Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management

  • Thomas J. Cusack
  • J. Ricardo Carhuapoma
  • Wendy C. ZiaiEmail author
Cerebrovascular Disorders (DG Jamieson, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Cerebrovascular Disorders


Purpose of review

Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated.

Recent findings

The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise.


Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.


Intraparenchymal hemorrhage IPH Intracerebral hemorrhage ICH Surgical management of intracranial hemorrhage Hematoma evacuation IVH Intraventricular hemorrhage 


Compliance with Ethical Standards

Conflict of Interest

Thomas J. Cusack and J. Ricardo Carhuapoma declare no conflict of interest. Dr. Wendy C. Ziai is supported by National Institutes of Health grants 5U01NS062851 and 1U01NS08082.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    • Krishnamurthi RV, Feigin VL, Forouzanfar MH, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010: findings from the global burden of disease study 2010. Lancet Glob Health. 2013;1(5):e259–e81. The first comprehensive assessment of the global burden of stroke in most regions looking at incidence, prevalence, mortality, disability, and trends. The paper showed that while the mortality from stroke has decreased in recent years, the absolute number of strokes has been increasing with a high proportion of stroke burden borne by developing nations. Scholar
  2. 2.
    Ikram MA, Wieberdink RG, Koudstaal PJ. International epidemiology of intracerebral hemorrhage. Curr Atheroscler Rep. 2012;14(4):300–6. Scholar
  3. 3.
    Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol. 2009;8(4):345–54. Scholar
  4. 4.
    Feigin VL, Lawes CMM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 2009;8(4):355–69. Scholar
  5. 5.
    Rincon F, Mayer SA. The epidemiology of intracerebral hemorrhage in the United States from 1979 to 2008. Neurocrit Care. 2013;19(1):95–102. Scholar
  6. 6.
    Zahuranec DB, Lisabeth LD, Sánchez BN, Smith MA, Brown DL, Garcia NM, et al. Intracerebral hemorrhage mortality is not changing despite declining incidence. Neurology. 2014;82(24):2180–6. Scholar
  7. 7.
    Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire community stroke project--1981-86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1990;53(1):16.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage - a powerful and easy to use predictor of 30-day mortality. Stroke. 1993;24(7):987–93. Scholar
  9. 9.
    •• Hemphill JC, III GSM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage a Guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–60. Delayed by a year at the time of preparation to allow for inclusion of a number of landmark studies, this is to date the most recent and comprehensive set of guidelines for the management of spontaneous ICH. It is essential reading for anyone in the field. Scholar
  10. 10.
    • van Asch CJJ, Luitse MJA, Rinkel GJE, van der Tweel I, Algra A, Klijn CJM. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol. 2010;9(2):167–76. This paper effectively marshals a large body of data to show with evidence what many practitioners already know to be true: that no significant impact has been made on decreasing case fatality in intracranial hemorrhage in recent years. The need for improved treatment and improved outcomes is urgent. Scholar
  11. 11.
    Ariesen MJ, Claus SP, Rinkel GJE, Algra A. Risk factors for intracerebral hemorrhage in the general population. Syst Rev. 2003;34(8):2060–5.Google Scholar
  12. 12.
    O'Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112–23. Scholar
  13. 13.
    Zia E, Hedblad B, Pessah-Rasmussen H, Berglund G, Janzon L, Engström G. Blood pressure in relation to the incidence of cerebral infarction and intracerebral hemorrhage. Hyperten Hemorrhage: Debated Nomencl Still Relevant. 2007;38(10):2681–5.Google Scholar
  14. 14.
    Zhang Y, Tuomilehto J, Jousilahti P, Wang Y, Antikainen R, Hu G. Lifestyle factors on the risks of ischemic and hemorrhagic stroke. Arch Intern Med. 2011;171(20):1811–8. Scholar
  15. 15.
    Andersen KK, Olsen TS, Dehlendorff C, Kammersgaard LP. Hemorrhagic and ischemic strokes compared stroke severity, mortality, and risk factors. Stroke. 2009;40(6):2068–72. Scholar
  16. 16.
