Graeb+IVH+Score 2

8/22/2019 Graeb+IVH+Score 2

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Douglas A . G raeb , M .D .W illiam D . R obertson , M .D .Joce lyn e S . L apoin te , M .D .R obert A . N ugen t, M .D .Ph ilip B . H arrison , M .D .

Com puted T om ograph ic D iagnosiso f In traven tr icu la r H em orrhageEtio logy an d P ro gn osis1

S ixty-eigh t pa tien ts w ith in trav en tr icu la rh em orrhage (IVH ) d iagnosed by com pu tedtom ography (CT ) w ere rev iew ed retro -sp ec tiv ely to d eterm ine th e etio lo gy andprogno sis , rela tionsh ip to de la yed hydro -cepha lus , and effect on neuro log ica l ou t-com e. T he m ost comm on cau ses w ere arup tu red aneurysm , traum a, and hyper-ten sive hem orrhag e. R up tu red aneurysm sof th e an ter ior commun icating a rterycan often be pred icted from the non -enhanced CT scan . T he tota l m orta lityra te w a s 50% ; how ever , 21% of patien tsre tu rned to norm al or had on ly m ildd isab ility . P atien ts in w hom no cau sewa s id en tified had a better p rognosis .D e layed hydrocephalu s w a s re la ted toth e e ffec ts o f subarachnoid hem orrhagerath er than ob s tru ction o f th e v en tr icu la rsys tem by b lood. IVH p er se is se ldom am ajor fa ctor in th e neuro log ica l ou tcom e.Index te rm s: A neury sm , ce reb ral. 1 (71 .73 0 #{149}ra in ,hemorrhage #{149} ra in , in ju rie s #{149} e ad , com pu tedtom ograph y . 1[0 ].l2 11 . Hyd ro cep halus. 1 [6] .43 72 .Sub ara chn oid spac e. hem o rrh age

R adio log y 143: 91-96 , A pr il 1 98 2

I F rom the D epa rtm en t of D iagno stic R adio log y .V ancouv er C eneral H o sp ita l, V an couver , B .C ., C anad a.R ece ived M ay 7, 1981; acc ep ted and rev is ion req ues tedA ug. 11 ; re v is ion rece ived S ep t. 18 .

P resen ted in par t a t the For ty - th ird A nnu al M eetingof the C anadian A ssoc iat ion of R ad io lo g is ts. M ontreal,Q ueb ec, C anada, M ay 11 -15 , 1 98 0 . sjh

B E FOR E com pu ted tom og raph y (C T ), th e c lin ica l d iag nos is o fin trav en tm icu lam hem orrh ag e (IV H ) w as usua lly sug gested by

sud den com a fo llow ed by seve re and often fa ta l b ra instem dys-fu nc tion (1 -3 ) . T h is so -ca lled c la ssica l p re sen ta tion w as g en e ra llya ssoc ia ted w ith m assive in traven tr icu lar h em orrhag e. H ow eve r , C Tfrequen tly d em onstra tes IV H even w hen the c lass ica l c lin ica lp ic tu re is absen t. Fo rtuna tely , a lthou gh it u sua lly occurs in asso cia tionw ith seve re b ra in traum a , even rela tive ly m assive IV H m ay havea g ood ou tcom e (4 ) (F ig . 1 ).

W hile seve ra l rep o rts have docum en ted the ab ility o f C T to sh owIV H (4-7 ) , to o ur know ledg e on ly on e sizab le se rie s has b een an a-lyzed , nam ely tha t o f L ittle e t a !. (8 ) w ho ob served 54 pa tien ts o fw hom on ly 9 su rv ived . O u r exp e rience su gg ests tha t th e p ro gno sisis som ewhat be tte r th an these s ta tistic s ind ica te. W e h ave rev iew edou r ow n cases to d ete rm ine the e tio lo gy and p ro gno sis and ev alu atethe m ole o f IV H in bo th de layed hyd roceph alu s and th e neuro lo g icalo u t come .

