A Pitfall of Neuroendoscopic Intraventricular Hematoma Removal - Delayed Obstructive Hydrocephalus Caused by a Small Remnant Clot -Case Report-

Abstract

A 57-year-old female presented with a left putaminal hemorrhage, intraventricular hematoma (IVH), and acute obstructive hydrocephalus. Neuroendoscopic surgery was performed for the IVH. Three days after successful IVH removal and improvement of her consciousness, the patient lapsed into a comatose state due to hydrocephalus caused by obstruction of the mesencephalic aqueduct by a small remnant clot. The small clot was identified by constructive interference with steady state magnetic resonance imaging and was removed during a second-look operation. Even after the cerebrospinal fluid circulation improves following neuroendoscopic surgery for IVH, the patient may nevertheless develop a lifethreatening condition without warning signs in the subacute phase. Awareness of this complication will lead to early diagnosis and correct management.

Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus due to Intraventricular Hemorrhage

“…23 Over the last 2 decades, several techniques have been used as alternatives or adjuncts to EVD placement in an attempt to avoid these pitfalls. These include adding fibrinolysis through the EVD, 23 microsurgical intraventricular clot evacuation, 24 rigid or flexible endoscopic clot evacuation, 1,6,7,[11][12][13][14][15][16][17]20 ETV, 3,14,15,18,25,26 or ETV combined with clot evacuation. 3,5,8,10,14,19 The administration of thrombolytic agents such as recombinant tissue-type plasminogen activator and urokinase, through the EVD, has been show to be safe and effective at accelerating clot clearance and possibly preventing catheter obstruction and reducing chronic hydrocephalus in patients with aneurysmal or spontaneous IVH compared with treatment with EVD alone.…”

“…30 Many authors recommend performing endoscopic intraventricular clot removal without ETV to obtain the short-term benefits in patients with IVH-obstructive hydrocephalus (►Table 3). 6,7,9,[12][13][14][15][16][17]20,31 In addition to obstructing CSF flow and causing obstructive hydrocephalus, IVH is directly associated with increased ICP, reduced cerebral perfusion and ischemia, periventricular brain damage and swelling, and increased morbidity and mortality. 25 Thus expedient removal of IVH should be considered a priority to improve patient outcome.…”

“…Indication was new-onset obstructive hydrocephalus in 10 and inability to wean EVD in 7 patients. All patients (n ¼ 17) had symptoms of raised intracranial pressure (ICP), with an average GCS score of 11 (range: [7][8][9][10][11][12][13][14]. The average Graeb score was 4.3 (range: 1-8) on preoperative computed tomography (CT) scan performed within 24 hours before ETV.…”

“…4 ETV and endoscopic intraventricular clot evacuation is an appealing modality to improve outcome and decrease treatment-related risks for patients with hemorrhage-related obstructive hydrocephalus. 1,3,[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] We sought to review our experience with ETV and clot evacuation for the treatment of IVH-related obstructive hydrocephalus.…”

Safety and feasibility of combined coiling and neuroendoscopy for better outcomes in the treatment of severe subarachnoid hemorrhage accompanied by massive intraventricular hemorrhage

“…[30][31][32][33][34] A flexible endoscope can easily provide access to the hematoma over a large ventricular area. This instrument requires skilled manipulation, without which it is difficult to remove the clots because the working channel is too narrow to suction or retrieve them.…”