J Neurosurg / October 14, 2011

DOI: 10.3171/2011.9.JNS10850
1
I
NTRAVENTRICULAR extension occurs in 30%45% of
patients with ICH and is an independent predictor of
poor outcome.
1,3,25,26
The presence of IVH signifcantly
increases the risk of death and IVH volume directly cor-
responds to the likelihood of death.
27
Recent reports have
demonstrated that early expansion of IVH worsens out-
come
25
and intraventricular clot removal reduces infam-
mation, hydrocephalus, and long-term functional defcits
in the setting of ICH.
12,18,23,28
Thus, the accurate assessment
of IVH volume and severity is critical, particularly to de-
termine the effcacy of novel treatments that aim to remove
Evaluation of intraventricular hemorrhage
assessment methods for predicting outcome following
intracerebral hemorrhage
Clinical article
Brian Y. Hwang, M.D., SaMuel S. Bruce, B.a., geoffreY appelBooM, M.D.,
MattHew a. piazza, B.a., aManDa M. carpenter, B.a., paul r. gigante, M.D.,
cHriStopHer p. Kellner, M.D., anDrew f. Ducruet, M.D., MicHael a. Kellner, B.S.,
rajeev DeB-Sen, KerrY a. vaugHan, B.a., pHilip M. MeYerS, M.D.,
anD e. SanDer connollY jr., M.D.
Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York,
New York
Object. Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) is an independent
predictor of poor outcome. Clinical methods for evaluating IVH, however, are not well established. This study sought
to determine the best IVH grading scale by evaluating the predictive accuracies of IVH, Graeb, and LeRoux scores in
an independent cohort of ICH patients with IVH. Subacute IVH dynamics as well as the impact of external ventricu-
lar drain (EVD) placement on IVH and outcome were also investigated.
Methods. A consecutive cohort of 142 primary ICH patients with IVH was admitted to Columbia University
Medical Center between February 2009 and February 2011. Baseline demographics, clinical presentation, and hospi-
tal course were prospectively recorded. Admission CT scans performed within 24 hours of onset were reviewed for
ICH location, hematoma volume, and presence of IVH. Intraventricular hemorrhage was categorized according to
IVH, Graeb, and LeRoux scores. For each patient, the last scan performed within 6 days of ictus was similarly evalu-
ated. Outcomes at discharge were assessed using the modifed Rankin Scale (mRS). Receiver operating characteristic
analysis was used to determine the predictive accuracies of the grading scales for poor outcome (mRS score 3).
Results. Seventy-three primary ICH patients (51%) had IVH. Median admission IVH, Graeb, and LeRoux scores
were 13, 6, and 8, respectively. Median IVH, Graeb and LeRoux scores decreased to 9 (p = 0.005), 4 (p = 0.002),
and 4 (p = 0.003), respectively, within 6 days of ictus. Poor outcome was noted in 55 patients (75%). Areas under the
receiver operating characteristic curve were similar among the IVH, Graeb, and LeRoux scores (0.745, 0.743, and
0.744, respectively) and within 6 days postictus (0.765, 0.722, 0.723, respectively). Moreover, the IVH, Graeb, and
LeRoux scores had similar maximum Youden Indices both at admission (0.515 vs 0.477 vs 0.440, respectively) and
within 6 days postictus (0.515 vs 0.339 vs 0.365, respectively). Patients who received EVDs had higher mean IVH
volumes (23 26 ml vs 9 11 ml, p = 0.003) and increased incidence of Glasgow Coma Scale scores < 8 (67% vs
38%, p = 0.015) and hydrocephalus (82% vs 50%, p = 0.004) at admission but had similar outcome as those who did
not receive an EVD.
Conclusions. The IVH, Graeb, and LeRoux scores predict outcome well with similarly good accuracy in ICH
patients with IVH when assessed at admission and within 6 days after hemorrhage. Therefore, any of one of the
scores would be equally useful for assessing IVH severity and risk-stratifying ICH patients with regard to outcome.
These results suggest that EVD placement may be benefcial for patients with severe IVH, who have particularly poor
prognosis at admission, but a randomized clinical trial is needed to conclusively demonstrate its therapeutic value.
