Medical Image of the Week: Intraventricular Hemorrhage Casting

Figure 1. Panel A: Computerized tomography of the head without contrast taken at an outlying facility displayed a right thalamic intraparenchymal hematoma, measuring 3.4 x 4.2 cm, with vasogenic edema and intraventricular rupture (blue arrow). Intraventricular hemorrhage casting is visualized in the right lateral ventricular causing obstructive hydrocephalus (red arrow). Panel B: Repeat non-contrast CT of the head 6 hours later revealed an increase in size of thalamic hematoma to 4.3 x 5.2 x 4.8 cm, an increase in amount of Intraventricular hemorrhage, progression of hydrocephalus from cast obstruction, and worsening vasogenic edema causing 5 mm left midline shift.

An 80-year-old woman with a past medical history of hypertension and hypercholesterolemia presented to an outlying hospital at 11:00 hours with slurred speech, left arm drift, and headache. A non-contrast CT of the head revealed an intraparenchymal hematoma in the right thalamus measuring 3.4 x 4.2 cm with an associated intraventricular rupture (Figure 1A, blue arrow). An intraventricular hemorrhage cast with secondary hydrocephalus was also noted on initial imaging (Figure 1A, red arrow). She was placed on a nicardipine drip for blood pressure control and subsequently transferred to OSF St. Francis Medical Center (OSFMC) for a higher level of care.

Upon arrival to OSFMC, the patient was poorly responsive, non-verbal, and could not follow commands.  She was directly admitted to the Neuroscience Intensive Care Unit for further management. Vitals signs were stable on presentation. Neurologic examination revealed a comatose patient with asymmetric and minimally reactive pupils, absent gag reflex, right gaze preference, brisk corneal reflex on the right and absent response on the left, absent deep tendon reflexes on the left upper and lower extremity, with absent response to painful stimuli on the left upper and lower extremity. Patient had a Glasgow Coma Scale score of 6, NIH stroke scale score of 23, and an Intracerebral Hemorrhage Score of 5. A repeat non-contrast CT scan of the head was performed at 17:00 hours to monitor for expansion of hematoma and progression of secondary hydrocephalus. Imaging revealed an interval increase in the size of the acute intraparenchymal hematoma, measuring 4.3 x 5.2 x 4.8 cm. In addition, there was an increase in amount of intraventricular hemorrhage, progression of hydrocephalus, and worsening vasogenic edema causing a mass effect with a 5 mm left midline shift (Figure 1B). At the request of the patient’s family members, her code status changed to DNR and she was made comfort care. No interventions were pursued and patient entered hospice care. 

Intracerebral hemorrhage (ICH) occurs in about 15% of strokes per year (1). The most common cause of spontaneous ICH is rupture of micro-aneurysms of small blood vessels in brain tissue, secondary to chronic hypertension. Hypertensive hemorrhages typically occur in the basal ganglia and thalamus, which are in close proximity to the cerebral ventricular system. Blood can accumulate at these sites forming an acute intraparenchymal hematoma, which can expand and exert mechanical pressure on the ventricular walls leading to intraventricular rupture and secondary intraventricular hemorrhage (IVH) (2). Intraventricular rupture occurs in approximately 45% of spontaneous ICH, which results in an expected mortality of 50-80% (1). Blood in the ventricular system can clot forming a “cast” (Figure 1A, red arrow). Ventricular casts are especially troublesome because the cast can block the outflow of cerebrospinal fluid causing an acute obstructive hydrocephalus, which can lead to increased intracerebral pressure (ICP), mass effect, and brain herniation (2). In Figure 1A, the intraventricular cast formation likely represents the patient’s normal ventricular size prior to ventriculomegaly from hydrocephalus. Figure 1B shows the typical progression of the intraparenchymal hematoma and obstructive hydrocephalus. There are several treatment options for management of an intraparenchymal hematoma with intraventricular rupture; they include reduction of ICP via ventriculostomy and medical therapy, surgical evacuation of the hematoma, and intraventricular thrombolytics to reduce casting and secondary obstructive hydrocephalus (2,3). Despite these interventions, the prognosis remains poor (3).

Melvin Parasram MS OMS4,¹ Mangala Gopal OMS4,² Lee Raube DO MS,³ Editha Johnson DO,⁴ Deepak Nair MD^4,5

¹Midwestern University, Arizona College of Osteopathic Medicine, Glendale, AZ USA

²Des Moines University, College of Osteopathic Medicine, Des Moines, IA USA

³Departments of Emergency Medicine and ⁴Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL USA  

⁵Illinois Neurological Institute, OSF St. Francis Medical Center, Peoria, IL USA

References

1. Hinson HE, Hanley DF, Ziai WC. Management of intraventricular hemorrhage. Curr Neurol Neurosci Rep. 2010 Mar;10(2):73-82. [CrossRef] [PubMed]
2. Hanley DF. Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage. Stroke. 2009 Apr;40(4):1533-8. [CrossRef] [PubMed]
3. Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A. Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. J Neurol. 2000 Feb;247(2):117-21. [CrossRef] [PubMed] 

Cite as: Parasram M, Gopal M, Raube L, Johnson E, Nair D. Medical image of the week: intraventricular hemorrhage casting. Southwest J Pulm Crit Care. 2016;13(5):220-3. doi: http://dx.doi.org/10.13175/swjpcc094-16 PDF 

November 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 38-year-old man presented to his primary care physician with complaints of pruritus, jaundice, and poor appetite. The patient had been diagnosed with hypertension one year earlier and was treated with hydrochlorothiazide and an angiotensin-converting enzyme inhibitor, but evidently did not tolerate the regimen well, and developed “tea-colored” urine following initiation of this therapy. He was also recently diagnosed with diabetes mellitus and also complained of intermittent right upper quadrant pain.

Laboratory data, including white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 99%.

Frontal and lateral chest radiographs (Figure 1) were performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven pages)

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography shows a focal, poorly defined right base opacity
3. Frontal and lateral chest radiography shows bilateral peribronchial and mediastinal lymph node enlargement
4. Frontal and lateral chest radiography shows cardiomegaly
5. Frontal and lateral chest radiography shows upper lobe bilateral linear and reticular abnormalities

Cite as: Gotway MB. November 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(5):207-15. doi: http://dx.doi.org/10.13175/swjpcc112-16 PDF