Intraventricular haemorrhage caused by aneurysms and angiomas

Aggravation of Enlarged Perivascular Spaces in the Centrum Semiovale of Patients with Aneurysmal Subarachnoid Hemorrhage

PURPOSE

This study aimed to investigate whether enlarged perivascular spaces (ePVS) within the basal ganglia (BG) or centrum semiovale (CSO) aggravate in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We retrospectively evaluated 139 patients who had undergone brain magnetic resonance imaging (MRI) within 1 month of aSAH occurrence from January 2007 to November 2018. Follow-up brain MRI of 99 patients were available. We scored ePVS in the BG and CSO on a score of 0-4 (0 = no ePVS, 4 ≥ 40 ePVS) on initial and follow-up T2-weighted MRI. Aggravation of ePVS was defined as an ePVS score increase of ≥ 1 on follow-up MRI compared to the initial score. We compared the characteristics between patients with and without aggravation of ePVS and investigated associated variables using logistic regression.

RESULTS

Aggravation of ePVS in the CSO and BG was noted in 31 (31.3%) and 6 (6.1%) patients, respectively. After adjusting for age, sex, and the MRI follow-up period, aggravation of ePVS in the CSO was independently associated with a high Fisher grade (p = 0.007) and high burden of initial ePVS in the CSO (p = 0.049).

CONCLUSION

Aggravation of ePVS, particularly those in the CSO, had occurred in the long-term follow-up of aSAH patients. This was independently associated with a high burden of aSAH. The amount of subarachnoid blood might have aggravated the drainage of interstitial fluid through glymphatic dysfunction.

The Prognostic Significance of a Cast Fourth Ventricle in Ruptured Aneurysm Patients With Intraventricular Hemorrhage in the Barrow Ruptured Aneurysm Trial (BRAT)

BACKGROUND

Ruptured aneurysms causing intraventricular hemorrhage (IVH) are associated with high morbidity. The presence of blood that completely fills the fourth ventricle (cast fourth ventricle, CFV) is thought to be particularly ominous, but studies documenting the outcome of such cases are lacking.

OBJECTIVE

To investigate the outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and CFV.

METHODS

We reviewed 406 patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT, NCT01593267, clinicaltrials.gov); 238 patients with aSAH and IVH were identified, and imaging was reviewed for the presence of CFV. Outcome was evaluated at the 1-yr follow-up. A poor outcome was defined as modified Rankin Scale score >2.

RESULTS

CFV was identified in 25 patients. Admission Glasgow Coma Score was lower in CFV patients, 7.8 versus 11.5 (P < .001). At discharge and the 1-yr follow-up, patients with CFV had a greater risk of a poor outcome (P < .001 and P = .002, respectively). In a subgroup analysis of 79 patients with IVH and initial Glasgow Coma Score ≤ 8, almost 50% of the patients with IVH but without CFV had made a good recovery versus 7% of patients with CFV (odds ratio [OR] 15, P = .002). On multivariate analysis, CFV was a greater predictor of a poor prognosis at 1 yr post-aSAH than Hunt and Hess grade >3 (6.4 OR vs 2.9 OR [P < .001], respectively).

CONCLUSION

The presence of CFV is a predictor of poor outcome in patients with aSAH. When compared to other patients with IVH and aSAH, CFV is a stronger predictor of a poor outcome than a poor Hunt and Hess Grade.

The risk factors of shunt-dependent hydrocephalus after subarachnoid space hemorrhage of intracranial aneurysms

Shunt-dependent hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) which indicated intensive care unit stay and unfavorable outcome. Our aim is to study the risk factors of shunt-dependent hydrocephalus after aneurysmal subarachnoid space hemorrhage. Patients with intracranial aneurysms treated in our department from January 2014 to October 2018 were included in the study. Patients' age, gender, history of hypertension and diabetes, location of aneurysms, Glasgow coma scale (GCS) score, Hunt-Hess grading, intraventricular hemorrhage, therapeutic option, shunt placement, clinical outcome, length of stay were analyzed. The follow-up period was 1 to 5 years. Statistics included Chi-squared, Student t test, 1-way analysis of variance, Pearson correlation coefficient, and multivariate logistic regression. About 845 cases with intracranial aneurysms treated in our department were included in the study. The mean age was 52.19 ± 9.51 years and the sex ratio was 317/528. About 14.3% (121/845) of the patients developed shunt-dependent hydrocephalus in the follow-up period. According to our results, older than 60, Hunt-Hess grading, GCS, coma, posterior circulation aneurysm, external ventricular drainage, and decompress craniotomy were risk factors of shunt dependency (P < .05). Moreover, older than 60, GCS 3 to 8, Hunt-Hess 3 to 5, and posterior circulation aneurysm were the independent risk factors of shunt dependency. Moreover, shunt dependency was related to longer hospital stay and unfavorable outcome (P < .05). In conclusion, patients older than 60, GCS 3 to 8, Hunt-Hess 3 to 5, and posterior circulation aneurysm need more strict observation and longer follow-up. Timely and appropriate treatment may benefit patients in recovery, while further exploration is still needed in the future.

