Medical management of acute intracerebral hemorrhage

Abstract

Purpose of review: Intracerebral hemorrhage (ICH) is the most serious but least treatable form of stroke, with prognosis critically dependent on both the size and degree of hematoma expansion. Treatments that target hematoma expansion offer potential to improve outcomes. This review analyzes the recent literature pertaining to the medical management of ICH.

Recent findings: Modern imaging studies have confirmed the dynamic nature of ICH. At least one-third of patients experience significant continued bleeding and hematoma expansion in the first few hours after onset, more so in warfarin-related ICH. Despite a strong biological rationale for benefit, a large clinical trial of recombinant activated factor VII failed to show any treatment effects on substantive outcomes despite clear attenuation of hematoma growth. The impact of recombinant activated factor VII is therefore severely restricted because of uncertain efficacy, definite hazard, and high cost. Accumulating evidence indicates beneficial effects from the early normalization of international normalized ratio levels and replacement of coagulation factors in warfarin-related ICH. Although high blood pressure (BP) is common and associated with poor outcomes in ICH, there is insufficient evidence to recommend a specific early BP management strategy, although recent randomized evidence indicates that such treatment is well tolerated and readily incorporated into routine clinical practice. Definitive evidence to support a low-cost, widely applicable treatment is urgently required for a condition in which therapy is primarily supportive.

Summary: In patients with acute ICH, rapid intensive BP-lowering treatment may provide protection against hematoma growth without concerns about safety and tolerability. How well such treatment can translate into overall benefits to patients is yet to be determined. At present, recombinant activated factor VII cannot be recommended for routine use, although BP lowering should generally follow conservative guidelines.