Spontaneous Cerebellar Hemorrhage with the Fourth Ventricular Hemorrhage : Risk Factors Associated with Ventriculoperitoneal Shunt

Objective

The purposes of this study are to investigate the factors that may be related to ventriculoperitoneal (VP) shunt in patients with cerebellar hematoma and the effect of severe fourth ventricular hemorrhage, causing obstructive hydrocephalus on subsequent VP shunt performance.

Methods

This study included 31 patients with spontaneous cerebellar hematoma and concomitant fourth ventricular hemorrhage, who did not undergo a surgical evacuation of hematoma. We divided this population into two groups; the VP shunt group, and the non-VP shunt group. The demographic data, radiologic findings, and clinical factors were compared in each group. The location of the hematoma (whether occupying the cerebellar hemisphere or the vermis) and the degree of the fourth ventricular obstruction were graded respectively. The intraventricular hemorrhage (IVH) score was used to assess the IVH severity.

Results

Ten out of 31 patients underwent VP shunt operations. The midline location of cerebellar hematoma, the grade of fourth ventricle obstruction, and IVH severity were significantly correlated with that of VP shunt operation (p=0.015, p=0.013, p=0.028). The significant variables into a logistic regression multivariate model resulted in statistical significance for the location of cerebellar hemorrhage [p=0.05; odds ratio (OR), 8.18; 95% confidence interval (CI), 1.00 to 67.0], the grade of fourth ventricle obstruction (p=0.044; OR, 19.26; 95% CI, 1.07 to 346.6).

Conclusion

The location of the cerebellar hematoma on CT scans and the degree of fourth ventricle obstruction by IVH were useful signs for the selection of VP shunt operation in patients with spontaneous cerebellar hematoma and concomitant acute hydrocephalus.     

重症脑室出血的临床救治

目的 探讨重症脑室出血的救治方法，以期降低重症脑室出血的死亡率。方法 早期采用双侧脑室交替或同时尿激酶灌注引流及早期改善脑血液循环等综合措施治疗。结果 本组救治50例重症脑室出血病人(GRAEB评分＞5分)，存活率72％(36／50)，死亡率28％(14／50)，36例存活患中5例因脑积水行脑室—腹腔分流术。结论 尽早疏通脑室梗阻，改善脑脊液循环与脑微循环是重症脑室出血救治成功的关键，脑室引流、尿激酶灌注治疗重症脑室出血是一种安全、可行、有效的方法。     

Severe Symptomatic Vasospasm following Intraventricular Hemorrhage from Arteriovenous Fistula

The authors present a rare case of severe vasospasm following the rupture of arteriovenous fistula. On initial CT scan, hematoma in the corpus callosum and left inferior frontal region with surrounding cerebromalacia and all ventricles without apparent subarachnoid hemorrhage were seen. Angiograms showed arterivenous fistula but did not show cerebral vasospasm. Thirteen days after admission the neurological state of patient suddenly deteriorated and bilateral motor weaknesses developed. Following angiograms revealed severe narrowing on the supraclinoid portion of bilateral internal carotid arteries, bilateral anterior cerebral arteries and bilateral middle cerebral arteries. Transluminal angioplasty and intra-arterial papaverine infusion were performed. The patient remained stable with moderate neurologic deficits.     

脑室出血的临床、CT观察及其影响预后因素的探讨

本文报告继发性脑室出血４３例，原发性脑出血２例。我们观察到脑内血肿容积１０ｍｌ以内者，即使破入脑室也预后良好。大血肿破入脑室后、血凝块堵塞室间孔，第三、四脑室时，患者迅速死亡。部分脑室出血尚未形成凝血块者，并不完全是致命的。脑内血肿仅破入侧脑室者大多可治愈，病死率为１９．２３％，破入侧脑室及第三、四脑室者病死率达５２．６３％，伴有侧脑室或／和第三脑室扩大者预后不良。     

Rapid Progression of Cerebral Infarction after Intraventricular Hemorrhage in Adult Moyamoya Disease

The authors present a rare case of adult moyamoya disease in which a patient experienced rapid progression of cerebral infarction after intraventricular hemorrhage (IVH). A healthy 39-year-old woman was admitted to our hospital with sudden headache, a decreased level of consciousness and mild tetraparesis. Initial magnetic resonance imaging revealed small cerebral infarction and IVH. Although the patient underwent conservative therapy including hypervolemia, hemodilution, keeping moderate hypertension and administration of a free radical scavenger, she showed a fulminant clinical course of cerebral infarction. The authors discuss the possible pathophysiology and suggest the treatment for such cases.     

