Study guide
Intraventricular Hemorrhage & Hydrocephalus
ABPN Neurocritical Care Study Guide Exam
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1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU
Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU
2 Chapter 2: Cerebral Physiology & Intracranial Dynamics
Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes
3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management
Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions
4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management
Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy
5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management
Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury
6 Chapter 6: Neuropharmacology, Analgesia & Sedation
ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU
7 Bleeding, Thrombosis & Hematologic Emergencies
Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity
8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine
Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention
9 Systemic Trauma & Environmental Injury
Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging
10 Cardiac Emergencies & Mechanical Support
IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies
11 Kidney Injury, Acid–Base & Renal Replacement
Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement
12 Systemic Infection & Endocrine Emergencies
Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies
13 Gastrointestinal & Hepatic Emergencies
Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects
14 Chapter 9: Neuroimaging in the Neuro-ICU
Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness
15 Chapter 10: Electrophysiology & Neuromonitoring
Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler
16 Angiography, Electrodiagnosis & CSF Analysis
Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage
17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria
Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria
18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies
Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction
19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage
Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH
20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia
Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations
21 Venous, Spinal & Traumatic Vascular Disease
Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury
22 Chapter 15: Traumatic Brain & Spinal Cord Injury
Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes
23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies
Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure
24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis
Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies
25 Neuroinflammation & Neurooncology
Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies
26 Pregnancy, Transplantation & Pediatric Care
Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care
27 Chapter 18: Neurosurgical & Perioperative Emergencies
Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies
28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU
Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor
Intraventricular Hemorrhage & Hydrocephalus
Key Takeaways Explain This Topic AI
Assess ventricular obstruction, declining consciousness, gaze changes, and brainstem signs rather than using blood volume alone to decide urgency.
Level the drain to the prescribed anatomic reference and distinguish drainage height in cm H2O from ICP in mm Hg.
An open conventional EVD does not simultaneously provide the same undisturbed ICP measurement as a correctly closed measurement system.
CLEAR III did not improve its primary mRS 0–3 outcome at 180 days; mortality was lower, with important disability tradeoffs.
Last updated: October 2026
- Intraventricular Hemorrhage and Hydrocephalus
- Blood, Obstruction, and CSF Circulation
CSF is produced predominantly by the choroid plexus, passes through the lateral ventricles, foramina of Monro, third ventricle, aqueduct, and fourth ventricular outlets, and reaches subarachnoid spaces. Resorption includes arachnoid and lymphatic pathways. Blood can obstruct a narrow passage acutely and can later impair resorption through inflammatory changes. Hydrocephalus may therefore be obstructive, communicating, or mixed over time. A patient who initially needs temporary drainage may later develop permanent shunt dependence.
Secondary IVH occurs when a parenchymal hemorrhage extends into the ventricles; thalamic and caudate locations are particularly close to ventricular structures. Primary IVH without a parenchymal source warrants assessment for vascular or other causes according to the clinical context. Describe which ventricles are involved, clot burden, third and fourth ventricular obstruction, ventricular enlargement, and transependymal flow. IVH severity scales such as the modified Graeb score support standardized description but do not replace assessment of the patient.
Declining consciousness, headache, vomiting, abducens weakness, and worsening brainstem signs can indicate hydrocephalus. Dorsal midbrain compression can produce impaired upgaze, light-near dissociation, convergence-retraction movements, or lid retraction. Not every feature must be present. Cushing physiology is a late danger signal rather than a required diagnostic triad. Reassess urgently when the examination changes, including repeat imaging and evaluation for seizure, rebleeding, systemic instability, or medication effects.
When and How to Drain
Ventricular drainage is recommended for ICH/IVH-associated hydrocephalus contributing to reduced consciousness. Coordinate neurosurgical placement, relevant coagulopathy correction, airway support, and treatment of herniation when present. An EVD can both divert CSF and measure pressure, but it is an invasive device with bleeding, infection, obstruction, and overdrainage risks. Placement and management require trained personnel and a documented protocol.
