Localized Thrombolysis with Tenecteplase for IVH in a Patient with GCS 4
Localized thrombolysis with tenecteplase is not recommended for patients with intraventricular hemorrhage (IVH) and a Glasgow Coma Scale (GCS) score of 4.
Recommended Management Approach for IVH with Low GCS
- External ventricular drain (EVD) placement is indicated for patients with IVH and reduced level of consciousness (GCS 4) to treat intracranial hypertension and improve survival 1
- For patients with moderate to large IVH and clinical hydrocephalus requiring EVD, intraventricular thrombolysis with alteplase (not tenecteplase) has been shown to improve survival compared to EVD alone 1
- The American Heart Association/American Stroke Association guidelines specifically recommend EVD with alteplase irrigation for IVH with clinical hydrocephalus 1
Rationale Against Using Tenecteplase for IVH
- Tenecteplase is FDA-approved for acute ischemic stroke, not for intraventricular hemorrhage 1
- Tenecteplase is contraindicated in patients with active internal bleeding and history of cerebrovascular accident according to FDA labeling 2
- There is no evidence supporting the use of tenecteplase for intraventricular thrombolysis in IVH patients 1, 3
- The CLEAR III trial, which is the largest RCT on intraventricular thrombolysis, specifically used alteplase (not tenecteplase) and showed mortality benefit 1
Evidence-Based Approach for IVH Management
- For patients with IVH and GCS ≤8, EVD placement alone improves survival compared to conservative treatment 1, 4
- Adding intraventricular thrombolysis with alteplase to EVD further reduces mortality compared to EVD alone or with saline 1, 3
- Typical alteplase dosing for intraventricular thrombolysis: 1-4 mg every 8-12 hours 3
- Safety data from CLEAR III showed no increase in symptomatic hemorrhage with intraventricular alteplase compared to saline 1
Special Considerations for Patients with Low GCS
- Patients with GCS ≤8 are at high risk for herniation and poor outcomes, requiring close monitoring of intracranial pressure 4
- Target cerebral perfusion pressure should be maintained at 50-70 mmHg 4
- Head of bed elevation to 30° and maintaining good head and body alignment can help reduce intracranial pressure 4
- Avoid hypoxia, hypercarbia, and hyperthermia as these can exacerbate raised intracranial pressure 4
Important Caveats
- While EVD with intraventricular thrombolysis using alteplase improves survival, the benefit for functional outcomes remains uncertain 1, 3
- Bacterial ventriculitis is a potential complication of EVD and intraventricular thrombolysis, though rates were actually lower in the alteplase group versus saline in the CLEAR III trial 1
- The extremely low GCS of 4 indicates a very poor prognosis regardless of intervention 4