The surgical treatment of intracerebral and intraventricular haematomas

Novel Anatomic Classification of Spontaneous Thalamic Hemorrhage Classified by Vascular Territory of Thalamus

BACKGROUND

Spontaneous thalamic hemorrhage has increased in incidence in recent years. Analysis of the characteristics of thalamic hemorrhage was based on the vascular territories of the thalamus.

METHODS

Retrospective analysis included 303 consecutive patients with spontaneous thalamic hemorrhage. Thalamic hemorrhage was classified into 4 types: anterior type (supplied mainly by the tuberothalamic artery), medial (mainly paramedian thalamic-subthalamic artery), lateral (mainly thalamogeniculate artery), and posterior (mainly posterior choroidal artery). The baseline characteristics, complications, and functional outcomes were assessed.

RESULTS

The anterior type was found in 10 patients (3.3%), the medial type in 47 (15.5%), the lateral type in 230 (75.9%), and the posterior type in 16 (5.3%). Intracerebral hemorrhage volume was smallest in the anterior type, and significantly smaller than in the medial (P = 0.002) and lateral types (P < 0.001). Intraventricular hemorrhage (IVH) or acute hydrocephalus was significantly associated with the medial type (P < 0.01 or P < 0.01, respectively). Non-IVH or non-acute hydrocephalus was significantly associated with the anterior (P < 0.05 or P < 0.05, respectively) and lateral (P < 0.05 or P < 0.05, respectively) types. Emergency surgery was correlated only with the medial type (P < 0.01). The independent predictors of poor outcome were age (odds ratio [OR], 1.07; P = 0.002), admission National Institutes of Health Stroke Scale score (OR, 1.32; P < 0.001), and type of thalamic hemorrhage (OR, 2.08; P = 0.038).

CONCLUSIONS

The present study proposed a novel anatomic classification of thalamic hemorrhage according to the major thalamic vascular territories.

A study of classification of spontaneous intraventricular haemorrhage: a report of 324 cases

In order to develop a practical classification of spontaneous intraventricular haemorrhage (IVH), a correlation was made between clinical and computed tomographic (CT) factors in 324 patients with IVH between September 1988 and December 1996. Spontaneous IVH was graded according to age, blood pressure, clinical conditions, conscious state on admission, primary site of bleeding, volume of intraparenchymal haematoma, degree of midline shift, degree of hydrocephalus and location of IVH, producing a score up to 20. A score of 0-5 was Grade I, 6-10 Grade II, 11-15 Grade III, 16-20 Grade IV. The mortality of each Grade, respectively, was 1.6%, 22.5%, 76% and 100%. The authors propose that this grading system may be a practical schema in the evaluation of the prognosis for IVH.

Emergent Clipping without Prophylactic Decompressive Craniectomy in Patients with a Large Aneurysmal Intracerebral Hematoma

OBJECTIVE

Many vascular neurosurgeons tend to remove bone flap in patients with large aneurysmal intracerebral hematomas (ICH). However, relatively little work has been done regarding the effectiveness of prophylactic decompressive craniectomy in a patient with a large aneurysmal ICH.

METHODS

Large ICH was defined as hematoma when its volume exceeded 25 mL, ipsilateral to aneurysms. The patients were divided into two groups; aneurysmal subarachnoid hemorrhage (SAH) associated with large ICH, January, 1994 - December, 1999 (Group A, 41 patients), aneurysmal SAH associated with large ICH, January, 2000 - May, 2005 (Group B, 27 patients). Demographic and clinical variables including age, sex, hypertension, vasospasm, rebleeding, Hunt-Hess grade, aneurysm location, aneurysm size, and outcome were compared between two groups, and also compared between craniotomy and craniectomy patients in Group A.

RESULTS

In Group A, 21 of 41 patients underwent prophylactic decompressive craniectomy. In Group B, only two patients underwent craniectomy. Surgical outcome in Group A (good 23, poor 18) was statistically not different from Group B (good 15, poor 12). Surgical outcomes between craniectomy (good 12, poor 9) and craniotomy cases (good 11, poor 9) in Group A were also comparable.

CONCLUSION

We recommend that a craniotomy can be carried out safely without prophylactic craniectomy in patients with a large aneurysmal ICH if intracranial pressure is controllable with hematoma evacuation.

Neuroendoscopic Aspiration of Hematocephalus Totalis: Technical Note

OBJECTIVE AND IMPORTANCE:

Massive intraventricular hemorrhage requires aggressive and rapid management to decrease intracranial hypertension. The amount of intraventricular blood is a strong prognostic predictor, and its fast removal is a priority. Neuroendoscopy may offer some advantages over more traditional surgical approaches. We describe here the technical details and clinical outcomes of the neuroendoscopic management of massive tetraventricular hemorrhage in 25 consecutive patients, highlighting the potential pitfalls and the advantages of the technique.

