Prognostic significance of third ventricle blood volume in intracerebral haemorrhage with severe ventricular involvement

Abstract

Background and purpose Intraventricular haemorrhage (IVH) is an independent predictor of poor outcome in spontaneous intracerebral haemorrhage (ICH). Larger IVH volume and increasing number of affected ventricles have been associated with worse prognosis, however, little is known about the prognostic value of blood volume in the different parts of the ventricular system. Therefore, the correlation of IVH volume in the third, fourth and lateral ventricles with outcome in patients with ICH and severe IVH, treated with intraventricular fibrinolysis (IVF), was investigated. Methods Patients with ICH <40 ml, severe IVH and acute hydrocephalus were treated with IVF. The course of IVH volume for each ventricle was measured by CT based volumetry. Outcome at 90 days was assessed by a telephone follow-up survey and correlated with initial IVH volume. Results 50 patients aged 62.5610.3 years with spontaneous ICH (12.5610.8 ml) and severe IVH (33.5625 ml) were included. Clearance of the third and fourth ventricle from blood occurred after 361.9 days. Initial IVH volume in the third ventricle (3.863.3 ml) was predictive for poor outcome (OR 2.6 per ml, p¼0.02). Correlation between larger IVH volume in the fourth ventricle and poor outcome showed a trend towards significance (p¼0.07). Total IVH volume and lateral ventricle IVH volume were not correlated with outcome. Conclusion Despite rapid clot removal, initial IVH volume in the third ventricle was a strong and independent negative predictor. This is possibly explained by irreversible damage of brainstem structures by the initial mass effect of IVH.

Minimally Invasive Surgery for Intracerebral and Intraventricular Hemorrhage

“…First, as with ICH, massive IVH has the capacity to induce local mass effect and potentially reduce regional perfusion, creating dysfunction and ultimately ischemic injury to the brain adjacent to the ventricular system. 32,33 Second, as with ICH, the hemotoxicity associated with the blood breakdown products may induce secondary brain injury in the days and weeks after IVH. [34][35][36][37] Third, blood products within the ventricular system have the capacity to induce long-term impairment in the function of normal cerebrospinal fluid absorption mechanisms, resulting in chronic hydrocephalus, requiring treatment with an indwelling permanent shunt.…”

Autonomic Effects of Intraventricular Extension in Intracerebral Hemorrhage

“…A recent study by Staykov et al could confirm the prognostic significance of the third ventricle blood volume even in a setting with aggressive treatment using external ventricle drainage, intraventricular fibrinolysis, and early lumbar drainage where the ''opening'' of the third and fourth ventricle was achieved as soon as 1.5 ± 0.6 days. The authors speculate that immediate damage to the brainstem caused by the ventricle hematoma may be crucial for the prognosis [26].…”

Clearing bloody cerebrospinal fluid

“…As recent findings have shown, different pathomechanisms, including mass effect, reduction of cerebral blood flow, autonomic impairment and the initiation of inflammatory processes contribute to its detrimental effects [9,[11][12][13]. As recent findings have shown, different pathomechanisms, including mass effect, reduction of cerebral blood flow, autonomic impairment and the initiation of inflammatory processes contribute to its detrimental effects [9,[11][12][13].…”

“…Obstructive hydrocephalus is caused by casting of the aqueduct or of the third and/or fourth ventricle. Furthermore, the ventricular clot exerts a volume-dependent mass effect on the surrounding brain tissue and causes a reduction of cerebral blood flow [7,10], possibly leading to further structural damage [11], autonomic impairment [12], and ultimately to poor outcome [13]. CSF production, however, continues and ultimately leads to an increase in intracranial pressure (ICP).…”