Current management of intraventricular hemorrhage

Intraventricular hemorrhage (IVH) continues to present a challenge to neurosurgeons, often being accompanied by significant morbidity and mortality. The purpose of this paper is to present a review of the recent literature concerning the treatment of patients with IVH, and describe our current management scheme for this disorder.

A literature search was conducted to identify key articles pertaining to the pathophysiology and treatment of IVH, focusing on the more recent articles. The bibliographies of selected papers were also screened for additional useful publications.

Management of IVH is primarily directed at controlling intracranial pressure through an external ventricular drain (EVD), but this catheter often becomes occluded by coagulated blood. The fibrinolytic system of the cerebrospinal fluid is limited, and blood may remain in the ventricles for months after a hemorrhage. IVH has a poor prognosis, partly because of the continuing mass effect of blood clots on the ventricular walls. Therefore, investigators have administered fibrinolytic agents directly into the ventricles of patients with IVH. Clinical studies of fibrinolytic therapy for IVH have found a 30 to 35% reduction in mortality with treatment, but have not yet clearly documented an improved neurologic outcome for the survivors.

Fibrinolytic therapy may be life saving in severe cases of IVH. While many issues need to be resolved, our current practice is to administer intraventricular tissue plasminogen activator (t-PA or alteplase) if hemorrhage involves > or =30% of the volume of one of the lateral ventricles and/or the 3(rd) or 4(th) ventricle. We currently give t-PA after ruling out or treating a possible source of further bleeding, such as an unsecured aneurysm.