(DOI: 10.3171/2011.9.JNS10850)
KeY worDS intraventricularhemorrhage intracerebralhemorrhage
GraebScore LeRouxScore IVHScore outcome vasculardisorders
1
Abbreviations used in this paper: AUROC = area under the ROC
curve; EVD = external ventricular drain; GCS = Glasgow Coma
Scale; ICH = intracerebral hemorrhage; IVH = intraventricular hem-
orrhage; mRS = modified Rankin scale; ROC = receiver operating
characteristic; tPA = tissue plasminogen activator.
B. Y. Hwang et al.
2 J Neurosurg / October 14, 2011
or reduce the effects of IVH. Methods to grade IVH sever-
ity, however, are not well established.
The IVH,
11
Graeb,
10
and LeRoux scores
17
were devel-
oped to estimate IVH severity based on gross hemorrhage
size and the presence of dilation within each ventricle (Fig.
1). The scores are useful for IVH evaluation at admission
and have been used to defne IVH severity
20
or to select
patients for studies;
21
however, their clinical effectiveness
to assess IVH or to predict outcome after ICH remains un-
clear. The aim of this study was to prospectively evaluate
the predictive accuracies of the IVH, Graeb, and LeRoux
scores for functional outcome at discharge in a single-
center, consecutive series of ICH patients with IVH. We
also sought to investigate the subacute IVH dynamic, as
well as the impact of EVD placement on IVH severity and
outcome.
Methods
Patient Selection and Data Collection
All patients with spontaneous ICH admitted to the
neurological intensive care unit of Columbia University
Medical Center between February 2009 and February 2011
were offered participation in the Columbia University In-
tracerebral Hemorrhage Outcomes Project. The study was
approved by the hospitals institutional review board, and
in all cases, informed consent was obtained from the pa-
tient or surrogate. The diagnosis of ICH was established by
CT scan. Patients were included in the analysis if they had
spontaneous nontraumatic ICH with evidence of IVH on
CT scans upon admission and within 24 hours of onset.
11

Patients were excluded if the ICH was due to secondary
causes such as trauma, aneurysm, or arteriovenous malfor-
mation rupture, or hemorrhagic conversion of an infarct.
Clinical Assessment and Management
All patients received standard neurological intensive
care unit management according to our institutional pro-
tocol, corresponding to the latest American Heart Asso-
ciation guidelines.
2,19
An EVD was placed in patients with
evidence of symptomatic hydrocephalus and a GCS score
< 8. The catheters were left in place until the total daily
amount of drained CSF became less than 100 ml and no
ventriculomegaly or increased intracranial pressure was
recorded after 48 hours of clamping. Surgical hematoma
evacuation was strongly considered for patients with cere-
bellar hemorrhage with clinical deterioration or those with
brainstem compression and/or hydrocephalus. Surgery was
also considered for patients with lobar clots greater than 30
ml and within 1 cm of the cortical surface. The decision
to administer intrathecal tPA was based on the preference
of the treating neurosurgeon. The protocol consisted of re-
moval of approximately 3 ml of CSF followed by 1 mg of
tPA delivered in 1 ml of saline, and a 2-ml saline fush.
Patients received intrathecal tPA twice daily until the deci-
sion was made to discontinue the therapy, based on nearly
complete clearance of blood from the ventricles. Further
details regarding the clinical management of the patients
have been described separately.
7
Baseline demographics,
medical history, clinical presentation, and clinical course,
including EVD insertions, were prospectively recorded.
Radiological Assessment
All CT scans were assessed using identical techniques.
Two authors (G.A. and C.P.K.) analyzed the scans while
blinded to radiologists reports and patient outcomes. Con-
sensus was then reached for each scan. Admission CT
scans performed within 24 hours of onset were reviewed
for ICH location, ICH volume, and presence of intraven-
tricular extension. Intraventricular hemorrhage severity
was assessed by determining the IVH,
11
Graeb,
10
and Le-
Roux scores
17
according to previously published criteria.
Intracerebral hemorrhage volume was determined using
the ABC/2 method.
16
Intraventricular hemorrhage volume
was measured as previously described, using a computer-
based planimetric analysis program, Medical Image Pro-
cessing, Analysis and Visualization (NIH).
11
Scans were
evaluated for the presence of hydrocephalus and the off-
cial radiology reports were consulted in questionable cases.