Set the prescribed reference at the appropriate approximation of the foramen of Monro, commonly the tragus/external auditory reference in the specified position. Relevel after changes in head or bed position. Drainage height is often ordered in cm H2O, while displayed ICP commonly uses mm Hg; one mm Hg is approximately 1.36 cm H2O. A drain height of 15 cm H2O corresponds to approximately 11 mm Hg, but the height is a hydrostatic drainage threshold rather than a guarantee that intracranial pressure always equals that number.
Specify continuous drainage, intermittent drainage, and measurement intervals explicitly. In a conventional system, an open drain affects the pressure signal; obtain a valid closed-system measurement according to protocol rather than reporting an open-drain value as undisturbed ventricular pressure. Some systems or a separate parenchymal monitor allow different configurations. Continuous and intermittent strategies have different goals and evidence across diseases. Do not claim that one approach always prevents infection, obstruction, or shunt dependence.
Troubleshoot Without Causing Injury
If output stops or the waveform changes, assess consciousness, pupils, symptoms, pressure, tubing, stopcocks, kinks, level, and the prescribed drainage threshold. No output can reflect obstruction, low pressure below the threshold, system error, or catheter position. Urgent CT and surgical review may be needed. Do not blindly aspirate, advance, or forcefully flush toward the patient. Manipulation requires the appropriately trained operator and the specific sterile protocol.
Unexpectedly high output, new positional headache, or neurologic change can indicate overdrainage. Recheck level and positioning and seek immediate direction. Excessive drainage can cause ventricular collapse, subdural collections, intracranial hypotension, and harmful compartmental gradients. Posterior fossa lesions require particular care, but selected cerebellar-infarction hydrocephalus can be managed by ventriculostomy; ongoing brainstem compression or deterioration changes the decompression decision.
Use sterile insertion and a closed system, avoid unnecessary sampling and manipulation, inspect for leak and infection, and remove the drain when no longer needed. Routine fixed-interval catheter exchange is not recommended for infection prevention. Suspected ventriculitis requires clinical assessment and appropriate cultures; normal routine CSF indices do not reliably exclude it after hemorrhage or surgery.
Clot Lysis and the CLEAR III Evidence
CLEAR III enrolled selected patients with an EVD, stable hemorrhage, small parenchymal ICH, and obstructing IVH. Alteplase 1 mg every eight hours for up to twelve doses was compared with saline through a tightly controlled protocol. This research regimen is not permission for unsupervised instillation. Drug delivery, sterile technique, catheter dead space, drainage interruption, imaging stability, pressure tolerance, and stopping rules require a trained multidisciplinary protocol. The study's catheter closure after instillation was one hour, not an invented two-hour default.
The primary outcome, mRS 0–3 at 180 days, was 48% with alteplase versus 45% with saline and was not significantly improved. Mortality at 180 days was lower, 18% versus 29%, but more survivors had very severe disability. Symptomatic bleeding was similar, and ventriculitis was less frequent in the alteplase arm. Interpret both survival and disability rather than calling the intervention an established independence treatment. Associations between greater clot removal and better outcomes do not prove a universal residual-volume target or justify applying lysis to unstable hemorrhage or an untreated vascular lesion.
When the patient is ready, assess whether drainage remains necessary using a protocol for clamp trials or staged elevation, serial examination, and imaging when appropriate. Evidence favoring faster weaning is strongest in selected populations and does not establish one universal infection or shunt outcome for all IVH. A failed trial requires reassessment of reversible factors and the need for continued diversion or permanent shunting.
Sources: CLEAR III and IDSA device-associated CNS infection guideline .
Decision Review
- Finding Management implication
- Reduced consciousness with hydrocephalus Urgent diversion assessment
- Stopped output and deterioration Check patient, system, imaging, and neurosurgical plan
- Persistent drainage dependence Assess clamp tolerance and possible permanent diversion