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Background Patients with intraventricular hemorrhage (IVH) frequently often require prolonged cerebrospinal fluid (CSF) diversion and permanent shunting, however radiographic features that predict downstream CSF diversion complexity remain incompletely defined. We evaluated whether early residual IVH burden and anatomic IVH dissemination predict ventriculoperitoneal (VP) shunt placement and drain-related burden.Methods We performed a retrospective single-center cohort study of patients with IVH requiring CSF diversion. Baseline clinical and radiographic variables were collected, including mGraeb score, segmented baseline and day-5 IVH volumes, and anatomic IVH extension pattern. Drain burden was defined as EVD replacement, clamp trial failure, VP shunt placement, infection, or tract hemorrhage. Multivariable logistic regression evaluated predictors of VP shunt placement, drain burden, and poor day-5 IVH clearance.Results A total of 77 patients were included in this analysis. The median age was 66.6 years (IQR 55.0-72.9), and 31 (40.3%) were female. Bilateral extension was present in 52 patients, third ventricular extension in 45, and fourth ventricular extension in 50; the most common phenotype was combined bilateral, third, and fourth ventricular involvement (n=29). In adjusted component models, bilateral extension was independently associated with VP shunt placement (OR 19.0, 95% CI 2.90-371; p=0.012) and drain burden (OR 4.60, 95% CI 1.43-16.5; p=0.013). Higher residual day-5 segmented IVH volume was also independently associated with VP shunt placement (OR 1.05, 95% CI 1.02-1.10; p=0.0049) and drain burden (OR 1.06, 95% CI 1.02-1.12; p=0.0286). Increasing anatomic extension count was associated with higher odds of VP shunt placement (OR 2.01, p=0.027) and drain burden (OR 2.40, p=0.003). Third and fourth ventricular extension on their own did not independently predict VP shunt or drain burden after adjustment. Higher baseline mGraeb score predicted poorer day-5 IVH clearance in the simpler model (OR 1.11, 95% CI 1.01-1.25; p=0.0459).Conclusions Both anatomic dissemination of IVH, particularly bilateral extension, and early residual ventricular blood burden were associated with downstream CSF diversion complexity. These findings suggest that radiographic IVH pattern and day-5 residual clot burden may help identify patients at risk for prolonged or complicated CSF diversion needs.Disclosures K. Agosto: None. M. Dhillon: None. M. Nasrallah: None. Y. Ramirez: None. J. Shin: None. T. Som: None. T. Hardigan: None. J. Mocco: None. C. Kellner: None.