Clinical features and prognostic factors in patients with intraventricular hemorrhage caused by ruptured arteriovenous malformations

Intraventricular hemorrhage (IVH) was associated with poor outcomes in patients with intracerebral hemorrhage. IVH had a high incidence in patients with ruptured arteriovenous malformations (AVMs). In this study, we aimed to discuss the clinical features and prognostic factors of outcomes in the patients with AVM-related IVH.From January 2010 to January 2016, we collected the data of the patients with AVM-related IVH retrospectively. The data, including clinical and radiological parameters, were collected to evaluate the clinical features. Univariate and multivariate logistic regression analyses were used to identify the prognostic factors for clinical outcomes (hydrocephalus, 6-month outcomes measured by the modified Rankin scale) in our cohort.A total of 67 eligible patients were included and 19 patients (28%) only presented with IVH. Thirty-three patients (49%) presented hydrocephalus, and 12 patients (18%) presented brain ischemia. Nineteen patients (28%) had a poor outcome after 6 months. In multivariate logistic regression, subarachnoid hemorrhage (SAH) (P = .028) was associated with hydrocephalus and higher Graeb score (P = .080) tended to increase the risk of hydrocephalus. The high Glasgow coma scale (P = .010), large hematoma volume of parenchyma (P = .006), and high supplemented Spetzler-Martin (sup-SM) score (P = .041) were independent factors of the poor outcome.IVH was common in ruptured AVMs and increased the poor outcomes in patients with the ruptured AVMs. The AVM-related IVH patients had a high incidence of hydrocephalus, which was associated with brain ischemia and SAH. Patients with lower Glasgow coma scale, lower sup-SM score, and smaller parenchymal hematoma had better long-term outcomes.

Factors that predict hydrocephalus following intraventricular hemorrhage

OBJECTIVE

To evaluate potential risk factors that can predict the development of hydrocephalus (HCP) in adult patients with intraventricular hemorrhage (IVH).

METHODS

Retrospective analysis of all adult patients presented to King Fahad Medical City between 2004 and 2011 with intraventricular hemorrhage to evaluate different variables and their association with HCP.

RESULTS

A total of 31 patients were included in the study, 14 patients (45.16%) developed HCP. Seventy-four percent of HCP patients (10 out of 14) had Graeb classification of ≥6 and/or had IVH affecting all ventricles, while 76% of the patients without HCP (13 out of 17) had a Graeb classification of <6 and/or had IVH only in the lateral ventricles (8 out of 17) or lateral ventricles and either third or fourth ventricle (5 out of 17). Statistical analysis showed that HCP is significantly associated with both Graeb classification of 6 or greater number of IVH affecting all ventricles and 3 versus 1-2 affected ventricles; (OR (95% CI, p value), respectively, 19.3(2, >20), p value<0.05; 8.5 (1.6, >30), p value<0.05.

CONCLUSION

HCP following IVH is present in approximately half of all IVH cases. In the present retrospective study, it was found that patients with higher grades of IVH and/or a greater number of affected ventricles had a greater risk of developing HCP.

Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients

Objective

The objective of this study was to compare the incidence of ventricular shunt placement for shunt-dependent hydrocephalus (SDHC) after clipping versus coiling of ruptured aneurysms.

Materials and Methods

A retrospective review was conducted in 215 patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent surgical clipping or endovascular coiling during the period from May 2008 to December 2011. Relevant clinical and radiographic data were analyzed with regard to the incidence of hydrocephalus and ventriculo-peritoneal shunt (VPS). Patients treated with clipping were assigned to Group A, while those treated with coiling were assigned to Group B.

Results

Of 215 patients (157 clipping, 58 coiling), no significant difference in the incidence of final VPS was observed between treatment modalities (15.3% vs. 10.3%) (p = 0.35). Independent risk factors for VPS for treatment of chronic hydrocephalus were as follows: (1) older than 65 years, (2) poorer Hunt-Hess grade IV and V, (3) Fisher grade III and IV, and (4) particularly initial presence of an intraventricular hemorrhage.

Conclusion

In this study comparing two modalities for treatment of aneurysm, there was no difference in the incidence of chronic hydrocephalus requiring VPS. A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis.

