Intraventricular hemorrhage in adults

David Goldemund M.D.
Updated on 19/06/2024, published on 22/08/2023


  • intraventricular hemorrhage (IVH), also known as hemocephalus, is characterized by the presence of blood within the cerebral ventricular system
  • initially, IVH is present in one-quarter of patients with intracerebral hemorrhage (ICH) but may occur later as an extension of the ICH
    • patients with larger hematomas, or those with hemorrhages in the caudate nuclei or thalamic locations, are more likely to bleed into the ventricles
  • IVH significantly increases the risk of obstructive hydrocephalus, which in turn increases morbidity and mortality
  • an important determinant of the outcome is the volume of the intraventricular hemorrhage
Primary intraventricular hemorrhages
  • the cerebral ventricular system consists of four interconnected cavities known as the cerebral ventricles (the lateral ventricles, the third ventricle, and the fourth ventricle)
  • each ventricle contains a choroid plexus responsible for the production of cerebrospinal fluid (CSF)
  • the ventricular system continues from the fourth ventricle into the central canal of the spinal cord
  • ventricles and the central canal of the spinal cord are lined with ependymal cells, a specialized epithelium connected by tight junctions; these junctions form the blood-cerebrospinal fluid barrier
Cerebral ventricles

Classification and etiology

Primary IVH

  • blood in the ventricles with little or no blood in the parenchyma   Intraventricular hemorrhage (hemocephalus)
  • possible causes:
    • vascular malformations (AVM, subependymal cavernous malformation, aneurysm)
    • coagulopathy  Primary intraventricular hemorrhage caused by warfarin overdose
    • intraventricular tumors (ependymoma, the choroid plexus metastases, etc.)
    • hypertensive bleeding

Secondary IVH

  • more frequent
  • a significant extraventricular component (either parenchymal or subarachnoid) is present with secondary expansion to the ventricles
    • propagation of intracerebral hematoma Secondary IVH from ICH in basal ganglia and thalamus  Secondary IVH from the thalamic bleeding  Secondary intraventricular hemorrhage
    • SAH (beware of possible reflux from the spinal SAH)
    • trauma (Ravi, 2019)

Clinical presentation

  • in primary IVH, symptoms resemble those of SAH (sudden and severe headache and meningeal syndrome)  → clinical presentation of SAH
  • in secondary IVH, signs and symptoms predominantly arise from the primary parenchymal lesion
  • extensive hemorrhages may lead to an altered level of consciousness, accompanied by cardiorespiratory compromise

Diagnostic evaluation

Non-contrast CT scan (NCCT)

  • the primary imaging technique for patients with acute stroke symptoms or sudden headache
  • blood within the ventricles is hyperdense and usually best visualized in the occipital horns
  • follow-up CT scans should be performed to exclude acute obstructive hydrocephalus  Obstructive hydrocephalus following IVH

Intraventricular hemorrhage (hemocephalus)


  • MRI is sensitive to small amounts of blood, especially in the posterior fossa (CT may be inconclusive due to artifacts)
    • FLAIR – signal intensity is time-dependent. Blood appears hyperintense in the first 48 hours; after that, the signal becomes more variable (exclude flow artifacts)
    • GRE, or preferably SWI  – detects even small amounts of blood in the occipital horns (characterized by a hypointense rim)
Intraventricular hemorrhage on MRI

Vascular imaging (CTA, MRA, DSA)

  • rule out vascular malformations, moyamoya, etc.


  • treat the underlying cause of bleeding
  • detect and treat possible obstructive hydrocephalus (serial neurological status examinations and repeated CT scans are required for the diagnosis)
    • external ventricular drainage (EVD) may reduce mortality, especially in patients with large ICH/IVH and impaired level of consciousness (LOC) (AHA/ASA 2022 1/B-NR)
      • for patients with a GCS score >3 and primary IVH or secondary IVH (with supratentorial ICH of <30-mL volume) requiring EVD, minimally invasive IVH evacuation with EVD plus thrombolytics is safe and reasonable compared with EVD alone to reduce mortality (AHA/ASA 2022 2a/B-NR)
      • for patients with a GCS score >3 and primary IVH or secondary IVH (with supratentorial ICH of <30-mL volume) requiring EVD, the effectiveness of minimally invasive IVH evacuation with EVD plus the use of thrombolytics to improve functional outcomes is uncertain
      • for patients with large ICH/IVH and impaired LOC, the efficacy of EVD to improve functional outcome is not well-established
    • intraventricular application of tPA may facilitate the thrombus evacuation from the ventricles; it appears safe, but clinical efficacy is unclear
      • CLEAR-IVH study – systemic bleeding 4%, ventriculitis 2%
      • CLEAR III trial – no substantial improvement in functional outcome at mRS 3 cutoff compared to saline irrigation; mortality reduced by 10%
        • intraventricular tPA protocol – 1 mg of alteplase, 8h apart; up to 12 doses
    • alternative procedures:  endoscopic evacuation of the hematoma with ventriculostomy, VP shunt, or lumbar drainage – benefit is unclear (AHA/ASA 2022 2b/C-LD)

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Intraventricular hemorrhage in adults