CLINICAL PRESENTATION:

Twenty-five patients, aged 7 to 80 years, presenting with massive ventricular hemorrhage were admitted between January 1996 and May 2004 to our neurosurgery unit after an emergency computed tomographic scan. Severity of ventricular hemorrhage was graded according to the Graeb scale; the mean Graeb score was 9.8 ± 2.9. Hemorrhages were secondary to vascular malformation in 12 cases.

INTERVENTION:

Endoscopy was performed on the first day in 17 cases, with a delay of 1 to 5 days in the remaining 8 cases. A flexible endoscope with “free-hand” technique was always preferred. The ventricular cleaning proceeded in three phases: lateral ventricle, third ventricle, and then aqueduct and fourth ventricle. In selected patients, a catheter, both for intracranial pressure monitoring and for drainage, was positioned. The procedure was successfully completed in all cases. There was no surgery-related mortality. The mean length of intensive care unit stay after the operation was 18 ± 12 days. Short-term mortality (1 mo) was 12%, whereas long-term (&gt;6 mo) mortality was 24%. Complete recovery (Glasgow Outcome Scale score, 5) was achieved in 40% of cases. A ventriculoperitoneal shunt was necessary in 12% of patients.

CONCLUSION:

Intraventricular hemorrhage, analogously to other ventricular diseases, can be treated successfully with flexible endoscopes. Obviously, the limitation of this study lies in its observational nature; however, the encouraging results reported here should prompt a randomized study to evaluate the effectiveness and efficiency of the endoscopic approach in comparison to the more established semiconservative management offered by external derivation with fibrinolytic agents.

Use of intraventricular tissue plasminogen activator and Guglielmi detachable coiling for the acute treatment of casted ventricles from cerebral aneurysm hemorrhage: two technical case reports

OBJECTIVE AND IMPORTANCE

We report two cases of massive intraventricular hemorrhage resulting from subarachnoid hemorrhage. Both patients had experienced a ruptured cerebral aneurysm and were initially moribund. The patients were treated with Guglielmi detachable coiling and then administration of intraventricular tissue plasminogen activator (tPA). Rapid clot resolution was demonstrated radiographically in both. Both patients survived and had a meaningful functional neurological recovery. These are the first reported cases of the acute use of intraventricular tPA after Guglielmi detachable coiling treatment for ruptured cerebral aneurysm.

CLINICAL PRESENTATION

A 59-year-old woman and a 44-year-old man presented with high-grade subarachnoid hemorrhage. Both had had extensive casting of their ventricular systems with blood.

INTERVENTION

The patients were treated with Guglielmi detachable coiling thrombosis of the aneurysm and then intraventricular administration of tPA for dissolution of blood clots. Both patients survived; one is able to carry out activities of daily living with moderate assistance, and the other is able to communicate with his family.

CONCLUSION

This is a novel method to manage patients with high-grade aneurysms with massive intraventricular blood clots. The tPA reduced the mass effect of the blood clot, possibly helping to improve the neurological grade; in addition, the administration of tPA helped keep the external ventricular drains functional, enabling treatment of the acute hydrocephalus. The safety of administering tPA after endovascular thrombosis was demonstrated in these two patients. Further investigation is required to determine the applicability of this approach on a broader scale.

Acute ventricular hemorrhage in adults with hydrocephalus managed by corpus callosotomy and fenestration of the septum pellucidum. Report of three cases

Three patients with hypertension-induced basal ganglia or thalamic hemorrhage and ventricular rupture underwent corpus callosotomy and fenestration of the septum pellucidum. A patient with a left thalamic hemorrhage underwent surgery on an emergency basis and made a complete physical recovery, although she retained mild psychomotor deficits. Another patient with a large right basal ganglia hemorrhage who also underwent surgery on an emergency basis retained a spastic left hemiparesis without evident psychomotor deficits. The third patient with a left thalamic and basal ganglia hemorrhage, who was initially awake and then lapsed into stupor days later, underwent surgery, but did not recover consciousness. Hydrocephalus was reversed and effectively controlled in all three patients without having to perform a shunt placement procedure.

Results of early surgical evacuation of packed intraventricular hemorrhage from aneurysm rupture in patients with poor-grade subarachnoid hemorrhage

OBJECT

The goal of this study was to evaluate the results of early surgical evacuation of "packed" intraventricular hemorrhage (IVH) in patients with poor-grade subarachnoid hemorrhage (SAH).

METHODS

The authors performed surgery within 24 hours after onset of SAH, identified on neuroimaging as a cast distending the ventricular system, in 74 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grades IV and V) without intracerebral hemorrhage. Eighteen of these patients had packed IVH; in these patients the intraventricular clots were extensively evacuated via frontal corticotomy performed under microscopic view.

