Intraventricular hemorrhage

Abstract

Primary intraventricular hemorrhage (IVH) is bleeding directly into the ventricles from a lesion contiguous with the ependymal surface. Secondary IVH results from either intracerebral or subarachnoid bleeding that extends into the ventricular system by parenchymal disruption or reflux through fourth ventricular foramina. The underlying causes of each type are extremely diverse, but trauma, chronic hypertension, vascular malformations, aneurysm rupture, and tumors account for the majority of IVHs in adults. The presentation of pure spontaneous IVH is sudden severe headache, while the clinical features of secondary IVH are governed by the location and severity of the primary hemorrhage. IVHs that do not expand the ventricles or obstruct CSF (cerebrospinal fluid) flow do not influence prognosis significantly, but large hemorrhages that compress periventricular tissues are associated with poor outcome, and fourth ventricular distention in particular is predictive of early death. Treatment of IVH includes treating the underlying cause and diverting CSF either temporarily or permanently when CSF flow is obstructed. A number of reports have suggested that intraventricular fibrinolysis using an agent such as tissue plasminogen activator (rt-PA) may be useful in speeding the clearance of intraventricular clots as well as ensuring adequate CSF drainage and intracranial pressure control. However, aggravation of intracranial bleeding with this treatment must remain a concern. The effect of intraventricular fibrinolytic treatment on patient outcome has not yet been fully studied in a controlled trial.