Current treatment options for intracerebral hemorrhage


Opinion statement

Intracerebral hemorrhage (ICH) remains the least treatable form of stroke. Despite ongoing attempts to find effective interventions based on the physiopathologic understanding of this disease, evidence-based medical therapies for ICH are limited to recommendations on blood pressure (BP) reduction, intracranial pressure monitoring, osmotherapy with adequate fluid resuscitation, fever and glycemic control, and seizure prophylaxis. Although the value of surgical treatment remains in doubt because of the negative results of the International Surgical Trial in Intracerebral Haemorrhage (STICH), a subgroup analysis of this study suggested better outcomes among patients with superficial hematomas who underwent surgical evacuation, supporting the ongoing STICH-II trial. Other approaches currently under study include ultra-early hemostatic therapy and BP reduction, thrombolytic therapy for intraventricular hemorrhage, and minimally invasive surgical approaches.

References and Recommended Reading

  1. 1.
    Broderick JP, Brott T, Tomsick T, et al.: Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg 1993, 78:188–191.PubMedGoogle Scholar
  2. 2.
    Flaherty ML, Woo D, Haverbusch M, et al.: Racial variations in location and risk of intracerebral hemorrhage. Stroke 2005, 36:934–937.PubMedCrossRefGoogle Scholar
  3. 3.
    Qureshi AI, Tuhrim S, Broderick JP, et al.: Spontaneous intracerebral hemorrhage. N Engl J Med 2001, 344:1450–1460.PubMedCrossRefGoogle Scholar
  4. 4.
    Skidmore CT, Andrefsky J: Spontaneous intracerebral hemorrhage: epidemiology, pathophysiology, and medical management. Neurosurg Clin N Am 2002, 13:281–288, v.PubMedCrossRefGoogle Scholar
  5. 5.
    Siddique MS, Gregson BA, Fernandes HM, et al.: Comparative study of traumatic and spontaneous intracerebral hemorrhage. J Neurosurg 2002, 96:86–89.PubMedGoogle Scholar
  6. 6.
    Mayer SA, Rincon F: Treatment of intracerebral haemorrhage. Lancet Neurol 2005, 4:662–672.PubMedCrossRefGoogle Scholar
  7. 7.
    Broderick J, Connolly S, Feldmann E, et al.: Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007, 38:2001–2023.PubMedCrossRefGoogle Scholar
  8. 8.
    Measuring and improving quality of care: a report from the American Heart Association/American College of Cardiology First Scientific Forum on Assessment of Healthcare Quality in Cardiovascular Disease and Stroke. Circulation 2000, 101:1483–1493.Google Scholar
  9. 9.
    Tellez H, Bauer RB: Dexamethasone as treatment in cerebrovascular disease. 1. A controlled study in intracerebral hemorrhage. Stroke 1973, 4:541–546.PubMedGoogle Scholar
  10. 10.
    Poungvarin N, Bhoopat W, Viriyavejakul A, et al.: Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987, 316:1229–1233.PubMedGoogle Scholar
  11. 11.
    Haemodilution in acute stroke: results of the Italian haemodilution trial. Italian Acute Stroke Study Group. Lancet 1988, 1:318–321.Google Scholar
  12. 12.
    Yu YL, Kumana CR, Lauder IJ, et al.: Treatment of acute cerebral hemorrhage with intravenous glycerol. A double-blind, placebo-controlled, randomized trial. Stroke 1992, 23:967–971.PubMedGoogle Scholar
  13. 13.
    Brott T, Broderick J, Kothari R, et al.: Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997, 28:1–5.PubMedGoogle Scholar
  14. 14.
    Mayer SA, Sacco RL, Shi T, Mohr JP: Neurologic deterioration in noncomatose patients with supratentorial intracerebral hemorrhage. Neurology 1994, 44:1379–1384.PubMedGoogle Scholar
  15. 15.
    Gujjar AR, Deibert E, Manno EM, et al.: Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: indications, timing, and outcome. Neurology 1998, 51:447–451.PubMedGoogle Scholar
  16. 16.
    Diringer MN, Edwards DF: Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 2001, 29:635–640.PubMedCrossRefGoogle Scholar
  17. 17.
    Mirski MA, Chang CW, Cowan R: Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol 2001, 13:83–92.PubMedCrossRefGoogle Scholar
  18. 18.
    Hemphill JC 3rd, Newman J, Zhao S, Johnston SC: Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke 2004, 35:1130–1134.PubMedCrossRefGoogle Scholar
  19. 19.
