exclude subarachnoid hemorrhage and to identify the IVH and evaluate its severity and potential for obstructive hydrocephalus. (See 'Computed tomography' above.) Individuals with primary IVH should have magnetic resonance imaging with magnetic resonance angiography and/or conventional angiography to identify the underlying etiology, particularly a vascular malformation or aneurysm that may require surgical intervention. (See 'Other neuroimaging studies' above.) Management Monitoring Because acute obstructive hydrocephalus often complicates IVH that involves the third and fourth ventricles, such patients should be closely monitored. When neurologic deterioration occurs, emergent CT scan should be done to exclude the development of obstructive hydrocephalus or recurrent hemorrhage. (See 'General measures' above and 'Computed tomography' above.) Blood pressure The optimal blood pressure management in patients with IVH is uncertain. For patients with IVH and elevated blood pressure, intravenous antihypertensives such as labetalol or nicardipine may be used to lower blood pressure gradually while maintaining adequate cerebral perfusion. Aggressive blood pressure lowering may minimize the risk of further hemorrhage but must be weighed against the risk of decreased cerebral perfusion in patients with increased ICP. (See 'Blood pressure management' above.) External ventricular drain We recommend external ventricular drainage (EVD) for patients with neurologic deterioration that occurs with ventricular enlargement over conservative management (Grade 1B). An EVD can reduce clot burden, treat hydrocephalus, and facilitate ICP monitoring. (See 'External ventricular drain' above.) Additional management options The use of intraventricular thrombolysis involves shared decision-making and after assessing individual risks and benefits and is reserved for patients at experienced centers with established protocols. 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J Neurosurg 2000; 93:976. Topic 1116 Version 23.0 https://www.uptodate.com/contents/intraventricular-hemorrhage/print 19/26 7/5/23, 12:22 PM Intraventricular hemorrhage - UpToDate GRAPHICS Glasgow Coma Scale (GCS) Score Eye opening Spontaneous 4 Response to verbal command 3 Response to pain 2 No eye opening 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localizing response to pain 5 Withdrawal response to pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Total The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. Graphic 81854 Version 9.0 https://www.uptodate.com/contents/intraventricular-hemorrhage/print 20/26 7/5/23, 12:22 PM Intraventricular hemorrhage - UpToDate Etiologies of thunderclap headache Most common causes of thunderclap headache: Subarachnoid hemorrhage Reversible cerebral vasoconstriction syndromes (RCVS) Conditions that less commonly cause thunderclap headache: Cerebral infection (eg, meningitis, acute complicated sinusitis) Cerebral venous thrombosis Cervical artery dissection Spontaneous intracranial hypotension Acute hypertensive crisis Posterior reversible leukoencephalopathy syndrome (PRES) Intracerebral hemorrhage Ischemic stroke Conditions that uncommonly or rarely cause thunderclap headache: Pituitary apoplexy Colloid cyst of the third ventricle Aortic arch dissection Aqueductal stenosis Brain tumor Giant cell arteritis Pheochromocytoma Pneumocephalus Retroclival hematoma Spinal epidural hematoma Varicella zoster virus vasculopathy Vogt-Koyanagi-Harada syndrome Disputed causes of thunderclap headache: Sentinel headache (unruptured intracranial aneurysm)* Primary thunderclap headache Sentinel headache due to an unruptured intracranial aneurysm is a possible cause of thunderclap headache, but supporting data are weak. https://www.uptodate.com/contents/intraventricular-hemorrhage/print 21/26 7/5/23, 12:22 PM Intraventricular hemorrhage - UpToDate There is controversy as to whether thunderclap headache can occur as a benign and potentially recurrent headache disorder in the absence of underlying organic intracranial pathology. Graphic 81710 Version 8.0 https://www.uptodate.com/contents/intraventricular-hemorrhage/print 22/26 7/5/23, 12:22 PM Intraventricular hemorrhage - UpToDate Intracerebral hemorrhage with intraventricular hemorrhage due to moyamoya syndrome Noncontrast head CT (A) showing hematoma in the right corpus striatum and lateral ventricles. Digital subtraction angiogram (B) showing critical stenosis of proximal right middle cerebral artery (arrow), prominent collateralization of both lenticulostriate vessels (circle), and branches of the anterior cerebral artery (thick arrows). CT: computed tomography. Courtesy of Glenn A Tung, MD, FACR. Graphic 132277 Version 1.0 https://www.uptodate.com/contents/intraventricular-hemorrhage/print 23/26 7/5/23, 12:22 PM Intraventricular hemorrhage - UpToDate Intraventricular hemorrhage due to ruptured periventricular arteriovenous malformation Noncontrast head CT (A) showing IVH. CT angiogram (B) showing abnormal tangle of vessels (circle) in the left perisplenial region. Digital subtraction angiogram (C) showing AVM nidus (circle). CT: computed tomography; IVH: intraventricular hemorrhage; AVM: arteriovenous malformation. Courtesy of Glenn A Tung, MD, FACR. Graphic 132281 Version 1.0 https://www.uptodate.com/contents/intraventricular-hemorrhage/print 24/26 7/5/23, 12:22 PM Intraventricular hemorrhage - UpToDate External ventricular drain An external ventricular drain (EVD) is a small catheter inserted through the skull usually into the lateral ventricle, which is typically connected to a closed collecting device to allow for drainage of cerebrospinal fluid. The EVD can also be connected to a transducer that records intracranial pressure. Graphic 56391 Version 2.0 https://www.uptodate.com/contents/intraventricular-hemorrhage/print 25/26 7/5/23, 12:22 PM Intraventricular hemorrhage - UpToDate Contributor Disclosures Brett L Cucchiara, MD No relevant financial relationship(s) with ineligible companies to disclose. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator-initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Richard P Goddeau, Jr, DO, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/intraventricular-hemorrhage/print 26/26