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1.  Early experience in endoscopic management of massive intraventricular hemorrhage with literature review 
Asian Journal of Neurosurgery  2014;9(3):124-129.
Massive intraventricular hemorrhage (IVH) is nearly always associated with hydrocephalus and is often treated with prolonged external ventricular drainage (EVD); however this procedure can lead to bacterial ventriculitis and meningitis, which can worsen the clinical outcomes. Endoscopic burr hole surgery to remove the hematomas in lateral and third ventricles is an alternative treatment option. We describe the surgical techniques and benefits of endoscopic surgery for acute massive IVH in four patients and discuss the current published literature-related to this condition. Four patients were treated endoscopically for massive IVH. Three patients presented with secondary IVH due to vascular malformation, tumoral bleed and chronic hypertension, while one case presented as massive primary IVH. Endoscopic wash out and removal of hematomas was normally performed together with an endoscopic third ventriculostomy. Recombinant factor VIIa was only administered prior to surgery for IVH secondary to vascular malformation and for cases with postoperative rebleeding which required second endoscopic surgery. Weaning from ventilator and EVD commenced on day 4 postoperatively. All treated patients recovered and did not require further shunt surgery. Good outcomes obtained may be related to early removal of hematomas, creation of new cerebrospinal fluid diversion pathway after thorough wash-out, early weaning from ventilator and EVD. Endoscopic surgery is beneficial in treating poor grade IVH with Graeb score of more than 6.
PMCID: PMC4323895
Endoscopy; factor VIIa; Graeb score; hydrocephalus; intraventricular haemorrhage
2.  Neuroendoscopic evacuation of intraventricular hematoma associated with thalamic hemorrhage to shorten the duration of external ventricular drainage 
We report neuroendoscopic evacuation of an intraventricular hematoma (IVH) in 13 patients with thalamic hemorrhage. We discuss strategies to improve the outcome and to shorten the management period by using external ventricular drainage (EVD).
Patients were classified into fair (modified Rankin scale [mRS] grade 4 or less) and poor (mRS grade 5) outcome groups, and depending on the duration of EVD, into short (7 days or shorter) and long EVD (8 days or longer) groups.
The postoperative residual IVH, graded using the Graeb score, was better for the fair outcome group than for the poor outcome group (3.9 [1.2] vs. 5.7 [1.0], P < 0.05). The postoperative Graeb score was significantly better for the short EVD group than for the long EVD group (3.6 [0.8] vs. 6.0 [0.6], P < 0.01). The duration of EVD was not correlated with the IVH at the fourth ventricle, but it was correlated with the IVH at the foramen of Monro (P < 0.05) and the third ventricle (P < 0.01). Reduction in the volume of thalamic hemorrhage had no effect on the neurological outcome or duration of EVD.
Neuroendoscopic evacuation of the IVH at the foramen of Monro and the third ventricle shortened the duration of EVD for hydrocephalus caused by thalamic hemorrhage with IVH involvement. Removal of the thalamic hemorrhage and IVH at the fourth ventricle was not necessary.
PMCID: PMC2940103  PMID: 20847924
External ventricular drainage; hydrocephalus; intraventricular hematoma; neuroendoscope; thalamic hemorrhage
3.  Remote cerebellar hemorrhage due to ventriculoperitoneal shunt in an infant: a case report 
Cerebellar hemorrhage remote from the operative site is an unpredictable and rare complication in neurosurgery, with reported rates of morbidity and mortality in the literature of 8.4% and 7.8%, respectively. The range of procedures associated with remote cerebellar hemorrhage is diverse and includes both supratentorial and spinal procedures that entail significant cerebral spinal fluid loss or resection of supratentorial content. We present here the first documented case of remote cerebellar hemorrhage after controlled supratentorial cerebral spinal fluid drainage by ventriculoperitoneal shunt, and discuss the proposed pathophysiology and treatment.
Case presentation
We present the case of a four-month-old Saudi Arabian male baby who presented with progressive symptoms and signs of congenital hydrocephalus. An uneventful ventriculoperitoneal shunting was performed with our patient recovering smoothly in the immediate postoperative period. On the next day, he had frequent episodes of vomiting and became lethargic. An urgent computed tomography scan of his brain revealed mild ventricular decompression and unexpected cerebellar hemorrhage. The infant was put under close observation, with marked spontaneous improvement over 48 hours and complete resolution of the hemorrhage on a follow-up computed tomography brain scan two weeks later. On regular outpatient visits at one, three and twelve months, he had no neurological deficit.
Remote cerebellar hemorrhage is a complication that remains enigmatic in terms of both the underlying mechanism and clinical behavior. Our case revealed that the risk factors identified in the literature are not sufficient in predicting patients at risk of developing remote cerebellar hemorrhage. Our report also adds to the growing body of evidence challenging the currently accepted hypothesis explaining the pathomechanism of remote cerebellar hemorrhage. It thereby remains an unpredictable hazard that requires further study and increased awareness, as many cases in the literature are incidental findings.
PMCID: PMC3443652  PMID: 22846583
4.  Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts 
Journal of neurosurgery. Pediatrics  2012;9(3):10.3171/2011.12.PEDS11136.
Preterm infants are at risk for perinatal complications, including germinal matrix–intraventricular hemorrhage (IVH) and subsequent posthemorrhagic hydrocephalus (PHH). This review summarizes the current understanding of the epidemiology, pathophysiology, management, and outcomes of IVH and PHH in preterm infants.
The MEDLINE database was systematically searched using terms related to IVH, PHH, and relevant neurosurgical procedures to identify publications in the English medical literature. To complement information from the systematic search, pertinent articles were selected from the references of articles identifed in the initial search.
This review summarizes the current knowledge regarding the epidemiology and pathophysiology of IVH and PHH, primarily using evidence-based studies. Advances in obstetrics and neonatology over the past few decades have contributed to a marked improvement in the survival of preterm infants, and neurological morbidity is also starting to decrease. The incidence of IVH is declining, and the incidence of PHH will likely follow. Currently, approximately 15% of preterm infants who suffer severe IVH will require permanent CSF diversion. The clinical presentation and surgical management of symptomatic PHH with temporary ventricular reservoirs (ventricular access devices) and ventriculosubgaleal shunts and permanent ventriculoperitoneal shunts are discussed. Preterm infants who develop PHH that requires surgical treatment remain at high risk for other related neurological problems, including cerebral palsy, epilepsy, and cognitive and behavioral delay. This review highlights numerous opportunities for further study to improve the care of these children.