MATER IALS AND M ETHODSO f 77 cases o f C T -d iagno sed IV H ava ilab le fo r stud y , 9 w ere d is -

carded becau se o f inad eq ua te fo llow -u p , po or scan qua lity , on becausethe IV H w as posto pe ra tive , leav ing 68 cases fo r rev iew . P rem a tu rein fan ts w ere n o t inc lu ded .

A ll pa tien ts had non-con tras t scans on an EM ! 1O1O S ; con tras t-enh an ced scans w ere also o b ta ined in 1 1 cases. In pa tien ts w ith arup tu red aneurysm , w e a ttem pted to loca te it on the non-co n trastscan , b ased o n th e s ite o f hem atom a form ation . In 29 pa tien ts scann edm ore than o nce , v en tricu la r s ize w as fo llow ed up in o rde r to de ter-m ine the re latio nsh ip be tw een suba rachn o id and /o n in traven tr icu lambleed ing an d d elay ed hydm ocepha lus , d ef ined as an in c rea se inven tr icu la r size deve lop in g a t lea st one w eek afte r the in itia l h em -om rhage . A ny inc rease in s ize w as a lso co rre lated w ith th e p resen ceof b lo od in the th ird and fo urth ven tric le s an d sub arach no id space.IV H w as g raded acco rd in g to the am oun t o f b lood w ith in each yen-tn icle ( TABLE I) , w ith a m ax im um score o f 1 2 : 1 -4 w as ca lled m ild , 5 -8m od era te , and 9-12 seve re.

O u tcom e w as asse ssed u sing th e G lasg ow sca le (9 ), in w hich pa -tien ts a re ass ig ned to one of five ca tegories: norm al o r m ild d isab ility(I), m od era te d is ab ility (II), m a jo r d isab ility (III) , vege tativ e sta te (IV ),o r dea th (V ). E ach p atien ts clin ica l reco rd w as a lso rev iew ed to d e-te rm in e th e cause o f death , on the na tu re o f any re sidu al neu ro lo g ica ldefic it in the case of su rv ivo rs.

RESULTSA ge and sex d istrib u tion s are sh own in F igure 2 . M ales an d fem ales


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Aneurysm

,a _.I I I

Trauma

rJf Hyper tens ive

f / / /kr/ i2ffAemorrhage0 20 40 60 80A ge

Severe IVH and righ t f ron tal hem atom acaused by a rup tured rig h t an ter io r c erebra la rtery aneu rysm . Th e p atie n t w as norm a l o ndischa rge excep t for m ild paresis of the lef t legsecond ary to spasm of the ves sel .

80

60U M a le (3 4 cases ) 40 F em a le (3 4 cases) 20

20 1 # {176 }16 a 2012 08 404 20

0 I I I I20 40 60 80

Ag e

a. A ge and sexd istr ibu tion of 6 8 pa tien ts w ith IVH .b. Age distribu t ion o f pat ien ts w ith IV H du e to a rup tured aneury sm , tra um a, or h ype rte nsiv e

hemorrhage.

Figure 3

25 17 1713 12

010 15Ca)

c10 55 3

SS P

-c 011 n(O 4 I# {231}5 % O O S % -

E tio log y o f 6 8 cases o f IV H . T he num ber of ca ses is ind ica ted at thetop o f ea ch co lum n .

F igu re 4 were affec ted in equa l num bers , w itha peak in cid en ce in the six th an d sev -en th decades w hich w as com posedm ain ly of pa tien ts w ith ru p tu red an -eu ry sm on hype rten sive hem o rrhage .P atien ts w ith traum a show ed a b i-phasic d istrib u tion , w ith p eak s at ag es1 0-3 0 and 60-80 . T he m ost frequen tcauses o f IV H w ere rup tu red an eu-rysm , traum a, and hyp er tens ive hem -om rh ag e (F ig . 3 ) .

A neurysm s o f the an te rio r ce reb ra l

Non -en hanced scan sh ow s a ru p tu red an te rio rcom m unicat ing a rtery (AC A ) aneu rysm w ithIV H and su barach no id b le ed ing . N ote theloc aliz ed h em atom a in th e an terio r in ter-hem isphe ric fissu re .

