(New recommendation) Intraventricular Hemorrhage IVH occurs in 45% of patients with spontaneous ICH and is an independent factor associated with poor outcome.190,202,203 Pooled analysis of 13 studies found IVH in association with ICH increased the risk of death from 20% without to 51% IVH can be primary, confined to the ventricles, or secondary, originating as an extension of an ICH. Most IVH is secondary and related to hypertensive hemorrhages involving the basal ganglia and thalamus.202,205 Although the insertion of a VC should theoretically aid in drainage of blood and CSF from the ventricles, VC use alone may be ineffec- tive because of difficulty maintaining catheter patency and the slow removal of intraventricular blood.188 Thus, there has been recent interest in the use of thrombolytic agents as adjuncts to VC use in the setting of IVH. Animal studies and clinical series have reported that intra- ventricular administration of fibrinolytic agents, including urokinase, streptokinase, and recombinant tissue-type plas- minogen activator (rtPA), in IVH may reduce morbidity and mortality by accelerating blood clearance and clot lysis.206 214 Retrospective analysis of 42 consecutive patients with IVH, 88% attributable to primary ICH, who were treated with intra- ventricular urokinase found death occurred in 21 patients Another prospective study compared 48 patients with IVH (caused by ICH in 40 [83%]) treated with intraventricular rtPA to 49 matched control patients treated with VC alone.207 Mortality was reduced from 30% to 10% in the group treated with rtPA, with 2 patients in the rtPA group diagnosed with ventriculitis. In a small pro- spective trial, 16 patients with IVH and ICH <30 mm3 were randomized to VC or VC plus urokinase.214 Clearance of IVH was faster with urokinase. 