Case Report

A case report with reference to radiographic features

Haemorrhage in the cavum veli interpositi as the primary haemorrhagic source of intraventricular haemorrhage:

Takeya Watabe, Natsuki Hattori, Teppei Tanaka, Yoko Kato, Hirotoshi Sano
Abstract: The cavum veli interpositi is not a rare ventricular anomaly, however it is usually asymptomatic. A case of primary haemorrhage in the cavum veli interpositi as the bleeding source of intraventricular haemorrhage, without vascular lesion or tumour, was diagnosed and treated by neuroendoscopic surgery. A 17-year-old woman with history of transient visual field loss 2 years ago had sudden onset of headache followed by vomiting. A head CT scan showed intraventricular haemorrhage with predominant haematoma in the cavum veli interpositi. A diagnostic angiography demonstrated no apparent vascular lesion, however remarkably delayed appearance of deep venous system and the straight sinus, with prominent collateral drainage toward the vein of Labbe was noted. An external ventricular drainage was placed immediately, followed by endoscopic removal of intraventricular haemorrhage excluding the haematoma in the cavum veli interpositi on day 3. The left internal cerebral vein was engorged and seemed to be congestive during surgery. The postoperative course showed good recovery without neurological deficit. An angiography was repeated 23 days after the onset and it demonstrated improved venous circulation. This is the first report on a primary haemorrhage in the cavum veli interpositi. The cause of bleeding was unknown, however, possible abnormal vascular anatomy in this anomalous space might be associated. The vein of Galen is shifted downward by the cavum veli interpositi and this might cause venous hypertension in the deep venous system. Improvement of the venous circulation on the angiography suggested compression of the veins by haematoma can cause impairment of blood circulation and this fact supports theoretical benefit of haematoma removal. Effectiveness of endoscopic treatment for intraventricular haemorrhage is discussed. Key words: Cavum veli interpositi, velum interpositum and intraventricular haemorrhage. (p105-107)

Introduction
The cavum veli interpositi is an abnormal enlargement of the velum interpositum, however it is not a rare anomaly and usually asymptomatic.2 We experienced a rare case of intraventricular haemorrhage associated with cavum veli interpositi as the primary haemorrhagic source, treated by neuroendoscopic surgery. Clinical and radiological features are reported and the mechanism of bleeding is discussed. Effectiveness of endoscopic treatment for intraventricular haemorrhage is also reported.

Case presentation
A 17-year-old woman woke up in the early morning due to sudden headache and nausea, followed by repeated vomiting. She was transferred to the emergency room in Fujita Health University Hospital by ambulance, and a head CT scan demonstrated intraventricular haemorrhage. The CT scan also showed a prominent haematoma between the lateral ventricles (Fig. 1) but it did not show any other suspicious bleeding source. The patient was lethargic and in a state of delirium on admission, the Glasgow Coma Scale score was 13 (E3V4M6), and had no focal neurological deficit. Diagnostic angiography was performed and it found no apparent vascular lesions. However, the straight sinus and the deep venous system were demonstrated remarkably later than the other veins (Fig. 2a), and collateral venous

Department of Neurosurgery Fujita Health University Hospital Dengakugakubo Toyoake, Aichi Japan Correspondence: Dr. Takeya Watabe Department of Neurosurgery Fujita Health University Hospital 1-98 Dengakugakubo Toyoake, Aichi - 470 1192 Japan Email: tkwatabe@wm.pdx.ne.jp

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drainage toward the vein of Labbe (Fig. 2b) was prominent. This patient had a history of transient visual field loss when she participated in a marathon 2 years previous, however no related abnormality was detected on work-ups by ophthalmologists and neurologists. A head MRI, which was taken at that time, had shown an asymptomatic cavum veli interpositi (Fig. 3).

ventricle through a laceration of choroidal fissure, the vein was engorged and seemed to be congestive (Fig. 5). The patients consciousness disturbance gradually improved after endoscopic surgery, and the ventricular drainage was removed 3 days after the surgery. The patient recovered to normal activity of daily life without any neurological deficit. A diagnostic angiography was repeated 23 days after the onset and the prior abnormal findings of the venous system had improved (Fig. 6). The haemorrhagic source remained unknown.

Figure 1 - A head CT scan on admission demonstrating intraventricular haemorrhage with abnormal haematoma between the bilateral lateral ventricle. Figure 4 - A head CT scan immediately after the endoscopic surgery.

Figure 2 - The venous phases of the left internal carotid angiogram performed on the first day. (a) Shows delayed appearance of deep draining system on later phase and (b) shows prominent collateral drainage to the vein of Labbe. Figure 5 - Intraoperative endoscopic view showing engorged left internal cerebral vein. Figure 6 - The venous phase of the right internal carotid angiogram performed on day 23 with improvement of appearance of the vein of Galen and internal cerebral vein noted.

