Download Intraventricular Hemorrhage

Clinical Program for
Cerebrovascular Disorders
Mount Sinai Medical Center
Intraventricular Hemorrhage
and TPA
Clinical Case Presentation
Clara Raquel Epstein, MD Fellow
Intraventricular Hemorrhage and TPA
Clinical Case Presentation
• A 70 year old right handed Hispanic male with a history
of hypertension, asthma, chronic renal insufficiency, s/p
Bilroth I and s/p hypertensive basal ganglia hemorrhage
on 10/28/98 presented on 11/9/99 with left upper
extremity weakness, slurred speech, dizziness, vomiting,
and blurred vision. Per history the patient ran out of his
antihypertensive medications two weeks prior to
admission and had complained of headaches for two
days prior to presentation. On arrival to the emergency
room the patient’s blood pressure was 246/120. In the
ER, the patient was subsequently intubated in order to
protect his airway from secretions.
Hospital Course
On admission a CT scan was obtained which showed
evidence of a right basal ganglia/thalamus hemorrhage
with intraventricular extension. There was also
enlargement of the ventricular system consistent with
hydrocephalus. As compared with the previous MRI
from 10/29/98, which demonstrated evidence of a focus
of hemorrhage in the posterior limb of the right
internal capsule, in the same location, it was suggested
that this could represent an underlying vascular
malformation such as a cavernous angioma.
Hospital Course
Neurosurgery was consulted and on 11/10/99, a
ventriculostomy was placed. The position of the
catheter was re-adjusted on 11/11/99 for maximal
placement considering the possibility of administering
TPA. Pre and post CT scans confirmed adequate
placement of the catheter to be relocated from the
anterior third ventricle to the frontal horn of the right
lateral ventricle. The ventricles were noted to be
slightly smaller from the previous scan obtained
11/9/99.
Hospital Course
The patient’s course in the NSICU is significant for
difficulty controlling his blood pressure fluctuations,
and respiratory distress with multiple intubations and
extubations. The renal service was consulted and the
patient has received multiple episodes of hemodialysis.
In addition, on 11/16/99 the GI service was consulted
for decreasing hemoglobin from the time of admission
of 11.1 to 8.1. An EGD was performed and there was
evidence of ulceration at the site of previous surgery.
Hospital Course
Neurologically the patient improved in the first couple of
days. He was able to follow commands. However, on
11/15/99, the patients neurologic status appeared to
once again decline. It was initially thought that this
change in status might be related to decreased CSF
drainage from the ventriculostomy.
Hospital Course
The current plan includes replacement of
the ventriculostomy and to continue
present management. The patient will
continue to be evaluated for the need
for placement of a ventriculoperitoneal
shunt.
Adam Davis, MD
Interventional Neuroradiology
Literature Review
Intraventricular hemorhage in adults: complications and treatment.
Naff NJ; Tuhrim S
New Horizons1997 Nov;5(4) : 359-63
Intraventricular hemorrhage (IVH) frequently occurs in the
setting of intracerebral and subarachnoid hemorrhage, and
is an independent and significant contributor to morbidity
and mortality in both conditions. Present therapy of IVH
is directed at treating the associated complications of
obstructive and communcating hydrocephalus. These
therapies are often inadequate to treat the complications
and do not remedy the underlying IVH. Intraventricular
thrombolysis is a promising but unproven new therapy that
directly addresses the IVH and my reduce the incidence of
obstructive and communicating hydrocephalus.
Intraventricular hemorhage in adults: clinical-computed tomographic correlations.
Weisberg LA, et al.
Computed Medical Imaging Graph 1991 Jan-Feb;15(1):43-51
The clinical and CT findings in 100 consecutive adult nontraumatic intraventricular
hemorrhage (IVH) cases were analyzed. There were 74 parenchymal brain
hemorrhages with secondary ventricular extension. The ventricles were filled
with blood and asymmetrically enlarged. If the hemorrhage involved putamen,
cerebellum, pons or subcortical cerebral hemishpheric white matter, IVH was
associated with large parenchymal hematomas; these patients had poor clinical
outcome. With thalamic or caudate hematomas, IVH frequently occurred with
large hematomas but may occur with small hematomas. The small hematomas
were located directly contiguous to the ventricular walls and caused extensive
ventricular blood. Patients with small thalamic and caudate hemorrhage with
intraventricular blood had good clinical outcome; whereas patients with large
hematomas had poor outcome. Primary IVH occurred in 24 cases. In these
cases, blood was seen in all ventricular chambers. Aneurysms involving the
anterior cerebral-anterior communicating artery region were the most common
etiology for primary IVH.
Literature Review
1.
2.
3.
4.
5.
6.
7.
8.
Intraventricular streptokinase infusion in acute post-haemorrhagic
hydrocephalus.
Fibrinolytic agents in the treatment of intraventricular hemorrhage in
adults.
Recombinant tissue plasminogen activator for the treatment of
spontaneous adult intraventricular hemorrhage.
Traumatic intraventricular hemorrhage treated with intraventricular
recombinant-tissue plasminogen activator: technical case report.
Intraventricular urokinase for the treatment of posthemorrhagic
hydrocephalus.
Fibrinolytic agents in the management of posthemorrhagic
hydrocephalus in preterm infants: the evidence.
A cohort study of the safety and feasibility of intraventricular
urokinase for nonaneurysmal spontaneous intraventricular
hemorrhage.
Outcome in patients with large intraventricular haemorrhages: a
volumetric study.