Introduction:

Ruptured aneurysms causing intraventricular hemorrhage (IVH) are associated with great mordbity. The presence of blood that completely fills the fourth ventricle (Casted Fourth Ventricle, or CFV) is thought to be particularly ominous, but outcomes of such cases are lacking in literature. A prospectively collected randomized trial of patients with documented aneurysmal subarachnoid hemorrhage (aSAH) was investigated, comparing outcomes of patients with CVF to all other patients with IVH.

Methods:

408 patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) were reviewed for IVH. A total of 240 patients suffering from an IVH were identified. The admission CT scans were retrospectively reviewed for the presence of a CFV. Clinical outcome was evaluated at discharge and at 1-year follow-up. A poor outcome was defined as a mRS >2.

Results:

25 patients were found to have CT evidence of CFV. Admission GCS was lower in patients with CFV, 7.7 vs 11.5 (p-value < 0.0001). At discharge and one-year follow up, patients with CFV had a 7 times greater risk of a poor outcome (p-value <0.001 and p-value = 0.034, respectively). A separate analysis analyzing 81 patients with initial GCS = 8 on admission, found a 14 times greater risk for poor outcome in patients with CFV at one-year follow up (p-value = 0.002). On multivariate analysis, CFV was found to be a greater predictor of a poor prognosis at one-year post-SAH than a Hunt and Hess Grade of > 3 (6.2 OR (p =0.001) vs 3.1 OR (p=0.001), respectively).

Conclusions:

The presence of CFV is strong predictor of poor outcome in patients with aSAH. When compared to other patients with IVH, those with CFV have worse outcomes. Furthermore, CFV is a stronger predictor of a poor outcome in patients with aSAH than a poor Hunt and Hess grade.

Patient Care:

This study will help clinicians to be able to better determine outcomes of patients with aneurysmal subarachnoid hemorrhage and effectively treat these patients.

Learning Objectives:

By the conclusion of this session participants should be able to: 1) Describe the outcomes of casted fourth ventricles in aneurysmal SAH patients. 2) Identify the prognostic value of casted fourth ventricles in aneurysmal SAH patients

References:

Bae I-S, Yi H-J, Choi K-S, Chun H-J: Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients. J Cerebrovasc Endovasc Neurosurg 16:78–84, 2014 Available: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4102754&tool=pmcentrez&rendertype=abstract. 2. Darby DG, Donnan GA, Saling MA, Walsh KW, Bladin PF: Primary intraventricular hemorrhage: clinical and neuropsychological findings in a prospective stroke series. Neurology 38:68–75, 1988 Available: http://www.ncbi.nlm.nih.gov/pubmed/3257294. 3. Donauer E, Reif J, Al-Khalaf B, Mengedoht EF, Faubert C: Intraventricular haemorrhage caused by aneurysms and angiomas. Acta Neurochir (Wien) 122:23–31, 1993 4. Dorai Z, Hynan LS, Kopitnik TA, Samson D, Milhorat TH, Hernesniemi J, et al: Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 52:763–771, 2003 5. Duan G, Yang P, Li Q, Zuo Q, Zhang L, Hong B, et al: Prognosis Predicting Score for Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage: A Risk Modeling Study for Individual Elderly Patients. Medicine (Baltimore) 95:e2686, 2016 Available: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=26886607. 6. Fogelholm R, Hernesniemi J, Vapalahti M: Impact of early surgery on outcome after aneurysmal subarachnoid hemorrhage. A population-based study. Stroke 24:1649–54, 1993 Available: http://stroke.ahajournals.org/cgi/doi/10.1161/01.STR.24.11.1649%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/8236337. 7. Garraway W, Whisnant J: The changing pattern of survival following stroke. Stroke:1983 8. Hayashi M, Handa Y, Kobayashi H, Kawano H, Nozaki J, Noguchi Y: Prognosis of intraventricular hemorrhage due to rupture of intracranial aneurysm. Zentralbl Neurochir 50:132–137, 1989 9. Hijdra A, van Gijn J, Nagelkerke NJ, Vermeulen M, van Crevel H: Prediction of delayed cerebral ischemia, rebleeding, and outcome after aneurysmal subarachnoid hemorrhage. Stroke 19:1250–1256, 1988 10. Hinson HE, Street NW, Street NW, Ziai WC: Management of Intravescular Hemorrhage. Curr Neurol Neurosci Repp 10:73–82, 2011 11. Hop JW, Rinkel GJE, Algra A, van Gijn J: Case-Fatality Rates and Functional Outcome After Subarachnoid Hemorrhage: A Systematic Review. Stroke 28:660–664, 1997 Available: http://stroke.ahajournals.org/content/28/3/660.abstract. 12. Hunt W, Hess R: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20, 1968 13. Ingall TJ, Whisnant JP, Wiebers DO, O’Fallon WM: Has there been a decline in subarachnoid hemorrhage mortality? Stroke 20:718–724, 1989 14. Lagares A, Putman CM, Ogilvy CS: Posterior fossa decompression and clot evacuation for fourth ventricle hemorrhage after aneurysmal rupture: Case report. Neurosurgery 49:208–211, 2001 15. Le Roux PD, Elliott JP, Newell DW, Grady MS, Winn HR: Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases. J Neurosurg 85:39–49, 1996 Available: http://www.ncbi.nlm.nih.gov/pubmed/8683281. 16. Ljunggren B, Säveland H, Brandt L, Zygmunt S: Early operation and overall outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 62:547–51, 1985 Available: http://www.ncbi.nlm.nih.gov/pubmed/3973724. 17. Mayfrank L, Hutter BO, Kohorst Y, Kreitschmann-Andermahr I, Rohde V, Thron A, et al: Influence of intraventricular hemorrhage on outcome after rupture of intracranial aneurysm. Neurosurg Rev 24:185–191, 2001 Available: http://www.ncbi.nlm.nih.gov/pubmed/11778824. 18. McDougall CG: The Barrow Ruptured Aneurysm TaSAHl. J Neurosurg:1–10, 2011 Available: http://www.ncbi.nlm.nih.gov/pubmed/24286146%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/23621600. 19. Milhorat TH: Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 20:15–20, 1987 20. Mocco J, Ransom ER, Komotar RJ, Schmidt JM, Sciacca RR, Mayer SA, et al: Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery 59:529–537, 2006 21. Mohr G, Ferguson G, Khan M, Malloy D, Watts R, Benoit B, et al: Intraventricular hemorrhage from ruptured aneurysm. Retrospective analysis of 91 cases. J Neurosurg 58:482–487, 1983 22. Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A: Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. J Neurol 247:117–121, 2000 Available: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10751114. 23. O’Kelly CJ, Kulkarni A V, Austin PC, Urbach D, Wallace MC: Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: incidence, predictors, and revision rates. Clinical article. J Neurosurg 111:1029–35, 2009 Available: http://www.ncbi.nlm.nih.gov/pubmed/19361256. 24. Rosen DS, Macdonald RL, Huo D, Goldenberg FD, Novakovic RL, Frank JI, et al: Intraventricular hemorrhage from ruptured aneurysm: clinical characteristics, complications, and outcomes in a large, prospective, multicenter study population. J Neurosurg 107:261–265, 2007 Available: http://www.ncbi.nlm.nih.gov/pubmed/17695378. 25. Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL: Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke 38:2315–2321, 2007 26. Ruscalleda J, Peiró A: Prognostic factors in intraparenchymatous hematoma with ventricular hemorrhage. Neuroradiology 28:34–37, 1986 27. Scheid R, Zimmer C, Schroeter ML, Ballaschke O, von Cramon DY: The Clinical Spectrum of Blunt Cerebrovascular Injury. Neurologist 12:255–262, 2006 Available: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00127893-200609000-00005. 28. Schievink WI, Wijdicks EF, Parisi JE, Piepgras DG, Whisnant JP: Sudden death from aneurysmal subarachnoid hemorrhage. Neurology 45:871–4, 1995 Available: http://www.ncbi.nlm.nih.gov/pubmed/19901813. 29. Starke RM, Komotar RJ, Otten ML, Schmidt JM, Fernandez LD, Rincon F, et al: Predicting long-term outcome in poor grade aneurysmal subarachnoid haemorrhage patients utilising the Glasgow Coma Scale. J Clin Neurosci 16:26–31, 2009