Hydrocephalus after intraventricular hemorrhage: the role of thrombin

Previous studies demonstrated that thrombin is an important factor in brain injury after intracerebral hemorrhage. This study investigated the effect of thrombin on hydrocephalus development in a rat intraventricular hemorrhage (IVH) model. There were three parts in this study. First, male Sprague-Dawley rats had an injection of 200 μL saline, autologous blood or heparinized blood, into the right lateral ventricle. Second, rats had an injection of 50 μL saline or 3U thrombin into the right lateral ventricle. Third, rats had an injection of thrombin (3U) with a protease-activated receptor-1 (PAR-1) antagonist, SCH79797 (0.15 nmol), or vehicle into the right lateral ventricle. Lateral ventricle volumes were measured by magnetic resonance imaging and the brains were used for immunohistochemistry and western blot analyses. Intraventricular injection of autologous blood induced hydrocephalus from day 1 to 28. Heparinized blood injection resulted in less hydrocephalus at all time points compared with blood injection alone (P<0.05). Intraventricular injection of thrombin caused significant hydrocephalus, ventricular wall damage, and periventricular blood-brain barrier disruption. Thrombin-induced hydrocephalus was reduced by co-injection of the PAR-1 antagonist SCH79797 (P<0.05). In conclusion, thrombin contributes to hydrocephalus development after IVH and thrombin-induced hydrocephalus is through PAR-1.

Idiopathic intraventricular aneurysm presenting with intraventricular hemorrhage: case report and review of the literature

Intraventricular hemorrhage (IVH) is a relatively commonly encountered problem in neurosurgical practice. The underlying causes could include hypertension, arteriovenous malformations (AVM), angiomas, trauma, tumors, aneurysms and moyamoya disease. Truly idiopathic intraventricular aneurysms (IVA) are rare. A high index of suspicion needs to be maintained since, with the appropriate treatment, the outcome is generally good. We report the case of a 14-year-old boy who presented with sudden onset headache and vomiting. CT angiogram pointed to the possibility of an IVA. This was confirmed by MRI with three-dimensional constructive interference in steady state (CISS-3D) sequences and digital subtraction angiography. The patient underwent microsurgical excision of the aneurysm and is doing well on follow-up. Idiopathic IVA can present with IVH at any age. MRI with CISS-3D and MR angiography would be the imaging modality of choice since it can also rule out other causes of intraventricular bleeding such as tumors and AVM. These lesions could be managed effectively by microsurgical excision/clipping. The necessity of investigating every patient who presents with IVH is debatable.

Intraventricular hemorrhage secondary to intranidal aneurysm rupture-successful management by arteriovenous malformation embolization followed by intraventricular tissue plasminogen activator: case report

BACKGROUND AND IMPORTANCE

Intraventricular hemorrhage related to arteriovenous malformation (AVM) rupture is associated with significant morbidity and mortality. Intraventricular tissue plasminogen activator (tPA) has been used to treat spontaneous intraventricular hemorrhage. We demonstrate the successful application of endovascular occlusion to seal the rupture site of an AVM followed by intraventricular tPA.

CLINICAL PRESENTATION

A 32-year-old woman presented with a right frontoparietal parasagittal AVM abutting the motor cortex. The AVM was diagnosed when the patient was 13 years old, and she initially underwent conservative management. At the age of 30, the patient suffered an intracranial hemorrhage, leaving her with left hemiparesis. After rehabilitation, the patient regained ambulation; however, she remained spastic and hyperreflexic on the left side. Two years after her major hemorrhage, she presented for elective treatment of her AVM. The patient was advised to undergo staged embolization before surgical resection of her AVM. The initial embolization was uneventful. A second embolization was complicated by intraventricular hemorrhage and coma. The patient was treated with placement of an external ventricular drain followed by embolization of intranidal aneurysm. After embolization of the intranidal aneurysm the ruptured, the patient was treated with intraventricular tPA. The patient had rapid clearance of the intraventricular hemorrhage and significant improvement in her neurological examination, following commands 24 hours later and returning almost to baseline.

CONCLUSION

This case demonstrates the feasibility of treating AVM-related intraventricular hemorrhage with tPA if the rupture source can be confidently sealed interventionally. This strategy can be lifesaving but needs further study to ensure its safety.

Rupture of anterior communicating artery aneurysms during computed tomography angiography: description of the pathway for intraseptal and intraventricular hemorrhage

Intraventricular hemorrhage is common after the rupture of anterior communicating artery (ACoA) aneurysms, although the anatomical pathway has not been described. Knowledge of the mechanism of hemorrhage may enhance understanding of its prognosis. Using CT angiography, the authors analyzed this pathway in 2 cases of ACoA aneurysm rupture associated with intraventricular hemorrhage. The initial hemorrhages created a hyperdense ventriculographic image on which the subsequent contrast medium ejection could be followed. The contrast medium entered the subarachnoid space of the anterior interhemispheric fissure and broke through the lamina rostralis into the septum pellucidum and into the frontal horns of the lateral ventricles. Thus, the authors provide an explanation for bleeding from ACoA aneurysms into the ventricular system in the presence of an intact lamina terminalis. The septum pellucidum may act as a buffer before extension of the bleeding into the ventricular system.

