Hashmi, M

Khatri, Ismail A.

Tamizuddin, S.

English

eCommons@AKU

Pakistan Journal ofNeurological Sciences (PJNS)Volume 5 | Issue 1 Article 64-2010Fatal Primary Intraventricular Hemorrhage in 3rdTrimester of Pregnancy with Rescue of BabyS. TamizuddinShifa International HospitalM HashmiLiaquat National HospitalIsmail A. KhatriShifa International HospitalFollow this and additional works at: https://ecommons.aku.edu/pjnsPart of the Neurology CommonsRecommended CitationTamizuddin, S.; Hashmi, M; and Khatri, Ismail A. (2010) "Fatal Primary Intraventricular Hemorrhage in 3rd Trimester of Pregnancywith Rescue of Baby," Pakistan Journal of Neurological Sciences (PJNS): Vol. 5 : Iss. 1 , Article 6.Available at: https://ecommons.aku.edu/pjns/vol5/iss1/6INTRODUCTIONPrimary intraventricular hemorrhage (PIVH) is a non-traumatic intracranial hemorrhage confined to theventricular system, without any bleeding in the cerebralparenchyma. PIVH in adults is relatively rare, comprising3.1% of all intracranial hemorrhages.1,2 A few cases ofPIVH in pregnancy have been reported, althoughpregnancy is not one of the risk factors for PIVH.  Thetrue incidence for PIVH in pregnancy is not known but it isconsidered rare. We report an unusual case of PIVH in a pregnant womanwho had sudden cardiac arrest after arrival to emergencyroom, and baby was rescued through emergencycesarean section after unsuccessful resuscitative effortsin mother. A review of literature is also presented withobservations on possible predictors of early mortality. CASE REPORTA 29-year-old woman, 30-week primigravida, presentedwith sudden onset of headache and vomiting for 24hours.  Headache was severe, generalized and wasinitially relieved by analgesics to some extent but later theheadache worsened. Her past medical history wasunremarkable.  Her pregnancy had been uneventful. Onarrival she was unconscious with Glasgow coma scale of4/15 with decerebrate posturing.  Her blood pressure was110/70 mm Hg. She was tachycardic and febrile, 103oF.Her pupils were equal and reactive. There were no otherlocalizing signs. Systemic examination was unremarkable,and non-revealing for her clinical status. A CT scan ofhead without contrast showed panventricular hemorrhagewith severe hydrocephalus. There was no parenchymalextension.  Shortly afterwards, she went into cardiacarrest. Resuscitation was attempted and cardiac rhythmwas restored in 10 minutes, but patient developed signsof brainstem death. The oxygenation was maintained withartificial mechanical ventilation. An urgent obstetricalultrasound showed a viable fetus. A live baby wasdelivered by an emergency caesarean section. The familyof patient refused autopsy to determine the cause ofPIVH.  V O L .  5 ( 1 )  J A N  -  M A R   2 0 1 0P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  18C A S E  R E P O R TFATAL PRIMARY INTRAVENTRICULAR HEMORRHAGEIN 3RD TRIMESTER OF PREGNANCY WITH RESCUEOF BABYShaista Tamizuddin,1 Mubashira Hashmi2 and Ismail A. Khatri11Section of Neurology, Shifa International Hospitals Ltd., and Shifa College of Medicine, Islamabad, Pakistan 2Department of Neurology, Liaquat National Hospital, Karachi, PakistanCorrespondence to: Dr. Khatri, Assistant Professor of Neurology, Shifa College of Medicine & Associate Consultant Neurologist, Shifa International Hospitals Ltd, Pitras BukhariRoad, Sector H-8/4, Islamabad, Paksitan. Phone no: +92-051-460-3175 Email: ismailkhatri@yahoo.com Pak J Neurol Sci 2010; 5(1):18-20ABSTRACTPrimary intraventricular hemorrhage (PIVH) in adults is rare. A number of risk factors have been associated with PIVH, thecommonest being hypertension, arterio-venous malformations, aneurysms, and coagulopathies. Although pregnancy is notone of the risk factors for PIVH but there have been a few cases of PIVH in pregnancy. Among the cases of PIVH reportedso far, the outcomes have been variable including survival of both mother and baby, survival of mother with death of baby,or death of both mother and baby. We report an unusual case of fatal PIVH in pregnancy in which mother sufferedcardiopulmonary arrest in emergency room, and the baby was rescued through an emergency cesarean section, whenmother had no signs of brain stem function.       