The phase 3 randomized CLEAR III trial is in progress. There are now reports of alternative procedures for IVH, such as endoscopic surgical evacuation and ventriculos- A comparison of 48 patients with IVH secondary to ICH and other causes and treated with endoscopic removal of IVH found 17% required permanent CSF diversion com- pared with 50% of 48 historical control patients treated with VC alone. Outcome on the modified Rankin scale was simi- lar. Two randomized trials have been reported comparing endoscopic removal of IVH with VC in patients with IVH secondary to primary ICH <30 mm3 In 1 of the studies, urokinase was also used in both treatment groups.223 Among the 46 patients treated with endoscopy compared with 44 treated with VC, mortality was not significantly different. One study reported improved outcome on the Glasgow Outcome Scale at 2 months with endoscopy but did not report the rate of permanent CSF diversion.223 The other suggested lower rates of permanent CSF diversion after endoscopy.221 Other reported management strategies for IVH include early ventric- endoscopic third ventriculostomy,225 or lumbar drainage.189 In a study comparing 16 patients treated with VC and lumbar drainage for ICH with IVH to 39 histori- cal control patients treated with VC alone, patients managed with VC plus lumbar drainage had a longer median duration of external CSF drainage but were significantly less likely to require permanent CSF diversion.189 IVH: Recommendations Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncer- tain (Class IIb; Level of Evidence B). (Revised from the previous recommendation) The efficacy of endoscopic treatment of IVH is uncertain (Class IIb; Level of Evidence B). 