A better grasp of the pathophysiology of IVH is beginning to impact the incidence of IVH and PHH. Neonatologists conduct rigorous Class I and II studies to advance the outcomes of preterm infants. The need for well-designed multicenter trials is essential because of the declining incidence of IVH and PHH, variations in referral patterns, and neonatal ICU and neurosurgical management. Well-designed multicenter trials will eventually produce evidence to enable neurosurgeons to provide their smallest, most vulnerable patients with the best practices to minimize perioperative complications and permanent shunt dependence, and most importantly, optimize long-term neurodevelopmental outcomes. (
PMCID: PMC3842211  PMID: 22380952
germinal matrix-intraventricular hemorrhage; hydrocephalus; preterm infant; subgaleal shunt; ventricular reservoir; ventriculoperitoneal shunt
5.  Endoscopic third ventriculostomy 
Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus. It is indicated in hydrocephalus secondary to congenital aqueductal stenosis, posterior third ventricle tumor, cerebellar infarct, Dandy-Walker malformation, vein of Galen aneurism, syringomyelia with or without Chiari malformation type I, intraventricular hematoma, post infective, normal pressure hydrocephalus, myelomeningocele, multiloculated hydrocephalus, encephalocele, posterior fossa tumor and craniosynostosis. It is also indicated in block shunt or slit ventricle syndrome. Proper Pre-operative imaging for detailed assessment of the posterior communicating arteries distance from mid line, presence or absence of Liliequist membrane or other membranes, located in the prepontine cistern is useful. Measurement of lumbar elastance and resistance can predict patency of cranial subarachnoid space and complex hydrocephalus, which decides an ultimate outcome. Water jet dissection is an effective technique of ETV in thick floor. Ultrasonic contact probe can be useful in selected patients. Intra-operative ventriculo-stomography could help in confirming the adequacy of endoscopic procedure, thereby facilitating the need for shunt. Intraoperative observations of the patent aqueduct and prepontine cistern scarring are predictors of the risk of ETV failure. Such patients may be considered for shunt surgery. Magnetic resonance ventriculography and cine phase contrast magnetic resonance imaging are effective in assessing subarachnoid space and stoma patency after ETV. Proper case selection, post-operative care including monitoring of ICP and need for external ventricular drain, repeated lumbar puncture and CSF drainage, Ommaya reservoir in selected patients could help to increase success rate and reduce complications. Most of the complications develop in an early post-operative, but fatal complications can develop late which indicate an importance of long term follow up.
PMCID: PMC3409989  PMID: 22865970
Cerebrospinal fluid shunt; endoscopy; endoscopic third ventriculostomy; hydrocephalus; neuroendoscpy; ventriculostomy
6.  Neuroendoscopic Surgery versus External Ventricular Drainage Alone or with Intraventricular Fibrinolysis for Intraventricular Hemorrhage Secondary to Spontaneous Supratentorial Hemorrhage: A Systematic Review and Meta-Analysis  
PLoS ONE  2013;8(11):e80599.
Background and Purpose
Although neuroendoscopy (NE) has been applied to many cerebral diseases, the effect of NE for intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial hemorrhage remains controversial. The purpose of this study was to analyze the effect of NE compared with external ventricular drainage (EVD) alone or with intraventricular fibrinolysis (IVF) on the management of IVH secondary to spontaneous supratentorial hemorrhage.
Methodology/ Principal Findings
A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library, CBM, VIP, CNKI, and Wan Fang database) was performed to identify related studies published from 1970 to 2013. Randomized controlled trials (RCTs) or observational studies (OS) comparing NE with EVD alone or with IVF for the treatment of IVH were included. The quality of the included trials was assessed by Jaded scale and the Newcastle-Ottawa Scale (NOS). RevMan 5.1 software was used to conduct the meta-analysis.
Eleven trials (5 RCTs and 6 ORs) involving 680 patients were included. The odds ratio (OR) showed a statistically significant difference between the NE + EVD and EVD + IVF groups in terms of mortality (OR, 0.31; 95% CI, 0.16-0.59; P=0.0004), effective hematoma evacuation rate (OR, 25.50, 95%CI; 14.30, 45.45; P<0.00001), good functional outcome (GFO) (OR, 4.51; (95%CI, 2.81-7.72; P<0.00001), and the ventriculo-peritoneal (VP) shunt dependence rate (OR, 0.16; 95%CI; 0.06, 0.40; P<0.0001).
Applying neuroendoscopic approach with EVD may be a better management for IVH secondary to spontaneous supratentorial hemorrhage than NE + IVF. However, there is still no concluive evidence regarding the preference of NE vs. EVD alone in the case of IVH, because insufficient data has been published thus far. This study suggests that the NE approach with EVD could become an alternative to EVD + IVF for IVH in the future.
PMCID: PMC3827437  PMID: 24232672
7.  Rapid resolution of an acute subdural hematoma by increasing the shunt valve pressure in a 63-year-old man with normal-pressure hydrocephalus with a ventriculoperitoneal shunt: a case report and literature review 
Symptomatic subdural hematoma development is a constant concern for patients who have undergone cerebrospinal fluid shunting procedures to relieve symptoms related to normal-pressure hydrocephalus. Acute subdural hematomas are of particular concern in these patients as even minor head trauma may result in subdural hematoma formation. The presence of a ventricular shunt facilitates further expansion of the subdural hematoma and often necessitates surgical treatment, including subdural hematoma evacuation and shunt ligation.
Case presentation
We present the case of a 63-year-old North American Caucasian man with normal-pressure hydrocephalus with an adjustable valve ventriculoperitoneal shunt who developed an acute subdural hematoma after sustaining head trauma. Conservative treatment was favored over operative evacuation because our patient was neurologically intact, but simple observation was considered to be too high risk in the setting of a low-pressure ventriculoperitoneal shunt. Thus, the valve setting on the ventriculoperitoneal shunt was increased to its maximum pressure setting in order to reduce flow through the shunt and to mildly increase intracranial pressure in an attempt to tamponade any active bleeding and limit hematoma expansion. A repeat computed tomography scan of the head six days after the valve adjustment revealed complete resolution of the acute subdural hematoma. At this time, the valve pressure was reduced to its original setting to treat symptoms of normal-pressure hydrocephalus.