Management of acute intracranial and intraventricular hemorrhage

OBJECTIVE

Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage.

DATA SOURCES

PubMed search and review of the relevant medical literature.

SUMMARY

The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery.

CONCLUSIONS

Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.

Predisposing factors related to shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and patients who develop hydrocephalus after SAH typically have a worse prognosis than those who do not. This study was designed to identify factors predictive of shunt-dependent chronic hydrocephalus among patients with aneurysmal SAH, and patients who require permanent cerebrospinal fluid diversion.

METHODS

Seven-hundred-and-thirty-four patients with aneurysmal SAH who were treated surgically between 1990 and 2006 were retrospectively studied. Three stages of hydrocephalus have been categorized in this paper, i.e., acute (0-3 days after SAH), subacute (4-13 days after SAH), chronic (>/=14 days after SAH). Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or ratio of frontal horn to maximal biparietal diameter more than 30% in computerized tomography.

RESULTS

Overall, 66 of the 734 patients (8.9%) underwent shunting procedures for the treatment of chronic hydrocephalus. Statistically significant associations among the following factors and shunt-dependent chronic hydrocephalus were observed. (1) Increased age (p < 0.05), (2) poor Hunt and Hess grade at admission (p < 0.05), (3) intraventricular hemorrhage (p < 0.05), (4) Fisher grade III, IV at admission (p < 0.05), (5) radiological hydrocephalus at admission (p < 0.05), and (6) post surgery meningitis (p < 0.05) did affect development of chronic hydrocephalus. However the presence of intracerebral hemorrhage, multiple aneurysms, vasospasm, and gender did not influence on the development of shunt-dependent chronic hydrocephalus. In addition, the location of the ruptured aneurysms in posterior cerebral circulation did not correlate with the development of shunt-dependent chronic hydrocephalus.

CONCLUSION

Hydrocephalus after aneurysmal SAH seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.

Intraventricular hemorrhage from ruptured aneurysm: clinical characteristics, complications, and outcomes in a large, prospective, multicenter study population

OBJECT

In this study the authors analyzed the relationship of intraventricular hemorrhage (IVH) to in-hospital complications and clinical outcome in a large population of patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

Data from 3539 patients with aneurysmal SAH were evaluated, and these data were obtained from four prospective, randomized, double-blind, placebo-controlled trials of tirilazad that had been conducted between 1991 and 1997. Clinical characteristics, in-hospital complications, and outcome at 3 months post-SAH (Glasgow Outcome Scale score) were analyzed with regard to the presence or absence of IVH.

RESULTS

Patients with SAH and IVH differ in demographic and admission characteristics from those with SAH but without IVH and are more likely to suffer in-hospital complications and a worse outcome at 3 months post-SAH.

CONCLUSIONS

The presence of IVH in patients with SAH has an important predictive value with regard to these aspects.

Ruptured distal anterior choroidal artery aneurysm

Ruptured aneurysms of the distal anterior choroidal artery (AchA) are extremely rare and management is dictated by clinical presentation. This report describes a rare patient with a distal AchA aneurysm and subarachnoid and intraventricular haemorrhage. A 60-year-old woman presented with a sudden onset of severe headache and vomiting. No aneurysms could be found on initial angiograms. A repeat angiogram performed 10 days after admission demonstrated an aneurysm in a branch of the cisternal segment of the left AchA without a definite neck. Surrounding vessels showed multifocal stricture and dilatation. Microsurgical clipping was not performed because the patient died suddenly due to pulmonary failure. The aetiology of the aneurysm in this case and surgical strategy are discussed.

Predicting the overall management outcome in patients with a subarachnoid hemorrhage accompanied by a massive intracerebral or full-packed intraventricular hemorrhage: a 15-year retrospective study

BACKGROUND

Patients with a subarachnoid hemorrhage (SAH) accompanied by a massive intracerebral hemorrhage (ICH) or a full-packed intraventricular hemorrhage (IVH) have poor outcomes. We evaluated the clinical factors to predict the overall outcome in such patients.

METHODS

Data on nontraumatic SAH patients were collected and classified into 3 groups: the pure SAH group (SAH accompanied with neither ICH nor IVH), the ICH group (SAH accompanied with a massive ICH; hematoma 30 mL), and the IVH group (SAH and all ventricles were full-packed with hematoma). One hundred seventy-nine patients were in the ICH group and 109 in the IVH group. We evaluated clinical factors, such as the Hunt & Hess (H&H) score on admission, age, sex, history, rebleeding ratio, and the computerized tomography findings (SAH score).