    Suh I, Jee SH, Kim HC, Nam CM, Kim IS, Appel LJ. Low serum cholesterol and haemorrhagic stroke in men: Korea medical insurance corporation study. Lancet. 2001;357(9260):922–5. Scholar
  17. 17.
    Suzuki K, Izumi M, Sakamoto T, Hayashi M. Blood pressure and Total cholesterol level are critical risks especially for hemorrhagic stroke in Akita. Japan Cerebrovasc Dis. 2011;31(1):100–6. Scholar
  18. 18.
    Sarwar N, Gao P, Seshasai SRK, Gobin R, Kaptoge S, Di Angelantonio E, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215–22. Scholar
  19. 19.
    Knudsen KA, Rosand J, Karluk D, Greenberg SM. Clinical diagnosis of cerebral amyloid angiopathy: validation of the Boston criteria. Neurology. 2001;56(4):537–9. Scholar
  20. 20.
    He J, Whelton PK, Vu B, Klag MJ. Aspirin and risk of hemorrhagic stroke - a meta-analysis of randomized controlled trials. Jama-J Am Med Assoc. 1998;280(22):1930–5. Scholar
  21. 21.
    Flaherty ML, Kissela B, Woo D, Kleindorfer D, Alwell K, Sekar P, et al. The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology. 2007;68(2):116–21. Scholar
  22. 22.
    Chatterjee S, Sardar P, Biondi-Zoccai G, Kumbhani DJ. New oral anticoagulants and the risk of intracranial hemorrhage: traditional and bayesian meta-analysis and mixed treatment comparison of randomized trials of new oral anticoagulants in atrial fibrillation. JAMA Neurol. 2013;70(12):1486–90. Scholar
  23. 23.
    Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the euro heart survey. Chest. 2010;138(5):1093–100. Scholar
  24. 24.
    Camm AJ, Lip GYH, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation. Eur Heart J. 2012;33(21):2719–47. Scholar
  25. 25.
    Dye JA, Rees G, Yang I, Vespa PM, Martin NA, Vinters HV. Neuropathologic analysis of hematomas evacuated from patients with spontaneous intracerebral hemorrhage. Neuropathology. 2014;34(3):253–60. Scholar
  26. 26.
    Halpin SFS, Britton JA, Byrne JV, Clifton A, Hart G, Moore A. Prospective evaluation of cerebral-angiography and computed tomography in cerebral hematoma. J Neurol Neurosurg Psychiatry. 1994;57(10):1180–6. Scholar
  27. 27.
    Zhu XL, Chan MSY, Poon WS. Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke. 1997;28(7):1406–9. Scholar
  28. 28.
    Keep RF, Hua Y, Xi G. Intracerebral haemorrhage: mechanisms of injury and therapeutic targets. Lancet Neurol. 2012;11(8):720–31. Scholar
  29. 29.
    Jauch EC, Pineda JA, Claude HJ. Emergency neurological life support: intracerebral hemorrhage. Neurocrit Care. 2015;23(2):83–93. Scholar
  30. 30.
    Goldstein LB, Bertels C, Davis JN. Interrater reliability of the nih stroke scale. Arch Neurol. 1989;46(6):660–2. Scholar
  31. 31.
    Wang C-W, Liu Y-J, Lee Y-H, Hueng D-Y, Fan H-C, Yang F-C, et al. Hematoma shape, hematoma size, Glasgow coma scale score and ICH score: which predicts the 30-day mortality better for intracerebral hematoma? PLoS One. 2014;9(7):e102326. Scholar
  32. 32.
    Bekelis K, Desai A, Zhao W, Gibson D, Gologorsky D, Eskey C, et al. Computed tomography angiography: improving diagnostic yield and cost effectiveness in the initial evaluation of spontaneous nonsubarachnoid intracerebral hemorrhage. J Neurosurg. 2012;117(4):761–6. Scholar
  33. 33.
    Delgado Almandoz JE, Jagadeesan BD, Moran CJ, Cross DT 3rd, Zipfel GJ, Lee JM, et al. Independent validation of the secondary intracerebral hemorrhage score with catheter angiography and findings of emergent hematoma evacuation. Neurosurgery. 2012;70(1):131–40; discussion 40.