Figure 1 F igure 2

92 A p ril 19 82 V olum e 143 , N um ber 1 G raeb and O thers

T AB L E I: S ys tem fo r G rad in g Sever ityof IV H

L atera l V en tric lesS core: 1 = t rac e of b loo d or m ild b leed in g

2 = le ss than half o f th e ven tric lefilled w ith b lood

3 = m o re than ha lf o f th e ven tr ic lefil led w ith b loo d

4 = v entric le f ille d w ith b loo d andexpanded

(E ach la teral ven tric le is s co red sepa rate ly )Th ird an d Fourth V entric les

S core: 1 = blood p resen t, v en tric le sizen o rma l2 = ven tric le filled w ith b loo d and

expandedTo tal S core (m ax im um 12)

T AB L E I I: A ccuracy of CT D iag no sisof A neurysm s a t D iffe ren tSites

CorrectNo.of C T

P rov ed D iag-S ite of A n eurysm Cases no sis

A nte rio r com muni-catingartery 6 4

A nterio r c erebra lartery 2 1

A zygou s a rte ry I 0Peric allosal ar tery 1 0C allosom a rg inal ar tery 1 0In ternal c aro tid artery 3 0M iddle ce reb ral ar tery 1 0P osterio r com m un i-

cat ing arte ry I 0P osterio r in ferio r

cerebe lla r a rte ry 1 0

U,

U,0U0a)0Ez


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Figure 6

Figure 5

CT D iagnos is o f In traven tn icu lar H em orrh ag e NEURORAD IOLOGY 93

C erebra l traum a w ith sev ere IV H (G lasg ow sco res : left ven tric le 4 ; righ t v en tric le 3 ; th ird v en tric le 2 ; fou rth ven tric le 2 ; to ta l 1 1) ., N ote the hem orrhage in th e sub ara chn oid spac e and the soft tis sue s of the sc alp and fac e. T he dila ta t ion of the latera l ven tr ic le s is p rob ab lyd ue to in trav en tricu lar ob stru ctio n of CSF flow .arte ry and its b ranch es , inc lu d ing th ean te rio r com m unica ting arte ry (A CA ),w ere the m o st com m on , co nstitu ting 1 1ou t o f 1 7 cases (6 5% ) ( TABLE II). O nlyrup tu res invo lv ing the AC A cou ldbe pred icted , be ing seen as lo ca lizedb leed ing in the an te rio r in tenhem i-spheric fissu re , ju s t an te rio r to the lam -m a te rm ina!is, in 4 ou t o f 6 cases (F ig .4) .

The d iagnos is o f traum a w as ev id en tf rom the h isto ry and phys ica l find in gsand w as confirm ed by au top sy in 11ou t o f 17 pa tien ts. Sw elling on hem on-rhage in the ex trac ran ia l so f t tis su e w aspresen t in 13 pa tien ts (76% ). P aren -chym al hem atom as w ere foun d in 12( 7 1%) . A dd itiona l f in d ings inc lu dedv en tricu la r en la rgem en t, m id line sh ift,su barach no id hem o rrhage , acu te sub -d una l hem atom a, ce reb ra l con tu sion ,sku ll frac tu re , and in trac ran ial a ir (F ig .5) .

H yp erten sive hem o rrhage , seen in13 cases, w as estab lished by hyp er ten -s ion 1 80 /100 (m ean , 22 0 /120) and ad eep parenchym al hem atom a on theC T scan . In 3 pa tien ts , ang io g rap hyshow ed no aneurysm ; 2 pa tien ts h adhypertensive hem orrhage a t au to psy .In 7 cases (5 4% ), the re w as b leed in gin to the tha lam us or b asa l gan g lia

b (F ig . 6 ) . T hree had b leed ing in to th etem pora l lo be , 1 in to the f ron ta l lo be ,and 1 in to th e p ons ; ano th er pa tien thad m ultip le h em orrhages th ro ughou t

T AB L E II I: C orre la tion BetweenDelayed H yd roc eph alu sand H em o rrhage (29 case s)

De l ay edNo . o f H ydro cep halus

Pa tie n ts N o. %IVH in th ird o r four th v en tric le

P resen t 1 9 9 47Ab sen t 10 3 30

S ub ara chn oid h em orrh ag eP resen t 15 1 0 67A bsen t 14 2 14

bo th hem isph eres and the cerebe llum .O nly 4 had CT ev idence o f subanach-no id b leed ing . O ther find in gs inc lud-ed ven tr icu la r en largem en t an d m id-line sh ift.