CONCLUSIONS

Overall, 42% of the 74 patients undergoing craniotomy in the acute stage had favorable outcomes, whereas 30% died. Using multivariate analysis, variables significantly associated with favorable outcome in patients with poor-grade SAH included absence of a packed intraventricular clot on computerized tomography scanning; absence of a history of cardiac disease; and a Glasgow Coma Scale score of 11 or 12. None of the 18 patients who had packed IVH had favorable outcomes and seven of these died. In six recently treated patients with packed IVH, which was examined using fluid-attenuated inversion recovery imaging, extensive periventricular brain damage was found both immediately after surgery and during the chronic stage. Accordingly, the authors believe that irreversible periventricular brain damage is already complete immediately after packed IVH occurs.

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.

Urokinase in the treatment of intraventricular hemorrhage

Large, randomized, double-blind trials on the use of urokinase for IVH are not available, and the studies published in the literature are not without flaws. However, it appears that in the current case-control reports, administration of urokinase through ventricular catheters is safe and is a promising alternative to current medical or surgical management. Investigation of other fibrinolytic agents such as recombinant alteplase is available, but is even more limited. Further trials will help to determine the best dosage and duration of urokinase therapy, as well as the overall efficacy of this new treatment option.

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.

A new trend in operative technique for intracerebral hemorrhage: a comparative study of stereotactic endoscopic removal and stereotactic catheter drainage

The development of less invasive methods to evacuate intracerebral hematomas (ICHs) has improved outcome in patients with traumatic brain injury. Eighteen patients with ICHs underwent surgery via one of two methods: stereotactic endoscopic removal (SER) or stereotactic catheter drainage (SCD). The outcome results were then compared. The patient population was composed of 11 men and seven women with a mean age of 53.3 years (range 33-81 years), all suffering from ICH in the basal ganglia. The mean hematoma volume was 34.4 ml (range 23-105 ml). All patients had major neurological deficits, but showed no sign of transtentorial herniation.

Ten patients underwent SCD and eight had SER. All procedures were performed within 24 hours of insult. After local anesthesia was induced in the patient, an intracranial pressure (ICP) monitoring catheter and an Otzuki cannula were placed through separate burr holes in the skull. Using the SER technique, the ICH was removed using suction and forceps through the side window of the cannula until the ICP had decreased significantly. Hemostasis was attained by lesioning with a Nd-YAG laser. In the SCD procedure, we placed a silicone catheter into the hematoma to drain it and then added urokinase. The hematoma was drained for 3 to 5 days in the SER method and 7 to 10 days in the SCD method. Rebleeding occurred in one of the early cases in which we used the SER procedure. At follow-up evaluation, the mortality rate was 13% in the SER group and 10% in the SCD group. The patients in whom outcome was most improved from these treatments were those who had been admitted with an impaired level of consciousness.

Stereotactic catheter drainage is a precise, safe, and brief procedure with a very low rebleeding rate, but its outcome effect was more delayed than other procedures. Stereotactic endoscopic removal can easily replace SCD, with a similar mortality rate. Both procedures can be accomplished under direct visualization so as to eliminate any undesirable event or outcome.

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.

Urokinase infusion for severe intraventricular haemorrhage

The purpose of this study was to explore in patients with intraventricular haematomas the effectiveness and complication rate of a treatment protocol including standard ventriculostomy and application of urokinase via the catheter. Our series includes 16 patients with severe CT-diagnosed intraparenchymal and predominantly intraventricular haemorrhages. In all cases, ventricular drainage was performed. Urokinase treatment was started immediately with intraventricular infusions of 10,000 U urokinase in 5 ml sterile physiological saline every 12 hours. Twelve patients had an excellent outcome, three good and one poor. There were no complications related to urokinase therapy. Side effects of the infusion volume were profuse sweating and headache which were present at 10 ml total infusion volume, but disappeared after reduction to 5 ml. A group of five patients with comparable lesions treated only with ventriculostomy served as controls. Two of them had a good outcome, two a poor one and one died. The late results in the urokinase-treated group were also favourable. Only one of the patients developed hydrocephalus and was shunted. In the control group, two patients required shunting for delayed hydrocephalus. We conclude that this protocol for urokinase treatment is safe and effective and can be used in almost all patients with intracerebroventricular haemorrhage.

Effect of recombinant tissue plasminogen activator on clot lysis and ventricular dilatation in the treatment of severe intraventricular haemorrhage