Programmable shunt valves afford the option for non-operative management of acute subdural hematoma in patients with ventricular shunts for normal-pressure hydrocephalus. As illustrated in this case report, increasing the shunt valve pressure may result in rapid resolution of the acute subdural hematoma in some patients.
PMCID: PMC3537755  PMID: 23174021
Normal-pressure hydrocephalus; Ventriculoperitoneal shunt; Acute subdural hematoma; Programmable shunt valve
8.  Scrotal perforation of peritoneal catheter: a rare complication of ventriculoperitoneal shunts 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 80.
The standard treatment for the hydrocephalus is ventriculoperitoneal shunts (VPS) operation that diverts the excess accumulated cerebrospinal fluid (CSF) from the ventricles or other CSF containing spaces to another area. The VPS operation has been reportedly associated with risk factor for different organs due to peritoneal catheter migration including umbilicus, anus, vagina, mouth, intestine, internal jugular vein, chest, liver.
A 45-day-old male infant was admitted to emergency department of Imam Reza hospital (Kermanshah Iran) with a history of fever, restlessness, leakage of clear fluid through diaper from 2 days ago which exited; appearing from tip of the white tube extruding from scrotum. The infant was born with the myelomeningocele and paraplegia. Therefore, he had previously undergone a surgery at the age of 3 days. One week later the infant developed progressive hydrocephalus and a medium–pressure VP shunt was inserted. He was discharged 3 days later with good health condition and the sutures were removed 12 days later. After a month the infant was brought to the emergency department in ill condition with the symptoms described above. At the PE fever detected and wet diaper was seen and by shunt pump compression clear fluid emerged from the tip of catheter. The CSF analysis revealed meningitis, no growth of pathologic organism 48 hours post-culture. The patient was hospitalized and appropriate antibiotic treatment was started. 10 days later CSF became acellular and the shunt was removed and another VP shunt was inserted contralaterally. After 4 days scrotal orifice was cured and the infant discharged.
Previous stories have reported many VS shunt-associated complications such as mechanical failure, functional failure, infections, obstruction, disconnection, migration, hematoma, and slit ventricle syndrome. Mechanical failures consist of obstruction, fracture, disconnection, migration. A search performed in the PubMed showed that until 2006 there has been no report of any case of scrotal skin perforation. Removing the shunt or replacing it with another one can be a good option for the management of any VS shunt failure. In case of leaking fluid, proximal diversion is recommended, while following the treatment of any infection, a new shunt insertion in another site is recommended.
Hydrocephalus, Ventriculoperitoneal shunt, Infant, Scrotal perforation, Peritoneal catheter
PMCID: PMC3571606
9.  Cytokines and Post-hemorrhagic Ventricular Dilation in Premature Infants 
American journal of perinatology  2012;29(9):731-740.
To determine in extremely low birth weight (ELBW) infants if elevated blood inteferon-γ (IFN-γ), interleukin-1β (IL-1β), IL-18, tumor necrosis factor-α (TNF-α), and transforming growth factor-β (TGFβ) are associated with need for shunt following severe intraventricular hemorrhage (IVH), or with ventricular dilation following milder grades /no IVH.
Study design
Whole blood cytokines were measured on postnatal days 1, 3, 7, 14, and 21. Maximum IVH grade in the first 28d, and shunt surgery or ventricular dilation on subsequent ultrasound (28d -36 w PMA) were determined.
Of 902 infants in the NICHD NRN Cytokine study who survived to 36w/discharge, 3.1% had shunts. Of the 12% of infants with severe (Gr III–IV) IVH, 26% had a shunt associated with elevated TNF-α. None of the infants without IVH (69%) or with Gr I (12%) or II (7%) IVH received shunts, but 8.4% developed ventricular dilation, associated with lower IFN-γ and higher IL-18.
Statistically significant but clinically non-discriminatory alterations in blood cytokines were noted in infants with severe IVH who received shunts and in those without severe IVH who developed ventricular dilation. Blood cytokines are likely associated with brain injury but may not be clinically useful as biomarkers for white matter damage.
PMCID: PMC3619127  PMID: 22773292
Infant; premature; Cytokines; Hydrocephalus; Intraventricular hemorrhage; Intracranial hemorrhage
10.  Center effect and other factors influencing temporization and shunting of cerebrospinal fluid in preterm infants with intraventricular hemorrhage 
There is little consensus regarding the indications for surgical CSF diversion (either with implanted temporizing devices [reservoir or subgaleal shunt] or shunt alone) in preterm infants with posthemorrhagic hydrocephalus. The authors determined clinical and neuroimaging factors associated with the use of surgical CSF diversion among neonates with intraventricular hemorrhage (IVH), and describe variations in practice patterns across 4 large pediatric centers.
The use of implanted temporizing devices and conversion to permanent shunts was examined in a consecutive sample of 110 neonates surgically treated for IVH related to prematurity from the 4 clinical centers of the Hydrocephalus Clinical Research Network (HCRN). Clinical, neuroimaging, and so-called processes of care factors were analyzed.
Seventy-three (66%) of the patients underwent temporization procedures, including 50 ventricular reservoir and 23 subgaleal shunt placements. Center (p < 0.001), increasing ventricular size (p = 0.04), and bradycardia (p = 0.07) were associated with the use of an implanted temporizing device, whereas apnea, occipitofrontal circumference (OFC), and fontanel assessments were not. Implanted temporizing devices were converted to permanent shunts in 65 (89%) of the 73 neonates. Only a full fontanel (p < 0.001) and increased ventricular size (p = 0.002) were associated with conversion of the temporizing devices to permanent shunts, whereas center, OFCs, and clot characteristics were not.