    Becker KJ, Baxter AB, Cohen WA, et al.: Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology 2001, 56:766–772.PubMedGoogle Scholar
  20. 20.
    Diringer MN: Intracerebral hemorrhage: pathophysiology and management. Crit Care Med 1993, 21:152–157.CrossRefGoogle Scholar
  21. 21.
    Papazian L, Albanese J, Thirion X, et al.: Effect of bolus doses of midazolam on intracranial pressure and cerebral perfusion pressure in patients with severe head injury. Br J Anaesth 1993, 71:267–271.PubMedCrossRefGoogle Scholar
  22. 22.
    Schramm WM, Jesenko R, Bartunek A, Gilly H: Effects of cisatracurium on cerebral and cardiovascular hemodynamics in patients with severe brain injury. Acta Anaesthesiol Scand 1997, 41:1319–1323.PubMedGoogle Scholar
  23. 23.
    Reynolds SF, Heffner J: Airway management of the critically ill patient: rapid-sequence intubation. Chest 2005, 127:1397–1412.PubMedCrossRefGoogle Scholar
  24. 24.
    Schramm WM, Strasser K, Bartunek A, et al.: Effects of rocuronium and vecuronium on intracranial pressure, mean arterial pressure and heart rate in neurosurgical patients. Br J Anaesth 1996, 77:607–611.PubMedGoogle Scholar
  25. 25.
    Broderick JP, Adams HP Jr, Barsan W, et al.: Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999, 30:905–915.PubMedGoogle Scholar
  26. 26.
    Passero S, Ciacci G, Ulivelli M: The influence of diabetes and hyperglycemia on clinical course after intracerebral hemorrhage. Neurology 2003, 61:1351–1356.PubMedGoogle Scholar
  27. 27.
    Broderick JP, Diringer MN, Hill MD, et al.: Determinants of intracerebral hemorrhage growth: an exploratory analysis. Stroke 2007, 38:1072–1075.PubMedCrossRefGoogle Scholar
  28. 28.
    Powers WJ, Zazulia AR, Videen TO, et al.: Autoregulation of cerebral blood flow surrounding acute (6 to 22 hours) intracerebral hemorrhage. Neurology 2001, 57:18–24.PubMedCrossRefGoogle Scholar
  29. 29.
    The Internet Stroke Center, Stroke Trials Registry: (ATACH) Antihypertensive Treatment in Acute Cerebral Hemorrhage. Available at Accessed February 2006.
  30. 30. Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage. Available at Accessed July 2007.
  31. 31.
    Liliang PC, Liang CL, Lu CH, et al.: Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage. Stroke 2001, 32:1195–1200.PubMedGoogle Scholar
  32. 32.
    Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr: Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 2002, 51:170–181; discussion 181–182.PubMedCrossRefGoogle Scholar
  33. 33.
    Adams RE, Diringer MN: Response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus. Neurology 1998, 50:519–523.PubMedGoogle Scholar
  34. 34.
    Lundberg N: Continuous recording and control of ventricular fluid pressure in neurosurgical practice. Acta Psychiatr Scand Suppl 1960, 36:1–193.PubMedGoogle Scholar
  35. 35.
    Chambers IR, Banister K, Mendelow AD: Intracranial pressure within a developing intracerebral haemorrhage. Br J Neurosurg 2001, 15:140–141.PubMedCrossRefGoogle Scholar
  36. 36.
    Fernandes HM, Siddique S, Banister K, et al.: Continuous monitoring of ICP and CPP following ICH and its relationship to clinical, radiological and surgical parameters. Acta Neurochir Suppl 2000, 76:463–466.PubMedGoogle Scholar
  37. 37.
    Qureshi AI, Suarez JI: Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000, 28:3301–3313.PubMedCrossRefGoogle Scholar
  38. 38.
    Qureshi AI, Wilson DA, Traystman RJ: Treatment of transtentorial herniation unresponsive to hyperventilation using hypertonic saline in dogs: effect on cerebral blood flow and metabolism. J Neurosurg Anesthesiol 2002, 14:22–30.PubMedCrossRefGoogle Scholar
  39. 39.
    Qureshi AI, Geocadin RG, Suarez JI, Ulatowski JA: Long-term outcome after medical reversal of transtentorial herniation in patients with supratentorial mass lesions. Crit Care Med 2000, 28:1556–1564.PubMedCrossRefGoogle Scholar
  40. 40.