Twelve patients with severe intraventricular haemorrhage (IVH) underwent intraventricular thrombolysis with recombinant tissue plasminogen activator (rtPA). External ventricular drainage was performed in all patients within 24 hours of haemorrhage. Fibrinolytic therapy was started within 24 hours from the onset of symptoms in ten cases, and in two further cases after 48 hours and 5 days, respectively. Two to 5 mg of rtPA were injected via the ventricular catheter into one or both lateral ventricles. The injection was repeated at intervals ranging from 6 to 24 hours until CT scans demonstrated a substantial reduction of intraventricular blood. The total rtPA doses per patient ranged from 3 to 31 mg. CT scans showed a marked reduction of intraventricular blood and normalization of ventricular size within 24 to 48 hours from the beginning of the fibrinolytic therapy. Rapid reduction of elevated intracranial pressure by continuous diversion of cerebrospinal fluid could be achieved in all patients, because the ventricular catheters never became obstructed by clotted blood during the fibrinolytic therapy. During the period of treatment, the level of consciousness, as classified according to the Glasgow Coma Scale, improved from a mean value of 7 to 12. One fatal case of meningitis most probably due to the ventriculostomy was the only complication related to the treatment. This method of treatment might improve the prognosis in patients in whom a large intraventricular haematoma volume, ventricular dilatation, and impaired cerebrospinal fluid circulation are major determinants for the outcome.

Intraventricular haemorrhage caused by aneurysms and angiomas

More than 200 intraventricular haematomas (IVH) have been treated in the Homburg Neurosurgical University Clinic since computed tomography was available and facilitated the diagnosis. Among 200 consecutive cases, which are analysed and presented in this publication, there were 71 patients with subarachnoid haemorrhage (SAH)--58 of whom with angiographically and/or pathologically verified aneurysms--, and 21 cases with intraventricular angiomas. IVH without concomitant intracerebral haematoma (ICH) and without evidence of SAH is highly suggestive of intraventricular angioma. In our experience panangiography [if available digital subtraction angiography (DAS)] should be done as soon as possible in all cases of IVH. It is a precondition for early diagnosis and operative elimination of the source of bleeding, because the retrospective analysis of our material shows that rebleeding is by far the highest single risk factor in cases with IVH caused by aneurysms or angiomas. We therefore recommend early microsurgical occlusion of the aneurysms and exstirpation or intravascular embolisation of the angioma. The best survival rate (76%) was achieved in IVH cases caused by angiomas. In aneurysms with IVH the survival rate was 35%, in IVH caused by other diseases 37%. The worst prognosis occurs in SAH with IVH without proven aneurysm or angioma. The survival rate of this group was only 8%.

Intraventricular hemorrhage in blunt head trauma: an analysis of 43 cases

Before the advent of computed tomography, intraventricular hemorrhage (IVH) from any source was thought rare and invariably fatal. Although intraventricular blood is readily identifiable with computed tomography, there has been little systematic study of its significance in blunt head trauma. Forty-three patients with traumatic IVH were prospectively identified in 1 year at Harborview Medical Center (University of Washington). Most were victims of motor vehicle accidents and suffered severe head injuries. IVH occurred alone in two patients; superficial contusions and subarachnoid hemorrhage were the most common associated finding. Blood was present in only one or both lateral ventricles in 25 patients; only the 3rd or 4th ventricles in 4 and all ventricles in 14 instances. There were 3 intracerebral hematomas and 14 basal ganglion hemorrhages. All of the former and half of the latter communicated with the adjacent lateral ventricle. Extra-axial hematomas appeared more common when only the lateral ventricles were involved, whereas corpus callosum or brain-stem hemorrhage appeared more likely when all the ventricles were involved. Acute hydrocephalus was rare, and ventricular drainage was needed in only four cases. Intracranial pressure (ICP) was elevated (> 15 mm Hg) in 46% of patients. The amount of IVH was related inversely with the Glasgow Coma Scale, but not with increased ICP. The presence of IVH indicated a poor outcome, with only half of the patients being independent at a 6-month follow-up. Poor outcome was associated with increasing age, low admission Glasgow Coma Scale, the presence of space occupying lesions if only the lateral ventricles were involved, and hemorrhage in all four ventricles.(ABSTRACT TRUNCATED AT 250 WORDS)

Lysis of intraventricular hematoma with tissue plasminogen activator. Case report

A 42-year-old woman suffered a severe intracerebral and intraventricular hemorrhage from a ruptured anterior cerebral artery aneurysm. Evacuation of the frontal hematoma and clipping of the aneurysm was performed but the intraventricular blood clot persisted, causing ventricular dilatation and high intracranial pressure (ICP) 24 hours after surgery despite external ventricular drainage. Over this period of time the patient's clinical condition improved from Grade V to Grade IVb (World Federation of Neurological Surgeons classification). The intraventricular hematoma was lysed with a total of 8 mg recombinant tissue plasminogen activator injected directly into the ventricles on the 1st and 2nd postoperative days, resulting in rapid normalization of ventricular size and ICP. The patient has since made a substantial recovery and has been able to return home.

Intraventricular hemorrhage in adults: clinical-computed tomographic correlations

The clinical and computed tomographic (CT) findings in 100 consecutive adult nontraumatic intraventricular hemorrhage (IVH) cases are 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 hemispheric 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.

