Teaching Case

A 79 year old woman had an episode of sudden clouding of consciousness in the morning. Clinical findings were: Somnolence, psychomotoric deceleration, slight right sided hemiparalysis stage 4 and increased left sided muscle idioreflexes. CT stated a circumscript cerebral hemorrhage and an internal hydrocephalus that vanished within two days completely.

A 79 year old woman was admitted to our stroke unit with a sudden clouding of consciousness in the morning and slight right sided hemiparalysis. Arterial hypertension, Osteoporosis and a presbyacusis were stated as clinical history. Clinical findings were: Somnolence, psychomotoric deceleration, slight right sided hemiparalysis stage 4 and increased left sided muscle idioreflexes. Emergency computed tomography of the brain (Siemens Sensation 16, plain with 4.5 and 9 mm slices) revealed a left sided intracerebral bleeding next to the left side ventricle (Fig 1 a, b). The third and both side ventricles were enlarged. At the bottom of the third ventricle at the top of the aqueduct a tiny hyperdense spot was visible (Fig 1 c). A venous CTA of the brain excluded a sinus vein thrombosis (not shown here). Treatment was conservatively by lowering systemic pressure. Repeated CT 2 days later revealed normal diameters of ventricles (Fig.2 a) and a much better delineated intracerebral hemorrhage (Fig 2 b). The clotting at the top of the aqueduct had disappaered again (Fig 2c). In between our patient regained consciousness and was sent to a rehabilitation centre for further treatment.

Intracerebral hemorrhage with perforation into the ventricle system is not uncommon and leads to temporary or permanent internal hydrocephalus in approximately 12.8% (1). External ventricle drainage is considered as the method of choice to improve patients’ outcome if an internal hydrocephalus develops (1). The latter finding is reported as significantly associated with the final outcome when stated on initial computed tomographic scan (2). It is advised to perform ventricular drainage in all comatose patients with intraventricular haemorrhage and acute hydrocephalus while evacuation of bleeding is considered usefull only in large hemorrhage larger than 3 cm of diameter (3). In our case a drainage had not become necessary because clinical state improved rapidly and intracerebral hemorrhage was somewhat of a circumscript extension. Nevertheless even a little drop of blood was able to enlarge ventricles to the observed extent.