Traumatic

Intraventricul
ar
Hemorrhage
dr. I Dewa Gede Sidan A.M.

Pembimbing

Prof. Dr. dr. Tjokorda Gde Bagus Mahadewa,M.Kes,

Sp.BS(K)
 BRAIN ANATOMY

Brain
The brain is housed inside the bony covering called the cranium.
Brain of an adult weigh ± 2% BM
(1.300 - 1.400 gr); The Monroe-Kellie Doctrine.

The Meningens
Duramater, Arachnoid, Piamater

Cerebrospinal Fluid
Cerebrospinal fluid (CSF) is found within the brain and surrounds
the brain and the spinal cord

The Ventricular Systems

The ventricular system is divided into four cavities called
ventricles, which are connected by a series of holes, called
foramen, and tubes.
 Meningens
Layers
• DURAMATER
• Periosteal layer
• Meningeal layer
• ARACHNOID
• PIAMATER

Spaces
• Subdural Space
• Subarachnoid Space
F
The Ventricular Systems
Ventricles
• Laterals (A)
• Third (B)
• Fourth (D)
Foramens
• Monroe (F)
• Sylvius (C)
• Luschka
• Magendie
CSF

Choroid Plexus
 The
Ventricular
Systems
 Intraventricular
Hemorrhage
Primary
• Bleeding directly into the ventricles from a
source or lesion that is in contact with or is
part of a ventricular wall
Secondary
• Intracerebral bleeding that dissects through
brain parenchyma to reach a ventricle or to
bleeding into the subarachnoid space that
spreads into the ventricles through the fourth
ventricular foramina
 Intraventricular
Hemorrhage
Refers to bleeding confined to the ventricular system within the brain

Primary Intraventricular Hemorrhage (PIVH) are uncommon  only

about 3% of all spontaneous intracerebral hemorrhage

More common occurs in the setting of intracerebral hemorrhage or

subarachnoid hemorrhage (secondary IVH)

Can fill one or more ventricles, and when of sufficient volume and
density, can result in formed ventricular blood clots or hematocephalus

An independent and important clinical problem when clots distend the

ventricular system, compress adjacent brain, or obstruct CSF flow to
cause hydrocephalus and elevated ICP
 Epidemiology of IVH

Large IVH IVH Related ICH

> 50% of patients with large IVH are IVH related to spontaneous parenchymal ICH
admitted in poor grades, and the is associated with an 86% incidence of a poor
mortality in such cases exceeds 64% prognosis and a 72% mortality rate

In United States IVH most common in

About 12,000 prematue Neonates
infants develop IVH 50-75% of preterm survivors with
every year IVH develop CP, mental
retardation, & hydrocephalus
 Epidemiology of IVH
Age and sex of 118 traumatic IVH
patients

Atzema, C., Mower, W. R., Hoffman, J. R., Holmes, J. F., Killian, A. J., Wolfson, A. B., & National Emergency X-Radiography Utilization Study (NEXUS) II Group. (2006).
Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma. Journal of Trauma and Acute Care Surgery, 60(5), 1010-1017.
 Etiology Intraventricular Hemorrhage

Primary Secondary
A rare neurological disorder, with bleeding Resulting from an expansion of an
confined to the ventricles only. existing intraparenchymal or
subarachnoid hemorrhage. Occur in 35%
Typically caused by intraventricular trauma, of moderate to severe traumatic brain
aneurysm, vascular malformations, or injuries.
tumors, particularly of the choroid plexus
Etiology Intraventricular
Hemorrhage
Arterial dissection; 7.40%
MMD &
AVMs;
ILSA;
25.92%
11.10%

Most Common
Hypertension; 55.80%
The clearance of erythrocytes from
CSF
Hemolysis
Which commences within hours and
reaches a plateau 2-10 days after IVH,
depending on the size of the hemorrhage

Phagocytosis
By macrophages, which occurs both in
the leptomeninges irritated by blood and
in arachnoid granulations engorged with
erythrocytes
Risk Factor of IVH
Prematurity
Occurs most frequently in infants born <32weeks or <1500
gr
Incidence is 26% for infants weighing 500-1500 gr. The
highest prevalence is in the least mature infants. Mortality
15%

Timing
Virtually all IVH in premature infants occurs in first five days.
50%, 25% and 15% on the 1st, 2nd and 3rd day. By the end of
the 1st week, 90% of hemorrhages can be detected

Others
Intrapartum asphyxia, chorioamnionitis, hypoxemia,
hypercabia, pneumothorax/ pulmonary hemorrhage
 Mechanism of injury
traumatic intraventricular hemorrhage

Atzema, C., Mower, W. R., Hoffman, J. R., Holmes, J. F., Killian, A. J., Wolfson, A. B., & National Emergency X-Radiography Utilization Study (NEXUS) II Group. (2006).
Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma. Journal of Trauma and Acute Care Surgery, 60(5), 1010-1017.
 Etiology Intraventricular Hemorrhage