  34. 34.
    Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005;352(17):1791–8. Scholar
  35. 35.
    Kuramatsu JB, Bobinger T, Volbers B, Staykov D, Lucking H, Kloska SP, et al. Hyponatremia is an independent predictor of in-hospital mortality in spontaneous intracerebral hemorrhage. Stroke. 2014;45(5):1285–91. Scholar
  36. 36.
    Gray JR, Morbitzer KA, Liu-DeRyke X, Parker D, Zimmerman LH, Rhoney DH. Hyponatremia in patients with spontaneous intracerebral hemorrhage. J Clin Med. 2014;3(4):1322–32. Scholar
  37. 37.
    van der Jagt M. Fluid management of the neurological patient: a concise review. Crit Care. 2016;20(1):126. Scholar
  38. 38.
    Hemphill JC, White DB. Clinical nihilism in neuro-emergencies. Emerg Med Clin North Am. 2009;27(1):27–37, vii-viii.
  39. 39.
    Becker KJ, Baxter AB, Cohen WA, Bybee HM, Tirschwell DL, Newell DW, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56(6):766–72. Scholar
  40. 40.
    •• Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score. A simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–7. ICH score has seen widespread clinical adoption over the last two decades. It has been repeatedly externally validated and enables rapid communication of ICH severity between providers. It was not intended to guide the decision to withold treatment, however. PubMedCrossRefGoogle Scholar
  41. 41.
    • Rost NS, Smith EE, Chang Y, Snider RW, Chanderraj R, Schwab K, et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage. The FUNC Score. 2008;39(8):2304–9. The most important consideration in ICH survivors is what their level of functional independence will be. This is a useful evidence based tool that allows providers to approximate what patient's functional outcomes might look like after survival.Google Scholar
  42. 42.
    Maas MB, Francis BA, Sangha RS, Lizza BD, Liotta EM, Naidech AM. Refining prognosis for intracerebral hemorrhage by early reassessment. Cerebrovasc Dis. 2017;43(3–4):110–6. Scholar
  43. 43.
    • Brouwers HB, Raffeld MR, van Nieuwenhuizen KM, Falcone GJ, Ayres AM, McNamara KA, et al. CT angiography spot sign in intracerebral hemorrhage predicts active bleeding during surgery. Neurology. 2014;83(10):883–9. The spot sign is widely understood to be a sign of clinical severity in ICH. Scholar
  44. 44.
    Dowlatshahi D, Demchuk AM, Flaherty ML, Ali M, Lyden PL, Smith EE. Defining hematoma expansion in intracerebral hemorrhage: relationship with patient outcomes. Neurology. 2011;76(14):1238–44. Scholar
  45. 45.
    Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997;28(1):1–5. Scholar
  46. 46.
    Hallevi H, Abraham AT, Barreto AD, Grotta JC, Savitz SI. The spot sign in intracerebral hemorrhage: the importance of looking for contrast extravasation. Cerebrovasc Dis. 2010;29(3):217–20. Scholar
  47. 47.
    Specogna AV, Turin TC, Patten SB, Hill MD. Factors associated with early deterioration after spontaneous intracerebral hemorrhage: a systematic review and meta-analysis. PLoS One. 2014;9(5):e96743. Scholar
  48. 48.
    Webb AJS, Ullman NL, Morgan TC, Muschelli J, Kornbluth J, Awad IA, et al. Accuracy of the ABC/2 score for intracerebral hemorrhage. Systematic review and analysis of MISTIE, CLEAR-IVH, and CLEAR III. Stroke. 2015;46(9):2470–6. Scholar
  49. 49.
    •• Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–65. INTERACT 2 was a landmark, guideline shifting large randomized trial that showed aggressive early blood pressure lowering in ICH to be, if only slightly impactful in improving functional outcomes, safe and not deleterious for patients. Scholar
  50. 50.
