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OBJECTIVES To investigate the relationship between internal cerebral vein (ICV) pulsation and intraventricular hemorrhage (IVH) and to identify the cutoff values that predict IVH. We hypothesized that the severity of ICV flow pulsations was related to IVH severity. STUDY DESIGN In this prospective observational study, ICV flow was measured in 61 extremely preterm infants using ultrasonography every 12 h until 96 h after birth and on days 7, 14, and 28. The ICV pulsation index (ICVPI = minimum/maximum ICV speed) was calculated and compared among the groups determined by Papile IVH classification. The ICVPI cutoff values for IVH were determined by receiver operating characteristic curve analysis. RESULTS Compared with those in the no IVH group (n=51), the ICVPI median values in the severe IVH (Grade 3-4) group (n=5) were lower at 25-96 h and on day 7, whereas those in the mild IVH (Grade 1-2) group (n=5) were lower at 37-60 h. All severe IVH events were initially detected within 60 h after birth. The ICVPI cutoff values for severe IVH were 0.92 at 13-24 h, 0.42 at 25-36 h, 0.58 at 37-48 h, and 0.55 at 49-60 h. Infants whose ICVPI values were below the cutoff value ≥3 times between 13 and 60 h had a significantly higher severe IVH incidence than those whose ICVPI values were below the cutoff value ≤2 times (57.1% vs. 1.9%, p<0.001). CONCLUSION Our results indicate that severe IVH had sustained pronounced internal cerebral vein pulsations and that the ICVPI values may help predict severe IVH. Further research on strategies to decrease venous pressure for IVH prevention is needed.