Intraventricular hemorrhage was scored and ICH and IVH
volumes were assessed based on the last scan performed
during this period.
Fig. 1. Grading scales for assessing IVH severity. A: The IVH score (range 023). The IVH score is calculated using the
following equation: 3 (right lateral ventricle score + left lateral ventricle score + hydrocephalus score) + third ventricle score +
fourth ventricle score. B: The Graeb score (range 012). C: The LeRoux score (range 016).
J Neurosurg / October 14, 2011
Intraventricular extension assessment in intracerebral hemorrhage
3
Outcome Assessment
Survival and functional outcomes at discharge were as-
sessed using the mRS, and patients were routinely followed
up after discharge by the study neurosurgeon (E.S.C.). Poor
outcome was defned as mRS scores 3.
Statistical Analysis
Continuous variables were dichotomized based on
clinical cutoff points or median values if they were not
normally distributed. The chi-square or Fisher exact tests
were used to fnd signifcant associations between categor-
ical or dichotomized variables. The 2-sided Student t-test
or the Mann-Whitney U-test was used for normally and
nonnormally distributed continuous variables, respective-
ly. Receiver operating characteristic analysis was used to
determine the predictive accuracies of the LeRoux, Graeb,
and IVH scores with regard to discharge poor outcome, as
measured by the AUROC. The ROC analysis measures
the ability of a scale to discriminate patients with a higher
probability of poor outcome from those with a lower prob-
ability of poor outcome by assigning the former a higher
score, and has been used to determine a clinical grading
scales predictive accuracy for outcome.
4,5,9
An AUROC
greater than 0.7 is generally considered useful, and an
AUROC between 0.8 and 0.9 indicates excellent accura-
cy.
8
Dependent AUROCs were compared nonparametri-
cally,
13
and the maximum Youden Index was identifed
for each scale to assess their prognostic performance. The
maximum Youden Index is the optimization of a func-
tion that gives equal weight to sensitivity and specifc-
ity. It is a method of ROC analysis that offers an alter-
native measure to AUROC; whereas AUROC concerns
a variables discriminative utility at all cutoff points, the
maximum Youden Index concerns only the cutoff point
at which the combination of sensitivity and specifcity is
maximal. A probability value 0.05 was considered sta-
tistically signifcant. Data analysis was performed with
SPSS version 17.
Results
Baseline Characteristics
Of the 142 primary ICH patients enrolled during the
study period, 73 (51.4%) met the inclusion criteria and were
included in the analysis. Baseline demographic and admis-
sion characteristics are outlined in Table 1. Patient charac-
teristics were similar to previously reported larger cohorts
with ICH.
14,15,29,31,32
The mean age of the entire cohort was
62.6 years, 47% were women, and 80% had a history of
hypertension. Fifty percent of patients had GCS scores <
8 at admission. Overall, 8% of patients received intrathe-
cal tPA, and 53% and 15% underwent EVD placement and
hematoma evacuation, respectively.
Radiographic Characteristics
Table 1 lists radiographic characteristics of the study
cohort. Mean ICH and IVH volumes were 27 33 ml and
17 22 ml, respectively. Sixty-seven percent had radio-
graphic evidence of hydrocephalus at admission. Median
IVH, Graeb, and LeRoux scores were 13, 8, and 6, respec-
tively. Within 6 days, the incidence of hydrocephalus de-
creased to 28% (p = 0.016). Median IVH, Graeb, and Le-
Roux scores signifcantly decreased to 9 (p = 0.005), 4 (p =
0.002), and 4 (p = 0.003), respectively. Thirty-four patients
(46.5%) had an increase in their IVH severity according to
IVH, Graeb, and LeRoux scores.
Clinical Outcome and Change in IVH Severity
Twenty-fve patients (34%) died during initial admis-
sion. Poor outcome (mRS score 3) was noted in 55 pa-
tients (75%). Increase or decrease in IVH severity within 6
postbleed days was not associated with outcome (p = 0.762
and p = 0.513, respectively).