A n ten iov en ous m alfo rm ation (A V M )w as d iagn osed by ang iogn ap hy in a ll 5cases. In tracereb ra l hem atom as w ereassoc ia ted w ith m id line sh ift in 3 andven tricu la r en la rgem en t in 2 .

T hree pa tien ts h ad a hem orrhag icd ia thesis es tab lish ed by coagu la tionstud ies . Tw o were ovenm edica ted w ithora l an ticoagu lan ts and 1 h ad pro fo undth rom bocy top en ia du e to ch em o th en-apy fo r acu te p nom yelocy tic leuke-m ia . N o charac te ristic CT fea tu res w erefound .

In 1 pa tien t (F ig . 7 ), IV H w as pre -sum ably caused by m etas tases fromrena l-ce ll ca rc inom a (wh ich had a lso

Hyper ten siv e h em orrhag e in to the rig h t b asa lg ang lia in a pat ien t w ith m ild IVH . (G lasg owscore s: left ven tric le 1 ; rig h t v en tric le 2 ;th ird ven tric le = 1; fou rth ven tric le 0 ; to ta l= 4 ). T he low -den sity area la teral to the lef tcauda te nu cleus is co ns iste n t w ith an o ldinfarc t o r h em orrhag e.

sp read to the lungs and bon e), a !-tho ugh w e hav e no p a th o log ica lp roof .

In 12 of th e 68 pa tien ts , the e tio log yw as und ete rm ined . A ng iography in 8fa iled to show the b leed ing s ite, a s d idau to psy in 1 case. Tw o pa tien ts d ied


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Figure16

ea 12I-)

Figure 9

Figure 10

O utcom e of IV H (68 ca ses) . Th e num ber ofcases is ind icated at the top o f e ach co lum n.

a)at0Ca)UI-a)a-

Ou tcom e o f IV H in fo ur m ain et io log ic ca teg ories. T he num be r of c ase s is ind ica ted a t the topof e ach co lum n .

Figure 7

94 Ap ril 19 82 V olum e 143 , N um be r 1 G raeb and O thers

a. b.

a. Scan show s a rou nd area of predom in an tly in cre ased d en sity po ste rom ed ial to th e rig h t tr igo ne (a rrow s) , w ith b leed in g in to b o th lateralven tr ic les.

b. V er tebral a ng iogram reveals abno rm al v essels (arrow h ead s) ar isin g f rom th e pos terio r choro id al ar teries; th is is co nsisten t w ith va scu larm eta sta ses , th ough th is w as n ot proved . N ote the m ass ef fec t cau sing an terio r d isp lacem en t of the la te ral pos ter io r cho ro idal a rte ry (sh ortarrow ) and caud al d isp la cem en t of the p osterio r p en icallosa l ar tery (lo ng a rrow ).

1 .3 7 .1 4 1 5 .2 8 3 3Days

L ength of CT fo llow -u p (2 9 case s).

Ou t come

I I I IN IV Va) 40010Ca)U 14

- - - 5 20103164186 Q 10

w itho u t u nde rgo in g an g iog raph y , and34 au top sy wa s not p er fo rm ed . Tw o e l-

de rly pa tien ts recov ered satis fac to rilyan d w ere no t investig ated becau se o fth eir age . T he re w ere no C T fea tu re sw h ich d is tingu ished th ese 12 p atien ts ,n o r w as th ere any s ign if ican t d iffe r-en ce in th e seve rity o f IV H be tw eenth is g ro up of 12 pa tien ts an d the 56 inw hom the e tio log y w as u nde tem -m in ed .

