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1.  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
2.  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  PMID: 25685202
Endoscopy; factor VIIa; Graeb score; hydrocephalus; intraventricular haemorrhage
3.  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
4.  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
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.  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
7.  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
8.  Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage 
Critical care medicine  2012;40(5):1601-1608.
Elevated intracranial pressure (ICP) is one of the proposed mechanisms leading to poor outcomes in patients with intraventricular hemorrhage (IVH). We sought to characterize the occurrence and significance of intracranial hypertension in severe IVH requiring extraventricular drainage (EVD).
Prospective analysis from two randomized multicenter clinical trials.
Intensive care units of 23 academic hospitals.
One hundred patients with obstructive IVH, and intracerebral hemorrhage (ICH) volume < 30cc requiring emergency EVD from two randomized multicenter studies comparing intraventricular recombinant tissue plasminogen activator (rt-PA) (n=78) to placebo (n=22).
ICP was recorded every 4 hours in all patients and before and after a 1 hr EVD closure period post-injection. ICP readings were analyzed at pre-defined thresholds and compared between treatment groups, pre- and post-injection of study agent, and pre- and post-opening of 3rd and 4th ventricles on CT. Impact on 30 day outcomes was assessed.
Measurements and Main Results
Initial ICP ranged from −2 to 60 mm Hg (median, interquartile range; 11,10). Of 2576 ICP readings, 91.5% (2359) were ≤ 20 mm Hg, 1.6% were >30, 0.5% were >40, and 0.2% were > 50 mm Hg. In a multivariate analysis threshold events > 20 and > 30 mm Hg were more frequent in placebo vs. rt-PA treated groups (p=0.03 and p=0.08, respectively). ICP elevation > 20 mm Hg occurred during a required 1 hr EVD closure interval in 207/868 (23.8%) injections of study agent although early re-opening of the EVD only occurred in 7.9%. After radiographic opening of the lower ventricular system, ICP events > 20 mmHg remained significantly associated with initial IVH volume (p=0.002), and EVD placement ipsilateral to the largest IVH volume (p=0.001), but not with thrombolytic treatment (p=0.05) or ICH volume (p=0.14). VP shunts were required in 13.6% of Pcb and 6.4% of rt-PA treated patients (p=0.37). Percentage of ICP readings per patient > 30 mmHg, and initial ICH and IVH volumes were independent predictors of 30 day mortality after adjustment for other outcome predictors (p=0.003; p=0.03; p<0.001, respectively). Independent predictors of poor modified Rankin Score (mRS) at 30 days were % of ICP events > 30 mmHg/patient (p=0.01) (but not > 20 mmHg), both ICH and IVH volume and pulse pressure.
ICP is not frequently elevated during monitoring and drainage with an EVD in patients with severe IVH although ICP > 30 mm Hg predicts higher short-term mortality. Thrombolytic therapy may reduce the frequency of high ICP events. ICP elevation appears to be significantly correlated with EVD placement in the ventricle with greatest clot volume.
PMCID: PMC4365868  PMID: 22430237
Intracranial pressure; intraventricular hemorrhage; hydrocephalus; thrombolysis; intracerebral hemorrhage
9.  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
10.  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
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.  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
13.  The isolated fourth ventricle 
BMJ Case Reports  2013;2013:bcr2013008791.
Isolated enlargement of the fourth ventricle, or ‘encysted’ fourth ventricle is a rare late complication following shunt insertion of the lateral ventricles for hydrocephalus. Caudal and rostral obstruction of the fourth ventricle and its subsequent dilation results in compression of adjacent cerebellum and brain stem structures; treatment with further shunt insertion directly to the fourth ventricle is invariably successful. There is potential for diagnostic delay, when clinical symptoms and signs of cerebellar and brain stem compromise are unrecognised or attributed to other factors, and attention on the CT is focused on the lateral ventricular system and the already existing  ventriculoperitoneal shunt, which will appear unchanged from previous scans. We report two cases with isolated fourth ventricular obstruction and review the literature to highlight the importance of recognising this condition.