Comparison of IVH Grading Scales in Predicting Outcome
Figure 2 left shows the ROC curves for the admission
IVH, Graeb, and LeRoux scores with regard to discharge
functional outcome. The 3 scores demonstrated good ac-
curacy for predicting outcome. The AUROCs of the IVH
(0.745, 95% CI 0.5890.900), Graeb (0.743, 95% CI 0.601
0.886) and LeRoux (0.744, 95% CI 0.6040.884) scores
were not statistically different (p = 0.646). The 3 scores
were also good at predicting outcome when assessed again
within 6 days of admission with similar AUROCs (0.765,
95% CI 0.6400.891 [IVH] vs 0.722, 95% CI 0.5960.848
[Graeb] vs 0.723, 95% CI 0.5970.850 [LeRoux]; Fig. 2
right). Furthermore, the 3 scores had similar maximum
Youden Indices and associated sensitivities and specifci-
ties when assessed at admission and within 6 days postic-
tus (Table 2). Admission IVH score of 9 (IVH volume of
approximately 6.0 ml) and 7 (IVH volume of approximate-
ly 3.3 ml) were associated with maximum Youden Index,
and thus were identifed as an optimal cutoff point for poor
outcome.
Impact of EVD on IVH Severity and Outcome
At admission, patients who received an EVD had sim-
ilar demographic characteristics as compared with those
who did not (Table 3). The proportion of patients with a
GCS score < 8 was signifcantly higher in the EVD group
(p = 0.015). The EVD group also had signifcantly worse
radiographic fndings with higher mean IVH volumes
compared with the non-EVD group (23 26 ml vs 9
11 ml, respectively; p = 0.003) and increased incidence of
hydrocephalus (82% vs 50%, respectively; p = 0.004). In-
traventricular hemorrhage severity, as assessed by IVH (17
vs 8, respectively; p < 0.001), Graeb (11 vs 3, respectively;
p < 0.001) and LeRoux scores (7 vs 3, respectively; p <
0.001) were signifcantly worse in the EVD group as com-
pared with the non-EVD group (Table 3). Within 6 days of
admission, the median IVH (17 vs 10; p = 0.001), Graeb
(7 vs 5; p < 0.001) and LeRoux scores (11 vs 5, p < 0.001)
signifcantly decreased in the EVD group compared with
the admission scores. During the same period, there was
no signifcant change in median IVH (8 vs 9, p = 0.058),
Graeb (3 vs 4, p = 0.182) or LeRoux scores (3 vs 4, p =
0.091) among patients who did not undergo EVD place-
ment. The EVD and non-EVD groups had similar postad-
mission IVH, Graeb, and LeRoux scores (Table 3). In ad-
dition, there was no signifcant difference in the incidence
B. Y. Hwang et al.
4 J Neurosurg / October 14, 2011
of poor outcome between the EVD and non-EVD groups
(79.5% vs 70.6%, p = 0.251).
Discussion
Comparison of the IVH, Graeb, and LeRoux Scores
In this study, we have demonstrated that the admis-
sion IVH, Graeb, and LeRoux scores predict functional
outcome at discharge with good accuracy. The 3 scores
retained their predictive accuracy when assessed within
6 days postictus, suggesting that they are robust against
potentially confounding factors, such as discrepancies in
medical or surgical management among patients. Although
the scores were not intended for predicting outcome per
se, their predictive accuracies refect their ability to assess
IVH severity and risk-stratify patients with regard to out-
come. Therefore, any 1 of the 3 scores can be considered
for IVH evaluation in the setting of ICH and assessment
of hemorrhage progression and treatment response, as well
as for incorporation into ICH grading scales for improved
outcome prediction and risk-stratifcation.