Figure 3 - A head MRI taken 2 years before intraventricular haemorrhage showing a small cavum veli interpositi.

Discussion
The cavum veli interpositi is not an infrequent ventricular anomaly. Picard et al,(8) reported 34% of children younger than 2-years-old to whom pneumoencephalography was performed had cavum veli interpositi, and Chen et al,(2) reported 21% of infants with sonographic study had this anomaly. The size is usually small, less than 10 mm, and large lesion are rare.9 The cavum veli interpositi is an abnormal enlargement of the velum interpositum. The velum interpositum is anatomically limited by the fornices and the hippocampal commissure from superolaterally, the tela choroidea as the roof of the third ventricle from inferiorly, and the medial walls of thalami from inferolaterally. The posterior wall was constituted by the continuum of the tela choroidea limiting the vein of Galen and the pineal cistern.9 It

Based on the findings on the latest head CT scan and previous head MRI, the primary haemorrhagic site was thought to be the cavum veli interpositi. An external ventricular drainage was inserted on day 0. Even though the bleeding source was unknown, endoscopic removal of the intraventricular haemorrhage was performed (Fig. 4) on day 3. The haematoma in the cavum veli interpositi was left to avoid rebleeding, however, the intraventricular haematoma was removed as much as possible and endoscopic third ventriculostomy was performed because the aqueduct and the fourth ventricle were filled with haematoma. The left internal cerebral vein was observed from the left lateral

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contains bilateral internal cerebral veins, and many important veins coursing on the tela choroidea to join the internal cerebral vein from the lateral ventricle through the choroidal fissure. There are several reports of pathological conditions in the velum interpositum. Although cystic lesions or enlargement as a large cavum veli interpositi are most frequent, tumours arising in this space are also reported.1,3,5-7 Only one case of intraventricular haemorrhage, due to tumour bleeding of atypical teratoid/rhabdoid tumour in the velum interpositum, was reported by Donovan et al.3 However, there is no report of primary haemorrhage in the velum interpositum or cavum veli interpositi with no evidence of vascular lesions or tumours. In the present case, angiography showed no apparent bleeding source. However, based on the findings of the head CT scan, the primary haemorrhage was thought to have occurred in the cavum veli interpositi and then extended to the lateral ventricles through laceration of the choroidal fissure. The cavum veli interpositi, though small could have pathological conditions of the vascular anatomy. There are no reports stating detailed vascular anatomy in the cavum veli interpositi, however, the vessels on the tela choroidea can be stretched or distorted due to enlargement and disfiguration of the cavity. This condition may be related to haemorrhage. Another hypothesis is venous hypertension causing venous bleeding. As described by Chen et al, certain percentages of the velum interpositum is elongated to the posterior side, making inferior shift of the vein of Galen.2 The cavum veli interpositi, as abnormal enlargement of the velum interpositum, can shift the vein of Galen more. Congestive venous hypertension can occur by an acute increase of compression of the vein of Galen, possibly caused by a particular posture or under a condition with increased demand of venous blood flow into a stenotic vein. The patient had a history of transient visual field loss during a marathon 2 years before intraventricular haemorrhage and this event might be related to such transient venous pathology. The angiography showed delayed appearance of deep venous system and the straight sinus. However, this findings might be caused by the venous compression due to the haematoma in the cavum veli interpositi, because the head MRI after intraventricular haemorrhage did not show any finding related to venous or sinus thrombosis. This finding improved after dissolution of haematoma. The abnormal findings of venous circulation on the angiographies and the improvement following evacuation of haematoma, delineated the harmful effect of the haematoma to the venous blood flow. Even though the haematoma in the cavum veli interpositi was not removed in the endoscopic surgery, these findings support the theoretical benefit of haematoma removal for intraventricular haemorrhage.

Intraventricular haemorrhages can also compress the veins on the ventricular wall, possibly causing the disturbance of blood flow in the periventricular structures. Endoscopic treatment of intraventricular haemorrhage was performed in this case, and the postoperative course showed gradual improvement of consciousness disturbance, suggesting improvement of related venous flow as well as better control of increased intracerebral pressure. The period of external ventricular drainage was shortened; this is also one of the advantages of endoscopic treatment. Endoscopic surgery is also a good treatment option for large cavum veli interpositi which is causing secondary problems.4 Though we did not attempt, haematoma in the cavum veli interpositi or velum interpositum may be effectively removed by endoscopic surgery through the choroidal fissure if no appropriate perforation site is found. During the endoscopic surgery in this case, direct observation of this lesion from outside was informative and the endoscope could reach the lesion without difficulty.

Conclusion
A rare case of intraventricular haemorrhage with cavum veli interpositi as its primary bleeding site is hereby reported as the first case of primary haemorrhage in this location without vascular lesions or tumours. The radiographic findings, especially the change of venous flow, probably due to compression by the haematoma, were confirmed by angiography and at surgery by the endoscopic approach.

References
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