Various grading systems and surgical techniques have been developed for the treatment of intraventricular hemorrhage (IVH); however, little attention has been paid to the fourth ventricle hematoma. Nonetheless, hemorrhagic dilation of the fourth ventricle may lead to catastrophic consequences for patients with massive IVH. We present two cases of massive IVH accompanied by massive fourth ventricle hematoma which was successfully removed with combination of suboccipital craniotomy for fourth ventricle hematoma and intraventricular fibrinolysis for supratentorial hematoma.
Intraventricular hemorrhage (IVH) is defined as bleeding into the intracranial ventricular system. It is classified as primary IVH when the bleeding originates from intraventricular sources or lesions and secondary IVH when a periventricular lesion (lesion in the putamen or thalamus, an aneurysm, or a vascular malformation) bleeds and ruptures into the ventricle [
The prognosis of IVH is very poor in the literature, with morbidity and mortality rates of up to 70% and 80%, respectively. Among those with massive flooding and marked dilation of the ventricles, the worst outcomes and highest mortality rates have been observed [
Recently, reports on the endoscopic removal of hematomas have shown better survival rates and prognoses compared with traditional surgical approaches, such as external ventricular drainage (EVD), EVD with intraventricular fibrinolysis, and hematoma evacuation by craniotomy [
Herein, we present two cases of massive IVH that were treated with emergent evacuation of fourth ventricle hematoma following EVD.
An 18-year-old woman presented in an unconscious state with a Glasgow coma scale (GCS) rating of 4. The motor response to painful stimuli was decerebration, and both pupils were pinpointed. Computed tomography (CT) scan revealed massive IVH extending from the lateral ventricle to the fourth ventricle accompanied by hydrocephalus. The fourth ventricle was clearly enlarged by the hematoma, and there was a significant mass effect on the brainstem and the posterior fossa cisterns. (
A 60-year-old woman presented with impaired consciousness. The GCS rating at admission was 8, and she showed weak bilateral localization upon exposure to painful stimuli. CT scan revealed a massive IVH with hydrocephalus and dilatation of the fourth ventricle (
Irrespective of the etiology, neurosurgeons often face a dilemma when confronted with massive IVH. Specifically, their choices in terms of treatment include EVD, intraventricular fibrinolysis, endoscopic evacuation, and craniotomy. In any case, it is clear is that the treatment goals of massive IVH should be the removal of intraventricular blood, rapid reversal of ventricular dilatation, and normalization of ICP.
Massive IVH is often accompanied by fourth ventricle hematoma. When the fourth ventricle dilates as a result of an intraventricular clot, the brainstem can undergo compression. If persistent, potential outcomes may include a decreased level of consciousness or death. So, similarly to cerebellar hemorrhage, massive fourth ventricular hematoma demands prompt decompression when a tight posterior fossa, brainstem compression, or basal cistern compression is observed [
With a rising interest in minimally-invasive techniques, endoscopic surgery and EVD with intraventricular fibrinolysis have come to be widely accepted. Compared to EVD alone, there is growing evidence to support the notion that endoscopic surgery and EVD in conjunction with intraventricular fibrinolysis can yield better results in terms of efficacy and safety in patients with massive IVH [
In our two cases, we took great care of unchanged neurological symptoms despite ventricular drainage, which suggests that the compartmentalization of ICP occurred between the supratentorial and infratentorial regions. Hence, we decided to conduct the treatment with a combination of EVD and fibrinolysis (for supratentorial clot removal) and hematoma evacuation with craniotomy (for infratentorial clot removal). Visible relaxation and pulsation of the posterior fossa was observed following removal of the clot, potentially indicating that fourth ventricle hematoma could be a major contributor to decreased levels of consciousness.
Although, it is debatable to conclude with only two cases that our method is better over the intraventricular fibrinolysis or other minimally-invasive techniques, we should consider whether the mass effect on posterior fossa is the main cause of decreased consciousness in patients with massive fourth ventricular hematoma and surgical evacuation could be an useful option in these conditions.
In the event that the fourth ventricle is enlarged by massive hematoma and significant mass effect is observed in the posterior fossa, prompt surgical clot removal or decompression could be beneficial in IVH patients. This is also true of other posterior fossa hematomas.
No potential conflict of interest relevant to this article was reported.
Informed consent was obtained from all individual participants included in this study.
Conceptualization : YSK, SPJ
Data curation : YSK, HSR
Formal analysis : YSK
Funding acquisition : SPJ
Methodology : SPJ, TSK
Project administration : YSK
Visualization : YSK
Writing - original draft : YSK
Writing - review & editing : SPJ, YSK
This study was supported by a grant (BCRI20039) of Chonnam National University Hospital Biomedical Research Institute.
Case 1. A and B : Initial computed tomography scan showed massive intraventricular hemorrhage with a fourth ventricle hematoma compressing the brainstem. C and D : The intranidal aneurysm was successfully obliterated in the forniceal arteriovenous malformation using Histoacryl® (B. Braun, Melsungen, Germany). Thick arrow indicates intranidal aneurysm.
Case 1. A and B : Removal of fourth ventricle hematoma was performed via midline suboccipital craniotomy. C and D : Postoperative computed tomography scan revealed complete removal of the fourth ventricle hematoma and slight improvement of the hydrocephalus.
Case 1. A : The intraventricular hemorrhage was almost completely resolved following eight doses of intraventricularly administered tissue plasminogen activator given over 4 consecutive days. B : Normal ventricle size was maintained by a shunt during follow-up computed tomography scan at 18 months after surgery.
Case 2. A and B : An initial computed tomography scan revealed massive intraventricular hemorrhage with a fourth ventricle hematoma compressing the brainstem. C and D : The fourth ventricle hematoma was removed via midline suboccipital craniotomy.
Case 2. A and B : A postoperative computed tomography scan showed complete removal of the fourth ventricle hematoma and improvement of the hydrocephalus. C and D : The intraventricular hemorrhage was almost completely resolved following six doses of intraventricularly administered tissue plasminogen activator given over 3 consecutive days.
Case 2. A and B : The ventricle’s normal size was maintained without a shunt during follow-up computed tomography scan at 12 months after surgery.