To our knowledge, this is the frst study to directly
compare the 3 most commonly used IVH grading scales
for their abilities to predict outcome after ICH with intra-
ventricular extension. With rapidly growing interest in nov-
el therapies for IVH in the setting of ICH, simple and ac-
curate assessment of IVH is becoming critical for system-
atic evaluation and monitoring of disease progression and
clinical effcacy of treatments. However, there is currently
no widely accepted, standardized method for measuring
IVH severity or volume. The recently developed IVH score
is different from the Graeb and LeRoux scores in several
aspects. First, unlike the Graeb and LeRoux scores, the
IVH score was specifcally developed in a cohort of ICH
patients with IVH, and hence, may better account for the
characteristics of IVH in this specifc population. Further-
more, the IVH score may be more sensitive to the differ-
ences in severity as it assesses hemorrhage size in thirds
rather than halves. The score also considers hydrocephalus,
an independent predictor of outcome after ICH,
6
separately
from IVH volume in each ventricle. This may enable the
IVH score to evaluate the severity of IVH with better ac-
curacy as compared with the other scales because hemor-
rhage burden and ventricular expansion do not necessarily
always go hand-in-hand. Nevertheless, in our cohort, the
difference in how hydrocephalus is evaluated by each scale
did not translate into improved predictive accuracy for the
IVH score. Also in our cohort, the potential advantages of
the IVH score failed to translate into improved predictive
TABLE 1: Demographic, admission, and radiographic data of the study population according to functional outcome
(mRS score) at discharge*
Parameter Overall mRS Score <3 mRS Score 3 p Value
no. of patients 73 18 55
demographic characteristics
mean age (yrs) SD 62.6 16.6 50.6 16.4 65.4 15.4 0.002
female 31 (42.5) 6 (33.3) 28 (50.9) 0.756
hx of HTN 58 (79.5) 10 (55.6) 48 (87.3) 0.467
admission characteristics
median GCS score (IQR) 7 (413) 15 (1415) 6 (411) <0.001
median ICH score (IQR) 3 (23.5) 7 (310) 14 (717) <0.001
mean ICH volume (ml) SD 27.35 32.96 13.37 23.79 30.67 34.10 0.077
mean IVH volume (ml) SD 16.92 21.84 4.41 5.15 19.94 23.25 <0.001
bleeding in lt lateral ventricle 61 (83.6) 8 (44.4) 53 (96.4) 0.008
bleeding in rt lateral ventricle 59 (80.8) 10 (55.6) 49 (89.1) 0.449
bleeding in 3rd ventricle 53 (72.6) 6 (33.3) 47 (85.5) 0.016
bleeding in 4th ventricle 44 (60.3) 5 (27.8) 39 (70.9) 0.037
hydrocephalus 49 (67.1) 5 (27.8) 44 (80.0) 0.005
infratentorial ICH 13 (17.8) 1 (5.6) 12 (21.8) 0.440
mean midline shift (mm) SD 3.65 4.97 2.07 3.37 4.03 5.23 0.188
median IVH score (IQR) 13 (617) 7 (310) 14 (717) 0.004
median LeRoux score (IQR) 8 (312) 3 (26) 9 (412) 0.005
median Graeb score (IQR) 6 (38) 3 (24) 6 (49) 0.005
hospital course
surgical hematoma evacuation 11 (15.1) 1 (5.6) 10 (18.2) 0.679
EVD placement 39 (53.4) 4 (22.2) 35 (63.6) 0.071
intrathecal tPA 6 (8.2) 0 (0) 6 (10.9) 0.588
* HTN = hypertension; IQR = interquartile range.
Statisticallysignifcant.
J Neurosurg / October 14, 2011
Intraventricular extension assessment in intracerebral hemorrhage
5
accuracy for outcome. Given the comparable performances
of the 3 scores, one important feature that distinguishes the
IVH score from the others is its ability to rapidly estimate
IVH volume without the need for time-consuming calcu-
lations that often involve computer-assisted planimetric
analysis. This is important because, once validated as a re-
liable and accurate volume estimation tool, the IVH score
will allow quick and routine clinical assessment of IVH
and total volume (IVH and ICH volume) at admission and
during treatment course. This will be useful to researchers
as clinical trials move toward novel therapies that address
both ICH and IVH volumes in recognition of their inde-
pendent effects on outcome.
12
Effects of Alterations in IVH Severity and Volume on
Outcome
Intraventricular hemorrhage volume is directly related
to the risk of poor outcome after ICH, with volumes of >
20 ml often leading to death.
24,25,30
In our cohort, admis-
sion IVH volume of 6.0 ml was associated with a signif-
cant increase in the likelihood of poor functional outcome.
This suggests that even relatively small IVH can lead to
clinically signifcant ventricular dysfunction, intracranial
hypertension, reduced cerebral perfusion, and secondary
cerebral injuries.
11
The lower threshold for poor outcome at
postadmission may be due to the prolonged exposure of the
ventricles to blood, which worsens IVH-mediated injuries
and neurological outcome.
22,23
Intraventricular hemorrhage is a dynamic condition
and its course depends on many factors, including mean
arterial pressure, baseline ICH volume, and treatment.