Ruptured intracranial aneurysms: an autopsy study of 133 patients

The autopsy findings of 133 patients with ruptured intracranial aneurysms were reviewed: 24 (18%) had multiple aneurysms. Intraventricular hemorrhage was seen in 53 patients (40%), and intracerebral hematoma was seen in 52 (39%). Intraventricular hemorrhage was seen most frequently in patients with anterior communicating artery aneurysms [21 of 40 (53%)]. Intracerebral hematoma occurred most frequently in patients with middle cerebral artery aneurysms [11 of 28 (39%)]. Hemorrhages arising from anterior communicating artery aneurysms had two types of penetration routes into the lateral ventricle. The first was through the inferomedial portion of the frontal lobe, and the second was through the corpus callosum. The second type was poorly visualized in horizontal sections of the brain. Of 40 patients with anterior communicating artery aneurysms, the first type of penetration route was observed in 15, and the second type was found in 3. The second type is rare, and if the hemorrhage is not massive, it may be overlooked in axial computed tomography scans. Of the 109 ruptured aneurysms, 18 (17%) were 4 mm or less in diameter, 50 (46%) were 5-9 mm in diameter, and 41 (38%) were 10 mm or larger in diameter. In the 21 patients with multiple aneurysms, unruptured aneurysms were smaller than ruptured aneurysms in 17 of 27 (63%), equal size in 9 (33%), and larger in 1 (4%). Regarding rerupture, the larger the ruptured aneurysms were, the higher the percentage of rerupture, that is, 11% of 18 ruptured aneurysms of 4 mm or less in diameter, 32% of 50 of 5-9 mm in diameter, and 37% of 41 of 10 mm or larger in diameter had reruptured. It seems that the larger the size of the aneurysm, the higher the risk of rerupture as well as of initial rupture.

Intracerebral hemorrhage from a metastatic brain tumor. Importance of differential diagnosis preceding stereotaxic hematoma aspiration

Three cases of sudden intracerebral hemorrhage, which were diagnosed as hemorrhage from metastatic brain tumors following stereotaxic aspiration of a hematoma, are reported. Two cases had subcortical hemorrhage and one had cerebellar hemorrhage. Neither contrast-enhanced computed tomography scans nor angiograms revealed any findings other than those indicating the hematoma in all three cases. However, retrospective study of the anamnesis showed very mild symptoms due to metastasis to the brain or spinal cord in one case each. In cases of intracerebral hematoma located at atypical sites, extreme care is required for the differential diagnosis.

Haematoma of cavum septi pellucidi due to hypertension

Haematoma of cavum septi pellucidi is a rare condition. Mass effect of the haematoma of cavum may block the foramen of Monro, leading to hydrocephalus and increased intracranial pressure. We are reporting a case of spontaneous haematoma of the cavum septi pellucidi caused by hypertension.

Traumatic intraventricular haemorrhage

The findings of computerized tomography and clinical features were studied in 19 patients with traumatic intraventricular haemorrhage. Blood was found in various portion of the ventricles. Main sites of the blood was as follows: around the foramen of Monro, 6 patients; in the body and occipital horn of the lateral ventricle, 5 patients; solely in the occipital horn, 8 patients. The haemorrhage around the foramen of Monro, resulting from contusion of the ventral portion of the corpus callosum, septum pellucidum, and fornix, showed an interesting CT finding. Intracranial co-existing lesions were seen in 17 patients, and extracranial lesions were seen in 13 patients, suggesting the external force was excessive. Both the Glasgow coma scale scores on admission and Glasgow outcome scale were generally unfavourable, but 4 patients showed good recovery. The final outcome was mainly influenced by the severity of the co-existing intracranial lesions.

The relationship between the capillary structure and hemorrhage in gliomas

A 48-year-old man was admitted with the sudden onset of symptoms of stroke caused by hemorrhage in an oligodendroglioma. Despite surgery and antiedema treatment, the patient died. Histological evaluation revealed an oligodendroglioma with calcified capillaries of the retiform type. To further investigate this phenomenon, a total of 160 gliomas were reviewed: 90 glioblastomas multiforme, 30 oligodendrogliomas, and 40 astrocytomas. Sufficient data were available for clinical evaluation in 100 cases. Of these, 5% (two oligodendrogliomas and three glioblastomas multiforme) were related to clinically significant hemorrhages. Of the remaining cases, microhemorrhages were found in 53.0% of the glioblastomas, in 56.7% of the oligodendrogliomas, and in 10.0% of the astrocytomas. In each case reviewed, the capillaries were assigned to one of three groups: axial, retiform, or glomeruloid. Statistical analysis revealed a significant association between hemorrhages and retiform capillaries in all three types of tumors, except that in oligodendrogliomas the statistical significance held true when calcification of the capillaries was also present. Glomeruloid-type capillaries were only weakly associated with hemorrhages, and no association was found for axial capillaries. A large-scale prospective study is necessary to more precisely assess the role of each of the three types of capillaries in hemorrhages of gliomas. Based on data available so far, patients with glial tumors with retiform capillaries, confirmed on biopsy, should be carefully monitored to exclude possible intratumoral hemorrhage.

