A case of pyogenic ventriculitis after severe subarachnoid hemorrhage

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  • Kuroda Yusuke
    Department of Neurosurgery, Mie University Graduate School of Medicine Department of Neurosurgery, Mie Prefectural General Medical Center
  • Shiba Masato
    Department of Neurosurgery, Mie University Graduate School of Medicine
  • Ichikawa Tomonori
    Department of Neurosurgery, Ise Red Cross Hospital
  • Hatazaki Seiji
    Department of Neurosurgery, Mie University Graduate School of Medicine
  • Toma Naoki
    Department of Neurosurgery, Mie University Graduate School of Medicine
  • Suzuki Hidenori
    Department of Neurosurgery, Mie University Graduate School of Medicine

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Other Title
  • 化膿性脳室炎を併発した重症くも膜下出血の一例
  • カノウセイ ノウシツエン オ ヘイハツ シタ ジュウショウク モ マク カ シュッケツ ノ イチレイ

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Abstract

<p>  A man in his 60s was referred to our hospital due to severe (World Federation of Neurological Surgeons grade 5) subarachnoid hemorrhage associated with hematoma in the genu of the corpus callosum and intraventricular hemorrhage due to a ruptured left distal anterior cerebral artery aneurysm. The aneurysm was treated with direct trapping, and external ventricular drainage was performed for acute hydrocephalus. After surgery, the patient required antibiotic therapy for pneumonia and sepsis due to carbapenem‒resistant Enterobacteriaceae. Ventricular drainage catheters were repeatedly replaced for prolonged hydrocephalus. At and after 30 days post‒admission, the patient was diagnosed with meningitis based on increased leukocytes in the cerebrospinal fluid (less than 424/μL). At 40 days post‒admission, diffusion‒weighted magnetic resonance images showed growing high‒intensity masses in the corpus callosum and bilateral lateral ventricles where the hematoma had been, and computed tomography revealed enhancement of the entire wall of ventricles by a contrast medium, leading to a diagnosis of pyogenic ventriculitis. Endoscopic aspiration of isolated and encapsulated empyema was performed and ventricles were irrigated. In spite of repeated ventricular drainage and endoscopic third ventriculostomy, however, the patient died because of uncontrolled hydrocephalus on the 95th hospital day. Considering the high mortality of pyogenic ventriculitis, early diagnosis and treatment are essential, but early diagnosis is sometimes difficult in cases with a limitedly increased number of leukocytes in the cerebrospinal fluid due to isolated and encapsulated intraventricular empyema, as in this case. In cases with prolonged ventricular drainage for hydrocephalus and intraventricular hemorrhage, pyogenic ventriculitis should be kept in mind for early diagnosis based on findings of computed tomography and magnetic resonance imaging.</p>

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