In m o st o f th e 2 9 pa tien ts w ith repea tscans , fo llow -up lasted o ne to fourw eeks (F ig . 8 ). W hile the assoc ia tion ofde lay ed hydrocepha lus w ith b lood inthe th ird on fourth ven tr icle w as no tsta tis tica lly s ign ifican t (P > 0 .3 ) , itsassoc iation w ith sub an ach no id hem -ornhage w as (P 0 .004) ( TABLE III) .

O utcom e is show n in F igure 9 . T herew as on ly 1 pa tien t in ca tegory IV ;how eve r, a s a pe rm anen t v eg eta tivesta te is as se rious as dea th fo r th e pa-tien t an d fam ily , ca teg o ries IV and Vare grouped toge ther here . T he ou t-com es in the fo u r catego rie s a re show nin F igu re 10 . C om pared to the m orta l-ity rate s in traum a (71% ), hyp er tens ivehem orrhage (6 2% ), an d rup tu red an-eurysm (53% ), p atien ts w ith b leed ingof u nde te rm in ed cause h ad a con sid -enab ly be tte r p rog nos is : th e m orta lityra te w as o n ly 25% , w hile 50% surv iv edw ith no d efic it o r o n ly m ild d isab ility .If the 4 pa tien ts w ho w ere no t inves ti-


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TABLE IV : Additiona l CTAbnorm alitie s in IVH

80Ou t c ome

I II I ll IV -V

IVH G radeSevere

Figure 11100

a)at0Ca)Ua)a-

Relationsh ip of ou tcom e to severi ty o f IVH . The num ber o f c asesis ind ica ted at the to p of ea ch co lum n.

Figure 12

100 UNi lJSAH on ly

It 0 0 O th er a bn orm alitie s 2 2 28

I II Il l IV-VOu t c ome

Re lationsh ip of ou tcom e to o th er C T abno rm alit ies. T he n um bero f ca ses is in d ic ate d a t the top o f e ach co lum n.

freq uen t fin d ing w hich can be used top red ic t th e site o f the an eu ry sm basedo n the C T scan , som eth ing w hich w asno t p oss ib le w ith rup tu res a t o the rsi tes .A lth ough suba rach no id b leed in gfrom ce reb ra l m e tas tase s (p articu la rlym a lign an t m e lan om a) is k now n too ccur (11 , 13 ), in tnaven tn icu lan b leed -ing from m etasta se s has no t b een re -p o rted p rev io usly to our know ledg e .W h ile th e C T appearance w as no t spe -c ific fo r m e ta sta se s, th e ang io g rap h icd em onstra tion of tum or vesse ls su p -po rts th is d iagno sis (F ig . 7 ) .

C T D iagno sis o f In tn av en tn icu lan H em orrh ag e NEURORAD IOLOGY 95

No. %Pa renchym a l hem atom aM idlin e sh ift

4222

6232

Subdu ral hem atom a 5 7Transten toria l hern iat ion 3 4Contusion 1 1R ecent in fa rct 1 1Subarach noid b leed ingNon e

119

1613

ga ted and h en ce m ay have a d iscov -en ab le cau se o f IV H are exc luded , th em o rta lity rate w as on ly 1 in 8 (1 2 .5% ).The m o re sev ere th e IV H , the w orsethe p rogn osis; ind eed , 90% of pa tien tsw ith seve re IV H died (F ig . 11 ) .

IV H is se ldom an iso la ted even t. In87% of o ur cases , ad d ition al abno r-m alitie s w ere seen o n C T (TABLE IV ) .P a tien ts w ith a p oor o u tcom e also hada h ighe r inc idence of a ssoc ia ted ab -no nm a litie s (F ig . 12 ) . A lthou gh on ly 9of ou r pa tien ts (13% ) had no add itiona labno rm alitie s , 7 had a good on ex cellen tou tcom e (ca tegory I on II). In a ll ca se s,fac to rs o th e r than IV H w ere su ff icien tto ex p la in th e neu ro lo g ica l ou tcom e.In 63 cases the cau se w as a p am enchy-m a l h em a tom a , m id line sh ift, ang io -g rap h ically dem onstra ted sp asm , onin ju ry to o the r o rgans . O f th e 5 m e-m a in ing pa tien ts , 3 su ffe red m assiv ere -b leed ing and d ied be fo re a rep ea tC T scan co u ld be o b ta ined , w h ile 2d ied o f po stope rativ e neuro log ica lcomplicat ions.

