables were categorized based on mRS to find out what factors contribute to the good prognosis of EVD patients. To assess the relationship between each independent variable with mRS, Chi Square, Fisher's exact and Spearman correlation tests were utilized using STATA software version 15. A neurosurgeon and two neurologists involved in data analysis and data grouping. Two radiolog y assistants were blinded to clinical outcomes and independently reviewed all the admission CT scans to verify ICH location, ICH volume, and IVH presence. (Figure 1).

From 313 stroke patients enrolled in Cileungsi
District Hospital in 2018, 100 patients were diagnosed as spontaneous ICH, five patients were diagnosed as primary IVH, and 16 patients had ICH-IVH. Table  1 shows characteristics for IVH patients, 3 patients with EVD, and 2 non-EVD patients. EVD was inserted in patients with head CT scan showed blood almost completely fill the lateral ventricle, blood in the third ventricle and fourth ventricle. However, the difference in blood appearance in CT scan between EVD and non-EVD groups was not significant. EVD insertion also did not demonstrate any significant improvement in the prognosis of patients (p =1.000). Regarding the characteristics of IVH patients, lower age (mean age 42 years old), mean pulse pressure 67 mmHg, lower GCS (mean GCS 9) correlated not significantly with bad prognosis. It is imperative to get a picture of what comorbid diseases that existed in both group patients (Table 3). Charlson Comorbid Indeks (CCI) up to 20 patients of both groups had peripheral vascular disease or hypertension. Severe renal diseases were diagnosed in 5 patients.

DISCUSSION
Primary IVH is defined as bleeding that has the source and is located in the ventricular chamber. 4 Around 45-70% of IVH is arising from an extension of intraparenchymal bleeding (secondary lesion) or bleeding from subarachnoid space extends into the ventricular system. 1,2 Risk factors for IVH include older age, 18 as in this study, the majority of patients' age group were above 46 years old. However, 3 patients were within 31-45 years age group in ICH and IVH group. These findings are also consistent with an inpatient database study from the Netherlands based on retrospective cohort study reported that the rate of ICH per 100,000 was 5.9 in 35-54 years, 37.2 in 55-74 years, and 176.3 in 75-94 years old in 2010. The incidence of spontaneous ICH increases with increased age. 3 Pulse pressure is defined as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP). In this study, mean pulse pressure in IVH patients that had bad prognosis was 67 mmHg, as opposed to ICH and IVH patients mean pulse pressure was 80,57±30,84 mmHg. These findings are also consistent with Chang et al 19 reported mean pulse pressure of mortality after intracerebral haemorrhage was 68.5 (±16.4) mmHg. Widened PP might be an independent predictor for higher mortality in ICH according to a study that included 672 patients. 19 Regarding GCS, there were no patients with GCS < 8 in IVH group. In the ICH-IVH group, 6 patients were in a coma. EVD was inserted in high GCS patients such as 2 patients with GCS 13-15 in IVH patients and 4 patients in ICH-IVH patients. The reason for EVD insertion in high GCS patients was for ventricular drainage or ICP monitoring. As current recommendations for the management of ICH with IVH or hydrocephalus are for ICP monitoring when GCS below 8 and for ventricular drainage or when there is a decrease of consciousness. 20 GCS did not make significant difference between EVD and non-EVD groups. However, there was a correlation between GCS and mRS in ICH-IVH group with EVD procedure. Higher GCS correlated with good outcomes in EVD patients as mean GCS 12,80±2,78 of patients resulted in good mRS and mean GCS 8,40±0,5 end in the poor outcome (mRS [4][5][6]. This result was supported by Weir, who demonstrated prediction of 2-week mortality and 3-month recovery (survival, living at home) based on the GCS in a large cohort of individuals with acute stroke. He suggested that the total GCS score can predict early mortality and 3-month recovery. 21 EVD did not correlate with improved outcomes in primary IVH patients nor ICH-IVH patients in this study. This result was supported by the fact that intraventricular blood and its breakdown cause inflammation of the ependymal layer and subependymal brain tissue. Besides, the clot also causes inflammation and fibrosis of arachnoid granulations, leading to delayed communications hydrocephalus. 4 This delayed process is manifested as loss of consciousness and sometimes, death. These results are consistent with Shapiro 22 et al suggested that ventriculostomy to reduce dilatation of the 4th ventricle does not improve the prognosis. Adam evaluated 22 patients with spontaneous ICH and hydrocephalus concluded that EVD drainage able to reduce the ventricular volume, but the prognosis is still poor. 23 Kumar collected 69 patients that treated with external ventricular drainage, and 52 patients were discharged in poor outcome. 7 Comorbid conditions are best evaluated with the use of the Charlson Comorbid Indeks (CCI). CCI is an independent predictor of the death rate of surgery patients as well as long term survival. 24 Peripheral vascular diseases were the most comorbid condition in both groups. High blood pressure puts the pressure on the thin arterial brain wall to rupture. As a result, brain product release into the brain tissue. This fact also supported by a study that concluded that mean arterial pressure more than 120 mmHg was one of the risk factors of IVH. 25 A study of 14 primary IVH patients, 7 patients had associated hypertension. 26 As seen in Table 1,2,3, the decision to insert the EVD, more likely based on the appearance of blood in the ventricle from the CT Scan imaging. 8 patients with score 1 in 4th ventricle and 3rd ventricle in ICH-IVH group had EVD procedure. Mean widths of the third ventricle were 4.23 ± 1.25mm and 3.81 ± 0.87mm in males and females respectively, whereas the mean 4th ventricular widths were, 7.87 ± 1.30 mm and 7.54 ± 1.33mm, in males and females. 27 This small size and inflammation process than progressing after there presence of clot or progressing to hydrocephalus were the plausible reasons to insert the EVD. These reasons were supported by the Naff 28 who concluded that IVH that is occluding one or both foramina of Monro or third ventricle should be managed with EVD because prone to development of hydrocephalus. A study on IVH by Stein 29 inserted EVD in patients that CT scan showed complete obstruction of blood in the third ventricle or foramina Monroe. This study result showed that blood in the fourth ventricle makes a difference in EVD insertion in ICH and IVH patients. This finding is consistent with Hughes 30 that concluded patients with fourth ventricle blood or dilation are more likely to benefit from EVD procedure.
Chen 12 adopted other maneuvers using an endoscope tube for evacuating the blood from the ventricle. This technique was proven to reduce chronic hydrocephalus; however, the outcome of patients was still poor because the endoscope tube could not be inserted further down until the fourth ventricle and it also means that the hydrocephalus was not entirely resolved. Shapiro 22 concluded that the poor outcomes of IVH related to the fourth ventricle blood clot due to brainstem compression, leading to inadequate perfusion of the brainstem.
Our study is limited in the following ways (1) the limited number of samples of the study. Some patients with massive ICH and IVH or primary IVH died before medical treatment even started. (2) Some medical records were incomplete. However, this study reinforces the data of ICH and IVH spontaneous patients in Indonesia. As our understanding, stroke is the first leading cause of disabilities and the secondhighest incidence after heart problems.
In conclusion, in our population, the decision to insert the EVD in ICH and IVH patients or primary IVH patients is solely based on the surgeons' preference. Based on our results, fourth ventricle blood significantly made a difference whether a patient requires EVD or not. Even though other characteristics did not show improving prognosis of IVH, but it still needs to be inserted in case of developing obstructive hydrocephalus that might cause the patient deceased.