Acute hydrocephalus after aneurysmal subarachnoid hemorrhage

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✓ Hydrocephalus, defined as a bicaudate index above the 95th percentile for age, was found in 34 (20%) of 174 prospectively studied patients with subarachnoid hemorrhage (SAH) who survived the first 24 hours and who underwent computerized tomography (CT) scanning within 72 hours. The occurrence of acute hydrocephalus was related to the presence of intraventricular blood, and not to the extent of cisternal hemorrhage. The level of consciousness was depressed in 30 of the 34 patients. Characteristic clinical features were present in 19 patients, including a gradual obtundation after the initial hemorrhage in 16 patients and small nonreactive pupils in nine patients (all with a Glasgow Coma Scale score of 7 or less). In the remaining 15 patients (44%), the diagnosis could be made only by CT scanning. After 1 month, 20 of the 34 patients had died: six from rebleeding (four after shunting), 11 from cerebral infarction (eight after an initial improvement), and three from other or mixed causes. Only one of nine patients in whom a shunt was placed survived, despite rapid improvement in all immediately after shunting. The mortality rate among patients with acute hydrocephalus was significantly higher than in those without, with the higher incidence caused by cerebral infarction (11 of 34 versus 12 of 140 cases, respectively; p < 0.001). Death from infarction could not be attributed to the extent of cisternal hemorrhage, the use of antifibrinolytic drugs, or failure to apply surgical drainage, but could often be explained by the development of hyponatremia, probably accompanied by hypovolemia.

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Address reprint requests to: Jan van Gijn, M.D., Department of Neurology, University Hospital Utrecht, P.O. Box 16250, 3500 CG Utrecht, The Netherlands.

© AANS, except where prohibited by US copyright law.

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Figures

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    Diagram showing the method for measuring the bicaudate index (A ÷ B). A = the width of the frontal horns at the level of the caudate nuclei; B = the diameter of the brain at the same level.

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    Graphs showing the incidence of acute hydrocephalus (hatched bars) in 174 patients related to two predisposing factors. Left: Distribution of relative ventricular size calculated by dividing the individual bicaudate index by the 95th percentile for age. Center: Distribution of the extent of cisternal hemorrhage (for a description of the grading system see text). Right: Distribution of the extent of intraventricular hemorrhage (for a description of the grading system see text).

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    Relationship between degree of ventricular dilatation and level of consciousness as determined by the Glasgow Coma Scale in 34 patients with acute hydrocephalus. Triangles = patients with small nonreactive pupils; circles = other patients; black symbols = patients who later died from cerebral infarction.

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    Computerized tomography scans in a 59-year-old woman with rupture of an aneurysm of the anterior communicating artery. Day of hemorrhage = Day 0. Left: Scan on Day 2, when the patient's Glasgow Coma Scale (GCS) score was 12 and the relative ventricular size was 1.4. Center: On Day 3, after external drainage, the GCS score was 14 (normal) and ventricular size was 0.7. Right: Scan on Day 4 showing rebleeding that led to death on Day 5.

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    Computerized tomography scans in a 59-year-old woman. Top Row: On Day 0 (the day of hemorrhage) the patient's Glasgow Coma Scale (GCS) score was 10. Cisternal and intraventricular hemorrhage suggests rupture of a basilar artery aneurysm. Ventricular size is 1.5. Center Row: On Day 7, after she had spontaneously improved to a GCS score of 13, she deteriorated to a score of 5, with right hemiplegia. The ventricular size was 0.8, and infarction can be seen in the territory of the left middle cerebral artery. The increased density of the blood in the posterior horns was caused by sedimentation, by the decrease in ventricular volume, and perhaps also by abnormal cerebrospinal fluid circulation. Lower Row: On Day 14, the day of death, additional and extensive infarction was visible in the right hemisphere, with ventricular shift to the left.

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    Diagram showing the extent of cisternal hemorrhage in all patients with acute hydrocephalus, and in those who subsequently died from infarction (black bars).

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