DISCUSS IONA lthou gh an eury sm s of the an te rio r

cereb ra l a rte ry and its b ranches m ad eup 65% of our se r ies , they accou n t fo ro n ly 3 6% of a ll rup tu red aneurysm sw ith subarachno id b leed ing (10) .O the r au tho rs have n o ted the inc rea sedlike liho od of in traven tn icu lam rup tu refrom aneu rysm s of these vesse ls , pa r-ticu lan ly the ACA (8 , 1 1). A n eurysm s ofthe A C A m ay read ily rup tu re in to thela te ra l ven tr icle s , a s on ly the re la tive lyth in o lfac to ry and p an a tenm ina l gy n iseparate the aneurysm s from thefro n ta l h o rn s.

O ur exp erience supports Y o ck s m e-po rt o f th e C T app ea ran ce o f a rup tu redA C A aneu rysm (12 ). T he m os t ch arac-ten istic featu re is a hem a tom a loca lizedto the an te r io r in te rh em isph em ic fis -su re , ju st an te r io r to th e lam ina tenm i-na lis . A lth ough prev iou sly desc rib edas an uncom m on even t (11), CTsu ggests th at it is ac tua lly a re la tive ly

T he ove ra ll m ortality ra te o f 50% inou r se rie s (F ig . 9 ) is co nside rab ly low erthan th e 83% rep orted by L ittle e t a !. (8 ) ,w h ich is on ly p artly exp lain ed by theg rea te r p ercen tag e of case s o f un de -tem m ined cause in our se r ies (1 8% vs .4%) . Fourteen p atien ts (2 1% ) re tu rnedto no rm a l on had on ly m ild d isab ility ,w h ile 10 (15% ) su rv iv ed w ith m od era ted isab i l i ty .

A s d em onstra ted w ith su bam achno idb leed in g of und ete rm ined e tio lo gy (14 ,1 5 ) , pa tien ts w ith IV H o f u nknow ncause have a sig n if ican tly be tte r p ro g -no sis . Ju st a s m icroscop ic vascu la r


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96 A pr il 1982 V olum e 143 , N um be r 1 G naeb and O the rs

m a lfo rm a tio ns have been pos tu la ted asa cause o f su banachno id b leed in g ofun de term in ed e tio lo gy (16) , s im ila rm a lfo rm atio ns ad jacen t to the epen-dym a l lin ing of the v en tric le s m ay bere sp ons ib le fo r som e cases o f IV H inw hich no cau se is foun d .

A pprox im ate ly 5 0% o f ou r pa tien tshad m ild en la rgem en t o f the la te ra lv en tric le s o n the in itial C T scan . A s nop rev io us scans w ere ava ilab le andm any pa tien ts w ere a t an ag e w hen a t-no phy co u ld b e exp ec ted , th is fin d ingw as d ifficu lt to in te rp re t; how eve r , an yinc rea se in ven tr icu la r size on subse -q uen t s cans w as consid e red sign if ican t.A llcock (17) has sta ted tha t dev elo p -m en t o f h ydrocepha lus a fte r IV H m ayb e du e to obs truc tion o f the f low of# {2 31} ereb rosp in a l flu id (C SF ) at the fom a-m en of M onno or aqu ed uc t o f S y lv iu s;a lth ough th is is like ly to be true inacu te case s, ou r stud y show s th a t h y -d ro cep ha lus w hich deve lo ps a t lea stone w eek a fter IV H can be co rrela tedw ith sub arach no id h em orrhag e on thein itial C T scan ra th er th an w ith IV H inth e th ird on fo urth v en tric le . In suchcases, th e hydm oceph alu s is m ore lik elyto be com m unica ting (due to ob litem a-tiv e am achno id itis in the po ste rio r fossao n im pa ired re so rp tion o f C SF in thea rach no id g ranu la tion s) than ob stru c -tive (18, 19).

