This is a multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) trial comparing the addition of early lumbar drainage to standard care in patients with intraventricular hemorrhage (IVH) in China. The primary objective is to evaluate whether early lumbar drainage improves long-term functional outcomes at 180 days, as measured by the modified Rankin Scale (mRS), and reduces complications in patients treated with external ventricular drainage (EVD) and intrathecal urokinase.

Intraventricular hemorrhage (IVH) is a life-threatening complication of acute stroke, associated with high rates of mortality and severe disability, fewer than 20% of survivors achieve favorable functional outcomes. Despite widespread use of external ventricular drainage (EVD) and intraventricular thrombolysis, the role of early lumbar drainage in improving outcomes remains controversial, with limited high-level evidence from randomized controlled trials.

This study uses a 1:1 stratified block randomization design, with stratification by the etiology of IVH, site of ventricular obstruction, and participating center. Eligible patients will be randomized to receive either:

Control group: Standard treatment with EVD plus daily intrathecal urokinase (30,000 IU) for up to 3 to 5 days.

Intervention group: The same standard EVD and urokinase regimen, plus early lumbar drainage initiated within 24 hours of EVD placement. Drainage will be titrated to a rate ≤8 mL/h, with a maximum daily volume of 200 mL, to maintain stable intracranial pressure.

The primary endpoint is the proportion of patients with a favorable functional outcome (mRS 0-3) at 180 days. Secondary endpoints include 90-day functional status, incidence of post-hemorrhagic hydrocephalus, hospital length of stay, and mortality. Safety endpoints include all-cause mortality, intracranial infection, and cerebral herniation. A total of 392 patients will be enrolled, with an interim efficacy analysis planned when 50% of participants complete their 180-day follow-up.

Inclusion Criteria:

• Aged 18 to 85 years old, no limitation on gender.
• First-ever intracerebral hemorrhage confirmed by CT/MRI, accompanied by third and/or fourth intraventricular hemorrhage, requiring external ventricular drainage.
• Baseline hemorrhage volume less than 30 mL, with stable clinical condition before randomization.
• External ventricular drainage performed within 48 hours of symptom onset.
• Randomization completed within 24 hours after EVD placement.
• Pre-morbid modified Rankin Scale (mRS) score of 0 or 1.
• Written informed consent obtained from the participant or their legally authorized representative.

Exclusion Criteria:

• Suspected or untreated ruptured intracranial aneurysm, arteriovenous malformation (AVM), or intracranial tumor, unless excluded by vascular imaging. Previously treated aneurysm or AVM must have been completed at least 3 months prior to enrollment.

• Choroidal vascular malformation or moyamoya disease.

  • Long-term oral anticoagulant use, persistent coagulation dysfunction, or known allergy to urokinase.

• Platelet count < 100×10⁹/L or INR > 1.4.

• Absolute contraindications to lumbar cistern drainage or external ventricular drainage, such as cerebral hernia or infection at the puncture site.

• Infratentorial hemorrhage volume ≥ 10 mL.

• Thalamic hemorrhage ≥ 10 mL, or accompanied by midbrain extension, oculomotor nerve palsy, or fixed dilated pupil.

• Hemiplegia with muscle strength grade 0 or 1.

• Active bleeding in the gastrointestinal, genitourinary, or respiratory system.

• Multiple ecchymoses or petechiae suggesting a bleeding tendency.

• Expected survival time less than 6 months.

• Severe, untreatable concomitant systemic diseases.

• Pregnancy.

• Participation in other interventional clinical trials within 30 days prior to randomization.

• Any other condition deemed inappropriate for enrollment by the investigator(s).