Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial

Santosh B. Murthy, Issam Awad, Sagi Harnof, Francois Aldrich, Mark Harrigan, Jack Jallo, Jean-louis R Caron, Judy Huang, Paul Camarata, Lucia Rivera Lara, Rachel Dlugash, Nichol McBee, Vahid Eslami, Daniel F. Hanley, Wendy C. Ziai

Research output: Contribution to journalArticle

7 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)355-362
Number of pages8
JournalNeurology
Volume89
Issue number4
DOIs
StatePublished - Jul 25 2017
Externally publishedYes

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Drainage
Hemorrhage
Odds Ratio
Confidence Intervals
Tissue Plasminogen Activator
Survivors
Intracranial Hypertension
Mortality
Intracranial Pressure
Emergencies
Multivariate Analysis
Placebos
Demography
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

Murthy, S. B., Awad, I., Harnof, S., Aldrich, F., Harrigan, M., Jallo, J., ... Ziai, W. C. (2017). Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial. Neurology, 89(4), 355-362. https://doi.org/10.1212/WNL.0000000000004155

Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial. / Murthy, Santosh B.; Awad, Issam; Harnof, Sagi; Aldrich, Francois; Harrigan, Mark; Jallo, Jack; Caron, Jean-louis R; Huang, Judy; Camarata, Paul; Lara, Lucia Rivera; Dlugash, Rachel; McBee, Nichol; Eslami, Vahid; Hanley, Daniel F.; Ziai, Wendy C.

In: Neurology, Vol. 89, No. 4, 25.07.2017, p. 355-362.

Research output: Contribution to journalArticle

Murthy, SB, Awad, I, Harnof, S, Aldrich, F, Harrigan, M, Jallo, J, Caron, JR, Huang, J, Camarata, P, Lara, LR, Dlugash, R, McBee, N, Eslami, V, Hanley, DF & Ziai, WC 2017, 'Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial', Neurology, vol. 89, no. 4, pp. 355-362. https://doi.org/10.1212/WNL.0000000000004155
Murthy SB, Awad I, Harnof S, Aldrich F, Harrigan M, Jallo J et al. Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial. Neurology. 2017 Jul 25;89(4):355-362. https://doi.org/10.1212/WNL.0000000000004155
Murthy, Santosh B. ; Awad, Issam ; Harnof, Sagi ; Aldrich, Francois ; Harrigan, Mark ; Jallo, Jack ; Caron, Jean-louis R ; Huang, Judy ; Camarata, Paul ; Lara, Lucia Rivera ; Dlugash, Rachel ; McBee, Nichol ; Eslami, Vahid ; Hanley, Daniel F. ; Ziai, Wendy C. / Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial. In: Neurology. 2017 ; Vol. 89, No. 4. pp. 355-362.
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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.",
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T1 - Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial

AU - Murthy, Santosh B.

AU - Awad, Issam

AU - Harnof, Sagi

AU - Aldrich, Francois

AU - Harrigan, Mark

AU - Jallo, Jack

AU - Caron, Jean-louis R

AU - Huang, Judy

AU - Camarata, Paul

AU - Lara, Lucia Rivera

AU - Dlugash, Rachel

AU - McBee, Nichol

AU - Eslami, Vahid

AU - Hanley, Daniel F.

AU - Ziai, Wendy C.

PY - 2017/7/25

Y1 - 2017/7/25

N2 - 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.

AB - 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.

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