Primary intraventricular traumatic hemorrhage

The history of five patients, having developed intraventricular bleeding following head injury, was reviewed. Only two patients survived, one of whom eventually lapsed into a persistent vegetative state. The only patient showing good recovery was an 8-year-old girl. Primary traumatic intraventricular hemorrhage should be considered a rare, but serious entity with a very poor prognosis.

Vascular malformations of the central nervous system: a morphological overview

Vascular malformations of the central nervous system (C.N.S.) are classified by size, location, and morphologic type, distinguishing capillary telangiectasias, cavernous malformations, venous angiomas, arteriovenous malformations (AVMs) including varix of the great vein of Galen, and other vascular malformations (e.g. Sturge-Weber syndrome). The morphology and predominant location pattern of the different types of vascular malformations in the brain and spinal cord, and their embryology are reviewed. In the brain and its coverings, all types mainly AVMs and venous angiomas do occur, representing 5-9% of all intracranial space-occupying lesions and 20-40% of the sources of surgically treated intracranial hemorrhages. 50-80% of the angiomas are located in the cerebral hemispheres, 10-18% in central brain areas (basal ganglia, internal capsule, choroid plexus), and 10-30% in the posterior fossa. The major types of cerebral vascular malformations are described with reference to their anatomical features, location, chief arterial and venous supply, and prominent complications. Spinal vascular malformations, accounting for 3 to 12% of spinal space-occupying lesions, include vertebral, extradural, dural, subpial and intramedullary angiomas which occur as isolated or complex vascular anomalies and may involve various covering layers at the same level. The preferential occurrence of angiomas on the dorsal surface of the cord and in the caudal regions is related to the embryologic development of spinal vasculature. Frequent association of spinal angiomas (20-25%) with other vascular anomalies and dysplasias emphasizes their hamartomatous nature and developmental origin. Spinal angiomas include capillary telangiectasias with extra- or intradural and, rarely, intramedullary location, cavernomas, mainly arising in vertebral bodies, venous angiomas, mainly located in vertebral bodies and in the extradural space, and AVMs constituting the commonest type, that may affect both the pial and radicular vessels and can penetrate into the cord. They present as simple AV fistulas, cirsoid angiomas with localized vascular plexuses and large complex convolutions ("juvenile" type). The complications of spinal angiomas include subarachnoid hemorrhage, rare epidural hematoma, hematomyelia, compression lesions of the cord and roots, and ischemic changes causing chronic progressive radiculomyelopathy, previously referred to as Foix-Alajouanine syndrome. Chronic damage to the cord and spinal roots results from pressure effects, thrombosis of the abnormal vessels, disorders of venous drainage, and "steal" phenomena related to the vascular anomalies.

The future role of neurosurgery in the case of vascular diseases of the central nervous system

On the basis of 2542 cerebro-spinal vascular diseases (933 aneurysms, 689 cerebro-spinal angiomas, 410 spontaneous intracerebral hematomas, 361 vascular bypass operations and 149 endarterectomies of neck vessels) the present situation and problems, as well as the future prospects of cerebral vascular neurosurgery are reviewed. It is expected that the main development will take place in the field of pathophysiology and pathochemistry of vascular diseases through the acquisition of data obtained not in experimental studies but in patients. This will refine the diagnosis and indications. It is not expected that the operative technique will undergo very substantial change. New methods in the application of laser and photosensitization techniques will be probably included in the technical armamentarium. Endovascular methods of treatment will be further developed and will lead to the limitation of the indications for direct operation. It is assumed that mortality and morbidity can be further reduced by improving the diagnosis and establishing the optimal lines of therapy.

Intracranial hematomas following aneurysmal rupture: experience with 309 cases

Three hundred and nine consecutive cases of intracranial hematomas due to aneurysmal rupture--representing 34% of the total number of patients with aneurysms observed in a 12-year period--were evaluated; of these, 211 were submitted to computed tomography scan. Hematomas were present on admission in 71% of patients and occurred at rebleeding in 29%. Ruptured middle cerebral artery aneurysms caused an intracranial hematoma more frequently than aneurysms in other locations. Ventricular hematomas were frequently observed--especially at rebleeding--in cases with anterior communicating artery aneurysms. Basal ganglia hematomas were detected in eight cases with internal carotid bifurcation aneurysms and in three with middle cerebral artery aneurysms. Subdural hematomas were observed in 32 cases, mainly due to ruptured middle-cerebral-artery and internal-carotid-artery aneurysms. As for clinical evolution, a rapid deterioration was observed in 39% of cases and a chronic course in 46%; a subacute deterioration was far less frequent. Delayed deterioration from vasospasm was observed in 8% of cases, and appeared to be related to the amount of subarachnoid bleeding associated with the hematoma. One hundred and forty-two patients were submitted to surgical treatment (evacuation of hematoma together with exclusion of aneurysm); deep coma, poor medical condition, stabilized neurological disability, or combinations of these factors accounted for the high number of patients not operated upon. Regardless of treatment, 24% of patients showed good results and 58% died. Presence of a large hematoma, ventricular hemorrhage, and shift of the ventricles represented significant risk factors, associated with a poor prognosis. A comparison between two groups of patients admitted within 3 days of hemorrhage--47 operated on early, and 149 with delayed treatment--showed that better results were achieved by early operations, especially for cases in Hunt's grades IV and V.