Considerable center variability exists in neurosurgical approaches to temporization of IVH in prematurity within the HCRN; however, variation between centers is not seen with permanent shunting. Increasing ventricular size—rather than classic clinical findings such as increasing OFCs—represents the threshold for either temporization or shunting of CSF.
PMCID: PMC3361965  PMID: 22546024
hydrocephalus; preterm infant; temporizing implant; intraventricular hemorrhage; cerebrospinal fluid shunt; Hydrocephalus Clinical Research Network
11.  Intraventricular hemorrhage 
Neurology  2008;70(11):848-852.
Spontaneous intracerebral hemorrhage (ICH) is frequently associated with intraventricular hemorrhage (IVH), which is an independent predictor of poor outcome. The purpose of this study was to examine the relationship between ICH volume and anatomic location to IVH, and to determine if ICH decompression into the ventricle is truly beneficial.
We retrospectively analyzed the CT scans and charts of all patients with ICH admitted to our stroke center over a 3-year period. Outcome data were collected using our prospective stroke registry.
We identified 406 patients with ICH. A total of 45% had IVH. Thalamic and caudate locations had the highest IVH frequency (69% and 100%). ICH volume and ICH location were predictors of IVH (p < 0.001). Within each location, decompression ranges (specific volume ranges where ventricular rupture tends to occur) were established. Patients with IVH were twice as likely to have a poor outcome (discharge modified Rankin scale of 4 to 6) (OR 2.25, p = 0.001) when compared to patients without IVH. Caudate location was associated with a good outcome despite 100% incidence of IVH. Spontaneous ventricular decompression was not associated with better outcome, regardless of parenchymal volume reduction (p = 0.72).
Intraventricular hemorrhage (IVH) occurs in nearly half of patients with spontaneous intracerebral hemorrhage (ICH) and is related to ICH volume and location. IVH is likely to occur within the “decompression ranges” that take into account both ICH location and volume. Further, spontaneous ventricular decompression does not translate to better clinical outcome. This information may prove useful for future ICH trials, and to the clinician communicating with patients and families.
PMCID: PMC2745649  PMID: 18332342
12.  A review of the current treatment methods for posthaemorrhagic hydrocephalus of infants 
Posthaemorrhagic hydrocephalus (PHH) is a major problem for premature infants, generally requiring lifelong care. It results from small blood clots inducing scarring within CSF channels impeding CSF circulation. Transforming growth factor – beta is released into CSF and cytokines stimulate deposition of extracellular matrix proteins which potentially obstruct CSF pathways. Prolonged raised pressures and free radical damage incur poor neurodevelopmental outcomes. The most common treatment involves permanent ventricular shunting with all its risks and consequences.
This is a review of the current evidence for the treatment and prevention of PHH and shunt dependency. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) and PubMed (from 1966 to August 2008) were searched. Trials using random or quasi-random patient allocation for any intervention were considered in infants less than 12 months old with PHH. Thirteen trials were identified although speculative interventions were also evaluated.
The literature confirms that lumbar punctures, diuretic drugs and intraventricular fibrinolytic therapy can have significant adverse effects and fail to prevent shunt dependence, death or disability. There is no evidence that postnatal phenobarbital administration prevents intraventricular haemorrhage (IVH). Subcutaneous reservoirs and external drains have not been tested in randomized controlled trials, but can be useful as a temporising measure. Drainage, irrigation and fibrinolytic therapy as a way of removing blood to inhibit progressive deposition of matrix proteins, permanent hydrocephalus and shunt dependency, are invasive and experimental. Studies of ventriculo-subgaleal shunts show potential as a temporary method of CSF diversion, but have high infection rates.
At present no clinical intervention has been shown to reduce shunt surgery in these infants. A ventricular shunt is not advisable in the early phase after PHH. Evidence exists that pre-delivery corticosteroid therapy reduces mortality and IVH and there may be trends towards reduced disability in the short term. There is also evidence that postnatal indomethacin reduces IVH but with no effect on mortality or disability. Overall, there is still no definitive algorithm for the treatment of PHH or prevention of shunt dependence. New therapeutic approaches in neonatal care, including those aimed at pre-empting PHH, offer the best hope of improving neurodevelopmental outcomes.
PMCID: PMC2642759  PMID: 19183463
13.  Endoscopic Third Ventriculostomy in Previously Shunted Children 
Minimally Invasive Surgery  2013;2013:584567.
Endoscopic third ventriculostomy (ETV) is a routine and safe procedure for therapy of obstructive hydrocephalus. The aim of our study is to evaluate ETV success rate in therapy of obstructive hydrocephalus in pediatric patients formerly treated by ventriculoperitoneal (V-P) shunt implantation. From 2001 till 2011, ETV was performed in 42 patients with former V-P drainage implantation. In all patients, the obstruction in aqueduct or outflow parts of the fourth ventricle was proved by MRI. During the surgery, V-P shunt was clipped and ETV was performed. In case of favourable clinical state and MRI functional stoma, the V-P shunt has been removed 3 months after ETV. These patients with V-P shunt possible removing were evaluated as successful. In our group of 42 patients we were successful in 29 patients (69%). There were two serious complications (4.7%)—one patient died 2.5 years and one patient died 1 year after surgery in consequence of delayed ETV failure. ETV is the method of choice in obstructive hydrocephalus even in patients with former V-P shunt implantation. In case of acute or scheduled V-P shunt surgical revision, MRI is feasible, and if ventricular system obstruction is diagnosed, the hydrocephalus may be solved endoscopically.
PMCID: PMC3742007  PMID: 23984061
14.  Low superior vena cava flow and intraventricular haemorrhage in preterm infants 
OBJECTIVES—To document the incidence, timing, degree, and associations of systemic hypoperfusion in the preterm infant and to explore the temporal relation between low systemic blood flow and the development of intraventricular haemorrhage (IVH).
STUDY DESIGN—126 babies born before 30 weeks' gestation (mean 27 weeks, mean body weight 991 g) were studied with Doppler echocardiography and cerebral ultrasound at 5, 12, 24, and 48 hours of age. Superior vena cava (SVC) flow was assessed by Doppler echocardiography as the primary measure of systemic blood flow returning from the upper body and brain. Other measures included colour Doppler diameters of ductal and atrial shunts, as well as Doppler assessment of shunt direction and velocity, and right and left ventricular outputs. Upper body vascular resistance was calculated from mean blood pressure and SVC flow.
