Update on Medical and Surgical Management of Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) accounts for 15% of all strokes in the US and Europe and 20% to 30% in Asian populations. ICH is associated with a higher morbidity, disability and mortality than ischemic strokes. Primary ICH originates from spontaneous rupture of small arteries and arterioles previously damaged by chronic hypertension or amyloid angiopathy. Secondary ICH is associated with underlying vascular abnormalities or other pathologies. Manifestation is acute with focal neurological signs and features of raised intracranial pressure. Despite our improved understanding of the pathophysiology of hematoma expansion and edema formation, management is primarily supportive, and outcomes remain poor. A recently published report has confirmed that there is no overall benefit from early surgery when compared with initial conservative treatment. In contrast, treatment with recombinant activated factor VII within 4 hours of onset limits hematoma growth at 24 hours, and reduces mortality and improves functional outcomes at 90 days. Several ICH scoring methods have recently been proposed for better prediction of outcome. These scoring methods may be useful in selecting suitable patients for clinical trials. Microbleeds are commonly seen on magnetic resonance imaging. Further studies are awaited to clarify the association between microbleeds and the future risk of ICH.