Key-words:
Hemorrhage - intraventricular - isolated - traumatic
Introduction
Isolated intraventricular hemorrhage ensuing a traumatic incident is a rare entity.
Its incidence following a nonpenetrating head injury is 0.4%–4%. It is commonly associated
with other lesions such as intracerebral contusions, subdural hemorrhage, extradural
hemorrhage, and subarachnoid hemorrhages and is commonly observed in a pediatric population
but rarely in an adult population. The outcome is poor in isolated intraventricular
hemorrhages. Herein, we report six cases of isolated intraventricular hemorrhage following
nonpenetrating head injuries.
Methods
We perform a retrospective analysis of all the cases of head injury which presented
to the department of neurosurgery at our hospital between 2010 and 2018. The records
were analyzed for clinical presentation, age groups of presentation, mode of injury,
Glasgow Coma Scale score at the time of presentation, mode of injury, radiological
findings, and Glasgow Coma outcome score. Radiological findings were assessed using
computed tomography (CT) of the brain and CT angiogram of the brain. The outcome was
assessed on the basis of the Glasgow outcome score at the time of discharge.
Case Reports
We present six cases of isolated intraventricular hemorrhages in a span of 8 years
(2010–2018) with their relevant clinical history, plain CT, and CT brain angiography
findings. Patients and their attendants have given their consent for the case report
being published.
Case 1
A 38-year-old male patient alleged to have sustained injuries due to falling from
height brought to the emergency department by relatives with complaints of loss of
consciousness since the time of injury associated with vomiting, ear bleed and two
episodes of seizures. No history of significant medical and surgical illness in the
past. The patient was chronic alcoholic and smoker. On examination, the patient was
in a state of the unconscious with a Glasgow Coma Scale score of E1V1M3 associated
with weakness of right upper and lower limb. CT scan of the brain was done which revealed
an isolated intraventricular hemorrhage in the right lateral ventricle and temporal
bone fracture. CT angiogram of the brain was done to rule out any vascular pathology
which revealed no abnormality. The patient was shifted to the neurointensive care
unit where was he was put under observation under cover of antiepileptics. The patient
regained consciousness after 4 days and was followed up with repeated scans which
revealed no evidence of hydrocephalus. The patient recovered and was discharged.
Case 2
A 65-year-old male patient alleged to have sustained injuries due to hitting by a
four-wheeler while crossing a road. He was brought to the emergency department by
relatives with complaints of loss of consciousness and nasal bleed. The patient was
a nonhypertensive and nondiabetic. On examination, the patient was drowsy with a Glasgow
Coma Scale Score of E2V2M3 without any focal deficits. CT of the brain revealed isolated
intraventricular hemorrhage and temporal bone fracture. CT Angiogram of the brain
was done which revealed no vascular abnormality. The patient was intubated, shifted
to neurointensive care, and kept under the cover of antiepileptics for observation.
The patient succumbed after 9 days.
Case 3
A 40-year-old male patient alleged to have sustained injuries due to falling from
a two-wheeler was brought to the emergency department by relatives with a history
of loss of consciousness since the time of injury and associated multiple limb injuries.
No history of seizures, ear, and nasal bleed. The patient was a nonhypertensive and
nondiabetic, and he also was a chronic alcoholic and smoker. On examination, the patient
was hypotensive and unconscious with a Glasgow Coma Scale score of E1V1M4. After intubation
and resuscitation, CT scan of the brain followed by a CT angiogram was done which
revealed an isolated intraventricular hemorrhage without any vascular pathology. The
patient shifted to the intensive care after adequate resuscitation and put on a ventilator.
He was then treated under the cover of antibiotics and antiepileptics. In spite of
adequate treatment, the patient succumbed after 10 days.
Case 4
A 3-year-old child was brought to the emergency department with complaints of fall
from a height with complaints of loss of consciousness, vomiting, and nasal bleed.
On examination, the child was drowsy with a Glasgow Coma Scale score of E4V4M6 without
any focal deficits. No evidence of any bony injuries. CT scan of the brain was done
which revealed intraventricular hemorrhage and nasal bone fracture. CT Angiogram of
the brain was done which showed no abnormality in the vasculature. The patient was
put on antiepileptics, and he recovered in 4 days and was discharged. The follow-up
was uneventful with a regression of intraventricular hemorrhage on repeat serial scans.
Case 5
A 30-year-old male patient alleged to have sustained head injuries due to fall from
a two-wheeler was brought to the emergency department with complaints of loss of consciousness
for a few minutes since the time of injury. No history of vomiting and ear bleed.