RESULTS—SVC flow below the range recorded in well preterm babies was common in the first 24 hours (48 (38%) babies), becoming significantly less common by 48 hours (6 (5%) babies). These low flows were significantly associated with lower gestation, higher upper body vascular resistance, larger diameter ductal shunts, and higher mean airway pressure. Babies whose mothers had received antihypertensives had significantly higher SVC flow during the first 24 hours. Early IVH was already present in 9 babies at 5 hours of age. Normal SVC flows were seen in these babies except in 3 with IVH, which later extended, who all had SVC flow below the normal range at 5 and/or 12 hours. Eight of these 9 babies were delivered vaginally. Late IVH developed in 18 babies. 13 of 14 babies with grade 2to 4 IVH had SVC flow below the normal range before development of an IVH. Two of 4 babies with grade 1 IVH also had SVC flow below the normal range before developing IVH, and the other 2had SVC flow in the low normal range. In all, IVH was first seen after the SVC flow had improved, and the grade of IVH related significantly to the severity and duration of low SVC flow. The 9 babies who had SVC flow below the normal range and did not develop IVH or periventricular leucomalacia were considerably more mature (median gestation 28 v 25weeks).
CONCLUSIONS—Low SVC flow may result from an immature myocardium struggling to adapt to increased extrauterine vascular resistances. Critically low flow occurs when this is compounded by high mean airway pressure and large ductal shunts out of the systemic circulation. Late IVH is strongly associated with these low flow states and occurs as perfusion improves.

PMCID: PMC1721081  PMID: 10794784
15.  Warfarin-related intraventricular hemorrhage 
Neurology  2011;77(20):1840-1846.
Oral anticoagulation therapy (OAT) with warfarin increases mortality and disability after intracerebral hemorrhage (ICH), the result of increased ICH volume and risk of hematoma expansion. We investigated whether OAT also influences risk of development of intraventricular hemorrhage (IVH), the volume of IVH and IVH expansion, and whether IVH is a substantive mediator of the overall effect of OAT on ICH outcome.
We performed a retrospective analysis of a prospectively collected single-center cohort of 1,879 consecutive ICH cases (796 lobar, 865 deep, 153 cerebellar, 15 multiple location, 50 primary IVH) from 1999 to 2009. ICH and IVH volumes at presentation, as well as hematoma expansion (>33% or >6 mL increase) and IVH expansion (>2 mL increase), were determined using established semiautomated methods. Outcome was assessed at 90 days using either the modified Rankin Scale or Glasgow Outcome Scale.
Warfarin use was associated with IVH risk, IVH volume at presentation, and IVH expansion in both lobar and deep ICH (all p < 0.05) in a dose-response relationship with international normalized ratio. Warfarin was associated with poor outcome in both lobar and deep ICH (p < 0.01), and >95% of this effect was accounted for by baseline ICH and IVH volumes, as well as ICH and IVH expansion.
Warfarin increases IVH volume and risk of IVH expansion in lobar and deep ICH. These findings (along with effects on ICH volume and expansion) likely represent the mechanisms by which anticoagulation worsens ICH functional outcome.
PMCID: PMC3233208  PMID: 22049204
16.  Spontaneous supratentorial intracerebral hemorrhage: Does surgery benefit comatose patients? 
Treatment of spontaneous supratentorial intracerebral hemorrhage (SICH) is still controversial. We therefore analyzed the comatose patients diagnosed as having spontaneous SICH and treated by surgery.
Materials and Methods:
We retrospectively analyzed the collected data of 25 comatose patients with initial Glasgow Coma Scale (GCS) ≤ 8 diagnosed as having spontaneous SICH and they had been treated by surgical evacuation between 1996 and 2008. The outcome was assessed using Glasgow outcome scale (GOS). The side and location of the hematoma and ventricular extension of the hematoma were recorded. The hematoma volume was graded as mild (<30 cc), moderate (30–60 cc) and massive (>60 cc).
Age of the patients ranged from 25 to 78 years (mean: 59.6 ± 15.14 years). Among the 25 patients studied, 11 (44%) were females and 14 (56%) were males. GCS before surgery was <5 in 8 (32%) patients and between 5 and 8 in 17 (68%) patients. The hematoma volume was less than 30 cc in 2 patients, between 30 and 60 cc in 9 patients and more than 60 cc in 14 patients. Fourteen of the patients had no ventricular connection and 11 of the hematomas were connected to ventricle. All the 25 patients were treated with craniotomy and evacuation of the hematoma was done within an average of 2 hours on admission to the emergency department. Postoperatively, no rebleeding occurred in our patients. The most important complication was infection in 14 of the patients. The mortality of our surgical series was 56%. GCS before surgery was one of the strongest factors affecting outcome GCS (oGCS) (P = 0.017). Income GCS (iGCS), however, did not affect GOS (P = 0.64). The volume of the hematoma also affected the outcome (P = 0.037). Ventricular extension of the hematoma did affect the oGCS and GOS (P = 0.002), but not the iGCS of the patients (P = 0.139).
Our data suggest that being surgically oriented is very important to achieve successful outcomes in a select group of patients with SICH.
PMCID: PMC2981755  PMID: 21085528
Mortality; outcome; spontaneous supratentorial intracerebral hemorrhage; surgery; treatment
17.  Cerebellar Glioblastoma Multiforme Presenting as Hypertensive Cerebellar Hemorrhage: Case Report 
Background Cerebellar glioblastoma multiforme (GBM) is rare and presents with increased intracranial pressure and cerebellar signs. The recommended treatment is radical resection, if possible, with radiation and chemotherapy.
Clinical Presentation A 53-year-old man presented with hypertensive cerebellar bleeding and a 2-day history of severe headaches, nausea, vomiting, gait instability, and elevated blood pressure. Computed tomography (CT) showed a left cerebellar hematoma with no obstruction of cerebrospinal fluid and no hydrocephalus. CT angiography showed no signs of pathologic blood vessels in the posterior cranial fossa. The patient was observed in the hospital and discharged. Subsequent CT showed complete hematoma resorption. Two weeks later, he developed headaches, nausea, and worsening cerebellar symptoms. Magnetic resonance imaging (MRI) showed a 4-cm diameter tumor in the left cerebellar hemisphere where the hemorrhage was located. The tumor was radically resected and diagnosed as GBM. The patient underwent radiation and chemotherapy. At a follow-up of 1.5 years, MRIs showed no tumor recurrence.
