Background: Intra-ventricular hemorrhage (IVH) post-aneurysmal subarachnoid hemorrhage (aSAH) is common, where peri-ventricular intra-cerebral clot has ruptured the ependymal lining. However primary intra-ventricular hemorrhage (PIVH) without associated parenchymal clot is rare. Migration of blood via outlet foramina of the fourth ventricle through CSF pulsation and flow is thought to be the mechanism for this occurrence and would account for small volumes in the sub-acute setting. Case Report: Here, we present a case of a 52-year-old woman with CT demonstrating spontaneous middle cerebral artery (MCA) bifurcation aneurysmal subarachnoid hemorrhage and a large acute third ventricular clot spanning the foramen Monroe. Conclusion: Reflexive hypertensive hemorrhages may occur in aSAH and that these hemorrhages may occur in varied locations.