Intraventricular Nicardipine for Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage

Introduction  Delayed ischemic deficit from vasospasm is a leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Although several treatment modalities have been used to reverse the deleterious effects of vasospasm, alternative therapies are needed, as conventional therapies are often ineffective or contraindicated. Intrathecal nicardipine has been suggested for the prevention of vasospasm. We report our clinical experience with intraventricular nicardipine for refractory vasospasm in eight patients in whom conventional therapies were ineffective, contraindicated, or technically not feasible. Method  Retrospective case series performed at a tertiary care university hospital. Results  Eight patients (median Hunt-Hess grade = 2, median Fisher score = 4) with refractory vasospasm received intraventricular nicardipine (4 mg every 12 h) for a total of 5–17 days. One patient died in the intensive care unit. Seven patients had moderate to good outcomes with 6 being discharged to home (median Rankin Score = 2). Intraventricular nicardipine was well tolerated with minimal side effects. Conclusion  Our preliminary observations suggest that intraventricular nicardipine could be considered as a safe and effective treatment modality to treat vasospasm refractory to conventional management. A randomized, controlled trial to verify the efficacy and safety of intrathecal nicardipine in the prevention and treatment of cerebral vasospasm is warranted.     

Primary Intraventricular Hemorrhage: Yield of Diagnostic Angiography and Clinical Outcome

Introduction  Primary intraventricular hemorrhage (IVH), bleeding in the ventricular system without a discernable parenchymal component, is a rare neurological disorder. To better define the features of primary IVH and the yield of diagnostic angiography in this condition, we retrospectively analyzed all cases of primary IVH evaluated at a tertiary referral hospital over a 6-year period and performed a systematic review of the literature. Methods  For the retrospective case series, all patients with primary IVH admitted to the neurovascular service at a single tertiary referral center over a 6-year period were identified by screening a departmental database. For the systematic review of the literature, all case series of patients with primary IVH diagnosed by computed tomography were identified in the Medline database. Results  From the systematic review, the majority of patients with spontaneous primary IVH presented with headache (69%), nausea/vomiting (53%), and altered mental status (66%). Most primary IVH patients had associated hydrocephalus (62%), and about one-third required ventricular drainage (34%). Diagnostic cerebral angiography was positive for a bleeding source in 56%. The two most common causes identified by angiography were arteriovenous malformations (58% of positive angiograms) and aneurysms (36% of positive angiograms). Approximately one-third of patients with primary IVH do not survive hospital discharge (39%). Patient age and amount of IVH independently predicted in-hospital mortality. Conclusions  Primary IVH is a rare form of intracerebral hemorrhage, with varying short-term outcomes that depend on patient age and the extent of intraventricular hemorrhage. The yield of diagnostic cerebral angiography in the setting of primary IVH is very high. The two most common causes of primary IVH identified on angiography are arteriovenous malformations and aneurysms. Routine catheter angiography in the setting of primary IVH is warranted. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Cerebellar Hemorrhage after Burr Hole Drainage of Supratentorial Chronic Subdural Hematoma

Cerebellar hemorrhage is an unusual complication of supratentorial neurosurgery. To the best of our knowledge, only three case reports have described the occurrence of cerebellar hemorrhage after burr hole drainage for the treatment of chronic subdural hematoma (SDH). We present the case of a patient with this rare postoperative complication of cerebellar hemorrhage after burr hole drainage of a chronic SDH. Although burr hole drainage for the treatment of chronic SDH is rare complication, it is necessary to be aware of the possibility of cerebellar hemorrhage after supratentorial surgery, even with limited surgery such as burr hole drainage of a chronic SDH.     

