What is the initial management for a patient with an intraventricular (IV) bleed?

Initial Management of Intraventricular Hemorrhage

For patients with intraventricular hemorrhage causing hydrocephalus and decreased level of consciousness, immediately place an external ventricular drain (EVD) to prevent irreversible brain damage or death. 1, 2

Immediate Assessment and Stabilization

Determine the Underlying Cause

• Identify the source of bleeding through imaging (CT with angiography) to guide subsequent management, as IVH typically occurs secondary to aneurysmal subarachnoid hemorrhage, hypertensive intracerebral hemorrhage, or vascular malformations 3
• Perform catheter angiography if spontaneous IVH occurs without detectable parenchymal hemorrhage to exclude vascular anomalies 4
• Consider additional workup including MRI and toxicology screening if the underlying cause is not apparent from initial imaging 3

Assess for Hydrocephalus

• Evaluate for acute obstructive hydrocephalus, which represents the most immediate life-threatening complication of IVH 3
• Monitor for neurologic decline attributable to hydrocephalus, as this mandates emergent intervention 3

External Ventricular Drainage

Indications for EVD Placement

• Place EVD emergently if hydrocephalus is contributing to decreased level of consciousness or neurologic decline 1, 2, 3
• Consider prophylactic EVD even for IVH not yet causing hydrocephalus if blood is occluding the foramina of Monro or third ventricle, as obstructive hydrocephalus may develop precipitously 3
• Small volume IVH unlikely to cause hydrocephalus based on location can be followed expectantly 3

Pre-Procedure Considerations

• Evaluate and correct coagulation defects before IVC insertion by checking prothrombin time and activated partial thromboplastin time 3
• Exercise extreme caution with slow, controlled CSF release in patients with unruptured aneurysms, as rapid decompression increases transmural pressure across the aneurysm wall and may precipitate rerupture 3
• Do not delay EVD placement for life-threatening hydrocephalus even in the presence of an unprotected aneurysm, but use meticulous technique 3

Intraventricular Fibrinolysis

Evidence and Efficacy

• Intraventricular thrombolytics reduce mortality from 47% to 23% according to meta-analyses, though this remains an investigational treatment 1, 2
• tPA accelerates clot dissolution (1-3 days) compared to urokinase (5-8 days) and reduces mortality from 60-90% with EVD alone to approximately 5% 2
• The CLEAR-IVH study demonstrated a 30-day mortality of 17% with symptomatic bleeding in 4% and bacterial ventriculitis in 2% of patients 2

Current Recommendations

• Consider intraventricular fibrinolysis for IVH causing or threatening obstructive hydrocephalus, but recognize this is Class IIb, Evidence Grade B (uncertain effectiveness, experimental) 2
• Use cautiously and only after vascular lesions have been definitively excluded 1

Contraindications

• Unrepaired cerebral aneurysms 3
• Untreated arteriovenous malformations 3
• Active clotting disorders 3

Dosing Protocols (if used)

• Standard dosing: 1-4 mg tPA every 8-12 hours 2
• Alternative: 3 mg tPA in 3 mL saline every 24 hours for 1-3 days 2
• Size-based: 1 mg tPA per 1 cm hematoma diameter 2

Monitoring and Complications

EVD Management

• Monitor duration carefully, as infection risk increases exponentially after 5 days with ventriculostomy infection rates of 27.6% 5
• Remove EVD as soon as clinically appropriate to minimize infectious complications 5
• Anticipate permanent shunt requirement in approximately 40% of patients 6

Expected Outcomes

• Mortality remains substantial at 20% without IVH versus 51% with IVH in the context of intracerebral hemorrhage 1, 2
• Patients with GCS 3-5 at EVD insertion have particularly poor prognosis, with mortality approaching 85% 5
• Better outcomes occur in patients with GCS 9-12, where mortality is approximately 23% 5