Low-dose Intraventricular Recombinant Tissue Plasminogen Activator (rtPA) Priming Combined with Neuroendoscopic Lavage and Continuous Ventricular Irrigation for Severe Preterm Intraventricular Hemorrhage : A Technical Note

Severe preterm intraventricular hemorrhage (IVH) with post-hemorrhagic ventricular dilatation (PHVD) may be difficult to manage when the clot burden is extensive and complete endoscopic evacuation is limited by clinical instability and rigid-scope constraints. We describe a staged clearance strategy in a preterm infant with bilateral grade IV IVH and progressive PHVD. Bilateral external ventricular drains (EVDs) were inserted for cerebrospinal fluid diversion. Low-dose intraventricular recombinant tissue plasminogen activator (0.1-0.3 mg per ventricle) was started 48 hours later and repeated every 48 hours for four sessions with a 2-hour dwell time under serial bedside cranial ultrasonographic surveillance. Sequential rigid neuroendoscopic lavage (NEL) was then performed, followed by 7 days of continuous ventricular irrigation using a bilateral inflow-outflow EVD configuration and a buffered glucose-containing artificial cerebrospinal fluid solution. No interval rebleeding, sustained intracranial hypertension, electrolyte instability, or culture-proven ventriculitis occurred during treatment. Ventricular size remained stable after drain removal, and no ventriculoperitoneal shunt had been required through the latest outpatient follow-up on postnatal day 157 (HD 151). This report presents a single-case conceptual proof-of-concept and technical feasibility experience for selected severe preterm IVH in a rigid-scope setting, rather than evidence of efficacy.