PMCID: PMC3645115  PMID: 23559656
14.  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
15.  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
16.  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
17.  Posthemorrhagic hydrocephalus in extremely low birth weight infants: Ommaya reservoir vs. ventriculoperitoneal shunt 
Child's Nervous System  2015;31(8):1261-1266.
The aim of this study was to analyze morbidity and initial surgery in infants with posthemorrhagic hydrocephalus (PHH) by comparing infants who were treated with a subcutaneous cerebrospinal fluid reservoir (Ommaya reservoir = CSF_R) with infants who primarily received a ventriculoperitoneal shunt (VPS).
Inclusion criteria were infants born between January 2006 and June 2014 who had a diagnosis of intraventricular hemorrhage (IVH) and underwent surgical intervention for hydrocephalus.
Twenty-five infants, with a median gestational age (GA) of 26.5 (28 ± 4) weeks and a median birth weight (BW) of 980 g (1205 ± 837), were included. The median umbilical artery pH (UApH) was 7.30 (7.20 ± 0.25). The median Apgar score at 10 min was 8 (7.4 ± 2). Twenty-five peri- and postnatal adverse events were encountered preoperatively. The IVH grades were grade II (n = 1), grade III (n = 17), grade IV (n = 6), and unknown grade (n = 1). Primary treatment consisted of CSF_R (n = 18) or VPS (n = 7) placement. There was a statistically significant difference between the postnatal ages of infants with CSF_R (32.5 days; 42 ± 28) and infants with VPS (163 days; 161 ± 18). Furthermore, we found a difference regarding GA but not BW between both groups. Arrest of PHH with shunt independence occurred in two infants from the CSF_R group (11 %).
In the present study, early insertion of CSF_R allowed stabilization of the infants and thus postponement of permanent VPS insertion. However, in a subgroup of patients, PHH develops over a more prolonged course, and VPS insertion can be performed initially without the need for CSF_R.
PMCID: PMC4513217  PMID: 26018211
Posthemorrhagic hydrocephalus; Ommaya reservoir; Ventriculoperitoneal shunt
18.  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
19.  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
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.  Relocation of ventricular catheter trough ventriculostomy due to congenital unilateral hydrocephalus: Nine year follow-up 
Congenital unilateral hydrocephalus is an uncommon entity occurring almost exclusively in children. Atresia, stenosis, membranous occlusion and even functional obstruction of the foramen of Monro have been described to be the main cause of this type of hydrocephalus. There are two options available in the surgical management of unilateral hydrocephalus: one is the placement of shunt CSF diversion from the dilated ventricle and the other is fenestration of the occluded foramen of Monro or septum pellucidum by endoscopy or by stereotactic method. Migration of the ventriculoperitoneal (VP) shunt in or out of ventricles is not so uncommon, but the relocation of the ventricular tip of a catheter from the ventricle into the quadrigeminal cisterns and superior vermis in association with ventriculostomy is extremely rare. Spontaneous ventriculostomy is a rare event and results from spontaneous rupture of a ventricle into the subarachnoid space.
Case Description:
A 5½-month-old baby with a right-sided congenital unilateral hydrocephalus underwent a VP shunt andhad experienced an uneventful outcome. Four years later on an MR imaging examination, the tip of the ventricular catheter passing through the medial wall of the ventricle and the quadrigeminal cistern was found to be situated in the superior vermis. During the follow-up period, there were no neurological difficulties. The cognitive and motor skill development corresponded well with the child's age. It transpired that the hydrocephalic ventricle reduced its size dramatically to normal.
We have described the extremely rare site of the relocation of the ventricular catheter after the treatment of the congenital unilateral hydrocephalus by VP shunting. Spontaneous ventriculostomy as a rare phenomenon may be the explanation of the relocation of the ventricular catheter.
