INTRACEREBRAL HEMORRHAGE

Intraventricular hemorrhage in adults

Created 22/04/2022, last revision 07/05/2023

Introduction

intraventricular hemorrhage (IVH) or hemocephalus is characterized by the presence of blood within the cerebral ventricular system
IVH is present initially in one-quarter of patients with ICH or may occur as a subsequent extension of the ICH
- patients with larger hematomas and caudate or thalamic locations are more likely to bleed into the ventricles
IVH is associated with a significant risk of obstructive hydrocephalus, which increases morbidity and mortality
an important determinant of outcome is the volume of intraventricular hemorrhage

The cerebral ventricular system

the ventricular system consists of four interconnected cavities called cerebral ventricles. Each ventricle comprises the choroid plexus, producing 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 ependyma, a specialized epithelium connected by tight junctions that form the blood-cerebrospinal fluid barrier

Classification and etiology

primary IVH: blood in the ventricles with little or no parenchymal blood
- vascular malformations (AVM, subependymal CCM, aneurysm)
- coagulopathy
- intraventricular tumors (ependymoma, the choroid plexus metastases)
- hypertensive bleeding
secondary IVH (more frequent): a significant extraventricular component is present (parenchymal or subarachnoid) with secondary expansion into the ventricles
- intraventricular propagation of intracerebral hematoma
  - present in up to 45% of patients with ICH [Hallevi, 2008]
- SAH (beware of possible reflux from spinal SAH)
- trauma (Ravi, 2019)

Clinical presentation

in primary IVH, symptoms are similar to SAH (sudden and severe headache, meningeal syndrome) → clinical presentation of SAH
in secondary IVH, signs and symptoms from the primary parenchymal lesion predominate
extensive hemorrhages may result in an altered level of consciousness with cardiorespiratory compromise

Diagnostic evaluation

Non-contrast CT scan (NCCT)

primary imaging technique in patients with acute stroke symptoms or sudden headache
blood in the ventricles is hyperdense, usually best seen in the occipital horns
look for signs of acute obstructive hydrocephalus on repeat CT

Intraventricular hemorrhage (hemocephalus)

MRI

MRI is sensitive to small amounts of blood, especially in the posterior fossa (CT is inconclusive here due to artifacts)
- FLAIR – signal intensity is time-dependent. In the first 48 hours, blood appears hyperintense, later the signal becomes more variable (exclude flow artifacts)
- GRE or better SWI – detects even small amounts of blood in the occipital horns (hypointense rim)

Vascular imaging (CTA, MRA, DSA)

rule out vascular malformations, moyamoya, etc.

Management

standard therapy as for intracerebral hemorrhage

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 be useful to 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 is 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 and accelerate the evacuation of thrombus from the ventricles; it appears to be safe, but the clinical effect is unclear
  - CLEAR-IVH study – systemic bleeding 4%, ventriculitis 2%
  - CLEAR III trial – no substantial improvement in functional outcome at the mRS 3 cutoff compared to saline irrigation; mortality reduced by 10%
- alternative procedures include the endoscopic evacuation of the hematoma with ventriculostomy, VP shunt, or lumbar drainage – the benefit is unclear (AHA/ASA 2022 2b/C-LD)