Not “doing the same thing over and over again”

Intracerebral hemorrhage (ICH) with intraventricular extension is a devastating disease occurring in 40% of patients with spontaneous ICH. Although the CLEAR III trial (NCT00784134) demonstrated mortality reduction with intraventricular alteplase (versus saline), lessons learned warrant a therapeutic trial focusing on disease severity and treatment endpoints that support a high likelihood of improvement. We must answer questions of maximizing therapy intensity in large intraventricular hemorrhage (IVH) to promote good neurologic outcomes if we are committed to treating ICH and the full spectrum of stroke severity.