Clinical Program for Cerebrovascular Disorders Mount Sinai Medical Center

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Clinical Program for Cerebrovascular
DisordersMount Sinai Medical Center

• Intraventricular Hemorrhage
• and TPA
• Clinical Case Presentation
• Clara Raquel Epstein, MD Fellow

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Intraventricular Hemorrhage and TPA Clinical Case
Presentation

• A 70 year old right handed Hispanic male with a
  history of hypertension, asthma, chronic renal
  insufficiency, s/p Bilroth I and s/p hypertensive
  basal ganglia hemorrhage on 10/28/98 presented on
  11/9/99 with left upper extremity weakness,
  slurred speech, dizziness, vomiting, and blurred
  vision. Per history the patient ran out of his
  antihypertensive medications two weeks prior to
  admission and had complained of headaches for two
  days prior to presentation. On arrival to the
  emergency room the patients blood pressure was
  246/120. In the ER, the patient was subsequently
  intubated in order to protect his airway from
  secretions.

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Hospital Course

• On admission a CT scan was obtained which showed
  evidence of a right basal ganglia/thalamus
  hemorrhage with intraventricular extension. There
  was also enlargement of the ventricular system
  consistent with hydrocephalus. As compared with
  the previous MRI from 10/29/98, which
  demonstrated evidence of a focus of hemorrhage in
  the posterior limb of the right internal capsule,
  in the same location, it was suggested that this
  could represent an underlying vascular
  malformation such as a cavernous angioma.

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Hospital Course

• Neurosurgery was consulted and on 11/10/99, a
  ventriculostomy was placed. The position of the
  catheter was re-adjusted on 11/11/99 for maximal
  placement considering the possibility of
  administering TPA. Pre and post CT scans
  confirmed adequate placement of the catheter to
  be relocated from the anterior third ventricle to
  the frontal horn of the right lateral ventricle.
  The ventricles were noted to be slightly smaller
  from the previous scan obtained 11/9/99.

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Hospital Course

• The patients course in the NSICU is significant
  for difficulty controlling his blood pressure
  fluctuations, and respiratory distress with
  multiple intubations and extubations. The renal
  service was consulted and the patient has
  received multiple episodes of hemodialysis. In
  addition, on 11/16/99 the GI service was
  consulted for decreasing hemoglobin from the time
  of admission of 11.1 to 8.1. An EGD was
  performed and there was evidence of ulceration at
  the site of previous surgery.

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Hospital Course

• Neurologically the patient improved in the first
  couple of days. He was able to follow commands.
  However, on 11/15/99, the patients neurologic
  status appeared to once again decline. It was
  initially thought that this change in status
  might be related to decreased CSF drainage from
  the ventriculostomy.

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Hospital Course

• The current plan includes replacement of the
  ventriculostomy and to continue present
  management. The patient will continue to be
  evaluated for the need for placement of a
  ventriculoperitoneal shunt.

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• Adam Davis, MD
• Interventional Neuroradiology

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Literature Review
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Intraventricular hemorhage in adults
complications and treatment.Naff NJ Tuhrim
SNew Horizons1997 Nov5(4) 359-63

• Intraventricular hemorrhage (IVH) frequently
  occurs in the setting of intracerebral and
  subarachnoid hemorrhage, and is an independent
  and significant contributor to morbidity and
  mortality in both conditions. Present therapy of
  IVH is directed at treating the associated
  complications of obstructive and communcating
  hydrocephalus. These therapies are often
  inadequate to treat the complications and do not
  remedy the underlying IVH. Intraventricular
  thrombolysis is a promising but unproven new
  therapy that directly addresses the IVH and my
  reduce the incidence of obstructive and
  communicating hydrocephalus.

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Intraventricular hemorhage in adults
clinical-computed tomographic correlations.Weisbe
rg LA, et al.Computed Medical Imaging Graph 1991
Jan-Feb15(1)43-51

• The clinical and CT findings in 100 consecutive
  adult nontraumatic intraventricular hemorrhage
  (IVH) cases were analyzed. There were 74
  parenchymal brain hemorrhages with secondary
  ventricular extension. The ventricles were
  filled with blood and asymmetrically enlarged.
  If the hemorrhage involved putamen, cerebellum,
  pons or subcortical cerebral hemishpheric white
  matter, IVH was associated with large parenchymal
  hematomas these patients had poor clinical
  outcome. With thalamic or caudate hematomas, IVH
  frequently occurred with large hematomas but may
  occur with small hematomas. The small hematomas
  were located directly contiguous to the
  ventricular walls and caused extensive
  ventricular blood. Patients with small thalamic
  and caudate hemorrhage with intraventricular
  blood had good clinical outcome whereas patients
  with large hematomas had poor outcome. Primary
  IVH occurred in 24 cases. In these cases, blood
  was seen in all ventricular chambers. Aneurysms
  involving the anterior cerebral-anterior
  communicating artery region were the most common
  etiology for primary IVH.

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Literature Review

• Intraventricular streptokinase infusion in acute
  post-haemorrhagic hydrocephalus.
• Fibrinolytic agents in the treatment of
  intraventricular hemorrhage in adults.
• Recombinant tissue plasminogen activator for the
  treatment of spontaneous adult intraventricular
  hemorrhage.
• Traumatic intraventricular hemorrhage treated
  with intraventricular recombinant-tissue
  plasminogen activator technical case report.
• Intraventricular urokinase for the treatment of
  posthemorrhagic hydrocephalus.
• Fibrinolytic agents in the management of
  posthemorrhagic hydrocephalus in preterm infants
  the evidence.
• A cohort study of the safety and feasibility of
  intraventricular urokinase for nonaneurysmal
  spontaneous intraventricular hemorrhage.
• Outcome in patients with large intraventricular
  haemorrhages a volumetric study.