• History & Exam 
    - A 75-year-old male presents with sudden onset severe headache and altered mental status. The patient is a poor historian and no other history is available. 
    - Exam: AAO x 2. Cranial nerve exam is normal. No major motor or sensory deficit elicited. 
    - Labs: INR of 2.4 (Normal < 1.3), otherwise labs are normal

    Figure 1. CT Head without contrast CT - Head without contrast reveals IVH in the fourth ventricle. Hydrocephalus and layered IVH is visible in the supratentorial views.

    Figure 2. Cerebral angiogram Angiogram reveals multiple aneurysms (arrows) in the posterior circulation and an early filling blush (arrowhead) in the midline.

    1. The most common etiology for a fourth ventricular hemorrhage in this age group is:

    2. The patientÂ’s mental status declines during transfer to the ICU. The need for an emergent ventriculostomy is recognized. How would you proceed at this point?

    3. In your opinion what is the acute pathology that the patient is suffering from?

    4. After successful placement of the ventriculostomy, what is the next step that you would take in the management of this patient? The various options are enumerated.

    5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Please add any suggestions or comments regarding this case:

    • The aneurysms are due to the avm. The bleed is from an aneurysm rupture. All of these can be surgically treated. This is a SMG 1 AVM (not eloquent, drains not to the galenic system, < 3CM). The morbidty and mortality is low < 5%. The cure rate is nearing 100%. These can be delt with a posterior approach. Alternative is to take the aneurysms by endovascular means and come back for surgery for the AVM.
    • Since the subarachnoid hemorrage of the fourth venricule by hipertension in old pacients it is not the most frecuent. I think the problem in by a PICA ruptured aneurysm, and it is mandatory to attack the aneurysm by clipping, and AVM too if it is posible at the same time. Treat this by endovascular coiling it could difficult and dangerous.
    • Some data wasn't presented. So answers are according with the alternatives
    • would not treat aneurysms or AVM
    • For these Cases of the Month, I wish that when the results are tabulated the following month,the reviewers would include an expert's view of what the reasonable answers should be. I feel this would enhance my learning further to know what an expert feels the right answer is. For this case, expert opinion answers to Questions 1, 3, & 4, would be greatly appreciated, rather than simply displaying pole results of what everyone thinks, which may not necessarily represent the best answer. Thru this type of expert commentary, we will truly gain even more from these excellent cases, rather than simply knowing what everyone else thinks, which could be wrong. I understand that for some questions there may not be a single right answer. But it would be nice to hear an expert's view on these types of questions also - even if it is simply to say that either answer would be reasonable.
    • Keeping in view the age of patient, I will treat the patient conservatively...of course after placing the vent. drain...
    • NMR, if possible, can help to identify the origine of bleeding.
    • Help me
    • I am in the opinion that we should not wait for lab result of INR while on FFP and Vit K.
    • not good or representative angiogram picture
    • is better for me this discussion

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