Supratentorial Intracerebral Hemorrhage: A Review of the Underlying Pathophysiology and its Relevance for Multimodality Neuromonitoring in Neurointensive Care

Supratentorial intracerebral hemorrhage (ICH) is a devastating condition with high morbidity and mortality. There are currently no proven pharmacological therapies for ICH, and the role of surgery is controversial. In the neurointensive care setting, management currently focuses on optimization of systemic physiology to offer neuroprotection by maintenance of adequate cerebral perfusion and substrate delivery, using targets derived principally from traumatic brain injury. Advances in technology, neuroimaging, and neuromonitoring techniques have significantly improved the detection of neural compromise and our understanding of the pathophysiology of ICH, including the nature of the perihematomal penumbra and role of mitochondrial dysfunction. Here, we review the developments in neuromonitoring and their application to ICH, highlighting the importance of multimodality neuromonitoring to comprehensively assess cerebral perfusion, oxygenation, and metabolic status as well as offer an extended window for the prevention, early detection, and treatment of secondary neuronal injury and complications such as hematoma expansion. Technical advances will likely lead to the development of noninvasive monitors that deliver continuous measurement of cerebral hemodynamics, oxygenation, and metabolism over multiple regions of interest simultaneously. A key future priority will be to provide high-quality robust evidence that multimodality monitoring-guided treatment can lead to improved outcome.