Conclusion Hypertensive cerebellar hemorrhage may be the first presentation of underlying tumor, specifically GBM. Patients undergoing surgery for cerebellar hemorrhage should have clot specimens sent for histologic examination and have pre- and postcontrast MRIs. Patients not undergoing surgery should have MRIs done after hematoma resolution to rule out underlying tumor.
PMCID: PMC4110145  PMID: 25097829
bleeding; cerebellar hemorrhage; cerebellum; glioblastoma multiforme; hypertension; hypertensive cerebellar bleed
18.  Coiling and neuroendoscopy: a new perspective in the treatment of intraventricular haemorrhages due to bleeding aneurysms 
Intraventricular haemorrhages (IVHs) caused by bleeding aneurysms are critical conditions that often carry a severe prognosis. Two main problems must be urgently dealt with: the secondary damage caused by intraventricular clotting and the risk of early rebleeding. A protocol of ultra‐early endoscopic ventricular evacuation, after securing the aneurysm with coils, is proposed to solve this challenge in the acute phase and within a few hours of onset.
Ten consecutive patients presenting with haematocephalus from aneurysm rupture were treated in our institute with coiling and endoscopic clot aspiration extended to the whole ventricular system. The only inclusion criteria were the presence of a massive IVH and an aneurysm appropriate for coiling. Computed tomography scans obtained before (within 4 h of symptom onset in all patients) and immediately after surgery were compared for Graeb score and ventriculocranial ratio (VCR); the Glasgow Outcome Scale (GOS) was assessed at 1 year.
All patients were treated within 2 days of onset. The procedure resulted in a mean 58% removal of ventricular blood and decrease of hydrocephalus; the mean (standard deviation (SD)) Graeb score reduced from 11.5 (0.7) to 4.7 (2.2) (p<0.001) and mean ventriculocranial ratio from 0.26 (0.06) to 0.17 (0.05) (p<0.001). No rebleeding or delayed hydrocephalus needing shunt was observed. Mortality at 1 year was 30%; marked disability (GOS = 3) and good recovery (GOS = 5) were observed in 40% and 30% of patients, respectively.
Early neuroendoscopic removal of blood casting from the lateral to the fourth ventricle after coiling of bleeding aneurysms is a feasible approach, allowing in most instances the rapid improvement of the IVH.
PMCID: PMC2077420  PMID: 16835289
19.  Early ductal shunting and intraventricular haemorrhage in ventilated preterm infants. 
AIM: To establish if there is an association between early cardiovascular adaptation and intraventricular haemorrhage (IVH). METHODS: One hundred and seventeen ventilated preterm infants (mean gestational age 27 weeks, mean birthweight 993 g) were studied echocardiographically within the first 36 hours. Measurements included right (RVO) and left ventricular outputs (LVO), ductus arteriosus (PDA) and atrial shunt diameter using colour Doppler and pulsed Doppler direction and velocity of both shunts. Clinical variables collected over the first 24 hours included use of antenatal steroids, respiratory severity, and mean blood pressure. Cerebral ultrasound scans were reported by a radiologist blinded to clinical and echocardiographic data. RESULTS: Antenatal steroids (two doses) had been given to 73% of the 86 infants with no IVH compared with 48% of the 21 infants with grades 1 and 2 IVH, and just 10% of 10 babies with grades 3 and 4 (P < 0.05). Both groups with IVH had significantly larger PDA diameters than the group with no IVH. Infants with grades 3 and 4 IVH had significantly lower RVO than the other infants. These differences were more pronounced when only infants with definite late IVH were analysed. Logistic regression analysis showed lack of antenatal steroids and larger PDA diameters were significantly associated with any grade of IVH and lack of antenatal steroids; lower RVO was significantly associated with grades 3 and 4 IVH. CONCLUSIONS: Larger early PDA shunts, lower RVO, and lack of antenatal steroids were significantly associated with IVH.
PMCID: PMC1061197  PMID: 8976684
20.  Safety of Intraventricular Hemorrhage (IVH) Thrombolysis Based on CT Localization of External Ventricular Drain (EVD) Fenestrations and Analysis of EVD Tract Hemorrhage 
Neurocritical care  2013;19(1):103-110.
The purpose of the study is to review the CT findings associated with ventriculostomy placement in regards to the safety of an EVD plus recombinant tissue plasminogen activator (rt-PA) for IVH.
A retrospective review was conducted for patients receiving intraventricular rt-PA for IVH from January 2004 to September 2009. Safety was assessed by the presence of EVD tract hemorrhage by CT at baseline after EVD placement, worsening hemorrhage after rt-PA, and CSF infection. IVH volumetrics were assessed by the Le Roux score and outcomes by Glasgow Outcome Scale and modified Rankin Scale.
Twenty-seven patients received rt-PA for IVH. Median dose was 2 mg (range 0.3–8) and a median of two doses (range 1–17) were given. Worsening EVD catheter tract hemorrhage after rt-PA was 46.7 %, with a significantly higher incidence of worsening tract hemorrhage seen with incorrectly placed EVDs (p = 0.04). IVH hematoma burden decreased by a median Le Roux score of 10 (range 3–16) prior to rt-PA to 4 (range 0–16) after rt-PA. There were no central nervous system bacterial infections.
Intraventricular rt-PA appears to be relatively safe especially when all EVD fenestrations are within the ventricle and reduces IVH burden similar to other studies. We describe a CT-based EVD tract hemorrhage grading scale to evaluate EVD tract hemorrhage before and after thrombolysis, and a bone-window technique to evaluate EVD fenestrations prior to IVH thrombolysis. Further research is needed evaluating these imaging techniques in regard to intraventricular thrombolytic safety and EVD tract hemorrhage.
