Delayed Intracerebral Hematoma after Ventriculoperitoneal Shunt in the Context of Ruptured Brain Arteriovenous Malformation: A Literature Review

Abstract

Hemorrhagic complications arising from ventricular drainage procedures are typically asymptomatic and of low volume. A particular subset of these complications, known as delayed intracranial hemorrhage (DICH), is however recognized for its particularly poor prognosis. We primarily aimed to identify epidemiological characteristics associated with DICH, to shed light on its occurrence and potential risk factors. To do so, we performed a retrospective analysis of a series of ten patients who presented with DICH in the context of a ruptured brain arteriovenous malformation (bAVM) and a systematic literature review of all DICH cases reported in the literature. Our ten patients showed delayed neurological deterioration after a ventriculoperitoneal shunt (VPS) procedure, with a computed tomography (CT) scan revealing a DICH surrounding the ventricular catheter, distinct and away from the nidus of their previously ruptured bAVM. Four patients (40%) rapidly declined and passed away, three (30%) required surgical management and the remaining three (30%) demonstrated gradual clinical improvement with conservative management. In the literature, most patients presenting with DICH had hydrocephalus associated with neurovascular disorders (47% of cases), such as bAVM rupture in our present series. These constatations point out the significance of the underlying pathologies potentially being predisposed to these unusual complications.

Keywords: arteriovenous malformation; brain hemorrhage; hydrocephalus; ventriculoperitoneal shunt.

Figure 1

Flow chart showing selection of the studies available in the literature for the present review, according to the PRISMA statement.

Figure 2

Initial CT scans of three different patients showing various intraventricular hemorrhagic extension patterns due to a ruptured bAVM.

Figure 3

Male patient in his 40s presenting with acute onset of headache. Emergency brain CT scan (A) revealed left parietal intraparenchymal hematoma and intraventricular hemorrhage. Digital subtraction angiography of the left internal carotid artery (ICA) lateral projection (B) showed an underlying left parietal bAVM. The two main arterial feeders originated from the pericallosal artery. Endovascular embolization was performed via distal microcatheterization of the feeders and ultra-selective angiography (C) followed by an injection of the embolic product (Onyx 18, Ev3 Neurovascular, Irvine, CA, USA). The final angiographic of the left ICA (D) shows complete bAVM exclusion.

Figure 4

Illustrative case vignette of one patient’s consecutive CT scans: preoperative scan (A), early post-operative check within 24 h (B) and delayed (5 days) scan after neurological deterioration (C₁,C₂) showing hematoma at the level of the catheter (C₁) and extension below (C₂).

Figure 5

Illustrative scans of three patients of the present series, showing the unusual complication of a delayed consistent hematoma surrounding the catheter pathway, and corresponding clinically to frank neurological deterioration.