From the Guidelines
The prognosis for intracerebral hemorrhage (ICH) with intraventricular extension (IVE) is generally poor, with high mortality rates and significant long-term disability in survivors, and the use of external ventricular drainage (EVD) with intraventricular thrombolysis is recommended to improve survival in patients with clinical hydrocephalus and reduced level of consciousness. Approximately 40-50% of patients with ICH and IVE die within the first month, and only about 20% achieve functional independence after six months, as reported in the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage 1. The presence of IVE is an independent predictor of poor outcome in ICH patients, and several factors influence the prognosis, including the initial Glasgow Coma Scale score, hematoma volume, presence of hydrocephalus, and the extent of intraventricular blood, as stated in the 2022 guideline 1.
Some key points to consider in the management of ICH with IVE include:
- The use of EVD to treat intracranial hypertension and remove blood products improves survival, as shown in the CLEAR III trial 1
- The addition of thrombolytic irrigation with alteplase or urokinase hastens intraventricular clot removal and results in further mortality reduction, as reported in the 2022 guideline 1
- Immediate management focuses on preventing further bleeding, controlling intracranial pressure, and managing complications, which may include blood pressure control, reversal of anticoagulation if applicable, and in some cases, surgical interventions such as external ventricular drainage or hematoma evacuation, as recommended in the 2022 guideline 1
- Survivors often face significant neurological deficits and require extensive rehabilitation, and long-term complications can include cognitive impairment, seizures, and recurrent stroke, as stated in the 2022 guideline 1
Overall, while the overall prognosis is poor, individual outcomes can vary widely, and early, aggressive management and rehabilitation are crucial for improving the chances of a more favorable outcome, as reported in the 2022 guideline 1.
From the Research
Prognosis of Intracerebral Hemorrhage with Intraventricular Extension
The prognosis of intracerebral hemorrhage (ICH) with intraventricular extension (IVE) is generally poor, with high morbidity and mortality rates.
- The case fatality rate for conservative treatment is 78% 2
- The case fatality rate for extraventricular drainage is 58% 2
- The case fatality rate for extraventricular drainage with fibrinolytic agents is 6% 2
Factors Affecting Prognosis
Several factors can affect the prognosis of ICH with IVE, including:
- Age: patients aged 80 years or older have a significantly higher mortality rate 3
- Hematoma volume: a hematoma volume of 30 mL or more is associated with a higher mortality rate 3
- Intraventricular hemorrhage: the presence of intraventricular hemorrhage is associated with a higher mortality rate 3
- Clinical status: the Glasgow Coma Scale score can affect the prognosis 3
Prediction of Outcome
The ICH-score can be used to predict the 30-day mortality in patients with ICH, including those with IVE 3
- The ICH-score is based on parameters such as age, hematoma volume, intraventricular expansion, and clinical status
- The score can help identify patients who may benefit from fibrinolytic therapy 3
Management and Treatment
The management of ICH with IVE includes:
- External ventricular drainage (EVD) to manage acute hydrocephalus 4
- Fibrinolytic therapy to reduce clot volume and improve outcomes 3
- Minimally invasive techniques to reduce hematoma volume 5
- Supportive ICU care and rehabilitation to improve patient outcomes 6
Shunt Dependency
Some patients with ICH and IVE may require placement of a permanent ventricular shunt 4
- Factors such as IVH score, bicaudate index, and blood volume in each ventricle can predict shunt dependency 4