PMCID: PMC3205507  PMID: 22059136
Congenital unilateral hydrocephalus; ventriculoperitoneal shunt; ventriculostomy
22.  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
23.  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
24.  A multicenter retrospective comparison of conversion from temporary to permanent cerebrospinal fluid diversion in very low birth weight infants with posthemorrhagic hydrocephalus 
The purpose of this study was to define the incidence of permanent shunt placement and infection in patients who have undergone the 2 most commonly performed temporizing procedures for posthemorrhagic hydrocephalus (PHH) of prematurity: ventriculosubgaleal (VSG) shunt placement and ventricular reservoir placement for intermittent tapping.
The 4 centers of the Hydrocephalus Clinical Research Network participated in a retrospective chart review of infants with PHH who underwent treatment at each institution between 2001 and 2006. Patients were included if they had received a diagnosis of Grade 3 or 4 intraventricular hemorrhage, weighed < 1500 g at birth, and had received surgical intervention. The authors determined the incidence of conversion from a temporizing device to a permanent shunt, the incidence of CSF infection during temporization, and the 6-month CSF infection rate after permanent shunt placement.
Thirty-one (86%) of 36 patients who received VSG shunts and 61 (69%) of 88 patients who received ventricular reservoirs received permanent CSF diversion with a shunt (p = 0.05). Five patients (14%) in the VSG shunt group had CSF infections during temporization, compared with 11 patients (13%) in the ventricular reservoir group (p = 0.83). The 6-month incidence of permanent shunt infection in the VSG shunt group was 16% (5 of 31), compared with 12% (7 of 61) in the reservoir placement group (p = 0.65). For the first 6 months after permanent shunt placement, infants with no preceding temporizing procedure had an infection rate of 5% (1 of 20 infants) and those who had undergone a temporizing procedure had an infection rate of 13% (12 of 92; p = 0.45).
The use of intermittent tapping of ventricular reservoirs in this population appears to lead to a lower incidence of permanent shunt placement than the use of VSG shunts. The incidence of infection during temporization and for the initial 6 months after conversion appears comparable for both groups. The apparent difference identified in this pilot study requires confirmation in a more rigorous study.
PMCID: PMC2895163  PMID: 19569911
hydrocephalus; premature birth; intraventricular hemorrhage
25.  Ventriculosubgaleal shunt procedure and its long-term outcomes in premature infants with post-hemorrhagic hydrocephalus 
Child's Nervous System  2010;26(11):1505-1515.
It is well known that 10–15% of hydrocephalus cases at childhood and 40–50% in premature infants, occur following Germinal matrix hemorrhage (GMH). Such hemorrhages are reported to arise due to the rupture of germinal matrix (GM) vessels as a result of cerebral blod flow changes among infants with <1500 g birth weight and <32 weeks old. Intraventricular hemorrhage (IVH) associated with GMH leads to a disruption in the cerebrospinal fluid (CSF) and ventricular dilatation. Ventriculosubgaleal shunt (VSGS) is preferred in those hydrocephalus cases because it is a simple and rapid method, precludes the need for repetitive aspiration for evacuation of CSF, establishes a permanent decompression without causing electrolyte and nutritional losses, and aims to protect the cerebral development of newborns with GMH.
Material and method
The present study comprises 25 premature cases, subjected to VSGS and diagnosed with post-hemorrhagic hydrocephalus (PHH) arising from IVH associated with GM, and low birth weight (LBW) in the Neurosurgery Department of the Medical Faculty of Erciyes University between July 2002 and September 2006. VSGS surgery was performed on those cases, and their clinical and radiological prognoses were monitored with regard to several parameters.
Mortality and morbidity results were found to be lower than those in PPH treatment methods. While prognosis of grade 4 GMHs was poor, grades 2 and 3 GMHs displayed a much better prognosis after VSGS along with complete recovery in some hydrocephalus cases.
PMCID: PMC2974185  PMID: 20300758
Germinal matrix hemorrhage; Hydrocephalus; Ventriculosubgaleal shunt

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