RESULTS

The result of multivariate logistic regression analysis of clinical variables in the ICH group, good and intermediate H&H grades, younger age (<70), no rebleeding, and lower SAH score were associated with a favorable outcome. In the result of the multivariate logistic regression analysis of clinical variables in the IVH group, only a higher SAH score was associated with an unfavorable outcome.

CONCLUSIONS

In the ICH group, factors that could be used to predict a favorable outcome included good and intermediate H&H scores (1, 2, and 3) on admission, younger age (<70), and a lower SAH score. In the IVH group, the main factor that could be used to predict a favorable outcome was a lower SAH score.

Intraventricular Hemorrhage after Aneurysmal Subarachnoid Hemorrhage: Pilot Study of Treatment with Intraventricular Tissue Plasminogen Activator

OBJECTIVE

Intraventricular (IVen) hemorrhage is considered a predictor of poor outcome after subarachnoid hemorrhage (SAH). This prospective study examines the feasibility and outcome of administration of IVen tissue plasminogen activator (tPA) after aneurysmal SAH.

METHODS

Ten patients with SAH who received IVen tPA after the aneurysm had been secured were compared with 10 age-, sex-, and Glasgow Coma Scale score-matched control patients. The primary end point was third and fourth ventricle clot resolution. IVen blood was quantified by use of the Graeb and Le Roux scales on admission and at an additional time (equal or longer for the control group) after the injection was terminated.

RESULTS

Six men and four women with a mean age of 52 years in each group were evaluated. On average, 3.5 mg tPA was injected 68 +/- 51 hours after admission without ensuing complications. Although the treated group had significantly more IVen blood on admission than control subjects (mean Le Roux scale +/- standard deviation, 11 +/- 3 versus 7.6 +/- 4.2, P = 0.055, and mean Graeb scale +/- standard deviation, 8.5 +/- 2.3 in tPA versus 5.3 +/- 3, P < 0.02), it also had a significant decrease in the amount of IVen blood (mean Le Roux and Graeb scale decrease +/- standard deviation, 6.7 +/- 3.3 and 4.8 +/- 2 in tPA patients versus 0.9 +/- 3.2 and 0.5 +/- 2.6 in control subjects, P = 0.002). The tPA group had a non-statistically significantly shorter length of stay, decreased mortality, and better Glasgow Outcome Scale and modified Rankin Scale scores at discharge. Treated survivors showed a decreased need for shunt placement (2 [22%] of 9 patients versus 5 [83%] of 6 control subjects, P = 0.04).

CONCLUSION

This pilot study shows that IVen tPA administration is feasible without complications after SAH and may be associated with better outcomes. These results warrant a randomized clinical trial.

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

OBJECT

This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms.

METHODS

In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated. The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I-III) and better Fisher Grade (1-3) and of patients with Fisher Grade 4 hemorrhage was performed. Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2-2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14-0.75) compared with that for endovascular embolization.

CONCLUSIONS

Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.

Current management of intraventricular hemorrhage

BACKGROUND

Intraventricular hemorrhage (IVH) continues to present a challenge to neurosurgeons, often being accompanied by significant morbidity and mortality. The purpose of this paper is to present a review of the recent literature concerning the treatment of patients with IVH, and describe our current management scheme for this disorder.

METHODS

A literature search was conducted to identify key articles pertaining to the pathophysiology and treatment of IVH, focusing on the more recent articles. The bibliographies of selected papers were also screened for additional useful publications.

RESULTS

Management of IVH is primarily directed at controlling intracranial pressure through an external ventricular drain (EVD), but this catheter often becomes occluded by coagulated blood. The fibrinolytic system of the cerebrospinal fluid is limited, and blood may remain in the ventricles for months after a hemorrhage. IVH has a poor prognosis, partly because of the continuing mass effect of blood clots on the ventricular walls. Therefore, investigators have administered fibrinolytic agents directly into the ventricles of patients with IVH. Clinical studies of fibrinolytic therapy for IVH have found a 30 to 35% reduction in mortality with treatment, but have not yet clearly documented an improved neurologic outcome for the survivors.

CONCLUSIONS

Fibrinolytic therapy may be life saving in severe cases of IVH. While many issues need to be resolved, our current practice is to administer intraventricular tissue plasminogen activator (t-PA or alteplase) if hemorrhage involves > or =30% of the volume of one of the lateral ventricles and/or the 3(rd) or 4(th) ventricle. We currently give t-PA after ruling out or treating a possible source of further bleeding, such as an unsecured aneurysm.

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

The purpose of this study was to identify factors predictive of shunt-dependent hydrocephalus among patients with aneurysmal subarachnoid hemorrhage. The data can be used to predict which patients in this group have a high probability of requiring permanent cerebrospinal fluid diversion.

METHODS

Seven hundred eighteen patients with aneurysmal subarachnoid hemorrhage who were treated between 1990 and 1999 were retrospectively studied, to identify factors contributing to shunt-dependent hydrocephalus. With these data, a stepwise logistic regression procedure was used to determine the effect of each variable on the development of hydrocephalus and to create a scoring system.