25

Nearly half of our cohort experienced an increase in their
IVH severity, suggesting that IVH progression is common
beyond the frst 24 hours despite standard neurocritical
management. Although hydrocephalus resolved and IVH
grades improved in a signifcant number of patients, the
overall mean IVH volume did not signifcantly change.
Furthermore, increase or decrease in IVH severity with-
in 6 days of hemorrhage was not signifcantly associated
with outcome. This suggests that subacute worsening in
IVH volume may not signifcantly worsen outcome once
patients are medically stabilized and hydrocephalus and
intracranial pressure are optimally managed. Surprisingly,
a decrease in IVH severity also did not have signifcant
infuence on outcome. It is possible that IVH either causes
a considerable amount of its damage in the early periods,
or IVH severity within the frst 24 hours determines the ex-
tent of cerebral injuries to come. Studies have reported that
early changes in IVH severity may signifcantly infuence
outcome. Steiner et al.
25
have reported that 17% of ICH
patients had IVH expansion within 24 hours of symptom
onset and that the growth was associated with severe dis-
ability and death. We did not investigate the incidence or
degree of IVH growth in the frst 24 hours. Further studies
are needed to determine the IVH dynamics and its clinical
impact on hospital course and outcome. Continued inves-
tigation into the IVH pathophysiology may also help iden-
tify an optimal timing and degree of intervention.
Impact of an EVD on Outcome in ICH Patients With IVH
Current treatment for IVH in ICH patients is EVD-as-
sisted drainage but its usefulness remains controversial.
21

In our cohort, patients who underwent EVD placement
had signifcantly higher IVH volume and incidence of hy-
drocephalus at admission with signifcantly worse IVH, as
assessed by the IVH grading scales. Based on our manage-
ment protocol, it is likely that a majority of patients with
Fig. 2. Comparison of ROC curves and AUROCs of admission (left) and postadmission (right) IVH scores, Graeb scores, and
LeRoux scores as predictors of discharge poor functional outcome (mRS score 3).
TABLE 2: Performance of the IVH, Graeb, and LeRoux scores for
predicting poor outcome (mRS score 3)
Score Youden Index Sensitivity Specifcity
admission
IVH 0.515 0.729 0.786
Graeb 0.477 0.763 0.643
LeRoux 0.440 0.797 0.714
w/in 6 days postictus
IVH 0.515 0.729 0.786
Graeb 0.339 0.339 1
LeRoux 0.365 0.508 0.857
B. Y. Hwang et al.
6 J Neurosurg / October 14, 2011
hydrocephalus in the EVD group were symptomatic from
ventricular expansion. Interestingly, patients who under-
went EVD placement and those who did not had similar
IVH severity within 6 days of hemorrhage, suggesting that
an EVD was effective at alleviating IVH and ventricular
obstruction. Although EVD insertion was not associated
with outcome, it is important to recognize that the EVD
group had similar mortality rates and functional outcome
as those who did not receive an EVD, despite having a
signifcantly worse prognosis at admission, which is con-
sistent with previous reports.
6,30
Although this prospective
observational study was not designed to isolate the impact
of EVD on outcome, our results suggest EVD placement,
in conjunction with neurocritical care and appropriate
surgical and medical interventions, may be benefcial in a
subset of ICH patients with IVH with particularly dismal
prognosis based on admission characteristics. A random-
ized clinical trial is needed to determine whether EVD
insertion improves outcome in ICH patients with IVH.
Study Limitations
This study has several limitations. First, only the ad-
mission scans and the last scan performed within 6 days
were used for our study. All the patients received at least 1
scan during this time period but they were not performed
on the same postbleed day. It is possible that not all wors-
ening or improvement in IVH was included in our analysis.
Second, we estimated the IVH volume based on the IVH
score. Although this method has been shown to be accu-
rate,
11
it is novel and is yet to be conclusively validated. In
addition, this study may have been underpowered for dif-
ferentiating the predictive accuracies of the scales, as well
as detecting small difference among subgroups of patients.
Our results must be validated in future studies with larger
cohorts and longer follow-up periods that are suffciently
powered to control for the heterogeneity of the study popu-
lation and treatments.