No history of medical or surgical illness in the past. The patient is a known alcoholic
and smoker. On examination, the patient was confused with a Glasgow Coma Scale score
of E4V4M6 without any focal deficits. CT scan of the brain revealed intraventricular
hemorrhage without any vascular abnormality on CT angiogram. The patient was put on
antiepileptics and observed. The patient was discharged after 6 days. The follow-up
was uneventful with a decrease in the intraventricular hemorrhage on serial CT scans.
Case 6
A 40-year-old male alleged to have sustained injuries in a road traffic accident,
where he was hit by a four-wheeler while walking on the road in a drunken state. He
had a history of loss of consciousness since then, with three episodes of vomiting
and bleeding from the right ear. On examination, he was unconscious with a Glasgow
Coma Scale score of E1V1M3, pupils were mitotic, sluggishly reacting to light bilaterally.
No history of seizures or neurological deficits. Patient blood pressure was 80/60
mmHg and pulse rate of 110 beats/min. Palpation of the abdomen revealed tenderness
and guarding in the left hypochondrium. Limbs examinations revealed bilateral femur
fractures. The patient was intubated, resuscitated, and stabilized. CT of the brain
and abdomen were done which revealed isolated intraventricular hemorrhages in both
lateral, third and fourth ventricles associated with cisternal and tentorial bleed
without hydrocephalus and a right temporal bone fracture, [[Figure 1]] along with a grade three splenic laceration and mild hemoperitoneum. CT angiogram
of the brain was performed to rule out any vascular pathology. There was no vascular
and tumoral pathology [[Figure 2]]. External ventricular drain was put and then shifted to neurointensive care. The
splenic injury was managed conservatively with strict monitoring of vitals. In spite
of good resuscitation, the patient succumbed on day two.
Figure 1: Hyperdense intraventricular hemorrhage seen in both the lateral ventricles with no
apparent brain parenchymal changes in various computed tomography images
Figure 2: Computed tomography angiogram of brain showing normal vasculature
Results
In the present study, intraventricular hemorrhage was most commonly observed in the
age groups of 30–40 years with a mean age of 36 years.
All the cases in our study were males. Mode of injury was road traffic accidents in
three cases and fall from height in the other three. On admission, Glasgow Coma Scale
score varied from 13 to 15 in two cases and 3–8 in four patients.
The most common clinical presentation at the time of presentation was a loss of consciousness
in all the six patients, vomiting was seen in three patients and ear-nose-throat bleeds
seen in the four patients. All the patients underwent noncontrast CT of the brain
and CT Angiogram to rule out vascular pathology and tumor pathology. All the patients
showed isolated intraventricular hemorrhages without any vascular and tumor pathology.
The outcome of the patients with isolated intraventricular hemorrhage is equivocal
in the present study, wherein three patients have succumbed, and other three have
recovered.
Discussion
Isolated intraventricular hemorrhage ensuing a traumatic event is extremely rare with
a prevalence of 0.4%–4% in all head traumas undergoing a CT scan.[[1]] Intraventricular bleed may occur when a severe force is applied to the head.
Traumatic intraventricular hemorrhages are usually associated with other lesions such
as intracerebral contusions, subdural hemorrhages, extradural hemorrhages, and subarachnoid
hemorrhage. Other causes of intraventricular hemorrhages are rupture of intracranial
aneurysms or vascular malformations, systemic bleeding tendencies, hypertensive intracerebral
bleed extending into the ventricles and neonatal germinal matrix bleed. In the absence
of other associated intracerebral bleeds, intraventricular bleed is caused by tearing
of subependymal veins in the septum pellucidum, fornix, or the choroid plexus.[[2]],[[3]]
Due to deficient fibrinolysis and hemolysis of the cerebrospinal fluid, spontaneous
resolution of intraventricular hemorrhage is slow. Various treatment modalities of
intraventricular hemorrhage include placement of external ventricular drain and administration
of fibrinolytic into the ventricles.
The outcome is poor in intraventricular hemorrhage. Cause of poor outcome is not clearly
known; it may be due to the presence of blood in the ventricles, hydrocephalus development
or due to increased intracranial pressure.[[4]] Lee et al. in their study found a good outcome for isolated intraventricular hemorrhage.[[5]] Is et al. reported a good outcome in a pediatric patient with an isolated intraventricular
hemorrhage.[[6]]
This case series in contrast to other studies report an equivocal outcome.
Conclusion
Traumatic isolated intraventricular hemorrhage is an extremely rare variant occurring
more commonly in males and the age groups of 30–40 years, in acceleration and deceleration
injuries with an equivocal outcome hence being reported.
Consent
Patient's attendants have given consent for the publication and also consent has been
obtained from the institution.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form, the patients have given their consent for their images and other clinical
information to be reported in the journal. The patient understands that name and initials
will not be published and due efforts will be made to conceal identity, but anonymity
cannot be guaranteed.
