Background: Aneurysmal rupture accompanies intraventricular hemorrhage (IVH) in 13% to 28% of cases and can occur with no or slight subarachnoid hemorrhage. Clinical characteristics of such patients as well as their optimal management remain unclear.
Methods: We performed direct surgery for 197 patients with ruptured cerebral aneurysms in the past four years at our institute. Among them, we studied nine patients (5%) presenting mainly with IVH. The patient age ranged from 44 to 83 years (mean 64 years). They comprised of five men and four women. We retrospectively analyzed the method of treatment and clinical results.
Results: The grading scale score before treatment was five in all the patients in WFNS grading and Hunt & Kosnik grading, which was poor in all cases. The site of the aneurysm was the anterior communicating artery in three, the middle cerebral in two, the basilar, the internal carotid-posterior communicating, tip of the internal carotid, and the posterior cerebral artery in one each. To prevent rerupture, aneurysmal clipping was performed in seven patients, including one via the transventricular approach, and coil embolization in one. To control intracranial pressure, ventricular drainage was performed in nine, and endoscopic evacuation of hematoma in one. While cerebral vasospasm was seen in only one patient because of little subarachnoid hemorrhage, the outcome at discharge was generally poor; modified Rankin Scale score at discharge was 3 in four patients, and 4 or more in five. On the contrary, the outcome was favorable when outflow of the cerebrospinal fluid could be obtained without vasospasm.
Conclusions: In patients with ruptured aneurysms presenting mainly with IVH, initial clinical status was severe probably because of the damage at the ventricular wall due to direct arterial pressure on it. Their treatment must include not only prevention of rerupture, but also control of acute hydrocephalus due to IVH. It is important to surgically obtain the outflow of the cerebrospinal fluid rapidly to obtain favorable outcomes.