Conclusions
The IVH score, Graeb score, and LeRoux score as-
sessed at admission predict discharge functional outcome
in ICH patients with IVH with good accuracy. Therefore,
any 1 of the 3 scores may be considered for IVH assess-
ment in the setting of ICH or for improving the perfor-
mance of ICH grading scales that incorporates IVH se-
verity for outcome prediction. Although IVH progression
is common after the frst 24 hours even with standard
optimal neurocritical care, its impact on clinical outcome
needs to be further elucidated. Future research is also
needed to better understand IVH pathophysiology, which
may help defne optimal timing and degree of interven-
tion. Although EVD placement remains one of the main
treatments of IVH and acute hydrocephalus, its impact
TABLE 3: Demographic, admission, and outcome data of study population according to EVD status
Parameter No EVD EVD p Value
no. of patients 34 39
demographic characteristics
mean age (yrs) SD 65.0 16.3 60.4 16.7 0.234
female (%) 14 (41.2) 20 (51.3) 0.388
hx of HTN (%) 26 (76.5) 32 (82.1) 0.556
admission characteristics
GCS score <8 (%) 13 (38.2) 26 (66.7) 0.015*
infratentorial ICH (%) 5 (14.7) 8 (20.5) 0.518
mean ICH volume (ml) SD 31.38 36.79 23.85 29.25 0.334
mean IVH volume (ml) SD 9.21 11.30 23.44 26.24 0.003*
hydrocephalus (%) 17 (50.0) 32 (82.1) 0.004*
median IVH score (IQR) 8 (414) 17 (1017) <0.001*
median LeRoux score (IQR) 3 (29) 11 (514) <0.001*
median Graeb score (IQR) 3 (26) 7 (510) <0.001*
postadmission characteristics (within 6 days postictus)
median IVH score (IQR) 9 (616) 10 (617) 0.701
median LeRoux score (IQR) 4 (210) 5 (210) 0.446
median Graeb score (IQR) 4 (28) 5 (27) 0.668
clinical course and outcome (%)
intrathecal tPA 0 6 (15.4) 0.027*
hematoma evacuation 3 (8.8) 8 (20.5) 0.202
in-hospital deaths 10 (29.4) 15 (38.5) 0.416
in-hospital poor outcome (mRS score 3) 24 (70.6) 31 (79.5) 0.251
* Statisticallysignifcant.
J Neurosurg / October 14, 2011
Intraventricular extension assessment in intracerebral hemorrhage
7
on clinical outcome remains controversial. Although an
EVD was associated with improvement in outcome in
patients with severe IVH with particularly poor progno-
sis at admission, a randomized clinical trial is needed to
conclusively demonstrate its therapeutic benefts in ICH
patients with IVH.
Disclosure
Brian Y. Hwang was supported by a Doris Duke Clinical
Research Fellowship.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Appelboom, Hwang,
Carpenter, CP Kellner, Ducruet, Meyers, Connolly. Acquisition
of data: Bruce, Piazza, Carpenter, Deb-Sen, Vaughan. Analysis
and interpretation of data: Appelboom, Hwang, Bruce, Piazza,
Carpenter, Gigante, CP Kellner, Deb-Sen, Vaughan. Drafting the
article: Appelboom, Hwang, Bruce, Carpenter, Gigante, CP Kellner,
M Kellner, Deb-Sen, Vaughan, Connolly. Critically revising the
article: all authors. Reviewed submitted version of manuscript: all
authors. Approved the final version of the manuscript on behalf of all
authors: Appelboom. Statistical analysis: Appelboom, Bruce, Piazza.
Administrative/technical/material support: Appelboom, Hwang,
Carpenter, CP Kellner, MA Kellner, Deb-Sen. Study supervision:
Appelboom, Hwang, Carpenter, CP Kellner, Meyers, Connolly.
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Manuscript submitted May 31, 2010.
Accepted September 14, 2011.
Current affiliation for Dr. Hwang: Department of Neurosurgery,
Johns Hopkins University School of Medicine, Baltimore, Maryland.
Please include this information when citing this paper: published
online October 14, 2011; DOI: 10.3171/2011.9.JNS10850.
Address correspondence to: Geoffrey Appelboom, M.D., Depart-
ment of Neurosurgical Surgery, Columbia University Medical Cen-
ter, New York, New York 10032. email: ga2294@columbia.edu.