PMCID: PMC3785325  PMID: 22544476
Intracerebral hemorrhage; Intraventricular hemorrhage; Cerebrovascular disease; Stroke; Critical care
21.  Frequency of Sustained Intracranial Pressure Elevation during Treatment of Severe Intraventricular Hemorrhage 
Elevated intracranial pressure (ICP) is an important marker of neurological deterioration. The occurrence and significance of elevated ICP and low cerebral perfusion pressure (CPP) in aggressively treated spontaneous intraventricular hemorrhage (IVH) are not defined.
We performed a secondary longitudinal exploratory data analysis of a randomized multicenter trial of urokinase (UK) versus placebo (Pcb) as a treatment for IVH. Eleven IVH patients who required an external ventricular drain (EVD) were randomized to receive either intraventricular UK or Pcb every 12 h until clinical response permitted EVD removal. ICP and CPP were recorded every 4 or 6 h, as well as before and 1 h after EVD closure for administration of study agent. ICP, CPP and the proportion of ICP readings above 20, 30, 40 and 50 mm Hg were analyzed.
Six UK and 5 Pcb patients aged 39–74 years (mean ± standard deviation; 53 ± 11 years) were enrolled. Initial ICP ranged from 0 to 38 mm Hg (10.9 ± 11.0), initial CPP from 65 to 133 mm Hg (100.5 ± 17.7). We recorded 472 ICP readings over the entire monitoring period. Of these 65 (14%) were >20 mm Hg, 23 (5%) >30 mm Hg, 9 (2%) >40 mm Hg and 3 (<1%) >50 mm Hg. Only 2 of 141 intraventricular injections of study agent with EVD closure were not tolerated and required reopening of the EVD.
In the intensive care unit, initial ICP measured with an EVD was uncommonly elevated (1/11 patients) in this group of severe IVH patients despite acute obstructive hydrocephalus. Frequent monitoring reveals ICP elevation >20 mm Hg in 14% of observations during use of EVD. ICP elevation, though it can occur, is not routinely associated with EVD closure for thrombolytic treatment with UK.
PMCID: PMC2909706  PMID: 19295201
Intracerebral hemorrhage; Thrombolysis; Intracranial pressure; Stroke; Hydrocephalus
22.  Intraventricular hemorrhage and ICH outcomes: Severity factor and treatment target 
Background and Purpose
This review focuses on the emerging principles of ICH management, emphasizing the natural history and treatment of intraventricular hemorrhage. The translational and clinical findings from recent randomized clinical trials are defined and discussed.
Summary of Review
Brain hemorrhage is the most severe of the major stroke subtypes. Extension of the hemorrhage into the ventricles (a 40% occurrence) can happen early or late in the sequence of events. Epidemiologic data demonstrate the amount of blood in the ventricles relates directly to the degree of injury and likelihood of survival. Secondary tissue injury processes related to intraventricular bleeding can be reversed by removal of clot in animals. Specific benefits of removal include limitation of inflammation, edema, and cell death as well as restoration of CSF flow, ICP homeostasis, improved consciousness, and shortening of ICU stay. Limited clinical knowledge exists about the benefits of IVH removal in humans, as organized attempts to remove blood have not been undertaken in large clinical trials on a generalized scale. New tools to evaluate the volume and location of IVH and to test the benefits/risks of removal have been employed in the clinical domain. Initial efforts are encouraging that increased survival and functional improvement can be achieved. Little controversy exists regarding the need to scientifically investigate treatment of this severity factor.
Animal models demonstrate clot removal can improve the acute and long term consequences of intraventricular extension from ICH by employing minimally invasive techniques coupled to rt-PA mediated clot lysis. The most recent human clinical trials show that severity of initial injury and the long term consequences of blood extending into the ventricles are clearly related to the amount of bleeding into the ventricular system. The failure of the last two pivotal brain hemorrhage RCTs may well relate to the consequences of intraventricular bleeding. Small proof of concept studies, meta-analyses, and preliminary pharmacokinetics studies support the idea of positive shifts in mortality and morbidity, if this one critical disease severity factor, IVH, is properly addressed. Understanding clinical methods for the removal of IVH is required, if survival and long term functional outcome of brain hemorrhage is to improve worldwide.
PMCID: PMC2744212  PMID: 19246695
IVH; ICH; thrombolysis; rt-PA; functional outcome
23.  Predictors and outcomes of shunt-dependent hydrocephalus in patients with aneurysmal sub-arachnoid hemorrhage 
BMC Surgery  2012;12:12.
Hydrocephalus following spontaneous aneurysmal sub-arachnoid hemorrhage (SAH) is often associated with unfavorable outcome. This study aimed to determine the potential risk factors and outcomes of shunt-dependent hydrocephalus in aneurysmal SAH patients but without hydrocephalus upon arrival at the hospital.
One hundred and sixty-eight aneurysmal SAH patients were evaluated. Using functional scores, those without hydrocephalus upon arrival at the hospital were compared to those already with hydrocephalus on admission, those who developed it during hospitalization, and those who did not develop it throughout their hospital stay. The Glasgow Coma Score, modified Fisher SAH grade, and World Federation of Neurosurgical Societies grade were determined at the emergency room. Therapeutic outcomes immediately after discharge and 18 months after were assessed using the Glasgow Outcome Score.
Hydrocephalus accounted for 61.9% (104/168) of all episodes, including 82 with initial hydrocephalus on admission and 22 with subsequent hydrocephalus. Both the presence of intra-ventricular hemorrhage on admission and post-operative intra-cerebral hemorrhage were independently associated with shunt-dependent hydrocephalus in patients without hydrocephalus on admission. After a minimum 1.5 years of follow-up, the mean Glasgow outcome score was 3.33 ± 1.40 for patients with shunt-dependent hydrocephalus and 4.21 ± 1.19 for those without.
The presence of intra-ventricular hemorrhage, lower mean Glasgow Coma Scale score, and higher mean scores of the modified Fisher SAH and World Federation of Neurosurgical grading on admission imply risk of shunt-dependent hydrocephalus in patients without initial hydrocephalus. These patients have worse short- and long-term outcomes and longer hospitalization.