RESULTS

Overall, 152 of the 718 patients (21.2%) underwent shunting procedures for treatment of hydrocephalus. Four hundred seventy-nine of the patients (66.7%) were female. Of the factors investigated, the following were associated with shunt-dependent hydrocephalus, as determined with a variety of statistical methods: 1) increasing age (P < 0.001), 2) female sex (P = 0.015), 3) poor admission Hunt and Hess grade (P < 0.001), 4) thick subarachnoid hemorrhage on admission computed tomographic scans (P < 0.001), 5) intraventricular hemorrhage (P < 0.001), 6) radiological hydrocephalus at the time of admission (P < 0.001), 7) distal posterior circulation location of the ruptured aneurysm (P = 0.046), 8) clinical vasospasm (P < 0.001), and 9) endovascular treatment (P = 0.013). The presence of intracerebral hematomas, giant aneurysms, or multiple aneurysms did not influence the development of shunt-dependent hydrocephalus.

CONCLUSION

The results of this study can help identify patients with a high risk of developing shunt-dependent hydrocephalus. This may help neurosurgeons expedite treatment, may decrease the cost and length of hospital stays, and may result in improved outcomes.

Tissue plasminogen activator for the treatment of intraventricular hematoma: the dose-effect relationship

In this study, we investigated the dose-effect relationship and safety of tissue plasminogen activator (tPA) for the treatment of intraventricular hemorrhage/hematoma (IVH) in rats. Adult male Sprague-Dawley rats were injected with autologous blood into the left lateral ventricle to establish IVH. Two hours later, Ringer's saline or 0.25-2 microg of tPA were administered directly to the IVH over 3 h. The regional cerebral blood flow (rCBF) on the surface of the left parietal cortex was measured with laser Doppler flowmetry. Twenty-four hours after the build-up of IVH, the brains were removed for morphometrical and histological studies. A dose of 0.5-2 microg tPA significantly diminished the IVH in a dose-dependent manner (p < 0.001). However, only the dose of 0.5 microg tPA significantly ameliorated the reduction of rCBF 24 h after IVH (p < 0.01). TPA did not improve the ventricular dilatation on the side with IVH. Instead, 1-2 microg of tPA caused additional injuries, including intraventricular leukocytosis and edema of periventricular tissues and choroid plexus on both hemispheres. These results indicate that higher doses of tPA may have detrimental effects on the brain. The dosage rate of 0.5 microg seems beneficial to treat 5 microl of IVH (equals to a dose of 0.1 mg/ml blood) in our model in terms of the satisfactory fibrinolysis and less damage to the brain.

Diagnostic imaging for intracerebral hemorrhage

Magnetic resonance imaging (MRI) is an excellent tool for the diagnosis and evaluation of intracerebral hemorrhage with its unique specificity to hemoglobin degradation products in different stages. Computed tomography (CT) remains the diagnostic test of choice in the setting of acute intracerebral hemorrhage because of its exquisite sensitivity and specificity for small amounts of intracerebral hemorrhage (although there is emerging evidence that MRI may be as sensitive as CT). The effects of the biochemical evolution of intracerebral hemorrhage on the temporal MRI signal changes are described. This article discusses imaging features of the common causes of intracerebral hemorrhage.

Primary intraventricular haemorrhage in adults

INTRODUCTION

Primary intraventricular haemorrhage (PIVH) is an uncommon type of intracerebral haemorrhage. Relatively little is known about clinical and imaging features, and even less about prognosis and predictors of mortality.

MATERIAL AND METHODS

We analysed clinical and imaging features, causative factors and outcome of 26 patients with CT brain scan evidence of PIVH. A multivariate regression model of failure time data was used to assess predictors of in-hospital mortality.

RESULTS

Loss of consciousness was the first manifestation of PIVH in six patients and occurred after all other symptoms in five. In other patients, onset was characterized by headache, vomiting, confusion and disorientation (n=8) or by headache with or without vomiting (n=7). Angiography revealed vascular malformations in eight patients (31%). Other possible causative factors were clotting disorder in one patient and arterial hypertension in 10. No cause was identified in seven patients. Early hydrocephalus was the most frequent complication and resolved spontaneously in a minority of patients. In-hospital mortality was high (42%): four patients died early of direct consequence of bleeding and seven died after clinical worsening because of increasing hydrocephalus or other adverse events. Multivariate analysis indicated Glasgow Coma Scale < or = 8 (OR 4.67; 95% CI 1.22-17.92) and early hydrocephalus (OR 4.93; 95% CI 1.13-21.59) as independent predictors of in-hospital mortality.