    •• Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):1033–43. ATACH II was a large randomized trial that considered specific blood presssure targets for blood pressure lowering in spontaneous ICH in the first 24 hours and at their impact on reducing death and disability. The groups in this trial had notably lower blood pressure targets than had been used in previous trials, but there was no significant improvement in outcomes with the intervention. Scholar
  51. 51.
    • Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2008;358(20):2127–37. A large well designed study that unfortunately failed to find clinical benefit to agressive blood pressure lowering. At the same time it did establish that such treatment was at least safe. Scholar
  52. 52.
    • Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2005;352(8):777–85. A study which failed to find clinical benefit using supplementation of recombinant factor VII. The approach is not used clinically in ICH and other trials of such an approach have not been forthcoming. Scholar
  53. 53.
    Huhtakangas J, Tetri S, Juvela S, Saloheimo P, Bode MK, Hillbom M. Effect of increased warfarin use on warfarin-related cerebral hemorrhage: a longitudinal population-based study. Stroke. 2011;42(9):2431–5. Scholar
  54. 54.
    Hickey M, Gatien M, Taljaard M, Aujnarain A, Giulivi A, Perry JJ. Outcomes of urgent warfarin reversal with frozen plasma versus prothrombin complex concentrate in the emergency department. Circulation. 2013;128(4):360–4. Scholar
  55. 55.
    Sarode R, Milling TJ, Refaai MA, Mangione A, Schneider A, Durn BL, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation. 2013;128(11):1234–43.PubMedGoogle Scholar
  56. 56.
    Marlu R, Hodaj E, Paris A, Albaladejo P, Cracowski JL, Pernod G. Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban: a randomised crossover ex vivo study in healthy volunteers. Thromb Haemost. 2012;108(2):217–24. Scholar
  57. 57.
    Maurice-Szamburski A, Graillon T, Bruder N. Favorable outcome after a subdural hematoma treated with feiba in a 77-year-old patient treated by rivaroxaban. J Neurosurg Anesthesiol. 2014;26(2):183. Scholar
  58. 58.
    Lambourne MD, Eltringham-Smith LJ, Gataiance S, Arnold DM, Crowther MA, Sheffield WP. Prothrombin complex concentrates reduce blood loss in murine coagulopathy induced by warfarin, but not in that induced by dabigatran etexilate. J Thromb Haemost : JTH. 2012;10(9):1830–40. Scholar
  59. 59.
    Pragst I, Zeitler SH, Doerr B, Kaspereit FJ, Herzog E, Dickneite G, et al. Reversal of dabigatran anticoagulation by prothrombin complex concentrate (Beriplex P/N) in a rabbit model. J Thromb Haemost : JTH. 2012;10(9):1841–8. Scholar
  60. 60.
    Saloheimo P, Ahonen M, Juvela S, Pyhtinen J, Savolainen ER, Hillbom M. Regular aspirin-use preceding the onset of primary intracerebral hemorrhage is an independent predictor for death. Stroke. 2006;37(1):129–33. Scholar
  61. 61.
    Toyoda K, Okada Y, Minematsu K, Kamouchi M, Fujimoto S, Ibayashi S, et al. Antiplatelet therapy contributes to acute deterioration of intracerebral hemorrhage. Neurology. 2005;65(7):1000–4. Scholar
  62. 62.
    Sansing LH, Messe SR, Cucchiara BL, Cohen SN, Lyden PD, Kasner SE. Prior antiplatelet use does not affect hemorrhage growth or outcome after ICH. Neurology. 2009;72(16):1397–402. Scholar
  63. 63.
    Moussouttas M, Malhotra R, Fernandez L, Maltenfort M, Holowecki M, Delgado J, et al. Role of antiplatelet agents in hematoma expansion during the acute period of intracerebral hemorrhage. Neurocrit Care. 2010;12(1):24–9. Scholar
  64. 64.
    Naidech AM, Liebling SM, Rosenberg NF, Lindholm PF, Bernstein RA, Batjer HH, et al. Early platelet transfusion improves platelet activity and may improve outcomes after intracerebral hemorrhage. Neurocrit Care. 2012;16(1):82–7. Scholar
  65. 65.