PMCID: PMC3467164  PMID: 22765765
Outcome; Risk factors; Hydrocephalus after spontaneous aneurysmal subarachnoid hemorrhage
24.  Minimally invasive evacuation of spontaneous intracerebral hemorrhage using sonothrombolysis 
Journal of neurosurgery  2011;115(3):592-601.
Catheter-based evacuation is a novel surgical approach for the treatment of brain hemorrhage. The object of this study was to evaluate the safety and efficacy of ultrasound in combination with recombinant tissue plasminogen activator (rt-PA) delivered through a microcatheter directly into spontaneous intraventricular (IVH) or intracerebral (ICH) hemorrhage in humans.
Thirty-three patients presenting to the Swedish Medical Center in Seattle, Washington, with ICH and IVH were screened between November 21, 2008, and July 13, 2009, for entry into this study. Entry criteria included the spontaneous onset of intracranial hemorrhage ≥ 25 ml and/or IVH producing ventricular obstruction. Nine patients (6 males and 3 females, with an average age of 63 years [range 38–83 years]) who met the entry criteria consented to participate and were entered into the trial. A ventricular drainage catheter and an ultrasound microcatheter were stereotactically delivered together, directly into the IVH or ICH. Recombinant tissue plasminogen activator and 24 hours of continuous ultrasound were delivered to the clot. Gravity drainage was performed. In patients with IVHs, 3 mg of rt-PA was injected; in patients with intraparenchymal hemorrhages, 0.9 mg of rt-PA was injected. The rt-PA was delivered in 3 doses over 24 hours.
All patients had significant volume reductions in the treated hemorrhage. The mean percentage volume reduction after 24 hours of therapy, as determined on CT and compared with pretreatment stability scans, was 59 ± 5% (mean ± SEM) for ICH and 45.1 ± 13% for IVH (1 patient with ICH was excluded from analysis because of catheter breakage). There were no intracranial infections and no significant episodes of rebleeding according to clinical or CT assessment. One death occurred by 30 days after admission. Clinical improvements as determined by a decrease in the National Institutes of Health Stroke Scale score were demonstrated at 30 days after treatment in 7 of 9 patients. The rate of hemorrhage lysis was compared between 8 patients who completed treatment, and patient cohorts treated for IVH and ICH using identical doses of rt-PA and catheter drainage but without the ultrasound (courtesy of the MISTIE [Minimally Invasive Surgery plus T-PA for Intracerebral Hemorrhage Evacuation] and CLEAR II [Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage II] studies). Compared with the MISTIE and CLEAR data, the authors observed a faster rate of lysis during treatment for IVH and ICH in the patients treated with sonolysis plus rt-PA versus rt-PA alone.
Lysis and drainage of spontaneous ICH and IVH with a reduction in mass effect can be accomplished rapidly and safely through sonothrombolysis using stereotactically delivered drainage and ultrasound catheters via a bur hole. A larger clinical trial with catheters specifically designed for brain blood clot removal is warranted.
PMCID: PMC3785332  PMID: 21663412
intracerebral hemorrhage; hypertensive hemorrhage; intraventricular hemorrhage; tissue plasminogen activator; ultrasound; sonothrombolysis
25.  Do antibiotic-impregnated shunts in hydrocephalus therapy reduce the risk of infection? An observational study in 258 patients 
Shunt infection in hydrocephalus patients is a severe, even life-threatening complication. Antibiotic-impregnated shunts (AIS) have been developed in an attempt to reduce rate of shunt infection. The study was performed to analyze if AIS can diminish the rate of shunt infection. The pathogenic nature of shunt infection in patients with AIS systems and those without antibiotic impregnated shunts (non-AIS) was compared.
Over a period of 24 months in the Department of Neurosurgery at University Hospital of Tübingen shunt surgery was performed in 258 patients. In 86 patients AIS systems were implanted. Shunt catheters were commercially impregnated with clindamycin and rifampicin. Analysis of the clinical data included sex, age, classification of hydrocephalus, shunt types and risk factors for shunt infection [age (< 1 year and > 80 years), prematurely born patients, external ventricular drainage, former shunt infection, former systemic infection, disturbance of consciousness, former radiation-/chemotherapy]. Infection rates and underlying bacterial pathogens of patients with AIS were compared to patients with implanted non-AIS systems (172 patients).
AIS and non-AIS patients did not differ in sex, etiology of hydrocephalus and the shunt type. In the AIS group 72 out of 86 patients had at least one risk factor (83.7 %), compared to 126 patients in the non-AIS group (73.3 %). There was no significant difference between the two groups (p = 0.0629; Fisher's exact test). In patients with no risk factors, only one patient with non-AIS suffered from shunt infection. In patients with one or more risk factors the rate for shunt infection was 7.14 % in patients with non-AIS and 6.94 % in patients with AIS. Former shunt infection (p = 0.0124) was related to higher risk for shunt infection. The use of AIS had therefore no significant advantage (p = 0.8611; multiple logistic regression).
Significantly related to a shunt infection was the number of shunt surgeries. 190 interventions in the AIS group (2.21 interventions per patient) and 408 in the non-AIS group (2.37 interventions per patient) had been performed (p = 0.3063; Wilcoxon). There was no shunt infection in the group of patients on whom only one shunt surgery was performed. In patients with at least two shunt surgeries the infection rate was 9%. The infection rate in AIS patients was 5/52 (9.6 %) and in the non-AIS 10/114 (8.77 %), (p = 1.0; Fisher's exact test). Staphylococcus epidermidis was the most frequent pathogen for shunt infection. Fourteen out of 15 infections occurred within the first 6 months of surgery. The most frequent pathogen for shunt infection was S. epidermidis. No toxic or allergic complications were seen using the AIS shunt systems. The presented data show a remarkably low infection rate of 5.8 % in the non-AIS group compared to other studies which demonstrated a significant decrease in the infection rate by AIS.
AIS did not significantly reduce shunt infection in hydrocephalus patients in the presented study. In the AIS group three patients suffered from shunt infections caused by skin ulceration or neurosurgical procedures with exposure of the cerebrospinal liquor after shunt implantation. AIS was not developed to prevent infection in such cases, therefore an advantage of AIS can not be excluded. In view of the presented data and the small number of reported studies a prospective randomized multicenter study is required.
PMCID: PMC1888699  PMID: 17488498

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