Obstructed foramina of Monro, cerebral aqueduct, 3rd or 4th ventricles are reliable predictors of hydrocephalus in hemorrhagic stroke patients

Hydrocephalus is a potential consequence of intracerebral hemorrhage with ventricular extension (ICH+IVH) and is independently associated with poorer prognosis. This study evaluated the modified Graeb (mGraeb) score as a predictor of hydrocephalus and proposed an alternative assessment method by analyzing the obstruction of the foramina of Monro, cerebral aqueduct, and the 3 rd or 4 th ventricles as sole predictors of hydrocephalus in ICH+IVH patients. This retrospective study included adult spontaneous ICH+IVH patients admitted to the National Brain Center and Siloam Hospital, Indonesia, between 2018 and 2023. Clinical information and imaging data were evaluated. Statistical analyses examined the correlation between hydrocephalus incidence and mGraeb score or obstruction of ventricular choke points. Tandem testing was performed to compare the two methods. One hundred and nineteen patients were included in this study. Hydrocephalus was diagnosed in 84 patients (70.6%). mGraeb score (p<0.001), obstructed foramina of Monro (p<0.001), cerebral aqueduct (p<0.001), 3 rd ventricle (p=0.002), 4 th ventricle (p=0.002), and any choke points (p<0.001) are significantly associated with the incidence of hydrocephalus. Tandem testing suggested that choke point obstructions are more sensitive (p<0.001), yet less specific (p=0.004) in predicting hydrocephalus compared to the mGraeb score. Both the mGraeb system and evaluating ventricular choke points are reliable predictors of hydrocephalus in ICH+IVH patients. Evaluating obstructions of the ventricular choke points is simpler and easier to be performed in clinical settings compared to the mGraeb score.