Arteriovenous malformations of the lateral ventricle

Nine cases with arteriovenous malformations (AVM's) predominantly involving the lateral ventricle are presented. All the AVM's were small, but caused intraventricular hemorrhage in eight cases. Only two patients had an intracerebral hemorrhage large enough to warrant evacuation. Eight patients were under the age of 40 years at the onset of their disease. Computerized tomography demonstrated intraventricular hemorrhage in eight patients, and after intravenous administration of contrast medium a small area of enhancement with dilated subependymal draining veins was seen in seven. The lateral ventricles were of normal size in seven cases, and only two patients required a shunting procedure. Angiography demonstrated that the lesion was an AVM in eight patients, and did not visualize the lesion in the ninth. One patient suffered a recurrent intraventricular hemorrhage when the AVM was demonstrated, although repeated angiography had failed to disclose a vascular lesion at his first intraventricular hemorrhage 14 months before. All nine lesions were resected by microsurgical techniques, and the results were excellent in eight patients. Of four caudate lesions, three were resected through a frontal transcortical approach and the other was operated on through an anterior transcallosal approach; the results were excellent in three of these patients. Only one (Case 4) was left with neurological deficits; he had confusion and disorientation following a right frontal transcortical approach. Even in the dominant hemisphere, lesions in the head of the caudate nucleus could be safely resected by an anterior transcallosal approach. Two choroidal lesions located in the temporal horn and trigone on the dominant side were resected through a middle temporal gyrus approach, and three thalamic lesions through a posterior transcallosal approach, all with excellent results. In all cases the brain opening required was about the width of the retractor (maximum 2.0 cm, average 1.5 cm).

Intraventricular blood without parenchymal clot following spontaneous subarachnoid haemorrhage

The position of an intracerebral haematoma shown on computerised tomography (CT) of patients who have suffered a recent spontaneous subarachnoid haemorrhage is a powerful indicator of the source of the bleed. In the absence of such a parenchymal clot, does the distribution of intraventricular blood have similar predictive value? The scans of 22 patients showing intraventricular blood without parenchymal clot were compared with subsequent angiographic appearances. The distribution of intraventricular blood does not appear to correlate with either the clinical status of the patient, or the nature, site or size of the bleeding lesion.

[Sports accident or natural death? Hematocephalus internus caused by rupture of a choroid plexus angioma]

This is a case report of a young policeman who collapsed in the course of a football game. He died seven days later due to a massive intraventricular hemorrhage that resulted in internal hematocephalus. The source of the bleeding was obviously a bilateral angioma of the choroid plexus of the lateral ventricles.

Spontaneous brain hemorrhage

Spontaneous brain hemorrhage accounts for about 10% of all strokes and is fatal in about 50% of the cases. Its incidence, in contrast to other types of strokes, has not declined. Hypertension accounts for about half of these hemorrhages; the rest are due to tumors, aneurysms and vascular malformations, inflammatory and degenerative vasculopathies and hematologic and iatrogenic disorders of coagulation. In some patients no cause is ever found. Hypertensive brain hemorrhage occurs in the deep gray nuclei of the hemispheres, the cerebellum, and the pons and results in specific clinical syndromes depending on the location. Computerized tomography has revolutionized the diagnosis of brain hemorrhage and is resulting in the development of rational criteria for medical and surgical management of these lesions. Intensive medical therapy guided by clinical status and continuous monitoring of ICP may improve outcome. Surgical removal of the hematoma is indicated in lobar and putaminal hemorrhages when the patient is deteriorating in spite of vigorous medical therapy. In addition most large (greater than 3 cm) cerebellar hemorrhages, as well as smaller cerebellar hemorrhages that result in significant brain stem compression should be evaluated. The roles of intensive medical therapy, elective late surgery and of immediate operation in improving eventual functional outcome need to be investigated further.