V O L .  5 ( 1 )  J A N  -  M A R   2 0 1 0P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  19DISCUSSIONPrimary intraventricular hemorrhage (PIVH) has beendescribed to have three clinical presentations includingsudden profound coma and death within 48 hours;sudden focal cerebral dysfunction; and sudden severeheadache, drowsiness or confusion without focalneurologic signs.2 Vertical gaze palsies, hyperthermia,miosis, unreactive pupils or decerebrate posturing havealso been described with third ventricle hematomas, butonly 1 out of 11 patients in the study by Angelopoulos etal., with blood in the third ventricle had elevatedtemperature.2A variety of risk factors have been associated with PIVH,hypertension being the most common.1-2,3-5 Otheretiologic factors include arteriovenous malformation(AVM), almost exclusively in patients under 50 years ofage,3-5 aneurysms, coagulopathies, choroid plexustumors and cysts, moyamoya disease and arteritis.1-2 Formost patients (25-48%), however, the cause is unknown.In our case, the patient did not have any of the knownrisk factors. However, we were unable to get an autopsyor a cerebral angiogram to evaluate moyamoya disease,and other potential causes of PIVH, therefore, weconsider our patient to have PIVH of undeterminedetiology.Hydrocephalus is a frequent complication.1-2,3-5 Passeroet al. found hydrocephalus in all patients with stupor orcoma (7 of 7); in 4 of 13 patients who were drowsy, andin 2 of 6 alert patients. Hydrocephalus has been reportedas poor prognostic factor.2,4-5 This seems to hold true inour case where patient presented in coma and CT scanshowed massive hydrocephalus.  Level of consciousness on admission is an importantprognostic factor.2,3-5 In the study by Marti-Fabregas etal. ,  al l  those who died had a decreased level ofconsciousness or were comatose on admission.4 Glasgowcoma scale 8 and early hydrocephalus are predictors ofin-hospital mortality.3 Diabetes mellitus and coagulopathyalso predict early mortality.1 In one series, hypertensivepatients were found to have less extensive bleeding thannon-hypertensive patients.3 Some investigators haveused the extent of blood in the ventricles to determinethe prognosis. The more severe the hemorrhage, theworse the prognosis.1,5-6 Death has been reported within48 hours of panventricular hemorrhage.2 Jayakumar et al.reported 70% mortality with panventricular blood and100% recovery with blood in one ventricle.5 Hameed etal. also found panventricular blood to predict earlymortality.1 However, some studies have found nosignificant correlation between extent of blood andoutcome.2,4 Our patient had panventricular hemorrhageand died soon after the diagnosis was established. This isin concordance with published literature.  The neurological outcome of PIVH is not uniformly poorand has changed as diagnostic ability has improved,allowing the recognition of more benign cases. Death isthought to occur invariably from brainstem dysfunction.4In-hospital mortality as high as 36-47% has beenreported.2,3,5 Patients with PIVH of unknown cause havebetter prognosis than those with a documentedmechanism of hemorrhage.1,6 The good prognosis is alsoattributable to the absence of parenchymal damage.4Various treatment options have been tried in PIVH likedirect or indirect cerebral revascularization surgery whichcan prevent both hemorrhagic and ischemic events inmoyamoya disease patients.7 Other than externalventricular drainage or ventriculo-peritoneal shunt, recentwork has focused on the use of intraventricular infusion ofthrombolytic agents.2 Findlay et al. treated 10 patientswith IVH with tissue plasminogen activator and concludedthat the treatment improved overal l  outcome byfacilitating rapid lysis of the IVH and drainage withnormalizat ion of ventr icular size and intracranialpressure.8Cases have been reported where mother had cerebralparenchymal hemorrhage in pregnancy and baby wasrescued by cesarean sect ion and mother diedsubsequently within 2 weeks.9,10 Among cases wheremother had PIVH, Mehrkens et al.,11 and Newman etal.,12 have reported cases in which mother survived andhealthy babies were delivered. Nakai and co-workersreported a case in which the patient suffered primary IVHin the 14th week of pregnancy.  