CONCLUSION

In patients with PIVH, hydrocephalus seems to be a critical determinant of in-hospital mortality and this suggests the need for early treatment strategies.

Fibrinolytic therapy in intraventricular hemorrhage

OBJECTIVE

To review the literature concerning intraventricular administration of fibrinolytic agents to treat patients with intraventricular hemorrhage (IVH).

DATA SOURCES

An extensive literature search (MEDLINE, EMBASE, Conference Proceedings) was conducted to identify articles in English published between 1966 and May 2000 pertaining to the pathophysiology of IVH and its treatment by intraventricular administration of recombinant tissue plasminogen activator (alteplase) or urokinase (u-PA). The bibliographies of selected identified articles were also screened for publications not found in the computerized search.

STUDY SELECTION

All pertinent publications were reviewed and considered. Those describing the intraventricular administration of fibrinolytic agents to patients with IVH were included.

DATA SYNTHESIS

IVH has a poor prognosis, partly due to the mass effect of blood clots on the ventricular walls. The cerebrospinal fluid has a limited fibrinolytic system. Therefore, clots may remain in the ventricles for months after a hemorrhage. The management of IVH is primarily directed at controlling intracranial pressure through an external ventricular drain, but this catheter often becomes occluded by coagulated blood. To overcome this problem, and to dissolve the residual blood clot, investigators have administered alteplase or u-PA directly into the ventricles of patients with IVH. Complications of this therapy include infection and possible rebleeding. Clinical studies of fibrinolytic therapy for IVH have found a 30-35% reduction in mortality with treatment, but to date, have not clearly documented improved neurologic outcome of the survivors.

CONCLUSIONS

Fibrinolytic therapy with alteplase or u-PA may be life-saving in severe cases of IVH. Yet many technical issues remain to be resolved, such as the optimal dose, frequency, method, timing, and duration of administration of the agent. Additional randomized, double-blind, placebo-controlled studies need to be performed so that the true value of this therapy can be assessed.

Recombinant tissue plasminogen activator for the treatment of spontaneous adult intraventricular hemorrhage

BACKGROUND

Intraventricular hemorrhage (IVH) has a poor prognosis with mortality rates of between 80 and 100% when all four ventricles are involved. Fibrinolytic therapy has been reported to improve overall outcome.

METHODS

Patients with severe primary IVH were treated by direct intraventricular injection of recombinant tissue plasminogen activator (rt-PA) into the lateral ventricles, followed by cerebrospinal fluid (CSF) drainage if the intracranial pressure rose above 20 mm Hg.

RESULTS

Over a 15-month period from 1995 through 1996, 10 patients were treated, (4 male and 6 female, mean age 35 years; range, 21-55 years). The mean Glasgow Coma Scale score on admission was 6 (range, 4-8) and the mean Graeb score for severity of IVH on the first CT scan was 10 (range, 8-12). Angiography was negative in five cases but identified arteriovenous malformations in three, a post-traumatic pseudoaneurysm in one, and Moya-moya disease in one. The mean total dose requirement of rt-PA was 8.25 mg (range, 6-12 mg) with a significant reduction in the mean Graeb score after 7 days to 3.9 (range, 2-7, p<0.0001). Outcome at 3 months was death in one case (mortality 10%), severe disability in two (20%), moderate disability in three (30%), and good result in four (40%). Four patients (40%) required subsequent CSF shunting. No complications of rehemorrhage, infection, or catheter obstruction were encountered.

CONCLUSION

Intraventricular fibrinolysis with rt-PA seems to be safe and effective for the treatment of severe IVH.

A cohort study of the safety and feasibility of intraventricular urokinase for nonaneurysmal spontaneous intraventricular hemorrhage

BACKGROUND AND PURPOSE

Small case series have reported potential benefit from thrombolysis after spontaneous intraventricular hemorrhage (IVH). Our objective was to review our experience using intraventricular urokinase (UK) in treating selected patients with IVH.

METHODS

Using medical records, we identified all patients who received ventriculostomies for CT-confirmed nonaneurysmal nontraumatic spontaneous IVH from December 1992 through November 1996. We reviewed charts and CT images and examined the data for associations with specific outcomes.

RESULTS

We identified 40 patients, 18 treated with ventriculostomy alone and 22 receiving adjunctive intraventricular UK. The initial Glasgow Coma Scale (GCS) scores of the two groups were similar (P = 0.5). While there was a trend for patients with any intraparenchymal hemorrhage (IPH) to receive UK (P = 0.07), the mean size of IPH in those who received ventriculostomy alone was larger than in those who received adjunctive UK (P = 0.002). There was lower mortality in the group treated with UK (31.8 versus 66.7%; P = 0.03), but there was only a trend toward an increase in favorable outcome (22.2% versus 36.4%; P = 0.3). Overall, the most significant association with outcome was neurological condition at presentation (GCS >5 versus < or = 5; P = 0.003). Receiving UK did not increase the occurrence of complications or hospital length of stay for survivors (P = 0.5).

