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Management of non-traumatic intraventricular hemorrhage

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Abstract

Intraventricular hemorrhage (IVH) is defined as the eruption of blood in the cerebral ventricular system and is mostly secondary to spontaneous intracerebral hemorrhage and aneurysmal and arteriovenous malformation rupture. IVH is a proven risk factor of increased mortality and poor functional outcome. Its seriousness is correlated not only with the amount of blood but also with the involvement of the third and fourth ventricles. There are four mechanisms that explain the pathophysiology of this event: acute obstructive hydrocephalus, the mass effect exerted by the blood clot, the toxicity of blood-breaking products on the adjacent brain parenchyma, and, lastly, the development of a chronic hydrocephalus. It is thus obvious that the clearance of blood from the ventricles should be a therapeutic goal. In cases of acute hydrocephalus, external ventricular drainage is a mandatory step, but proven often insufficient. The concomitant use of intraventricular fibrinolytics such as recombinant tissue plasminogen activator or urokinase seems to be beneficial at least in the context of spontaneous intracerebral hemorrhage, in which their use is now accepted but not yet validated by a randomized trial. Given the potential neurotoxicity of these agents, further research is needed in order to identify the best treatment for intraventricular fibrinolysis (IVF). The endoscopic retrieval of intraventricular blood was also described recently and seems to be as efficient as IVF, but its use is limited to specialized centers. IVH represents a therapeutic challenge for neurosurgeons, neurologists, and intensivists. Thus, a better understanding of this dramatic event will help in better tailoring the treatment strategies.

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Acknowledgments

The authors thank Miss Apollonia Annang for her assistance in English corrections and Keven Ponte for his computing assistance.

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The authors declare that they have no conflict of interest or financial disclosure.

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Authors and Affiliations

  1. Department of Neurosurgery, Caen University Hospital, Avenue de la Cote de Nacre, Caen, 14000, France

    Thomas Gaberel, Christian Magheru & Evelyne Emery

  2. INSERM, U919, Sérine Protease and Pathophysiology of the Neurovascular Unit, SP2U, UMR CNRS 6232, Centre d’Imagerie et de Neurosciences Appliquées aux Pathologies GIP Cyceron, University Caen Lower Normandy, bl Henri Becquerel, Caen, France

    Thomas Gaberel & Evelyne Emery

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  1. Thomas Gaberel
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Correspondence to Thomas Gaberel.

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Comments

Dattatraya Muzumdar, Mumbai, India

Gaberel et al. present a review on non-traumatic intraventricular hemorrhage and discuss the pathophysiology and management in detail.

Intraventricular hemorrhage is a serious condition which can result in enhanced morbidity and mortality. The bleeding is deep-seated and causes obstructive hydrocephalus. The management protocols are diverse and the outcomes are not universally uniform, ranging from severe morbidity to imminent mortality.

The manuscript is well written and discussed. It covers a wide range of reports in the literature and presents them in a concise manner. This would serve as a marker for future research and randomized controlled studies in this difficult to “understand and manage” condition. Quality of life studies evaluating the improvement in higher functions and integration of the patient into the society would be helpful.

Joachim Oertel and Guilherme Ramina Montibeller, Homburg/Saar, Germany

Gaberel et al. undertook the difficult task of summarizing a subject where no or only very little evidence exist. They report on the optimal treatment strategy for non-traumatic intraventricular hemorrhage (IVH).

IVH is a common situation in neurosurgery with frequent guarded prognosis and a high mortality rate. It can occur primarily or secondary to intraparenchymal or subarachnoid hemorrhage. The combination of intracerebral hemorrhage or subarachnoid hemorrhage and blood in the ventricles is associated with a poor outcome [1, 3, 4, 6]. There are still great controversies about the treatment of this pathology, from the clinical management to the indication of surgery. The development of hydrocephalus after hemorrhage in ventricles is not uncommon, and the ideal surgical intervention is still under debate. External ventricular drainage, intraventricular fibrinolysis, and endoscopic third ventriculostomy are some of the possibilities.

The most frequent treatment of intraventricular hemorrhage is ventricular drainage, with or without fibrinolysis. Because of frequent clotting of the external ventricular drains and the need of recurrent exchanges, the management of this condition is frequently awkward. The idea of an endoscopic intraventricular operation, when clear vision is of utmost important, seems at first sight out of question. Neuroendoscopic experience in intraventricular hemorrhage is rarely described in the literature. Longatti et al. reported the treatment of IVH with the neuroendoscope in 13 cases over a period of 7 years [5]. A flexible endoscope was used, and the clinical outcome was evaluated. A good amount of intraventricular blood could be removed in all patients. This series of cases was small, but the results indicated that a rigid endoscope could provide a superior intraventricular view with better possibilities. Chen et al. compared the endoscopic surgery and external ventricular drainage for intraventricular hemorrhage caused by thalamic hemorrhage [1]. The outcome and mortality rate where not significantly different between the two groups. Nevertheless, in the endoscopic surgery group, the need of a ventricular shunt was importantly lower, and the intensive care unit stay was shorter. In 2009, our group published a study reporting the experience of endoscopic third ventriculostomy performed by hemorrhage-related obstructive hydrocephalus in 34 patients [7]. Based on the results, endoscopic third ventriculostomy can be considered a valuable treatment option, especially in patients with predominant cerebrospinal fluid obstruction and lack of a large space-occupying hemorrhage.

In all, the optimal treatment of IVH remains still unclear. However, numerous studies have been published which demonstrate a beneficial effect of a more aggressive surgical therapy than just external drain placement. The presented manuscript of Gaberel et al., from the University Hospital of Caen, Management of Non-traumatic Intraventricular Hemorrhage, reviews the etiology, the prognostic factors, and the classification of this disease. The group discusses the pathophysiology and the various opinions of the current debate. The paper evaluates the various aspects of the treatment decision. Nevertheless, randomized studies should give us evidence that a more aggressive treatment provides superior results before more definite conclusions can be made [8].

References

[1] Chen CC, Liu CL, Tung YN, Lee HC, Chuang HC, Lin SZ, Cho DY (2011) Endoscopic surgery for intraventricular hemorrhage (IVH) caused by thalamic hemorrhage: comparisons of endoscopic surgery and external ventricular drainage (EVD) surgery. World Neurosurg 75(2):264–8

[2] Gaberel T, Emery E, Vivien D (2011) Letter by Gaberel et al. regarding article, “Dose effect of intraventricular fibrinolysis in ventricular hemorrhage. Stroke 42(9):e548–9; author reply e550 (E-pub 4 Aug 2011)

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[5] Longatti PL, Martinuzzi A, Fiorindi A, Maistrello L, Carteri A (2004) Neuroendoscopic management of intraventricular hemorrhage. Stroke 35(2):e35–8 (E-pub 22 Jan 2004)

[6] Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A (2000) Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. J Neurol 247(2):117–121

[7] Oertel JM, Mondorf Y, Baldauf J, Schroeder HW, Gaab MR (2009) Endoscopic third ventriculostomy for obstructive hydrocephalus due to intracranial hemorrhage with intraventricular extension. J Neurosurg 111(6):1119–1126

[8] Vulcu S, Oertel J (2011) Therapy of obstructive hydrocephalus due to intraventricular hemorrhage: is there a need for neuroendoscopy? Neurol India 59(6):846–847

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Gaberel, T., Magheru, C. & Emery, E. Management of non-traumatic intraventricular hemorrhage. Neurosurg Rev 35, 485–495 (2012). https://doi.org/10.1007/s10143-012-0399-9

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