    •• Baharoglu MI, Cordonnier C, Salman RA-S, de Gans K, Koopman MM, Brand A, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605–13. Platelet transfusion was demonstrated to lead to worse, not better outcomes in ICH patients. This had been a common clinical practice worldwide up until this study came out, and even afterward the practice has not been completely eliminated. Scholar
  66. 66.
    Frontera JA, Lewin JJ 3rd, Rabinstein AA, Aisiku IP, Alexandrov AW, Cook AM, et al. Guideline for reversal of Antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical care society and Society of Critical Care Medicine. Neurocrit Care. 2016;24(1):6–46. Scholar
  67. 67.
    Li X, Sun Z, Zhao W, Zhang J, Chen J, Li Y, et al. Effect of acetylsalicylic acid usage and platelet transfusion on postoperative hemorrhage and activities of daily living in patients with acute intracerebral hemorrhage. J Neurosurg. 2013;118(1):94–103. Scholar
  68. 68.
    Skaf E, Stein PD, Beemath A, Sanchez J, Bustamante MA, Olson RE. Venous thromboembolism in patients with ischemic and hemorrhagic stroke. Am J Cardiol. 2005;96(12):1731–3. Scholar
  69. 69.
    Kim KS, Brophy GM. Symptomatic venous thromboembolism: incidence and risk factors in patients with spontaneous or traumatic intracranial hemorrhage. Neurocrit Care. 2009;11(1):28–33. Scholar
  70. 70.
    Maramattom BV, Weigand S, Reinalda M, Wijdicks EFM, Manno EM. Pulmonary complications after intracerebral hemorrhage. Neurocrit Care. 2006;5(2):115–9. Scholar
  71. 71.
    Lacut K, Bressollette L, Le Gal G, Etienne E, De Tinteniac A, Renault A, et al. Prevention of venous thrombosis in patients with acute intracerebral hemorrhage. Neurology. 2005;65(6):865–9. Scholar
  72. 72.
    Dennis M, Sandercock P, Reid J, Graham C, Forbes J, Murray G. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet. 2013;382(9891):516–24. Scholar
  73. 73.
    Nyquist P, Bautista C, Jichici D, Burns J, Chhangani S, DeFilippis M, et al. Prophylaxis of venous thrombosis in Neurocritical care patients: an evidence-based guideline: a statement for healthcare professionals from the Neurocritical care society. Neurocrit Care. 2016;24(1):47–60. Scholar
  74. 74.
    Boeer A, Voth E, Henze T, Prange HW. Early heparin therapy in patients with spontaneous intracerebral haemorrhage. J Neurol Neurosurg Psychiatry. 1991;54(5):466–7. Scholar
  75. 75.
    Orken DN, Kenangil G, Ozkurt H, Guner C, Gundogdu L, Basak M, et al. Prevention of deep venous thrombosis and pulmonary embolism in patients with acute intracerebral hemorrhage. Neurologist. 2009;15(6):329–31. Scholar
  76. 76.
    De Herdt V, Dumont F, Henon H, Derambure P, Vonck K, Leys D, et al. Early seizures in intracerebral hemorrhage: incidence, associated factors, and outcome. Neurology. 2011;77(20):1794–800. Scholar
  77. 77.
    Bladin CF, Alexandrov AV, Bellavance A, Bornstein N, Chambers B, Cote R, et al. Seizures after stroke: a prospective multicenter study. Arch Neurol. 2000;57(11):1617–22. Scholar
  78. 78.
    Szaflarski JP, Rackley AY, Kleindorfer DO, Khoury J, Woo D, Miller R, et al. Incidence of seizures in the acute phase of stroke: a population-based study. Epilepsia. 2008;49(6):974–81. Scholar
  79. 79.
    Beghi E, D'Alessandro R, Beretta S, Consoli D, Crespi V, Delaj L, et al. Incidence and predictors of acute symptomatic seizures after stroke. Neurology. 2011;77(20):1785–93. Scholar
  80. 80.
    Biffi A, Rattani A, Anderson CD, Ayres AM, Gurol EM, Greenberg SM, et al. Delayed seizures after intracerebral haemorrhage. Brain. 2016;139(Pt 10):2694–705. Scholar
  81. 81.
