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Intraventricular haemorrhage

Intraventricular haemorrhage (IVH) merely denotes the present of blood within the ventricular system of the brain, and is responsible for significant morbidity due to the development of obstructive hydrocephalus in many patients. 

It can be divided into primary or secondary, primary haemorrhage being far less common than secondary:

  • primary: the dominant finding is that of blood in the ventricles, with little if any parenchymal blood
  • secondary: a large extraventricular component is present (e.g. parenchymal or subarachnoid) with secondary extension into the ventricles

In adults secondary intraventricular haemorrhage is usually the result of an intracerebral haemorrhage (typically basal ganglia hypertensive haemorrhage) or subarachnoid haemorrhage with ventricular reflux.

Intraventricular haemorrhage is a distinct entity in paediatrics and considered separately; see intraventricular haemorrhage of the newborn.

Epidemiology

There are numerous causes of intraventricular haemorrhage and as such no single demographic can be identified; rather the each underlying aetiology contributes its own patient population. Having said that, secondary haemorrhage is far more common and as such the dominant demographic is that of patients with intraparenchymal or subarachnoid haemorrhage: older individuals are thus most commonly affected. 

Clinical presentation

Clinical presentation of intraventricular haemorrhage (regardless of cause) is similar to that of subarachnoid haemorrhage. Patients experience sudden onset of severe headache 2. Signs of meningism are also present (i.e. photophobia, nausea and vomiting and neck stiffness). Larger haemorrhages can result in loss of consciousness, seizures, and brainstem compression with cardiorespiratory compromise. 

Pathology

Causes

Some of the more common causes of primary intraventricular haemorrhage in adults include 2

Secondary causes of intraventricular haemorrhage include: 

Radiographic features

CT

Non contrast CT of the brain is the mainstay of acute evaluation of patients presenting to with sudden onset headache or stroke-like symptoms. Blood in the ventricles appears as hyperdense material, heavier than CSF and thus tends to pool dependently, best seen in the occipital horns. Acutely, if the volume is significant blood can fill the ventricle, and clot forming a 'cast'. 

There is often obstructive hydrocephalus, and care must be taken in distinguishing this from ex-vacuo dilatation of the ventricles. 

MRI

MRI is more sensitive than CT to very small amounts of blood, especially in the posterior fossa, where CT remains marred by artefact. 

Both FLAIR and more recently SWI (especially at 3T) are sensitive to small amounts of blood. Especially the latter will demonstrate tiny amounts of blood pooling in the occipital horns, and resulting in susceptibility induced signal drop out 3-4.

On FLAIR the signal intensity will vary depending on the timing of the scan. Within 48 hours blood will appear as hyper-intense to the attenuated adjacent CSF 4. Later the signal is more variable and can be difficult to distinguish from flow related artifact (particularly in the third and fourth ventricles) unless other sequences are also used. 

Treatment and prognosis

The main treatment approaches of intraventricular haemorrhage can be divided into two:

  • treatment of the underlying cause of haemorrhage (e.g. aneurysm, AVM, etc) 
  • treatment of obstructive hydrocephalus

The later may merely require careful monitoring of clinical state and serial CT brains to assess for ventricular size, or may require ventricular drain placement. A number of patients will go on to require permanent CSF diversion (VP shunt). 

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