T he e ffect o f IV H on ou tcom e cou ldpe rh ap s be as se ssed m o st accu rate ly ina p rosp ectiv e fa sh ion by com parisonw ith a con tro l g ro up w ith ou t IV H ;h ow eve r, o b ta in ing an unb iased co n-tro l g rou p pre sen ts a p rob lem in tha tthe u ltim a te sev erity o f b ra in dam ageis d ifficu lt if no t im po ss ib le to eva lua tep ro spec tive ly . O ur app ro ach w as tocorre la te the c lin ica l reco rd and th e C Tscan w ith ou tcom e in each case. In ou rse rie s , ou tcom e w as d ete rm ined byassoc ia ted b ra in in ju ry ra the r thanby IV H itse lf. F ac to rs such as pam en chy-m a! h em atom a , m id line sh ift, c e reb raledem a , and vasosp asm had p red ic tab lee ffects w h ich in each case w ere su ffi-cien t to exp lain the n eu ro log ica l o u t-com e . P a tien ts w ith IV H and no add i-tio na ! C T abno rm a litie s had a m uchbe tter ou tcom e , and tho se in w hompanenchym al dam ag e w as co nfined tosilen t a rea s o f th e b rain (su ch as thefron ta l lo bes) also d id w e ll. O ur f ind -in gs ind ica te th at IV H per se i s s el do ma m ajo r co n tr ibu to r to the neuro log ica lou tcom e in these pa tien ts .

A s C T is now cap ab le o f d isc losin gIV H in m any cases w here it co u ld n o tbe d iagn osed c lin ica lly , th is fin d ing by

itse lf shou ld no t be overem phas ized . Inthe g reat m a jo rity o f case s, th e even tua lou tcom e w ill b e de term in ed by thep re sence o r absence of a sso cia ted b ra inabn orm a lities . E v en sev ere IV H needno t be cause fo r a g loom y p rogno sisin a ll ca se s.

S UMMARYS ix ty -e igh t pa tien ts w ith C T -d iag -no sed IV H w ere rev iew ed retrosp ec -

tive ly . Th e m o st freq uen t causes w erea rup tu red an eu rysm , traum a, and hy-pe rten sive hem orrh age ; le ss frequen tcau ses inc lud ed b leed in g from an am -te rio venou s m a lfo rm a tion , a hem on-rhag ic d ia thesis , o n pro bab le m eta sta -ses . In 12 pa tien ts the cause w as un -de te rm ined . R up tu red an eu rysm s o fthe an ter io r cereb ral a rte ry and itsb ranches (in clu d ing th e A C A ) cau sedIV H m o re often than o the r aneurysm sand co u ld frequen tly be p red ic ted bythe ir app ea ran ce on non-en hancedC T scans.

Th e ov e ra ll m orta lity ra te w as 5 0% .H ow eve r, 21% of p atien ts retu rn ed tono rm al o n had on ly m ild d is ab ility ,w h ile 15% had on ly m od era te d isab il-i ty . Pa tien ts w ith IV H of u nde te rm inedcau se had a m uch be tte r p rogn osis .IV H due to ce reb ral traum a ca rr ied theh ig hest m ortality m a te (7 1% ) and w ou ldappea r to be an om in ous fin d ing . H y -dro cep ha lu s w h ich deve lops one w eekor m o re a fter IV H can b e co rre la tedw ith su bam achno id b leed ing on the C Tscan ra the r th an w ith b lo od in the th irdo r fou rth ven tr icle and is th ere fo rem o re lik e ly to be com m unica ting thanob stru ctiv e . IV H p er se se ldom has am a jo r e ffec t on the neu ro lo g ica l o u t-come .D epa rtm ent o f D iagn ostic R adio log yV ancouv er G eneral H o sp ita l85 5 W . 12 th A v e.V anco uv er, B .C . V 5Z 1M 9Can ad a

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