Outcome of Fourth Ventricular Hemorrhage in Ruptured Brain Aneurysms: Impact of Active Blood Clearance and Delayed Cerebral Ischemia Prevention

BACKGROUND AND OBJECTIVES: Blood in the fourth ventricle is associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We investigated (1) the prognostic significance of the amount of blood in the fourth ventricle and (2) the influence of active blood clearance and delayed cerebral ischemia prevention (ABCD). METHODS: We reviewed 817 consecutive aSAH patients admitted between January 1, 2009, and December 31, 2022, assessing blood amount in the fourth ventricle using a fourth ventricular hemorrhage scale (FVH): grade 1 (no or minimal blood), grade 2 (partially filled), grade 3 (completely filled/cast), and grade 4 (ballooning). Incidence of poor outcomes was evaluated using multivariate analysis before and after the introduction of ABCD (October 2015). Subsequently, a 1:1 matched-pairs analysis compared outcomes specifically between patients who underwent ABCD and matched controls receiving standard care. Neurological outcomes were evaluated at 6 months (independent modified Rankin scale). RESULTS: Before ABCD, poor outcomes occurred in 31/41 FVH grade 3 patients (76%; odds ratio (OR) 4.4) and in 38/41 FVH grade 4 patients (93%; OR 29.1). After ABCD, the incidence of poor outcomes decreased to 23/40 in FVH grade 3 patients (58%; P = .043; OR 1.3) and 31/41 in FVH grade 4 patients (76%; P = .017; OR: 3.6). The matched-pairs analysis also showed improvement in poor outcomes for FVH grade 4 patients who underwent ABCD compared with standard care (64% vs 89%, P = .024), but not for FVH grade 1 to 3 patients. No increase in the incidence of ventriculitis was seen in patients receiving ABCD treatment ( P = .836). CONCLUSION: Ballooning fourth ventricular hemorrhage (grade 4 FVH) is a powerful predictor of poor outcomes after aSAH. With the introduction of ABCD, the prognosis of these patients improved considerably and 25% reached functional independence 6 months after aSAH.