A 31-year-old female presented with sudden onset headache, vomiting, and loss of consciousness with right-sided weakness. She had undergone IVF and embryo implantation the previous day. CT scan showed a large intracerebral hemorrhage with intraventricular extension. She was treated with mannitol, lasix, and levetiracetam. An external ventricular drain was inserted. Over the next few weeks, she received intraventricular alteplase to clear the blood and antibiotics due to elevated CSF protein and white cells. The ventricular drain was removed after the bleeding cleared and her condition improved.

1. CASE PRESENTATION-IVH
Dr Surendra Patel
Fellow-CCM
RTIICS Kolkata
20/11/14

2. 31 year female presented on 11/9/14
at 9.30 am
• Sudden onset of headache with vomiting f/b loss of
consciousness with right side hemiparesis since 4am.
• Transfer from local hospital where she receive inj-diazepam
i/m ---? For convulsion
• She had undergone IVF n embryo implant one day
back—f/b inj progesterone 100 mg i/m for 3 days and
given inj enoxaparin 40 mg s/c. on regular folic acid.
[NO Record available]
• No h/o HTN,DM, coagulopathy , epilepsy
• Menstrual h/o- ovulation induction, embryo transfer-

3. O/E in emg…….
• Gcs- E1V1M2 pupil- b/l small size n sluggish reactive,
rt hemiparesis, ? Diazepam effect
• Vitals-
– pulse- 85/min
– Rr -18/min
– Bp- 130/80 mmhg
– Temp- 101 f
– Spo2- 100% in room air Rbs-134
• Airway- patent bt not protective
• Breathing –laboured
• Abg-ph-7.447, pco2-28.2 po2-197, hco3-19, be-5.0,

4. Cont….
• Cns- could not be assessed properly. GCS-E1V1M2 -
? diazepam
• Chest-b/l clear, no added sounds
• Cvs- S1S2, no murmur
• P/A – soft, IPS present
• P/V- no bleeding ….wnl
• Urgent Intubation
• CT scan urgent

5. investigation
• Ct brain- large acute intracerebral hemorrhage with perifocal
edema in perietal region with IVE [GRAEB SCORE-11]
• given
– Inj mannitol 300ml + inj lasix 20 mg stat n TDS
– INJ LEVIPIL 500 BD
• CT-angio- wnl
• Hb-12.8/tc-18.9-N86%/pc-304 /inr-1.19
• Cxr-wnl
• Cr-0.9/bun-7/na-136/k-4.1/
• Lft-wnl
• Neurosurgical opinion taken

6. Graeb score
Intraventricular hematoma
• Components
• Each lateral ventricle
– 1 = trace of blood
– 2 = less than 50% filled
– 3 = more than 50% filled
– 4 = completely filled and expanded
• 3th and 4th ventricles
– 0 = no blood
– 1 = blood present, size normal
– 2 = filled with blood and expanded
• Calculation
Graeb score = righ ventricular score + left ventricular score +
3th ventricular score + 4th ventricular score
Hwang BY, Bruce SS, Appelboom G, Piazza MA, Carpenter AM, Gigante PR, et al. Evaluation of intraventricular
hemorrhage assessment methods for predicting outcome following intracerebral hemorrhage. J Neurosurg
2012; 116:185-192.

7. 11/09/14

8. Modified graeb score
• The mGS is thus based on the fourth ventricle (maximum
score 4), third (maximum score 4), right and left lateral
ventricles (maximum score 4 for each), right and left
occipital horns (maximum score 2 for each), and the right
and left temporal horns (maximum score 2 for each).
• An additional score of +1 is given to each compartment if it
is expanded beyond normal anatomic limits attributable to
Clot.
• The maximum possible score is 32, in which every
compartment is filled with blood and expanded. A score
• of zero denotes no intraventricular blood.
(Stroke. 2013;44:635–641.)

10. mGRAEB score
• The CLEAR B study included 360 scans from 36 subjects.
– The mGS score and IVH volume were highly correlated (R =
0.80, P<0.0001, R2 0.65).
– Baseline mGS was predictive of poor outcome (area under
receiving operating characteristic curve 0.74, 95% confidence
interval, 0.57–0.91), whereas the original Graeb scale was
not.
• The VISTA study included 399 participants.
– Each unit increase in the mGS led to a 12% increase in the
odds of a poor outcome (odds ratio, 1.12; 95% confidence
interval, 1.05–1.19).
• Measures of reliability (intra- and inter- reader) were
good in both studies
(Stroke. 2013;44:635–641.)

11. Day-2 ------12/09
• Neurosurgical opinion
• Plan next--- EVD insetion
• GCS- E3M4-5VT
• Inj cefuroxime 500 mg iv bd

12. Repeat CT on14/09/14

13. 14/09----20/09
• Plan to give inj alteplase 1 mg f/b 4 ml flush
with sterile NS through left EVD
• Clamp for 1 hr then release
• Repeat 8 hourly------remaining discard
• Right EVD removed ON 16/09/14

14. • CSF sent for exam on 20/09/14 shows low sugar-
34, high protien-334, cell count 150….
75% neutrophils
• Inj ceftriaxone 2g iv bd + inj amikacine 500 mg iv
bd
• Extubated on 21/09/14
• CSF c/s received on 24/09----no growth

15. • Left EVD removed on 24/09/14
• CSF sent for exam----sugar-n/protein-70/cells-
45
• Shifted in HDU on24/09/14
• Discharge on 5/10/14 along with Ryles tube
and Foleys catheter
• With GCS---E4M6V2

16. Before discharge

17. Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage
• AHA Recommendation
Although intraventricular administration of
recombinant tissue-type plasminogen activator in
IVH appears to have a fairly low complication rate,
efficacy and safety of this treatment is uncertain
and is considered investigational (Class IIb; Level of
Evidence: B).
Stroke. 2010;41:2108-2129

18. CLEAR IVH trial- phase 2
More Than a Glimmer of Hope
• Naff et al report the results of a phase II trial to clear blood from the ventricles in
patients with small supratentorial ICH (30 Ml) and massive IVH.
• All patients had an EVD
• were randomized within 24 hours to receive 3 mg/3 mL of recombinant tissue-type
plasminogen activator (rtPA) or 3 mL of normal saline injected via the
extraventricular drainage into the ventricular spaces every 12 hours until CT
evidence of clot resolution was sufficient to remove the catheter.
• With 18% /day, the blood clot resolution was significantly higher in the rtPA–
treated pts compared to 8% / day for the placebo (P0.001),
• treatment duration was shorter.
• Mortality and complications such as bleeding events were similar in both treatment
arms,

19. • Mortality was 19% in the rtPA–treated group and
23% in the placebo group.
• Ventriculitis occurred among 8% and 9%,
respectively,
• symptomatic bleeding was reported for 23% of
the rtPA– treated group and 5% of the placebo
group.
• also a trend toward better clinical outcome at 30
days.
• The prespecified functional outcome measures
were all improved in the rtPA group.
Naff N, Williams M, Keyl PM, Tuhrim S, Bullock MR, Mayer S, et al. Low-dose recombinant tissue-type plasminogen
activator enhances clot resolution in brain hemorrhage: the Intraventricular Hemorrhage Thrombolysis
Trial. Stroke. 2011;42:3009 –3016.

20. CLEAR -3 TRIAL
• A pivotal phase III study (Clot Lysis: Evaluating
Accelerated Resolution of Hemorrhage with
rtPA III [CLEAR III]) of the effect of
thrombolytic based removal of ventricular
blood on functional outcome is underway.
• Results may came in 2015

21. THANK YOU