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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

Abstract

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.

Summary

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.

Keywords

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

Notes

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

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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

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