    Misra UK, Kalita J, Ranjan P, Mandal SK: Mannitol in intracerebral hemorrhage: a randomized controlled study. J Neurol Sci 2005, 234:41–45.PubMedCrossRefGoogle Scholar
  41. 41.
    Schwab S, Georgiadis D, Berrouschot J, et al.: Feasibility and safety of moderate hypothermia after massive hemispheric infarction. Stroke 2001, 32:2033–2035.PubMedCrossRefGoogle Scholar
  42. 42.
    Schwab S, Spranger M, Schwarz S, Hacke W: Barbiturate coma in severe hemispheric stroke: useful or obsolete? Neurology 1997, 48:1608–1613.PubMedGoogle Scholar
  43. 43.
    Rincon F, Mayer SA: Therapeutic hypothermia for brain injury after cardiac arrest. Semin Neurol 2006, 26:387–395.PubMedCrossRefGoogle Scholar
  44. 44.
    Fogelholm R, Murros K, Rissanen A, Avikainen S: Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study. J Neurol Neurosurg Psychiatry 2005, 76:349–353.PubMedCrossRefGoogle Scholar
  45. 45.
    Baird TA, Parsons MW, Phanh T, et al.: Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 2003, 34:2208–2214.PubMedCrossRefGoogle Scholar
  46. 46.
    Capes SE, Hunt D, Malmberg K, et al.: Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001, 32:2426–2432.PubMedCrossRefGoogle Scholar
  47. 47.
    Williams LS, Rotich J, Qi R, et al.: Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology 2002, 59:67–71.PubMedGoogle Scholar
  48. 48.
    Van den Berghe G, Schoonheydt K, Becx P, et al.: Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology 2005, 64:1348–1353.PubMedGoogle Scholar
  49. 49.
    Commichau C, Scarmeas N, Mayer SA: Risk factors for fever in the neurologic intensive care unit. Neurology 2003, 60:837–841.PubMedGoogle Scholar
  50. 50.
    Schwarz S, Hafner K, Aschoff A, Schwab S: Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology 2000, 54:354–361.PubMedGoogle Scholar
  51. 51.
    Szczudlik A, Turaj W, Slowik A, Strojny J: Hyperthermia is not an independent predictor of greater mortality in patients with primary intracerebral hemorrhage. Med Sci Monit 2002, 8:CR702–CR707.PubMedGoogle Scholar
  52. 52.
    Mayer S, Commichau C, Scarmeas N, et al.: Clinical trial of an air-circulating cooling blanket for fever control in critically ill neurologic patients. Neurology 2001, 56:292–298.PubMedGoogle Scholar
  53. 53.
    Flint AC, Hemphill JC, Bonovich DC: Therapeutic hypothermia after cardiac arrest: performance characteristics and safety of surface cooling with or without endovascular cooling. Neurocrit Care 2007, 7:109–118.PubMedCrossRefGoogle Scholar
  54. 54.
    Passero S, Rocchi R, Rossi S, et al.: Seizures after spontaneous supratentorial intracerebral hemorrhage. Epilepsia 2002, 43:1175–1180.PubMedCrossRefGoogle Scholar
  55. 55.
    Claassen J, Jette N, Chum F, et al.: Electrographic seizures and periodic discharges after intracerebral hemorrhage. Neurology 2007, 69:1356–1365.PubMedCrossRefGoogle Scholar
  56. 56.
    Temkin NR: Antiepileptogenesis and seizure prevention trials with antiepileptic drugs: meta-analysis of controlled trials. Epilepsia 2001, 42:515–524.PubMedCrossRefGoogle Scholar
  57. 57.
    Vespa PM, O’Phelan K, Shah M, et al.: Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome. Neurology 2003, 60:1441–1446.PubMedGoogle Scholar
  58. 58.
    Wintzen AR, de Jonge H, Loeliger EA, Bots GT: The risk of intracerebral hemorrhage during oral anticoagulant therapy: a population study. Ann Neurol 1984, 16:553–558.PubMedCrossRefGoogle Scholar
  59. 59.
    Hart RG, Boop BS, Anderson DC: Oral anticoagulants and intracranial hemorrhage. Facts and hypotheses. Stroke 1995, 26:1471–1477.PubMedGoogle Scholar
  60. 60.
    Makris M, Greaves M, Phillips WS, et al.: Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy. Thromb Haemost 1997, 77:477–480.PubMedGoogle Scholar
  61. 61.
    Yasaka M, Sakata T, Minematsu K, Naritomi H: Correction of INR by prothrombin complex concentrate and vitamin K in patients with warfarin related hemorrhagic complication. Thromb Res 2002, 108:25–30.PubMedCrossRefGoogle Scholar
  62. 62.