An inherent fragility of the germinal matrix vasculature sets the ground

for hemorrhage and fluctuation in the cerebral blood flow induces the
rupture of vasculature

Fragility of germinal matrix vasculature

• Paucity of pericytes
• Reduced fibronectin in the basal lamina
• Reduced GFAP expression in the astrocyte endfeet
Clinical Features
Spontaneous and Primary IVH
• Sudden headache, vomiting, and sometimes altered mental
status

Generalized Seizure
• Occur, but without any significant associated ICH

Hydrocephalus
• Non Communicating Hydrocephalus can occur acutely after
IVH if clots obstruct CSF drainage within the ventricular
system, and Communicating Hydrocephalus may develop
more gradually or even in a delayed fashion
Rapid and Advanced Neurologic Deterioration
and with Sudden Death
Clinical Features in Child
Most infants are asymptomatic or demonstrate subtle signs
that are easily overlooked. PVH-IVH subsequently is found
on surveillance sonography

One Subgroup of Infants with PVH-IVH Presents with the

Following:
•A sudden unexplained drop in hematocrit levels
• Possible physical findings related to anemia (eg. pallor, poor perfusion) or
hemorrhagic shock
•Another subgroup of infants with PVH-IVH presents with extreme signs
•A sudden and significant deterioration associated with anemia, metabolic
acidosis, glucose instability, respiratory acidosis, apnea, hypotonia, and
stupor is present

Physical Finding Related to This Signs

•Poor Perfusion, pallor or an ashen color, irregularities of respiratory pattern,

signs of respiratory distress including retractions and tachypnea, hypotonia,
and altered mental status
• Neurological signs: fullness of the fontanels, seizures, and posturing
Clinical Features in Adult
RADIOLOGI
C
EXAMINATI
ON:
CT SCAN -
MRI
Radiologic Examinations – CT
SCAN

Non contrast CT Scan 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
Radiologic Examinations – MRI

More sensitive than CT to very small

amounts of blood

Both FLAIR and more recently SWI are

sensitive to small amounts of blood

Within 48 hours blood will appear as

hyper-intense to the attenuated
adjacent CSF
 Grade and Scoring

Modified Graeb Score Papile’ Cassification

Management of IVH

Identify Underlying Cause Of IVH

• Aneurysm repair
• AVM or tumor excision
• Blood pressure control
• Correction of bleeding disorder

EVD
• Routine EVD use in grade IV and V patients is
advocated
• The role of an EVD in grade III patients is less
certain  calculation of the modified Graeb score
for IVH may help predict need for an EVD
• Patients with coma, modified-GS >13 and dilation
of the fourth ventricle were more likely to require
EVD
 Management of IVH
Medical Care

• Correction of anemia, acidosis, and hypertension, as well as

ventilatory support, might be required in those neonates who
present with acute deterioration
• Serial lumbar puncture, although once used to prevent
progressive hydrocephalus, is not indicated

Surgical Care

• Serial lumbar punctures have been used to manage early

hydrocephalus
• A multicenter evaluation of serial lumbar punctures demonstrated no
benefit when the individual with PVH-IVH is aged 30 months
• Acetazolamide  diminish CSF production and limit late or rapidly
progressive hydrocephalus. Its use in the treatment of early
ventricular dilatation is probably limited
• Ventriculostomy placement  management of significant
hydrocephalus while awaiting definitive surgical drainage
• Ventriculoperitoneal and ventriculosubgaleal shunting remain the
definitive treatments for posthemorrhagic hydrocephalus requiring
surgical intervention
 Prognosis of Traumatic IVH

Prognosis: Determined by associated brain injuries rather than by the tIVH

itself.

One case of truly isolated tIVH did have a poor outcome, but this patient had
significant medical problems and a presenting GCS 8.

Therefore, if a physician does encounter a rare case of tIVH, the management

should be determined by the patient’s clinical presentation and associated
injuries, and in the case of isolated tIVH, in the presence of a normal
neurologic examination, it is unlikely to warrant further evaluation.

A clinical decision instrument that included abnormal GCS and level of

alertness should correctly identify tIVH patients who need a CT scan.

Atzema, C., Mower, W. R., Hoffman, J. R., Holmes, J. F., Killian, A. J., Wolfson, A. B., & National Emergency X-Radiography Utilization Study (NEXUS) II Group. (2006).
Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma. Journal of Trauma and Acute Care Surgery, 60(5), 1010-1017.
Sequele of IVH
Posthemorrhage Hidrocephalus
• Usually presents with rapid increases in head
circumference
• Sign and symptoms may not be evident for several
weeks due to compliance of neonatal brain
• Believed to be due to impaired CSF reabsorption
following the inflammation related to blood in the
CSF
• No proven effective interventions have been
described to date
Periventricular Leukomalacia (PLV)
• Classic white matter abnormality following IVH
• Attributed to profound and long-lasting decreases in
CSF
• PVL may progress to porencephaly (hole in the brain)
• Depending on severity, may lead to spastic
dysplasia, visual defects, or cognitive impairment
MATUR
SUKSM
A