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LETTER TO EDITOR
Year : 2009  |  Volume : 57  |  Issue : 3  |  Page : 357-358

Rapid resolution of hydrocephalus due to simultaneous movements of hematoma in the trigono-occipital horn and the aqueduct


1 Department of Neurosurgery, Koyanagi Memorial Hospital, Saga
2 Department of Radiology, Kurume University School of Medicine,Kurume, Fukuoka

Date of Acceptance05-Jun-2009
Date of Web Publication8-Jul-2009

Correspondence Address:
Naoshi Hagihara
Department of Neurosurgery, Koyanagi Memorial Hospital, Saga

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.53275

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How to cite this article:
Hagihara N, Abe T, Inoue K, Watanabe M, Tabuchi K. Rapid resolution of hydrocephalus due to simultaneous movements of hematoma in the trigono-occipital horn and the aqueduct. Neurol India 2009;57:357-8

How to cite this URL:
Hagihara N, Abe T, Inoue K, Watanabe M, Tabuchi K. Rapid resolution of hydrocephalus due to simultaneous movements of hematoma in the trigono-occipital horn and the aqueduct. Neurol India [serial online] 2009 [cited 2019 Sep 18];57:357-8. Available from: http://www.neurologyindia.com/text.asp?2009/57/3/357/53275


Sir,

A 61-year-old female had an episode of headache lasting for three days. Findings upon physical examination were negative except for progressive disorientation. A computer tomography (CT) scan revealed intraventricular hematoma (IVH) in the left trigone and occipital horn, and hydrocephalus [Figure 1]a and blood clots in the aqueduct [Figure 1]b. As we suspected the presence of subarachnoid hemorrhage (SAH), we planned for an immediate magnetic resonance imaging (MRI). There was a waiting period for approximately 50 min between the initial CT scan and acquiring the MRI. During this period the patient was kept quiet in bed. MRI T1-weighted images done after 50 min of the initial CT scan showed temporal horn of the left lateral ventricle filled with a clot exhibiting high signal intensity [Figure 1]c. MR images also revealed the resolution of hydrocephalus [Figure 1]d. After MR imaging, she was more alert relieved of headache. No vascular anomaly was detected on MR angiography. She was discharged without neurological deficit.

In our patient the initial CT scan showed left IVH in the tigone and occipital horn with obstructive hydrocephalus due to clot in the aqueduct. MRI done 50 min later showed resolution of hydrocephalus and blood in the temporal horn of the left lateral ventricle. For the period between CT scan and MRI, she was lying in the supine position. It was very unlikely for the clot to move from trigono-occipital horn (TOH) to the inferior horn of the lateral ventricle in this position.

Spontaneous resolution of acute hydrocephalus without aspiration of cerebrospinal fluid (CSF) or drainage procedures is rare, and only a few cases have been reported previously. [1],[2] The presumed mechanism for the spontaneous resolution in these patients is aqueductal trapping and releasing of the clot.

Cerebrospinal fluid dynamic in different types of hydrocephalus have been well studied. [3],[4],[5],[6],[7] We hypothesize the following possible mechanism for the spontaneous resolution of the hydrocephalus in our patient. Our patient had obstructive hydrocephalus secondary to the clot in the aqueduct with elevated intraventricular pressure. The blood clot in the left trigone and occipital horn might have resulted in the obstruction and entrapment of the left temporal horn leading to a significant elevation of pressure in the entrapped left temporal horn. We feel the pressure gradient between the entrapped left temporal horn and the rest of the ventricular system might have given a way in the blood clot located at the left trigone and occipital horn. This would have resulted in further increase in intraventricular pressure resulting in unplugging of the clot in the aqueduct leading to spontaneous resolution of the hydrocephalus. Subsequent to these events the clot in the left trigone and occipital horn might have slipped into the temporal horn.

Our patient also demonstrates two other aspects: (1) the difficulty in identifying the cause of IVH and (2) how treatment strategies can change depending on the changes in the clinical status and investigative findings. Nomura [2] reported an interesting case in which hydrocephalus spontaneously improved six hours after onset due to movement of a clot plugging the aqueduct. However, it is very difficult to define the time window for unplugging of clot in the aqueduct in such cases. Resolution of the clot is likely to depend on the amount and location of the clot in the ventricle. The best approach in such patients would be to closely monitor the clinical status. If there is any deterioration in the level of consciousness, the therapeutic strategies, such as ventricular drainage or endoscopic removal of the clot should be instituted. We emphasize the importance of considering conservative management of hydrocephalus in a clinically stable patient with such clinical presentation.

 
  References Top

1.Abubacker M, Bosma JJ, Mallucci CL, May PL. Spontaneous resolution of acute obstructive hydrocephalus in the neonate. Childs Nerv Syst 2001;17:182-4.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Nomura S, Orita T, Tsurutani T, Kajiwara K, Izumihara A. Transient hydrocephalus due to movement of a clot plugging the aqueduct. Comput Med Imaging Graph 1997;21:351-3.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Joseph VB, Raghuram L, Korah IP, Chacko AG. MR ventriculography for the study of CSF flow. AJNR Am J Neuroradiol 2003;24:373-81.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Kosteljanetz M. CSF dynamics in patients with subarachnoid and/or intraventricular hemorrhage. J Neurosurg 1984;60:940-6.  Back to cited text no. 4  [PUBMED]  
5.Linninger AA, Xenos M, Zhu DC, Somayaji MR, Kondapalli S, Penn RD. Cerebrospinal fluid flow in the normal and hydrocephalic human brain. IEEE Trans Biomed Eng 2007;54:291-302.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Oi S, Kudo H, Yamada H, Kim S, Hamano S, Urui S, et al. Hydromyelic hydrocephalus. Correlation of hydromyelia with various stages of hydrocephalus in postshunt isolated compartments. J Neurosurg 1991;74:371-9.  Back to cited text no. 6    
7.Zhu DC, Xenos M, Linninger AA, Penn RD. Dynamics of lateral ventricle and cerebrospinal fluid in normal and hydrocephalic brains. J Magn Reson Imaging 2006;24:756-70.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]


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