    Heit JA: Perioperative management of the chronically anticoagulated patient. J Thromb Thrombolysis 2001, 12:81–87.PubMedCrossRefGoogle Scholar
  63. 63.
    Chowdhury P, Saayman AG, Paulus U, et al.: Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol 2004, 125:69–73.PubMedCrossRefGoogle Scholar
  64. 64.
    Wjasow C, McNamara R: Anaphylaxis after low dose intravenous vitamin K. J Emerg Med 2003, 24:169–172.PubMedCrossRefGoogle Scholar
  65. 65.
    Fredriksson K, Norrving B, Stromblad LG: Emergency reversal of anticoagulation after intracerebral hemorrhage. Stroke 1992, 23:972–977.PubMedGoogle Scholar
  66. 66.
    Sorensen B, Johansen P, Nielsen GL, et al.: Reversal of the International Normalized Ratio with recombinant activated factor VII in central nervous system bleeding during warfarin thromboprophylaxis: clinical and biochemical aspects. Blood Coagul Fibrinolysis 2003, 14:469–477.PubMedCrossRefGoogle Scholar
  67. 67.
    Freeman WD, Brott TG, Barrett KM, et al.: Recombinant factor VIIa for rapid reversal of warfarin anticoagulation in acute intracranial hemorrhage. Mayo Clin Proc 2004, 79:1495–1500.PubMedGoogle Scholar
  68. 68.
    Wakefield TW, Stanley JC: Intraoperative heparin anticoagulation and its reversal. Semin Vasc Surg 1996, 9:296–302.PubMedGoogle Scholar
  69. 69.
    Mannucci PM, Remuzzi G, Pusineri F, et al.: Deamino-8-Darginine vasopressin shortens the bleeding time in uremia. N Engl J Med 1983, 308:8–12.PubMedGoogle Scholar
  70. 70.
    Mayer SA, Brun NC, Begtrup K, et al.: Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2008, In press.Google Scholar
  71. 71.
    Juvela S, Heiskanen O, Poranen A, et al.: The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment. J Neurosurg 1989, 70:755–758.PubMedCrossRefGoogle Scholar
  72. 72.
    Zuccarello M, Brott T, Derex L, et al.: Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke 1999, 30:1833–1839.PubMedGoogle Scholar
  73. 73.
    Fernandes HM, Gregson B, Siddique S, Mendelow AD: Surgery in intracerebral hemorrhage. The uncertainty continues. Stroke 2000, 31:2511–2516.PubMedGoogle Scholar
  74. 74.
    Mendelow AD, Gregson BA, Fernandes HM, et al.: Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005, 365:387–397.PubMedGoogle Scholar
  75. 75.
    Rabinstein AA, Atkinson JL, Wijdicks EF: Emergency craniotomy in patients worsening due to expanded cerebral hematoma: to what purpose? Neurology 2002, 58:1367–1372.PubMedGoogle Scholar
  76. 76.
    Bhattathiri PS, Gregson B, Prasad KS, Mendelow AD: Intraventricular hemorrhage and hydrocephalus after spontaneous intracerebral hemorrhage: results from the STICH trial. Acta Neurochir Suppl 2006, 96:65–68.PubMedGoogle Scholar
  77. 77.
    STICH II Trial: News. Available at Accessed April 2007.
  78. 78.
    Ott KH, Kase CS, Ojemann RG, Mohr JP: Cerebellar hemorrhage: diagnosis and treatment. A review of 56 cases. Arch Neurol 1974, 31:160–167.PubMedGoogle Scholar
  79. 79.
    Auer LM, Deinsberger W, Niederkorn K, et al.: Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989, 70:530–535.PubMedGoogle Scholar
  80. 80.
    Teernstra OP, Evers SM, Lodder J, et al.: Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke 2003, 34:968–974.PubMedCrossRefGoogle Scholar
  81. 81.
    Murthy JM, Chowdary GV, Murthy TV, et al.: Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. Neurocrit Care 2005, 2:258–262.PubMedCrossRefGoogle Scholar
  82. 82.
    Mayer SA, Brun NC, Begtrup K, et al.: Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2005, 352:777–785.PubMedCrossRefGoogle Scholar
  83. 83.
    Mayer SA, Chong J: Critical care management of increased intracranial pressure. J Int Care Med 2002, 17:55–67.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Neurological Intensive Care UnitNeurological InstituteNew YorkUSA

Personalised recommendations