What is the management strategy for an intraventricular (IVH) bleed?

Management of Intraventricular Hemorrhage

For patients with intraventricular hemorrhage and impaired consciousness, place an external ventricular drain (EVD) immediately, and add intraventricular thrombolysis with alteplase to reduce mortality from 40.9% to 22.4%. 1, 2

Initial Assessment and Risk Stratification

Determine severity using these parameters:

• Glasgow Coma Scale score (GCS <13 indicates severe disease) 1
• ICH volume (>11 mL indicates higher risk) 1
• Graeb score (≥7 indicates moderate to severe IVH) 1
• Presence of hydrocephalus on CT imaging 1

IVH dramatically worsens prognosis: mortality increases from 20% in ICH without IVH to 51% in ICH with IVH. 3, 2, 4

Primary Intervention: External Ventricular Drainage

EVD placement is mandatory (Class I recommendation) for patients with large IVH and impaired consciousness to reduce mortality. 1

Technical specifications:

• Use bolted and antibiotic-coated catheters rather than tunneled/uncoated catheters—this significantly reduces infection rates (P < 0.001) 2
• Correct coagulopathy before insertion: reverse warfarin, consider platelet transfusion if on antiplatelet agents 1
• Allow slow, controlled CSF release to avoid precipitating aneurysm rerupture if that is the underlying cause 5

Critical timing consideration: If IVH is secondary to unruptured aneurysm, delay EVD placement until aneurysm is secured unless hydrocephalus is causing neurologic decline—then EVD must be placed emergently despite the risk. 5

Add Intraventricular Thrombolysis (Class IIa Recommendation)

For patients with GCS >3 and ICH volume <30 mL requiring EVD, add intraventricular alteplase to the EVD—this is safe and reasonable to reduce mortality. 1

Proven mortality benefit:

• Mortality reduced from 40.9% to 22.4% (P < 0.00001) 2
• Functional outcomes improved: 47.2% good outcomes versus 38.3% without thrombolysis (P = 0.03) 2
• Catheter occlusion reduced from 37.3% to 10.6% (P = 0.0003) 2

Dosing protocol:

• Standard: 1 mg alteplase per 1 cm of maximum hematoma diameter 2, 4
• Administer every 8-12 hours 2, 4
• Alternative: 3 mg alteplase in 3 mL 0.9% saline every 24 hours for 1-3 days 4

Safety profile:

• Symptomatic bleeding occurs in 4% of patients 2, 4
• Bacterial ventriculitis occurs in 2% of patients 2, 4

Contraindications to thrombolysis:

• Unrepaired cerebral aneurysms 5, 6
• Untreated arteriovenous malformations 5
• Active coagulopathy 5

ICP Monitoring and Management

Monitor comprehensively: ICP, cerebral perfusion pressure, and hemodynamic function. 2

First-line interventions when ICP elevated (>20 mm Hg):

• Obtain repeat CT scan to assess for hematoma expansion 2
• Administer mannitol bolus (0.25-1.0 g/kg) OR hypertonic saline (23.4% 30 mL bolus) 2
• Drain CSF through the EVD 1

Important caveat: ICP elevation is not universal—in the CLEAR III trial, ICP was not frequently elevated during monitoring in patients with small ICH (<30 mL) and IVH. 1 Patients with small hematomas and limited IVH usually will not require aggressive ICP treatment. 1

Special Considerations

Neuroendoscopic evacuation (Class IIb—uncertain benefit):

• For patients with ICH <30 mL volume and IVH requiring EVD, neuroendoscopic evacuation plus EVD (with or without thrombolytic) has uncertain effectiveness for improving functional outcomes and reducing permanent shunt dependence 1
• This remains an option at specialized centers but is not standard of care 7

Functional outcomes remain uncertain: While EVD plus thrombolysis clearly reduces mortality, the benefit for functional outcomes is not well established (Class IIb evidence). 1 However, prioritizing survival is paramount, and the mortality benefit is definitive.

Shunt dependency: Relates to initial blood volume but is unaffected by fibrinolysis (P = 0.98). 2 Approximately 30-50% of patients with IVH develop hydrocephalus requiring potential permanent shunting. 1

Common Pitfalls to Avoid

• Do not delay EVD placement in patients with impaired consciousness and large IVH—mortality benefit is clear 1
• Do not use EVD alone when thrombolysis is indicated (GCS >3, ICH <30 mL)—you will miss the opportunity to reduce mortality by nearly half 2
• Do not place EVD before securing aneurysm unless hydrocephalus is causing active neurologic decline 5
• Do not use tunneled or uncoated catheters—infection rates are significantly higher 2