Hemorrhage into third ventricle

Case #45: CT brain, 12/2/93: intraventricular bleed into third ventricle

CC: progressive weakness

HX: This 77 y/o RHM was transferred from Burlington, IA. , for progressively worsening somnolence. He presented locally, a day earlier, with HA, nausea, vomiting and frequent falls in the context of progressive weakness. He was admitted locally with a diagnosis of gastroenteritis, weakness and dehydration. His mental status worsened overnight. A HCT scan revealed an intraventricular hemorrhage.

PMH: 1) Left parietal stroke 4/91. 2) Atrial Fibrillation, now on Coumadin. 3)Coronary angioplasty x 2 in past. 4) HTN

SHx/ FHx: Retired farmer. No hx of Tobacco or ETOH use.

MEDS: K-dur, Monopril, Calan SR, Transderm Nitropatch, Lanoxin, Coumadin 2.5mg qd, Quinidex.

EXAM: T36.5 HR 100 BP161/61 RR15 99% O2 Sat.

MS: somnolent, not oriented. Sparse vocalizations that are poorly intelligible.

CN: Pupils 5/3 decreasing to 4.5/2/5 on exposure to light. +/+corneas and gag. Oculocephalic reflex intact. Facial movement symmetric.

MOTOR: Generalized weakness ( 4+/4+) throughout. Difficult to assess secondary to mental status.

Sensory: WD to PP in all extremities.

Coordination/Gait/Station: ND

Reflexes: 2+ throughout. Bilateral Babinski signs.

Course: The HCT , performed on the outside, showed an acute 3rd ventricular hemorrhage with hydrocephalus. He underwent emergent right frontal ventriculostomy placement. His elevated PT=18 was corrected enroute to surgery with FFP and Vit K . Later that day he underwent 4-vessel cerebral angiogram. This study was unremarkable. He initially improved, but then worsened and on 12/14/93 underwent right occipito-parietal ventriculoperitoneal shunt placement. He was discharged 2/4/94. 1/8/97, he represented to UIHC after striking the side of his head on a tree. He subsequently began to experience progressive unsteadiness and mental status decline and was diagnosed with a SDH on HCT scan.