    Passero S, Rocchi R, Rossi S, Ulivelli M, Vatti G. Seizures after spontaneous supratentorial intracerebral hemorrhage. Epilepsia. 2002;43(10):1175–80. Scholar
  82. 82.
    • Mullen MT, Kasner SE, Messé SR. Seizures do not increase in-hospital mortality after intracerebral hemorrhage in the Nationwide inpatient sample. Neurocrit Care. 2013;19(1):19–24. It is still not uncommon for many patients with ICH to get prophylactic antiepileptic drugs.This study demonstrated that, counterintuitively for many, the practice is not helpful and possibly harmful. Scholar
  83. 83.
    Zandieh A, Messe SR, Cucchiara B, Mullen MT, Kasner SE. Prophylactic use of antiepileptic drugs in patients with spontaneous intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2016;25(9):2159–66. Scholar
  84. 84.
    Battey TW, Falcone GJ, Ayres AM, Schwab K, Viswanathan A, McNamara KA, et al. Confounding by indication in retrospective studies of intracerebral hemorrhage: antiepileptic treatment and mortality. Neurocrit Care. 2012;17(3):361–6. Scholar
  85. 85.
    Messe SR, Sansing LH, Cucchiara BL, Herman ST, Lyden PD, Kasner SE. Prophylactic antiepileptic drug use is associated with poor outcome following ICH. Neurocrit Care. 2009;11(1):38–44. Scholar
  86. 86.
    Naidech AM, Beaumont J, Jahromi B, Prabhakaran S, Kho A, Holl JL. Evolving use of seizure medications after intracerebral hemorrhage: a multicenter study. Neurology. 2017;88(1):52–6. Scholar
  87. 87.
    Lyden PD, Shuaib A, Lees KR, Davalos A, Davis SM, Diener HC, et al. Safety and tolerability of NXY-059 for acute intracerebral hemorrhage: the CHANT trial. Stroke. 2007;38(8):2262–9. Scholar
  88. 88.
    Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972–6. Scholar
  89. 89.
    Geeganage C, Beavan J, Ellender S, Bath PM. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012;10:Cd000323.PubMedGoogle Scholar
  90. 90.
    Yaghi S, Moore P, Ray B, Keyrouz SG. Predictors of tracheostomy in patients with spontaneous intracerebral hemorrhage. Clin Neurol Neurosurg. 2013;115(6):695–8. Scholar
  91. 91.
    Elmer J, Hou P, Wilcox SR, Chang Y, Schreiber H, Okechukwu I, et al. Acute respiratory distress syndrome after spontaneous intracerebral hemorrhage. Crit Care Med. 2013;41(8):1992–2001. Scholar
  92. 92.
    Alsumrain M, Melillo N, DeBari VA, Kirmani J, Moussavi M, Doraiswamy V, et al. Predictors and outcomes of pneumonia in patients with spontaneous intracerebral hemorrhage. J Intensive Care Med. 2012;28(2):118–23. Scholar
  93. 93.
    Anderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, et al. Cluster-randomized, crossover trial of head positioning in acute stroke. N Engl J Med. 2017;376(25):2437–47. Scholar
  94. 94.
    Kimura K, Iguchi Y, Inoue T, Shibazaki K, Matsumoto N, Kobayashi K, et al. Hyperglycemia independently increases the risk of early death in acute spontaneous intracerebral hemorrhage. J Neurol Sci. 2007;255(1–2):90–4. Scholar
  95. 95.
    Meier R, Bechir M, Ludwig S, Sommerfeld J, Keel M, Steiger P, et al. Differential temporal profile of lowered blood glucose levels (3.5 to 6.5 mmol/l versus 5 to 8 mmol/l) in patients with severe traumatic brain injury. Crit Care (London, England). 2008;12(4):R98. Scholar
  96. 96.
    Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354(5):449–61. Scholar
  97. 97.
    Godoy DA, Di Napoli M, Rabinstein AA. Treating hyperglycemia in Neurocritical patients: benefits and perils. Neurocrit Care. 2010;13(3):425–38. Scholar
  98. 98.
