🩸 Intraventricular Hemorrhage (IVH)

🧠🩸 Intraventricular Hemorrhage (IVH) in the NeuroICU – Comprehensive Review

📌 I. Introduction

• IVH = bleeding into the cerebral ventricular system
• Historically fatal; modern NeuroICU care 💉 improves outcomes
• Mortality: 30–50% in severe cases
• Mechanisms:
  • ➡️ Extension from parenchymal hemorrhage (45–50%)
  • 🧫 Primary intraventricular bleeding (20–30%)
  • 🌊 Subarachnoid hemorrhage with ventricular reflux (20–25%)

📊 II. Classification Systems

🟢 Graeb Scale (0–12)

• 0: No blood
• 1–4: Trace to mild (<50% of ventricle)
• 5–8: Moderate (≥50%)
• 9–12: Severe (ventricle expanded)

🔵 Modified Graeb Scale (mGS, 0–16)

• More precise for clot volume
• Lateral ventricles: 1 pt per 25% filling (0–4 each)
• Third/fourth ventricles: 1 pt per 25% filling

🟡 LeRoux Scale

• Clot size + hydrocephalus per ventricle
• Separate hemorrhage & hydrocephalus scores

🔴 IVH Score (0–3)

• 1 pt each for: blood in 3rd, 4th, lateral ventricles
• Higher = worse prognosis

🔬 III. Pathophysiology

⚡ Primary Injury Mechanisms

• 🧠 Mass Effect & ↑ICP: Direct clot expansion
• 🔥 Chemical Ependymitis: Blood degradation products → ependymal inflammation
• 🚰 Obstructive Hydrocephalus: Clot blocks
  • Foramina of Monro → unilateral hydrocephalus
  • Cerebral Aqueduct → tricompartmental hydrocephalus
  • 4th ventricle outlets → transependymal CSF flow
• 💧 Periventricular Edema: Ischemic injury

🧪 Secondary Injury Cascade

• 🧬 Inflammation: Microglia, IL-1β, TNF-α
• ⚡ Oxidative stress: Hemoglobin → iron-mediated free radicals
• 🧱 BBB disruption: VEGF → vasogenic edema
• 🩸 Cerebral hypoperfusion: Autoregulation failure

🔋 Metabolic Changes

• 🌡️ Global CBF ↓ 50% in severe IVH
• 🌀 Periventricular “penumbra”
• 🍬 CSF: lactate ↑, pH ↓, glucose ↓

🧩 IV. Etiologies & Clinical Presentations

🏥 Primary IVH

• 🩺 Hypertensive hemorrhage (40–50%) – thalamus, basal ganglia
• 🧬 AVMs (10–15%)
• 🏗️ Cavernomas (5%) – subependymal
• 🎯 Tumors (3–5%) – choroid plexus, metastases
• 💉 Coagulopathies (10%) – anticoagulants, thrombocytopenia
• 🧓 Cerebral amyloid angiopathy (elderly)
• 🌊 Venous infarction

⚠️ Secondary IVH

• 🩸 SAH with ventricular extension (PCOM, ACOM, basilar tip)
• 🚑 Traumatic IVH
• 🔄 Hemorrhagic transformation of ischemic stroke
• 🧬 Moyamoya disease

🌡️ Clinical Spectrum

• 💥 Catastrophic: sudden headache → coma (Graeb 8–12)
• ⏳ Subacute: progressive headache, nausea, lethargy
• 🖐️ Focal: deficits depending on primary hemorrhage
• 🚰 Hydrocephalic: headache + vomiting + lethargy

🧪 V. Diagnostic Evaluation

🖥️ Neuroimaging

• 🩻 Non-contrast CT: gold standard
  • Quantify volume (mGS ≥5 → poor prognosis)
  • Assess parenchymal component, mass effect, hydrocephalus
  • Signs: “Cast” (ventricles filled), “Swirl” (active bleeding)
• 🌉 CT Angiography: detect AVM/aneurysm, “spot sign” predicts expansion
• 🧲 MRI (GRE/SWI/DWI/FLAIR): microbleeds, cavernomas, ischemia, transependymal flow
• 🔍 DSA: for negative CTA with high suspicion, repeat in 6–8 weeks if needed

💧 Cerebrospinal Fluid Analysis

• 💉 Lumbar puncture: therapeutic + diagnostic in communicating hydrocephalus
• CSF: xanthochromia, ↑ protein, pleocytosis
• Drainage: 20–30 mL/hr; monitor opening pressure

🧰 NeuroICU Monitoring

• 🚰 EVD: ICP monitoring + CSF drainage
  • Level at tragus, drain 10–15 cm H₂O
  • Complications: infection 5–20%, hemorrhage 2–5%, malfunction
• 🌡️ Multimodality Monitoring
  • PbtO₂ >20 mmHg
  • Cerebral microdialysis: LPR <25, glucose >0.8 mmol/L
  • Continuous EEG: detect non-convulsive seizures (10–20%)