CATHETER-BASED INTERVENTIONS IN THE MANAGEMENT OF INTRACEREBRAL HEMORRHAGE: A SYSTEMATIC REVIEW

Abstract

Background: Spontaneous intracerebral haemorrhage (ICH) is a devastating stroke subtype with high mortality and poor functional outcome. Extension of blood into the ventricles causing intraventricular haemorrhage (IVH) and obstructive hydrocephalus further worsens prognosis. Catheter‑based interventions external ventricular drainage (EVD) and minimally invasive surgical evacuation with intralesional thrombolysis seek to remove clot, reduce mass effect and restore cerebrospinal fluid flow. The efficacy and safety of these interventions remain debated.

Objectives: To systematically evaluate the evidence for catheter‑based interventions in adults with spontaneous ICH or IVH, comparing outcomes against standard medical management or alternative surgical approaches.

Methods: Randomized trials, quasi‑experimental studies, cohorts, case–control and cross‑sectional studies enrolling adults with spontaneous ICH/IVH who received catheter‑based interventions (EVD, intraventricular thrombolysis, minimally invasive catheter‑based evacuation) were included. Outcomes were mortality, functional status, hematoma volume/clearance, re‑bleeding, infection and complications. Two reviewers independently screened titles/abstracts and full texts, extracted data and assessed risk of bias using RoB 2 for randomised trials and ROBINS‑I or NOS for observational studies. Narrative synthesis was performed; quantitative pooling was not feasible due to heterogeneity. Certainty of evidence was appraised qualitatively.

Results: Fifteen studies (four randomised trials and eleven observational studies) were included. Early pilot data suggested that minimally invasive catheter evacuation plus recombinant tissue‑type plasminogen activator (rt‑PA) substantially increased clot removal and reduced peri‑haematomal oedema compared with medical management. Phase 2 trial MISTIE II showed a higher proportion of patients achieving modified Rankin Scale (mRS) 0–3 at 180 days after adjustment, albeit with more symptomatic bleeding. The double‑blind CLEAR III trial of intraventricular alteplase versus saline found no functional‑outcome benefit but significantly reduced mortality and infection rates. The phase 3 MISTIE III trial did not demonstrate improved functional outcome at 365 days (45 % vs 41 %; adjusted risk difference 4 %; p = 0.33) but reported lower early mortality. Observational studies consistently reported lower mortality associated with EVD, although none showed functional‑outcome benefit. Intraventricular thrombolysis via EVD decreased inpatient mortality (adjusted OR 0.67; 95 % CI 0.52–0.87). Recent small retrospective series using bedside catheter aspiration with urokinase achieved large haematoma reduction and acceptable mortality. Catheter‑related infection rates were low (~2.2 %), and prophylactic protocols reduced this risk. Overall, the evidence suggests that catheter‑based interventions may reduce mortality but have not definitively improved functional outcomes.

Conclusions: Catheter‑based interventions play an important role in managing obstructive hydrocephalus and reducing haematoma burden in ICH/IVH. Intraventricular thrombolysis via EVD reduces mortality and infection but does not improve functional outcome. Minimally invasive surgical evacuation with rt‑PA removes clot effectively and may confer early mortality benefit, yet robust evidence of functional improvement is lacking. Future trials should refine patient selection, standardise procedural protocols and explore adjunctive pharmacotherapy to translate biological efficacy into functional recovery.