    Rincon F, Lyden P, Mayer SA. Relationship between temperature, hematoma growth, and functional outcome after intracerebral hemorrhage. Neurocrit Care. 2013;18(1):45–53. Scholar
  99. 99.
    Broessner G, Beer R, Lackner P, Helbok R, Fischer M, Pfausler B, et al. Prophylactic, Endovascularly based, long-term Normothermia in ICU patients with severe cerebrovascular disease. Bicenter Prospective, Randomized Trial. 2009;40(12):e657–e65.Google Scholar
  100. 100.
    Marehbian J, Greer DM. Normothermia and stroke. Curr Treat Options Neurol. 2017;19(1):4. Scholar
  101. 101.
    Lord AS, Karinja S, Lantigua H, Carpenter A, Schmidt JM, Claassen J, et al. Therapeutic temperature modulation for fever after intracerebral hemorrhage. Neurocrit Care. 2014;21(2):200–6. Scholar
  102. 102.
    •• 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(3):635–40. The entire edifice of neurocritical care and stroke neurology rests on the idea that neurologic patients have better outcomes when cared for in dedicated units by specially trained practitioners. This paper helps add to the growing body of evidence that in spite of ongoing challenges in the management of ICH, expert care can improve outcomes. Scholar
  103. 103.
    Compagnone C, Murray GD, Teasdale GM, Maas AIR, Esposito D, Princi P, et al. The Management of Patients with Intradural post-traumatic mass lesions: a multicenter survey of current approaches to surgical management in 729 patients coordinated by the European brain injury consortium. Neurosurgery. 2005;57(6):1183–92. Scholar
  104. 104.
    Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Medical progress: spontaneous intracerebral hemorrhage. N Engl J Med. 2001;344(19):1450–60. Scholar
  105. 105.
    Aronowski J, Zhao X. Molecular pathophysiology of cerebral hemorrhage. Second Brain Inj. 2011;42(6):1781–6.Google Scholar
  106. 106.
    Bratton SL, Chestnut RM, Ghajar J, FF MCH, Harris OA, Hartl R, et al. VI. Indications for intracranial pressure monitoring. J Neurotrauma. 2007;24(supplement 1):S-37–44.Google Scholar
  107. 107.
    Fried HI, Nathan BR, Rowe AS, Zabramski JM, Andaluz N, Bhimraj A, et al. The insertion and Management of External Ventricular Drains: an evidence-based consensus statement. Neurocrit Care. 2016;24(1):61–81. Scholar
  108. 108.
    Kamel H, Hemphill JC. Characteristics and sequelae of intracranial hypertension after intracerebral hemorrhage. Neurocrit Care. 2012;17(2):172–6. Scholar
  109. 109.
    Ziai WC, Melnychuk E, Thompson CB, Awad I, Lane K, Hanley DF. Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage. Crit Care Med. 2012;40(5):1601–8. Scholar
  110. 110.
    Bhattathiri PS, Gregson B, Prasad KSM, Mendelow AD. Intraventricular hemorrhage and hydrocephalus after spontaneous intracerebral hemorrhage: results from the STICH trial. In: Hoff JT, Keep RF, Xi G, Hua Y, editors. Brain Edema XIII. Vienna: Springer Vienna; 2006. p. 65–8. Scholar
  111. 111.
    Hallevi H, Albright KC, Aronowski J, Barreto AD, Martin-Schild S, Khaja AM, et al. Intraventricular hemorrhage: anatomic relationships and clinical implications. Neurology. 2008;70(11):848–52. Scholar
  112. 112.
    Gaberel T, Magheru C, Emery E. Management of non-traumatic intraventricular hemorrhage. Neurosurg Rev. 2012;35(4):485–95. Scholar
  113. 113.
    Huttner HB, Köhrmann M, Berger C, Georgiadis D, Schwab S. Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case–control study. J Neurosurg. 2006;105(3):412–7. Scholar
  114. 114.•
    Hanley DF, Lane K, McBee N, Ziai W, Tuhrim S, Lees KR, et al. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet. 389(10069):603–11. The first large randomized controlled trial to establish a protocol for thrombolytic treatment of IVH which improved mortality, but failed to meet the primary endpoint of improved functional outcome.Google Scholar
  115. 115.
    Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database Syst Rev. 2008;(4):Cd000200.Google Scholar
  116. 116.
    •• Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, 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(9457):387–97. A landmark trial that failed to show improved outcomes in all ICH patients with early surgery, but identified a subgroup of patients who might benefit from early surgery. Scholar
  117. 117.
    Steiner T, Kaste M, Forsting M, Mendelow D, Kwiecinski H, Szikora I, et al. Recommendations for the management of intracranial haemorrhage - part I: spontaneous intracerebral haemorrhage. Cerebrovasc Dis. 2006;22(4):294–316. Scholar
  118. 118.
    Gregson BA, Broderick JP, Auer LM, Batjer H, Chen X-C, Juvela S, et al. Individual patient data subgroup meta-analysis of surgery for spontaneous Supratentorial intracerebral hemorrhage. Stroke. 2012;43(6):1496–504. Scholar
  119. 119.
    Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382(9890):397–408. Scholar
  120. 120.
    Wang J-W, Li J-P, Song Y-L, Tan K, Wang Y, Li T, et al. Stereotactic aspiration versus craniotomy for primary intracerebral hemorrhage: a meta-analysis of randomized controlled trials. PLoS One. 2014;9(9):e107614. Scholar
  121. 121.
    Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, et al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases Perihematomal edema. Stroke. 2013;44(3):627–34. Scholar
  122. 122.
    Luney MS, English SW, Longworth A, Simpson J, Gudibande S, Matta B, et al. Acute posterior cranial fossa hemorrhage—is surgical decompression better than expectant medical management? Neurocrit Care. 2016;25(3):365–70. Scholar
  123. 123.
    van Loon J, Van Calenbergh F, Goffin J, Plets C. Controversies in the management of spontaneous cerebellar haemorrhage. A consecutive series of 49 cases and review of the literature. Acta Neurochir. 1993;122(3–4):187–93. Scholar
  124. 124.
    Spiotta AM, Fiorella D, Vargas J, Khalessi A, Hoit D, Arthur A, et al. Initial multicenter technical experience with the Apollo device for minimally invasive intracerebral hematoma evacuation. Neurosurgery. 2015;11(Suppl 2):243–51. Scholar
  125. 125.
    • Bauer AM, Rasmussen PA, Bain MD. Initial single-center technical experience with the BrainPath system for acute intracerebral hemorrhage evacuation. Operative Neurosurgery. 2017;13(1):69–76. Blind evacuation of clot has limitations that direct visualization overcomes. If technology like this proves capable of reducing clot burden with decreased damage to brain this will be an interesting area of research in the coming years. Scholar
  126. 126.
    Labib MA, Shah M, Kassam AB, Young R, Zucker L, Maioriello A, et al. The safety and feasibility of image-guided BrainPath-mediated Transsulcul hematoma evacuation: a multicenter study. Neurosurgery. 2017;80(4):515–24. Scholar
  127. 127.
    Schepers VP, Ketelaar M, Visser-Meily AJ, de Groot V, Twisk JW, Lindeman E. Functional recovery differs between ischaemic and haemorrhagic stroke patients. J Rehabil Med. 2008;40(6):487–9. Scholar
  128. 128.
    Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2007(4):Cd000197.Google Scholar
  129. 129.
    Bai Y, Hu Y, Wu Y, Zhu Y, He Q, Jiang C, et al. A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of patients with hemorrhagic stroke. J Clin Neurosci : Off J Neurosurg Soc Australasia. 2012;19(10):1376–9. Scholar
  130. 130.
    Cumming TB, Thrift AG, Collier JM, Churilov L, Dewey HM, Donnan GA, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011;42(1):153–8. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Thomas J. Cusack
    • 1
  • J. Ricardo Carhuapoma
    • 1
  • Wendy C. Ziai
    • 1
    Email author
  1. 1.Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology/Critical Care MedicineThe Johns Hopkins HospitalBaltimoreUSA

Personalised recommendations