Prevalence of Shunt Dependency and Clinical Outcome in Patients with Massive Intraventricular Haemorrhage Treated with Endoscopic Washout and External Ventricular Drainage

Background: Intraventricular haemorrhage (IVH) causes blockage of ventricular conduits leading to hydrocephalus, increased intracranial pressure (ICP), and a reduced level of consciousness. The current standard management of IVH is insertion of an external ventricular drainage (EVD) catheter. However, this procedure addresses only the problems of acute hydrocephalus and raised ICP. Endoscopic washout allows for a more complete removal of the intraventricular clot. This study compared these two types of treatment in terms of shunt dependency and relevant clinical outcomes. Methods: Patients who were 10–80 years old and presented with a Graeb score of more than six were randomised into endoscopic washout and EVD treatment groups. A CT brain was repeated on each patient within 24 hours after surgery, and if a patient’s Graeb score was still more than six, a repeat endoscopic washout was performed to clear the remaining clots. All patients were monitored for shunt dependency at two weeks and three months, and clinical outcomes were measured at six months after the procedure. Results: A total of 39 patients were recruited; 19 patients were randomised into the endoscopic washout group, and 20 were randomised into the EVD group. However, three patients in the endoscopic group refused that treatment and opted for EVD insertion. Patients treated with endoscopic washout had significantly less drainage dependency at two weeks (P < 0.005) and at three months (P < 0.004) as compared to patients in the external ventricular drainage group. The reduction in Graeb scores was also significantly greater in the endoscopic washout group (P < 0.001). However, the functional outcome at six months measured via a modified Rankin scale score was no different in the two groups of patients. The difference in the functional outcome of the patients was mainly dependent on the initial pathology, with those presenting with a thalamic bleed with IVH showing a poor functional outcome. This parameter was also influenced by the Glasgow Coma Scale (GCS) score on admission, with those patients with a score of 12 or less having a poor functional outcome (MRS 5–6) at three and six months after the surgery. Conclusions: The use of neuroendoscopy in patients with a massive IVH significantly reduced drainage dependency. However, it did not alter the final functional outcome.

Clinical-Computed Tomographic Correlation of Spontaneous Intraventricular Hemorrhage Patients

Little has been known about clinical outcome in computed tomography(CT) documented intraventricular hemorrhage (IVH), especially in the third and fourth ventricles. A series of 114 patients with IVH in spontaneous intracranial hemorrhage diagnosed by CT, from January 1994 to December 1996, were studied retrospectively. The clinical findings, especially Glasgow Outcome Score(GOS), of these patient were compared with computed tomographic parameters on the Graeb's score, evidence of third ventricular hemorrhage, patency of fourth ventricle and hemorrhagic dilatation of fourth ventricle. The results were as following: 1) The underlying etiologies, in descending order, were hypertensive intracerebral hemorrhage(61.4%), subarachnoid hemorrhage(16.7%), moyamoya disease(13.2%), vascular malformation(5.3%), and unknown cause(3.5%). Moyamoya disease was the most common cause of pure IVH. 2) The bifrontal index (BFI), as an indicator of acute hydrocephalus after IVH, was closely correlated with consciousness level on admission, but not with GOS. 3) Graeb's score was correlated with GOS, but not with the volume of the intracerebral hematoma. 4) The third ventricular hemorrhage was associated with a worse outcome and hemorrhagic dilatation(>10.0mm) was associated with high mortality. 5) The absence of patency and the lateral dilatation(>20.0mm) in the fourth IVH was correlated with outcome. 6) In patients having the hemorrhagic dilatation of the fourth ventricle, Graeb's score and volume of intracerebral hematoma did not affect the outcome. In conclusion, Graeb's score, hemorrhagic dilatation of third ventricle, absence of fourth ventricle patency and lateral dilatation of the fourth ventricular hemorrhage in CT findings are correlated with the outcome in spontaneous IVH.

Clinical Analysis of Prognostic Factors for Hypertensive Intracerebral Hemorrhage

The authors reviewed medical records of 219 patients who were admitted due to the hypertensive intracerebral hemorrhage(HICH) between January 1993 and December 1994. The relationship between the patient's age and sex, Glasgow Coma Scale(GCS) on the admission, location and volume of intracerebral hematoma, Graeb score, ventriculocranial ratio(VCR) and the maximum transverse diameter of fourth ventricle were analyzed. The neurological outcome for survivors was determined two years after admission. Forty normal brain scans were obtained to determine the normal range of VCR and the maximum transverse diameter of fourth ventricle. From reviewing the cases, the authors found; the most common age group of HICH was 7th and 8th decades with slight male preponderance(1:0.75); VCR of the lateral ventricle and maximum transverse diameter of the 4th ventricle were 0.16 and 1.14 cm in 40 normal brain scans, respectively; basal ganglia(42%) and thalamus(29.2%) were the most common sites of HICH hemorrhage in 219 patients followed by subcortex(13.7%), pons(7.3%) and cerebellum(4.6%); the fourth ventricular dilation(>1.35cm in diameter) and increased VCR(>0.24) were the most significant predictors for poor outcome.

The Analysis of Intraventricular Hemorrhage Treated with Simple EVD or Infusion of Urokinase

Among all of the spontaneous TCH(intracerebral hemorrhage), the presence of IVH(intraventricular hemorrhage) is showing higher mortality and morbidity. Since the introduction of EVD(extraventricular drainage) and direct intraventricular infusion of Urokinase as a effective therapeutic methods of IVH, it's mortality and morbidity has been decreased. But, in cases of hemorrhage extended into all ventricular chambers showes poor prognosis even the EVD and infusion of Urokinase. Authors analyzed 40 cases of IVH treated with simple EVD or direct intraven-tricular infusion of Urokinase. The results were as follows: 1) The most common age groups of IVH patients were 5th and 6th decades and 22 patients were male, 18 patients were female. 2) All 15 cases of Urokinase treated group revealted over the 7 point of Graeb score. 3) On admission, Glasgow coma scale scores were under the 8 at the 11 cases(73%) of Urokinase treated group and 18 cases(72%) of simple EVD group. 4) Time of cleared ventricles showed fast at the Urokinase treated group than simple EVD group. 5) Incidence of complications were similar on both groups. 6) Prognosis revealed lower morbidity and mortality at the Urokinase treated group than simple EVD group. 7) In cases of high Graeb score and low Glasgow coma scale on admission showed poor prognosis in both groups.