CONCLUSIONS

Intraventricular UK remains a safe and potentially beneficial intervention. While it appeared to lower mortality, a randomized, placebo-controlled trial is needed to explore whether the therapy can increase the incidence of favorable outcomes.

Mental Dullness after thrombolytic therapy

Images

[Focalized multiple beam radiotherapy: an alternative in the treatment of deep cerebral arteriovenous malformations]

BACKGROUND

Cerebral arteriovenous malformations are usually treated by excision or selective embolization. Some untreatable malformations may be presently cured by radiosurgery.

CASE REPORT

A 10-year-old girl without previous illness suffered from a sudden quadriventricular hemorrhage due to arteriovenous malformation. Initially the child recovered with symptomatic treatment. Neurosurgery and arterial embolization being impossible, Gamma-Unit treatment was performed. Treatment was first well tolerated but 8 months later, left hemiparesis and language disorders occurred, due to radionecrosis. These complications were dramatically improved by corticosteroids.

CONCLUSION

Gamma-Unit treatment can be successfully proposed for treating those malformations that are inaccessible to surgery or embolization.

Ventricular dilatation in experimental intraventricular hemorrhage in pigs. Characterization of cerebrospinal fluid dynamics and the effects of fibrinolytic treatment

BACKGROUND AND PURPOSE

Hemorrhagic ventricular dilatation (HVD) is a prominent feature of human intraventricular hemorrhage (IVH) and a strong indicator for poor outcome. We developed an IVH model to define the mechanisms responsible for HVD and to test the efficacy of intraventricular administration of tissue plasminogen activator (TPA) in the treatment of HVD.

METHODS

Isolated IVH was produced in pigs by injecting 10 mL of blood simultaneously with thrombin into the right lateral ventricle. The treatment group received 1.5 mg of TPA after induction of IVH. Intraventricular blood volume and the volume of the lateral ventricles were assessed by CT after 90 minutes, 7 days, and 42 days. Intracranial pressure, the pressure-volume index, and the resistance to outflow of cerebrospinal fluid (R(out)) were measured 30 minutes and 7 days after IVH.

RESULTS

After IVH, the volume of the lateral ventricles increased from 1.98 +/- 0.69 to 6.43 +/- 1.23 mL (P < .001). There was a linear relationship between ventricular and clot volume (P = .014). Initially, R(out) increased from 24.34 +/- 7.13 to 63.56 +/- 64.91 mm Hg/mL per minute (P < .001). After 7 days, restoration of normal cerebrospinal fluid circulation occurred, but the ventricles were still significantly enlarged (5.24 +/- 1.76 mL, P < .001) and filled with blood. Within 6 weeks, ventricular volume had returned to normal values, paralleled by complete clot resolution. Intraventricular administration of TPA significantly accelerated clot clearance and restoration of normal ventricle volume.

CONCLUSIONS

These results suggest that intraventricular bleeding may cause impairment of cerebrospinal fluid circulation but that the mass effect of clots distending the ventricle walls is the most important mechanism responsible for HVD. This model closely imitates several prominent features of human IVH and may therefore be a useful tool for preclinical assessment of the efficacy and safety of treatment with TPA.

Thrombolytic therapy in neurointensive care

Thrombolytic therapy has been studied in acute ischemic stroke, intracranial hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, and sagittal sinus thrombosis. This form of therapy has an evolving role in contemporary neurologic practice, and increased investigational fervor will ensure more exacting therapeutic alternatives for stroke victims in the future.

Intraventricular recombinant tissue plasminogen activator for lysis of intraventricular haemorrhage

A prospective series of 20 patients with moderate to severe intraventricular haemorrhage (IVH) was studied for the effect of intraventricular administration of recombinant tissue plasminogen activator (rt-PA) on reduction of haematoma volume and prognosis. On the day of haemorrhage ventriculostomy was performed and 2 to 5 mg of rt-PA were injected via the external ventricular drainage, followed by drainage closure for two hours. In 14 patients rt-PA treatment was repeated. Computed tomography showed complete clot lysis or substantial reduction of intraventricular haematoma volume in 19 patients within 96 hours; the clearance of the third and fourth ventricle preceded the clearance of the lateral ventricles. Decrease of ventricular enlargement was seen in all but one patient with initial ventricular dilatation. Increase of haematoma volume and ventricular size was found in one patient. Outcome was minor or no neurological deficit in nine patients, disabling neurological deficit in six patients, and vegetative status in four patients. One patient did not survive the IVH. Intraventricular treatment with rt-PA seems effective in rapid lysis of intraventricular haematoma and normalisation of impaired CSF circulation. This treatment may contribute to an improvement in prognosis of moderate to severe IVH.