脑室出血并发脑积水的风险评估与治疗

脑室出血（IVH）约占自发性颅内出血患者的1／3。脑室出血并发出血后脑积水（PHH）是导致不良预后的独立危险因素。在建立修订的Graeb评分标准之后,结合logistic回归分析法建立预测PHH发生概率的数学模型,发现修订的Graeb评分标准比原Graeb评分标准预测不同类型的IVH并发PHH发生更加科学适用。按PHH发生几率大小进行分组,比较各组外科引流与内科保守治疗的病死率,建立了IVH的临床三级治疗方案,即评分1～4分行内科治疗,5～9分者在做好外科引流准备的条件下保守治疗,10～12分者积极引流。同时还对脑室外引流的时间、并发症、引流管拔除等相关问题进行了讨论。     

四脑室出血为主的自发性脑出血的救治

目的探讨四脑室出血为主的脑出血患者的救治经验。方法回顾分析我院2011-06—2013-02四脑室出血为主的脑出血患者68例,采取保守治疗14例,侧脑室钻孔引流术32例,侧脑室钻孔并后颅窝开颅手术22例。结果术后3个月,按GOS预后评分,预后良好44例,预后不良16例,死亡8例(11.8%)。结论对四脑室出血为主的自发性脑出血患者,采取恰当的治疗,可明显改善病人的预后,提高患者的救治率。     

Intraventricular Glioblastoma Multiforme with Previous History of Intracerebral Hemorrhage : A Case Report

GBM is the most common primary brain tumor, but intraventricular GBM is rare and only few cases have been reported in the literature. The authors report a case of 64-year-old man who had a remote history of previous periventricular intracerebral hemorrhage. Brain computed tomography (CT) and magnetic resonance (MR) imaging showed an intraventricular lesion with inhomogeneous enhancement, infiltrative borders and necrotic cyst, and obstructive hydrocephalus. The patient underwent surgical removal through transcortical route via the bottom of previous hemorrhage site and the final pathologic diagnosis was GBM. We present a rare case of an intraventricular GBM with detailed clinical course, radiological findings, and pathological findings, and the possible origin of this lesion is discussed.     

Moyamoya病的影像学特征及脑室出血的原因分析

目的探讨Moyamoya病的影像学特征及脑室内出血的原因。方法对我院6年来确诊的Moyamoya病27例患者的CT、DSA和临床资料进行回顾性对比分析。结果89%(24/27)病人有脑室内出血,DSA显示均有烟雾血管和脉络膜前动脉异常扩张。结论成人Moyamoya病最常见的表现是脑室内出血,这可能与脉络膜前动脉异常扩张有关。     

儿童第四脑室-小脑脚-脑干区肿瘤的手术治疗

目的 研究第四脑室-小脑脚-脑干区肿瘤的形态学特点，以及安全地切除此部位肿瘤的手术方法。方法 儿童（15岁以下）第四脑室-小脑脚-脑干区肿瘤（室管膜瘤和星形细胞瘤）23例。术前头颅MRI证实瘤体起源于小脑脚或侧隐窝，分别向第四脑室，脑干，CPA和斜坡生长。采用枕下正中外侧拐入路，术中分区域切除肿瘤，结果 全切除肿瘤12例，近全切除9例，大部切除2例，无手术死亡，术后病理证实室管膜瘤13例，恶性室管膜瘤2例，星形细胞瘤8例。结论 起源于小脑脚或侧隐窝的肿瘤，以脑干为中心呈半弧形生长，肿瘤侵袭范围包括第四脑室，小脑脚，脑干，CPA和斜坡，合适的手术入路和术中分区域切除肿瘤的技术，可以做到安全地全切除和/或近全切除肿瘤。     

Stereotactic Hematoma Removal of Spontaneous Intracerebral Hemorrhage through Parietal Approach

ObjectiveTo determine the advantages of parietal approach compared to Kocher''s point approach for spontaneous, oval-shaped intracerebral hemorrhage (ICH) with expansion to the parietal region.MethodsWe divided patients into two groups : group A had burr holes in the parietal bone and group B had burr holes at Kocher''s point. The hematoma volume, Glasgow coma scale (GCS) score, and modified Barthel Index (mBI) score were calculated. At discharge, we evaluated the patients'' Glasgow outcome scale (GOS) score, modified Rankin Scale (mRS) score, motor grade, and hospitalization duration. We evaluated the patients'' mBI scores and motor grades at 6 months after surgery.ResultsThe hematoma volume in group A was significantly less than that in group B on postoperative days 1, 3, 5, 7, 14, and 21. Group A had significantly higher GCS scores than did group B on postoperative days 1 and 3. Group A had higher mBI scores postoperatively than did group B, but the scores were not significantly different. No differences were observed for the GOS score, mRS score, motor grade at discharge, or duration of hospitalization. The mBI score of group A at 6 months after surgery was significantly higher, and more patients in group A showed muscle strength improvement.ConclusionIn oval-shaped ICH with expansion to the parietal region, the parietal approach is considered to improve the clinical symptoms at the acute phase by removing the hematoma more effectively in the early stages. The parietal approach might help promote the long-term recovery of motor power.     

