INTRACEREBRAL HEMORRHAGE

Intraventricular hemorrhage

Created 22/04/2022, last revision 23/09/2022

  • intraventricular hemorrhage (IVH) or hemocephalus is characterized by the presence of blood within the cerebral ventricular system
  • IVH is present initially in one-quarter of patients with ICH or may occur as a subsequent extension of the ICH
    • patients with larger hematomas and caudate or thalamic locations bleed more often into the ventricles
  • IVH is associated with a significant risk of obstructive hydrocephalus, which increases morbidity and mortality
  • an important determinant of the outcome is the intraventricular hemorrhage volume
Primary intraventricular hemorrhages

The cerebral ventricular system

  • the ventricular system consists of four interconnected cavities known as cerebral ventricles. Each ventricle comprises the choroid plexus, producing cerebrospinal fluid (CSF). The ventricular system continues from the fourth ventricle into the central canal of the spinal cord
  • ventricles and the central canal of the spinal cord are lined with ependyma, a specialized epithelium connected by tight junctions that form the blood-cerebrospinal fluid barrier
Cerebral ventricles

Classification and etiology

  • primary IVH: blood in the ventricles with little or no parenchymal blood     Intraventricular hemorrhage (hemocephalus)
    • vascular malformations (AVM, subependymal CCM,  aneurysm)
    • coagulopathy  Primary intraventricular hemorrhage caused by warfarin overdose
    • intraventricular tumors (ependymoma, the choroid plexus metastases)
    • hypertensive bleeding
  • secondary IVH (more frequent): a significant extraventricular component is present (parenchymal or subarachnoid) with secondary expansion into the ventricles
    • intraventricular propagation of intracerebral hematoma  Secondary intraventricular hemorrhage
    • SAH (beware of possible reflux from spinal SAH)
    • trauma (Ravi, 2019)

Clinical presentation

  • in primary IVH, symptoms are similar to SAH (sudden and severe headache, signs of meningeal syndrome)  → clinical presentation of SAH
  • in secondary IVH, signs and symptoms from primary parenchymal lesion predominate
  • extensive hemorrhages can lead to an altered level of consciousness with cardiorespiratory compromise

Diagnostic evaluation

Non-contrast CT scan (NCCT)

  • primary imaging technique in patients with acute stroke symptoms or sudden headache
  • blood in the ventricles is hyperdense, usually best seen in the occipital horns
  • seek for signs of acute obstructive hydrocephalus on repeated CT  Obstructive hydrocephalus following IVH
Intraventricular hemorrhage (hemocephalus)

MRI

  • MRI is sensitive to small amounts of blood, especially in the posterior fossa (CT is inconclusive here because of artifacts)
    • FLAIR – the signal intensity depends on the timing. In the first 48 hours, blood appears hyperintense, later the signal is more variable (exclude flow artifacts)
    • GRE or better SWI  – detect even small amounts of blood in the occipital horns (hypointense rim)
Intraventricular hemorrhage on MRI

Vessel imaging (CTA, MRA, DSA)

  • rule out vascular malformations, moyamoya, etc.

Management

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