Intracranial pressure management in severe intraventricular hemorrhage: A minireview

Table 1 Evolution of the Monro-Kellie doctrine in intraventricular hemorrhage management

Era	Core mechanism	Clinical applications	Key limitations in IVH
1.0 (1783-20th century)	Static volume compensation	CSF displacement to spinal compartment	Neglects compensatory thresholds and dynamic interactions
2.0 (2016)	Venous capacitance shifts	Jugular optimization during EVD clamping	Overlooks arterial inflow dynamics during autoregulatory failure
3.0 (2019)	Parenchymal deformation	Management of chronic hydrocephalus	Limited relevance to acute hemorrhage phases
4.0 (2025)	Integrated neurodynamics: CA + glymphatics + ICC	Predictive analytics for compliance failure	Requires advanced multimodal monitoring integration

IVH: Intraventricular hemorrhage; CSF: Cerebrospinal fluid; EVD: External ventricular drainage; CA: Cerebrovascular autoregulation; ICC: Intracranial compliance.

Table 2 Comparative analysis of intracranial pressure monitoring techniques in severe intraventricular hemorrhage

Technique	Accuracy	Advantages	Limitations	IVH-specific utility
EVD with ICP integration	Gold standard	Therapeutic drainage + monitoring	Infection risk (8%-15%), occlusion by clot	Enables thrombolytic administration, preferred for obstructive hydrocephalus
Parenchymal fiberoptic	± 2 mmHg	Low infection risk, compartment-specific data	Drift > 1 mmHg/day, no therapeutic function	Essential for large parenchymal extensions (> 15 mL)
ONSD ultrasound	Unstable, sensitivity 90%, specificity 60%-85%	Rapid bedside application	Overestimates ICP in acute hydrocephalus	Best for rapid triage when EVD unavailable
TCD pulsatility index	r = 0.68 with ICP	Autoregulation assessment	Operator-dependent, limited temporal windows	CPP titration during vasopressor use

IVH: Intraventricular hemorrhage; EVD: External ventricular drainage; ICP: Intracranial pressure; ONSD: Optic nerve sheath diameter; TCD: Transcranial Doppler; CPP: Cerebral perfusion pressure.