Neurocritical Care

, Volume 30, Issue 2, pp 380–386 | Cite as

Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial

  • Natalie L. UllmanEmail author
  • Pouya Tahsili-Fahadan
  • Carol B. Thompson
  • Wendy C. Ziai
  • Daniel F. Hanley
Original Article



The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions.


ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4–6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment.


Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01–3.47) and mortality at 180 days (OR 2.73, CI 1.27–5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4–6 (OR 3.20, CI 1.30–7.88) and higher mRS at 180 days (OR 2.33, CI 1.24–4.35), while obstruction by IVH was not.


Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.


Stroke Intracerebral hemorrhage Intraventricular hemorrhage Alteplase Thrombolytic Thalamus Functional outcomes Modified Rankin Ventricular system Neuroimaging Computed tomography 



We wish to thank the CLEAR III patients and their families and the CLEAR III investigators and coordinators who provided and cared for them. The CLEAR III study was funded by the National Institute of Neurological Disorders and Stroke.

Author Contribution

NLU contributed to study conception and design, acquisition of data, analysis and interpretation of data, and drafting of the manuscript. PTF contributed to study conception and design, acquisition of data, and critical revision to the manuscript. CBT contributed to analysis and interpretation of data, and critical revisions to the manuscript. WCZ contributed to acquisition of data, analysis and interpretation of data, and critical revision to the manuscript. DFH contributed to study conception and design and critical revision to the manuscript.

Source of support

Dr. Daniel F. Hanley was awarded significant research support of Grants R01NS046309, 5U01 NS062851-05, and 5U01 NS080824-02.

Compliance with Ethical Standards

Conflict of interest

Ms. Thompson, Dr. Hanley, Dr. Ullman, and Dr. Ziai report grants from the National Institutes of Health (NINDS) during the conduct of the study. Dr. Tahsili-Fahadan has nothing to disclose.

Clinical trial registration NCT00784134.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  1. 1.Division of Brain Injury OutcomesJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Division of Neurosciences Critical Care, Department of NeurologyJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Neuroscience Intensive Care Unit, Department of MedicineVirginia Commonwealth UniversityFalls ChurchUSA
  4. 4.Biotstatistics CenterJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA

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