Neurosurgery notes/Vascular/Haemorrhagic diseases/Intraventricular haemorrhage

Intraventricular haemorrhage

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Haemorrhagic diseases
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Newborn IVH/ICH

Aetiologies

  • Most occur as a result of extension of intraparenchymal haemorrhages
    • In the adult:
      • Spontaneous ICH: especially thalamic or putaminal haemorrhages (p.1408)
      • Associated with AVM
    • In newborns: extension of subependymal haemorrhage
  • Pure intraventricular haemorrhage (IVH) is usually the result of a rupture of
    • Aneurysm:
      • Accounts for ≈ 25% of IVH in adults,
      • Second only to extension of intracerebral haemorrhage as the most common cause.
      • IVH occurs in 13–28% of ruptured aneurysms in clinical series.
      • More common with the following aneurysms: a-comm, distal basilar artery or carotid terminus, VA or distal PICA (p.1252)
    • Vertebral artery dissection (or dissecting aneurysms) (p.1395)
    • Intraventricular AVM
    • Intraventricular tumour
    • SAH outside the ventricles refluxing into foramina of Luschka and/or Magendie

Graeb Score

  • Used to stratify the severity of the IVH.
  • Maximum score is 12 for two lateral ventricles, and the 3rd and 4th ventricles.
    • For lateral ventricles:
        1. Trace blood
        1. < 50% ventricle filled
        1. > 50% ventricle filled
        1. Casting of ventricle
    • For 3rd and 4th ventricles:
        1. Blood present
        1. Casting of ventricle and expansion

Natural history

  • Intracerebral hemorrhage with IVH:
    • 32–44% mortality
  • All four ventricles IVH:
    • 60–90% mortality
    • Primary IVH: 30–50% mortality
    • External ventricular drain placement with tissue plasminogen activator: Reduced mortality to 30–35%

ICH in young adults (15 - 45 yrs)

  • Aetiology
    • In a review of 72 patients age 15–45 yrs suffering nontraumatic ICH a cause was found in 76 pts
        • Etiology
        %
        Ruptured AVM
        29.1
        Arterial hypertension
        15.3
        Ruptured saccular aneurysm
        9.7
        Sympathomimetic drug abuse
        6.9
        Tumorᵃ
        4.2
        Acute EtOH intoxication
        2.8
        Preeclampsia/eclampsia
        2.8
        Superior sagittal sinus thrombosis
        1.4
        Moyamoya
        1.4
        Cryoglobulinemia
        1.4
        Undetermined
        23.6
      • ᵃHemangioma, ependymoma, metastatic choriocarcinoma...see Hemorrhagic brain tumors (p. 1406)
    • 3 patients had labour or postpartum haemorrhages: Pregnancy & intracranial haemorrhage
    • AVM: lobar haemorrhages in this age group are highly suggestive of AVM.
      • Of 40 lobar haemorrhages, 37.5% were determined to be from AVMs.
    • Herpes simplex encephalitis:
      • May produce haemorrhagic changes on CT, especially in the temporal lobes
    • Drug abuse:
      • Esp: sympathomimetics (cocaine)
    • Leukaemia:
      • ICH may be the initial presentation of leukaemia in a young adult (may be due to metastases (chloroma) or to thrombocytopenia).
  • Outcome
    • Overall in-hospital survival (including those treated medically was 87.5%.

IVH/ICH of new born (preterm IVH most common)

  • Other causes of intracerebral hemorrhage in the newborn
    • Birth trauma
      • Causing
        • Subdural hemorrhage,
        • Tentorial hemorrhage,
        • Parenchymal hemorrhage,
        • Subarachnoid blood.
      • Found on imaging (U/S or CT)
      • Presentation
        • Seizures,
        • Apnea,
        • Bradycardia, or, rarely,
        • Focal neurological deficits. It rarely requires surgical intervention
    • Choroid plexus hemorrhage can result in IVH.
      • Some develop into HCP and might require shunt
    • Hemorrhagic stroke has been identified in 6.2 per 100,000 live births.
      • Presentation
        • Encephalopathy (100%)
        • Seizures (65%).
      • Aetiology
        • Idiopathic (75%)
        • Thrombocytopenia
        • Cavernous malformation.
      • Risk factors for perinatal hemorrhagic stroke include:
        • Male gender, fetal distress, emergent C-section, prematurity, and post-maturity
    • Tumors in the neonate can present with hemorrhage
    • Vascular malformations of any form can present in the neonate with hemorrhage (Rare)
      • Vein of Galen malformations are diagnosed in the neonate in about 40% of cases.
      • Most of these infants present with fulminant congestive heart failure and 50% have ventriculomegaly