J Korean Neurosurg Soc.  2022 Mar;65(2):325-330. 10.3340/jkns.2021.0122.

Direct Removal of Fourth Ventricle Hematoma in Massive Intraventricular Hemorrhage

• Kim YS
• Ryu HS
• Kim TS
• Joo SP

• KMID: 2527189
• DOI: http://doi.org/10.3340/jkns.2021.0122

Abstract

Various grading systems and surgical techniques have been developed for the treatment of intraventricular hemorrhage (IVH); however, little attention has been paid to the fourth ventricle hematoma. Nonetheless, hemorrhagic dilation of the fourth ventricle may lead to catastrophic consequences for patients with massive IVH. We present two cases of massive IVH accompanied by massive fourth ventricle hematoma which was successfully removed with combination of suboccipital craniotomy for fourth ventricle hematoma and intraventricular fibrinolysis for supratentorial hematoma.

Keyword

Brain stem; Craniotomy; Fourth ventricle; Intraventricular hemorrhage

Figure

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  Fig. 1. Case 1. A and B : Initial computed tomography scan showed massive intraventricular hemorrhage with a fourth ventricle hematoma compressing the brainstem. C and D : The intranidal aneurysm was successfully obliterated in the forniceal arteriovenous malformation using Histoacryl® (B. Braun, Melsungen, Germany). Thick arrow indicates intranidal aneurysm.

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  Fig. 2. Case 1. A and B : Removal of fourth ventricle hematoma was performed via midline suboccipital craniotomy. C and D : Postoperative computed tomography scan revealed complete removal of the fourth ventricle hematoma and slight improvement of the hydrocephalus.

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  Fig. 3. Case 1. A : The intraventricular hemorrhage was almost completely resolved following eight doses of intraventricularly administered tissue plasminogen activator given over 4 consecutive days. B : Normal ventricle size was maintained by a shunt during follow-up computed tomography scan at 18 months after surgery.

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  Fig. 4. Case 2. A and B : An initial computed tomography scan revealed massive intraventricular hemorrhage with a fourth ventricle hematoma compressing the brainstem. C and D : The fourth ventricle hematoma was removed via midline suboccipital craniotomy.

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  Fig. 5. Case 2. A and B : A postoperative computed tomography scan showed complete removal of the fourth ventricle hematoma and improvement of the hydrocephalus. C and D : The intraventricular hemorrhage was almost completely resolved following six doses of intraventricularly administered tissue plasminogen activator given over 3 consecutive days.

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  Fig. 6. Case 2. A and B : The ventricle’s normal size was maintained without a shunt during follow-up computed tomography scan at 12 months after surgery.

Reference

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