11/12/2025
Intraventricular Hemorrhage in the NeuroICU:
VI. Medical Management
Acute Stabilization (First Hour)
Airway Protection: GCS ≤8 → intubation with neuroprotective agents (etomidate, fentanyl)
Blood Pressure Management:
ICH Guidelines: Target SBP 140-160 mmHg
IVH Specific: More aggressive control may be needed (SBP 120-140) to prevent expansion
Agents: Nicardipine drip (first-line), labetalol, clevidipine
Avoid precipitous drops >25% in first 24 hours
Coagulation Reversal (Immediate):
Warfarin: 4-factor PCC (25-50 IU/kg) + IV vitamin K
DOACs: Andexanet alfa (apixaban/rivaroxaban) or PCC
Heparin: Protamine sulfate
Platelets: Maintain >100,000 for procedural safety
ICP and Hydrocephalus Management
EVD Strategy:
Early Placement: Modified Graeb ≥5 or any IVH with hydrocephalus
Drainage Protocol: Intermittent vs continuous drainage
Weaning: Begin when CT shows resolving blood, CSF clears (5-7 days)
Intraventricular Thrombolytics (see Section VII)
Medical Adjuncts:
Acetazolamide: 500 mg IV q8h for communicating hydrocephalus
Mannitol/Hypertonic Saline: For transtentorial herniation
CSF Production Suppression: Omeprazole, furosemide
Neuroprotection and Secondary Prevention
Temperature Control: Strict normothermia (36-37.5°C), avoid fever
Glycemic Control: Target 140-180 mg/dL
Seizure Prophylaxis:
Levetiracetam: 20 mg/kg load, then 500-1000 mg BID
Duration: 7 days for lobar hemorrhage, 30 days if cortical involvement
Venous Thromboembolism Prevention:
SCDs immediately, chemical prophylaxis at 24-48 hours if stable
Nutrition: Early enteral feeding, avoid overfeeding (target 25 kcal/kg)
VII. Intraventricular Thrombolysis (IVT)
Evidence Base
CLEAR III Trial: Largest RCT (n=500)
Protocol: 1 mg alteplase q8h via EVD until clot clearance
Result: No mortality benefit but improved functional outcomes in moderate IVH
Subgroup benefit if clot reduction >80%
Modified Protocols:
Accelerated lysis: 1-2 mg tPA q6-8h
Low-dose: 0.3-0.5 mg tPA for milder IVH
Combined with lumbar drainage: For communicating hydrocephalus
Current Indications
Primary IVH with Graeb score ≥6
Obstructive hydrocephalus not resolving with EVD alone
Fourth ventricular casts with obstructive hydrocephalus
Young patients with large IVH burden
Contraindications
Absolute: Unsecured aneurysm/AVM, coagulopathy, platelets 30 mL), brainstem compression
Technique
"Clot Lysis Irrigation" Protocol:
Clamp EVD, instill 1 mg tPA in 3 mL saline
Clamp 60 minutes
Unclamp to drain, repeat q8h
Monitor: Daily CT, fibrinogen levels, neurological exam
"Dose-to-Clear" Approach:
Continue lysis until third/fourth ventricle cleared
Average: 4-8 doses over 2-3 days
VIII. Surgical Interventions
Endoscopic Evacuation
Techniques:
Neuroendoscopic Washout: Rigid scope, irrigation/suction
Endoscopic Third Ventriculostomy: For obstructive hydrocephalus
Combined Approaches: Evacuation + ETV
Evidence: Multiple small series show faster clot clearance, reduced EVD duration
Timing: Early (24-72 hours) for maximal benefit
Candidates: Young patients, primary IVH, failed IVT
Minimally Invasive Surgery
Stereotactic Aspiration: For localized clots (occipital horn)
IR-guided Aspiration: Combined with thrombolytics
Neuroendoscopic-Assisted Evacuation: Real-time visualization
Decompressive Craniectomy
Indications: Massive IVH with parenchymal component >60 mL, refractory ICP
Timing: Early (1000, glucose 1 month)
Chronic Hydrocephalus: NPH syndrome (gait, cognition, incontinence)
Post-Hemorrhagic Ventricular Slit: Decreased compliance
Cognitive Impairment: Executive dysfunction, memory deficits
Endocrine Dysfunction: Hypothalamic-pituitary injury
X. Prognostication and Outcomes
Predictors of Poor Outcome
Clinical:
Age >75 years
GCS ≤8 on admission
Absent pupillary reflexes
Medical comorbidities (CAD, CKD, diabetes)
Radiographic:
Modified Graeb score ≥8
Fourth ventricular involvement
Concurrent parenchymal hemorrhage >30 mL
Midline shift >5 mm
Physiologic:
Refractory ICP >25 mmHg
PbtO₂ 2 hours
Malignant EEG patterns (burst suppression, periodic discharges)
Functional Outcomes
Mortality: 30-50% overall, 80% if Graeb ≥10
Good Recovery (mRS 0-2): 15-25% with aggressive management
Severe Disability (mRS 4-5): 30-40%
Long-Term Shunt Dependence: 30-50%
Prognostic Scales
IVH Score (0-3): Simple bedside tool
FUNC Score: Predicts functional independence
ICH Score Modified for IVH: Adds ventricular extension
XI. Special Populations
Neonatal IVH
Grading (Papile): I-IV based on location and severity
Unique Considerations: Germinal matrix hemorrhage in preterm infants
Management: Serial LPs, ventricular reservoir, eventual shunt
Traumatic IVH
Usually from shearing forces or extension
Correlates with diffuse axonal injury
Monitor for evolving contusions
Anticoagulant-Associated IVH
Higher expansion rates
Aggressive reversal critical
Consider delayed angiography if etiology unclear
XII. Neurorehabilitation and Recovery
Acute Rehabilitation
Begin in ICU: Physical/occupational therapy, speech evaluation
Screen for dysphagia: 40-60% incidence
Early mobilization protocols
Cognitive Rehabilitation
Frontal/Executive Dysfunction: Common with frontal horn involvement
Memory Impairment: Fornix/hippocampal circuit disruption
Behavioral Changes: Disinhibition, apathy
Ventriculoperitoneal Shunt Management
Shunt Malfunction Signs: Headache, nausea, decreased consciousness
Shunt Infection: Usually within 6 months
Overdrainage: Slit ventricle syndrome, hygromas
XIII. Future Directions and Research
Emerging Therapies
Intraventricular Neuroprotective Agents:
Erythropoietin, N-acetylcysteine
Iron chelators (deferoxamine)
Advanced Clearance Techniques:
Automated irrigation systems
Ultrasound-enhanced thrombolysis
Biomarker-Guided Therapy:
CSF inflammatory markers (IL-6, MMP-9)
Microdialysis-guided management
Clinical Trials Needed
Optimal thrombolytic dose and timing
Endoscopic vs medical management trials
Neuroprotective agent trials
Shunt vs no shunt in chronic hydrocephalus
XIV. Summary and Key Practice Points
IVH is treatable: Aggressive modern management improves outcomes
EVD is first-line: Place early for hydrocephalus or Graeb ≥5
Consider thrombolytics: For significant IVH burden, especially in younger patients
Search for etiology: All non-hypertensive IVH needs vascular imaging
Multimodality monitoring: Guides therapy in severe cases
Anticipate complications: Hydrocephalus, infection, delayed deterioration
Rehabilitation is crucial: Begin early, address cognitive deficits....
Dr Mohammad Samim Sardar
Neurosurgeon