Factors affecting the prognosis in thalamic hemorrhage

The present study deals with the factors affecting the prognosis in the acute stage of 29 cases with hypertensive thalamic hemorrhage diagnosed by CT scan. It was thought that the following factors were significantly related to the outcome of the patients who were unable to lead daily life, remained in vegetative state or died: (1) consciousness level was below 10 in the so-called 3-3-9 formula, (2) bilateral Babinski's signs were observed, (3) localization of the hematoma was all the thalamic nuclei type, (4) hematoma volume was above 10 ml, (5) the maximum dimension of hematoma was over 30 or 35 mm, maximum width over 30 mm, maximum length over 25 mm and maximum height over 30 or 40 mm, and (6) the ventricles were dilatated. The prognosis had no significant relationship with the age of the patients, the side of the hematoma, the presence or the absence of ventricular penetration of the hematoma, or the existence of midline shift. We believe that in the acute stage of hypertensive thalamic hemorrhage, the prognosis can be forecasted by neurological findings, accurate calculation of the hematoma volume and size, localization of the hematoma and presence or absence of ventricular dilatation as determined by CT scan.

Intraventricular hemorrhage from ruptured aneurysm. Retrospective analysis of 91 cases

Intraventricular hemorrhage (IVH) from aneurysm rupture is generally considered to be of grave prognostic significance. Ninety-one cases have been studied retrospectively from seven medical centers. The overall mortality rate was 64%. The dramatically poor condition of these patients leads to their rapid admission to the hospital. Eighty-seven percent were admitted on Day 0 or 1, and more than half were classified neurologically as Grade 4 or 5. A multiple regression analysis explained 56% of the variance in survival, using the variables of ventriculocranial ratio (VCR), day of admission, diastolic blood pressure, location of aneurysm, associated intracerebral hematoma, age, grade on admission, sex, and systolic blood pressure. No patient with a VCR of more than 0.25, as calculated from the initial computerized tomography (CT) scan, survived. No patient whose smallest VCR was 0.23 or more survived. This ratio can be simply measured with a millimeter ruler from the CT scan. Patients with IVH usually had enlarged ventricles, even initially. The overall results suggest that early management of intracranial hypertension should be more generally considered, although even when this was done the prognosis was still guarded. The timing of surgery was not an important determinant of outcome, although a significant number of patients died awaiting surgery.

Intraventricular hemorrhage in severe head injury

A series of 30 patients suffering posttraumatic intraventricular hemorrhage (IVH) after closed head injury is reviewed. Clotted blood and a mixture of blood and cerebrospinal fluid could be distinguished by computerized tomography (CT). Posttraumatic IVH was associated with diffuse brain lesions in most cases; intracerebral lesions with contusion, and subdural hematomas coexisted with posttraumatic IVH in eight and four instances, respectively. In two more cases, no CT abnormality other than IVH was noted. All patients in this series were in deep coma at the time of CT examination, and only seven survived. The early clinical findings, the site of ventricular hematoma, and the final outcome are analyzed.

Posttraumatic intraventricular haemorrhages

Of a series of 350 patients studied for blunt head trauma by CT scan 10 were found to have an intraventricular haemorrhage (IVH); in 8 cases we could find concomitant CT abnormalities as well as intracerebral contusion or haemorrhage, and in two cases no other CT abnormality was noted. CT scan represents the first reliable and non-surgical tool for identifying this process. Two possible mechanisms that govern the formation of an IVH are postulated: a) an erosion of the ventricular wall by an intracerebral haemorrhage; b) the rupture of subependymal veins deformed by the negative pressure following dilatation of the ventricular wall. The prognosis in our cases is severe.

Aneurysm of the posterior inferior cerebellar artery presenting as intraventricular hemorrhage in a child: report of a case with survival

A case of intraventricular hemorrhage secondary to a ruptured aneurysm of the posterior inferior cerebellar artery in a child is presented. Treatment is discussed and the literature is reviewed.

[Delayed traumatic intracerebral hemorrhage. Report of 5 cases]

Five cases of traumatic delayed intracerebral hemorrhage are reported. At the admission two patients showed only contusional injury and three had acute intracranial hematomas, one with an extradural infratentorial and two with supratentorial hematomas, which were immediately removed. Repeated CT-scans revealed the delayed intracerebral hemorrhage. Three patients developed an intracerebral hemorrhage within the first 24 hours after admission. The possible mechanisms producing these lesions are discussed. The high mortality of these patients (four in our series) is associated with severe brain damage after the traumatism.

Arteriovenous malformations. Summary of 100 consecutive supratentorial cases

One hundred cases of macroscopic supratentorial arteriovenous malformations are studied, along with the significant literature. On the basis of morphology, they are subdivided into straight-line, single-unit, multiple-unit, intra- and extracranial, venous-wall types, and one other of questionable type. The study does not confirm a relationship of pregnancy to bleeding. It does confirm the absence of vasospasm in association with these lesions, the increasing tendency of the lesion to bleed the smaller it is, the equal sex distribution, the peak incidence in the patient's fourth decade, the lack of significance of family history, and the lack of associated vascular lesions. The study stresses the advantages of preopertive three-dimensional angiography, surgical magnification, and intraoperative serial angiography. It is emphasized again that the fistula itself must be removed or obliterated.