Pearls & Oy-sters: The Price of Patency

Fourth ventricular hemorrhage is a devastating subtype of hemorrhagic stroke that can be primary or secondary to subarachnoid hemorrhage. In both cases, inflammatory reactions triggered by blood in the subarachnoid space peak in the first week. This report describes a 61-year-old woman with a secondary fourth ventricular hemorrhage managed with IRRAflow active irrigation and drainage system, which expedited recanalization of the fourth ventricle and clearance of cisternal subarachnoid hemorrhage on days 3 and 5, respectively. However, the patient developed an intractable headache on day 7, despite normal imaging, intracranial pressure, and laboratory investigations. This case highlights caudal sac inflammation as a hidden culprit of unremitting headache after recanalization of the fourth ventricle despite normal investigations.