Clinical Program for Cerebrovascular Disorders Mount Sinai Medical Center Intraventricular Hemorrhage and TPA Clinical Case Presentation Clara Raquel Epstein, MD Fellow

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.

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.

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.

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.

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.

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.

Adam Davis, MD Interventional Neuroradiology

Literature Review

Intraventricular hemorhage in adults: complications and treatment. Naff NJ; Tuhrim S New Horizons1997 Nov;5(4) : 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.

Intraventricular hemorhage in adults: clinical-computed tomographic correlations. Weisberg LA, et al. Computed Medical Imaging Graph 1991 Jan-Feb;15(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.

Literature Review 1.Intraventricular streptokinase infusion in acute post-haemorrhagic hydrocephalus. 2.Fibrinolytic agents in the treatment of intraventricular hemorrhage in adults. 3.Recombinant tissue plasminogen activator for the treatment of spontaneous adult intraventricular hemorrhage. 4.Traumatic intraventricular hemorrhage treated with intraventricular recombinant-tissue plasminogen activator: technical case report. 5.Intraventricular urokinase for the treatment of posthemorrhagic hydrocephalus. 6.Fibrinolytic agents in the management of posthemorrhagic hydrocephalus in preterm infants: the evidence. 7.A cohort study of the safety and feasibility of intraventricular urokinase for nonaneurysmal spontaneous intraventricular hemorrhage. 8.Outcome in patients with large intraventricular haemorrhages: a volumetric study.