She subsequently had alarge infarct and died 16 days later. Her cerebralangiography confirmed moyamoya.13 Kim et al. reporteda unique case in which patient had moyamoya diseaseand had intracranial hemorrhages in two consecutivepregnancies. The first was intraventricular hemorrhage in27th week gestation, and second was intracerebralhemorrhage in 28th week of pregnancy. The babydelivered after the first pregnancy died but the babydelivered in the second pregnancy survived.14To the best of our knowledge, no case has been reportedso far in which mother had PIVH and died before babywas rescued. Our case is one of the rare situations inwhich fatal primary IVH occurred during pregnancy andthe baby was rescued with an emergency cesareansection when no brainstem function was present in themother. ACKNOWLEDGEMENTThe authors thank Syed Nizam Ahmed, MD, AshrafTamizuddin, MD for helping with bibliography and criticallyreviewing the manuscript, and Southern Illinois UniversitySchool of Medicine Library for providing full text articles forbibliography.REFERENCES1. Hameed B, Khealani BA, Mozzafar T, Wasay M. Prognostic indicators in patients with primary intraventricular hemorrhage. J Pak Med Assoc.2005;55:315-317.2. Angelopoulos M, Gupta SR, Azat Kia B. Primary intraventricular hemorrhage in adults:clinical features, risk factors and outcome. Surg Neurol.1995;44:433-436.3. Passero S, Ulivelli M, Reale F. Primary intraventricular haemorrhage in adults. Acta Neurol Scand. 2002;105:115-119.4. Marti-Fabregas J, Piles S, Guardia E, Marti-Vilalta JL. Spontaneous primary intraventricular hemorrhage:clinical data, etiology and outcome. J Neurol. 1999;246:287-291.5. Jayakumar PN, Taly AB, Bhavani UR, Arya BY, et al. Prognosis in solitary intraventricular hemorrhage. Clinical and computed tomographic observations.  Acta Neurol Scand. 1989;80:1-5.6. Graeb DA, Robertson WD, Lapointe JS, Nugent RA, et al. Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis.Radiology 1982;143:91-96.7. Marcinkevicius E, Liutkus D, Gvazdaitis A.  Experience of treatment of moyamoya disease at the Clinic of Neurosurgery of Kaunas University of Medicine. Medicina (Kaunas) 2006;42:130-136.8. Findlay JM, Grace MG, Weir BK. Treatment of intraventricular hemorrhage with tissue plasminogenactivator. Neurosurgery. 1993;32:941-947.9. Williams DL, Martin IL, Gully RM. Intracerebral hemorrhage and Moyamoya disease in pregnancy. Can J Anaesth. 2000;47:996-1000.10. Sun JC, Yakimov M, al-Badawi I, Honey CR. Hemorrhagic moyamoya disease during pregnancy. Can J Neurol Sci. 2000;27:73-76.11. Mehrkens JH, Steiger HJ, Strauss A, Winkler PA. Management of haemorrhagic type moyamoya disease with intraventricular haemorrhage during pregnancy. Acta Neurochir (Wien). 2006;148:685-689.12. Newman P, Al-Memar A. Intraventricular haemorrhage in pregnancy due to Moya-moya disease. J Neurol Neurosurg Psychiatry 1998;64:686.13. Nakai Y, Hyodo A, Yanaka K, Nose T. Fatal cerebral infarction after intraventricular hemorrhage in a pregnant patient with moyamoya disease. J Clin Neurosci. 2002;9:456-458.14. Kim TS, Lee JH, Kim IY, Lee JK, et al. Moyamoya disease with repeated intracranial haemorrhage in two consecutive pregnancies. J Clin Neurosci. 2004;11:525-527.V O L .  5 ( 1 )  J A N  -  M A R   2 0 1 0P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  20

Fatal Primary Intraventricular Hemorrhage in 3rd Trimester of Pregnancy with Rescue of Baby

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Fatal Primary Intraventricular Hemorrhage in 3rd Trimester of Pregnancy with Rescue of Baby

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