What is the treatment for an intraventricular (within the ventricles of the brain) hemorrhage (bleed)?

Treatment of Intraventricular Hemorrhage

Intraventricular hemorrhage should be treated with external ventricular drainage (EVD) combined with intraventricular fibrinolysis (alteplase), which reduces mortality from 40.9% to 22.4% and improves functional outcomes. 1

Core Treatment Goals

The management of IVH targets three critical objectives 1:

• Prevent further bleeding through blood pressure control and reversal of coagulopathy
• Evacuate the hematoma to reduce mass effect and facilitate CSF flow
• Maintain normal intracranial pressure (ICP) to preserve cerebral perfusion pressure and prevent secondary brain injury

Primary Intervention: External Ventricular Drainage

EVD placement is mandatory for patients with hydrocephalus causing decreased level of consciousness. 2, 3

EVD Catheter Selection

• Use bolted and antibiotic-coated catheters rather than tunneled/uncoated catheters, as they significantly reduce infection rates (P < 0.001) 1
• Antibiotic-coated catheters are superior to silver-impregnated catheters for infection prevention (P < 0.001) 1

Critical Timing Considerations

• In patients with ruptured aneurysms causing IVH, delay EVD placement until aneurysm repair when possible, as lowering ICP increases transmural pressure across the aneurysm wall and may precipitate rerupture 4
• If hydrocephalus causes significant neurologic decline with an unrepaired aneurysm, EVD must be placed immediately with slow, controlled CSF drainage 4

Intraventricular Fibrinolysis: The Evidence-Based Addition

Add intraventricular alteplase (tPA) when hemorrhage involves ≥30% of lateral ventricle volume and/or involves the 3rd or 4th ventricle. 5

Mortality and Functional Outcome Benefits

• Mortality reduction: 22.4% with fibrinolysis versus 40.9% without (P < 0.00001) 1
• Functional outcome improvement: 47.2% good outcomes with fibrinolysis versus 38.3% without (P = 0.03) 1
• Meta-analysis demonstrates mortality reduction from 47% to 23% 3
• Catheter occlusion reduced from 37.3% to 10.6% with fibrinolysis (P = 0.0003) 1

Dosing Protocols

Standard dosing: 1 mg alteplase per 1 cm of maximum hematoma diameter, administered every 8-12 hours 3

Alternative regimens include 3:

• 1-4 mg every 8-12 hours
• 3 mg tPA in 3 mL 0.9% saline every 24 hours for 1-3 days

Contraindications to Fibrinolysis

Do not administer intraventricular fibrinolytics in 4:

• Unrepaired cerebral aneurysms
• Untreated arteriovenous malformations
• Active coagulopathy or uncorrected clotting disorders

Safety Profile

• Symptomatic bleeding occurs in 4% of patients 3
• Bacterial ventriculitis occurs in 2% of patients 3
• The American Heart Association classifies this as Class IIb (may be considered), Level of Evidence B, noting relatively low complication rates but uncertain effectiveness 3

ICP Monitoring and Management

Comprehensive monitoring includes ICP, cerebral perfusion pressure, and hemodynamic function. 1

Stepwise ICP Management Algorithm (when ICP > 20-25 mmHg) 1:

1. First-line interventions:

   • Repeat CT scan to assess for expansion
   • Mannitol bolus (0.25-1.0 g/kg) or hypertonic saline (23.4% 30 mL bolus)

2. Second-line interventions if ICP remains elevated:

   • Sedation and neuromuscular blockade
   • Consider mild hyperventilation (PaCO₂ 30-35 mmHg)

3. Withdraw ICP therapies when ICP normalizes

Clinical Prognostic Factors

IVH dramatically worsens prognosis, with mortality increasing from 20% in ICH without IVH to 51% in ICH with IVH. 6

• The amount of intraventricular blood directly correlates with injury severity and survival likelihood 7
• Involvement of the 3rd and 4th ventricles indicates worse prognosis 8
• Shunt dependency relates to initial blood volume but is unaffected by fibrinolysis (P = 0.98) 1

Special Considerations for Isolated IVH

For isolated intraventricular hemorrhage without parenchymal involvement 2:

• EVD is reasonable for hydrocephalus causing decreased consciousness
• Intraventricular thrombolytics show promise but remain investigational
• Exercise particular caution with fibrinolytics when vascular lesions haven't been definitively excluded

Common Pitfalls to Avoid

• Do not delay EVD placement when IVH occludes the foramina of Monro or third ventricle, even without current hydrocephalus, as obstructive hydrocephalus may develop precipitously 4
• Correct coagulopathy before IVC insertion by checking PT/PTT and reversing deficiencies 4
• Do not use fibrinolysis as monotherapy—EVD remains the foundation of treatment 1
• Recognize that EVD alone is often insufficient as catheters become occluded with clotted blood and removal occurs slowly 3