Multifactorial Respiratory and Circulatory Deterioration After Intraventricular Hemorrhage in a Young Obese Patient: Diagnostic Uncertainty in Neurocritical Care

Respiratory and systemic deterioration after intraventricular hemorrhage (IVH) can be difficult to interpret when airway, infectious, neurogenic, and treatment-related factors develop in parallel. A 31-year-old obese man (body mass index 37.56 kg/m2) arrived late at night with right caudate hemorrhage, massive IVH, and acute hydrocephalus. Initial consciousness disturbance was mild and oxygenation was preserved, so close observation was selected. Approximately 6–7 h after arrival, worsening headache, restlessness, and progression of hydrocephalus prompted bilateral external ventricular drainage (EVD). The right EVD output remained poor despite lowering the drainage level. From Day 2 to Day 3, positional snoring, desaturation, tachypnea, fever, and inflammatory marker elevation developed; oxygenation improved with lateral positioning and head elevation, suggesting obesity-related upper-airway compromise with probable sleep-disordered breathing (SDB). On Day 4, recurrent hypoxemia required intubation, and computed tomography (CT) showed entrapment of the right lateral ventricle, prompting endoscopic clot evacuation. Chest CT after the second procedure showed bilateral lower-lobe consolidation consistent with hospital-acquired pneumonia (HAP), and cefazolin was changed to meropenem. Serial glucose measurements showed no persistent hypoglycemia, and early coagulation profiles were not markedly abnormal. However, cultures, arterial blood gas analysis, lactate measurement, echocardiography, abdominal CT, and autopsy were not obtained. Despite treatment, hyperpyrexia, persistent tachypnea, and vasopressor-dependent hypotension progressed, and he died on Day 7. The terminal course was most consistent with infection-associated circulatory collapse and ventilatory failure, while central hyperthermia and other unexcluded causes may have contributed. This case illustrates diagnostic uncertainty rather than a single confirmed terminal diagnosis and emphasizes early systemic evaluation when respiratory, thermal, and circulatory findings evolve after IVH.