实验性脑室出血BAEP的改变及其病理基础

本实验系采用侧脑室恒压(5.2kPa)注血建立兔脑室出血动物模型来研究BAEP在各个时期的变化,并探讨其变化的病理基础。结果显示:注血后BAEPⅠ、Ⅲ、Ⅴ波PL及Ⅰ-Ⅲ,Ⅲ-Ⅴ波IPL在3小时内可以正常或轻度缩短,而后随时间逐渐延长,12小时后,Ⅰ、Ⅲ、Ⅴ波PL及Ⅰ-Ⅱ,Ⅲ-Ⅴ波IPL进一步延长,波幅逐渐降低,Ⅴ至Ⅰ波先后消失。其延长的可能机制:①髓鞘周期线分离;②神经细胞内外Na~+,K~+浓度差下降;③神经递质含量减少。     

Intraventricular aneurysms: Case reports and review of the literature

Background

Intraventricular aneurysms are rare, with only 49 cases have been reported to date in the literature. Treatment of these aneurysms is difficult because of their deep location, small size, and specific angioarchitecture.

Methods

We report four patients with intraventricular aneurysms. In the third patient, the aneurysm self-occluded during procedure of endovascular embolization, which has previously not been reported in the literature.

Results

The first patient was discharged without definitive treatment of his intraventricular aneurysm and died 1 year later. The third patient's aneurysm self-occluded during the procedure of endovascular embolization procedure. The aneurysms of the second and fourth patients were successfully embolized by coils and Onyx, respectively.

Conclusions

The conclusions drawn from our experience and a comprehensive review of the literature include the following: (1) intraventricular aneurysm should be considered in patients with isolated intraventricular hemorrhage; (2) intraventricular aneurysms are frequently very small (<5 mm diameter), and therefore, cannot always be detected on initial angiography; (3) small intraventricular aneurysms cannot usually be clipped or occluded without sacrificing the parent artery; (4) if an intraventricular aneurysm is identified, it should be treated by endovascular embolization or clipping rather than conservative treatment; (5) endovascular embolization should be the first treatment option, and craniotomy can also be considered.     

Etiological differences between the isolated lateral ventricle and the isolated fourth ventricle

Objective To determine if an etiological difference exists between isolation of the lateral ventricle and isolation of the fourth ventricle after ventricular shunting.Methods Cases of symptomatic isolation of the lateral and fourth ventricles were reviewed retrospectively. The ages at presentation of ventricular isolation, the time course to development of isolation, the number of shunt surgeries leading up to symptomatic isolation, the types of shunt valves utilized, and the background of infection were analyzed.Results Twenty-six patients had lateral ventricle isolation and 11 patients had fourth ventricle isolation. Infection, hemorrhage, Chiari malformation/myelomeningocele, and aqueductal stenosis were factors contributing to hydrocephalus requiring treatment in these patients. Compared to 26.9% of patients with lateral ventricle isolation, 90.9% of patients with fourth ventricle isolation had a previous history of infection.Conclusions Prior meningitis and ventriculitis frequently contributed to fourth ventricle isolation. Lateral ventricle isolation seems to arise from functional obstruction of the foramen of Monro related to prior shunting.     

Advances in Therapeutic Approaches for Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) results in high rates of morbidity and mortality, with intraventricular hemorrhage (IVH) being associated with even worse outcomes. Therapeutic interventions in acute ICH have continued to emerge with focus on arresting hemorrhage expansion, clot volume reduction of both intraventricular and parenchymal hematomas, and targeting perihematomal edema and inflammation. Large randomized controlled trials addressing the effectiveness of rapid blood pressure lowering, hemostatic therapy with platelet transfusion, and other clotting complexes and hematoma volume reduction using minimally invasive techniques have impacted clinical guidelines. We review the recent evolution in the management of acute spontaneous ICH, discussing which interventions have been shown to be safe and which may potentially improve outcomes.Electronic supplementary materialThe online version of this article (10.1007/s13311-020-00902-w) contains supplementary material, which is available to authorized users.