INTRODUCTION: Intraventricular hematoma (IVH) occurs in approximately 40% of acute intracerebral hemorrhage (ICH) patients and is significantly associated with worse clinical outcomes. According to cerebrospinal fluid dynamics, some blood within the ventricles may circulate through the subarachnoid spaces, leading to its apparent "disappearance" on follow-up imaging. We aim to investigate the association between initial IVH involvement and significant early ICH retraction at follow-up imaging. METHODS: Data are from the MCAHP (Multiphase CT Angiography Hematoma Prediction) Study, which included consecutive patients with acute ICH investigated with multimodal CT imaging. Patients who underwent surgery before follow-up imaging were excluded. IVH severity was assessed using the IVH score. The primary outcome was significant early ICH retraction, defined as volume decrease (⩾3 ml or ⩾15%) between the initial and follow-up scans. Secondary outcomes included early absolute and relative ICH decrease. Associations between outcomes and initial IVH involvement or IVH score were assessed with logistic regression adjusted for age, baseline NIHSS, initial ICH volume, and onset-to-CT time. RESULTS: Overall, 177 ICH patients were included. The median age was 71 years (IQR = 59-80), 71 (40.1%) patients were female, and 64 (36.2%) presented with initial IVH involvement. Patients with initial IVH, compared to those without, had a larger initial ICH volume (28.5 ml [IQR = 12.7-52.5] vs. 18.9 ml [IQR = 8.1-30.6], p < 0.001) and different ICH location (deep = 54.7% vs 47.8%; lobar = 35.9% vs 46.0%; infratentorial = 7.3% vs 6.2%; p < 0.001). Early ICH retraction was observed in 33 (18.6%) patients: 21 (32.8%) with initial IVH and 10 (10.6%) without initial IVH. There was a significant association between early ICH retraction and initial IVH involvement (adjusted odds ratio [aOR] 4.02 [95% CI = 1.72-9.41]) and IVH score (aOR 1.14 [95% CI = 1.05-1.23] per 1-point increase). Similar results were observed for secondary outcomes. CONCLUSION: Initial IVH involvement is associated with early ICH retraction - "intraventricular washout." This might result in an underestimation of hematoma expansion occurrence and severity in these patients, with potential implications when evaluating the predictive performance of hematoma expansion markers/scores and the radiological efficacy of hemostatic treatments.

Department of Biomedical Sciences Humanitas University Milan Italy

Department of Clinical Neurosciences University of Calgary Calgary AB Canada

Department of Medicine Division of Neurology University of British Columbia Vancouver Canada

Department of Medicine Division of Neurology University of Ottawa Ottawa ON Canada

Department of Medicine Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand

Department of Neurology Kyoto Prefectural University of Medicine Kyoto Japan

Department of Neurology National Institute of Mental Health and Neurosciences Bengaluru India

Department of Neurology University Ostrava Ostrava Czech Republic

Department of Radiology University of Calgary Calgary AB Canada

IRCCS Humanitas Research Hospital Milan Italy

Neuroscience Center King Faisal Specialist Hospital and Research Centre Riyadh Saudi Arabia

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GBD 2021 Stroke Risk Factor Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2021: a systematic analysis for the global burden of disease study 2021. Lancet Neurol 2024; 23: 973–1003. PubMed

Morotti A, Boulouis G, Dowlatshahi D, et al.. Intracerebral haemorrhage expansion: definitions, predictors, and prevention. Lancet Neurol 2023; 22: 159–171. PubMed

Yogendrakumar V, Ramsay T, Fergusson D, et al.. New and expanding ventricular hemorrhage predicts poor outcome in acute intracerebral hemorrhage. Neurology 2019; 93: e879–e888. PubMed PMC

Hanley DF. Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage. Stroke 2009; 40: 1533–1538. PubMed PMC

Hallevi H, Albright KC, Aronowski J, et al.. Intraventricular hemorrhage: anatomic relationships and clinical implications. Neurology 2008; 70: 848–852. PubMed PMC

Dowlatshahi D, Deshpande A, Aviv RI, et al.. Do intracerebral hemorrhage nonexpanders actually expand into the ventricular space? Stroke 2018; 49: 201–203. PubMed

Bergsneider M. Evolving concepts of cerebrospinal fluid physiology. Neurosurg Clin N Am 2001; 12: 631–638. PubMed

Iliff JJ, Wang M, Liao Y, et al.. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid β. Sci Transl Med 2012; 4: 147ra111. PubMed PMC

Horn M, Teleg E, Tanaka K, et al.. Timing of spot sign appearance, spot sign volume, and leakage rate among phases of multiphase CTA predict intracerebral hemorrhage growth. AJNR Am J Neuroradiol 2024; 45: 693–700. PubMed PMC

Kosior JC, Idris S, Dowlatshahi D, et al.. Quantomo: validation of a computer-assisted methodology for the volumetric analysis of intracerebral haemorrhage. Int J Stroke 2011; 6: 302–305. PubMed

Morgan TC, Dawson J, Spengler D, et al.. The modified graeb score: an enhanced tool for intraventricular hemorrhage measurement and prediction of functional outcome. Stroke 2013; 44: 635–641. PubMed PMC

Hallevi H, Dar NS, Barreto AD, et al.. The IVH score: a novel tool for estimating intraventricular hemorrhage volume: clinical and research implications. Crit Care Med 2009; 37: 969–974, e1. PubMed PMC

Klahr AC, Kate M, Kosior J, et al.. Early hematoma retraction in intracerebral hemorrhage is uncommon and does not predict outcome. PLoS One 2018; 13: e0205436. PubMed PMC

Cao S, Zheng M, Hua Y, et al.. Hematoma changes during clot resolution after experimental intracerebral hemorrhage. Stroke 2016; 47: 1626–1631. PubMed PMC

Puy L, Parry-Jones AR, Sandset EC, et al.. Intracerebral haemorrhage. Nat Rev Dis Primers 2023; 9: 14. PubMed

Yogendrakumar V, Moores M, Sikora L, et al.. Evaluating hematoma expansion scores in acute spontaneous intracerebral hemorrhage: a systematic scoping review. Stroke 2020; 51: 1305–1308. PubMed

Morotti A, Boulouis G, Dowlatshahi D, et al.. Standards for detecting, interpreting, and reporting noncontrast computed tomographic markers of intracerebral hemorrhage expansion. Ann Neurol 2019; 86: 480–492. PubMed

Yogendrakumar V, Mayer SA, Steiner T, et al.. Exploring hematoma expansion shift with recombinant factor VIIa: a pooled analysis of 4 randomized controlled trials. Stroke 2023; 54: 2990–2998. PubMed

Concha M, Xu L, Horn M, et al.. Predictors of intracranial hemorrhage volume expansion in patients receiving factor Xa inhibitors in ANNEXA-4: time and severity matter most. Stroke 2024; 4: e000997.

Horn M, Banerjee A, Kasickova L, et al.. Total intracranial hemorrhage volume measurement summating all compartments best in traumatic and nontraumatic intracranial bleeding. Brain Behav 2024; 14: e3481. PubMed PMC