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Acute Treatment of Hypertensive Intracerebral Hemorrhage

  • Cerebrovascular Disorders
  • Published:
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Opinion statement

Hypertensive intracerebral hemorrhage remains an entity in search of definitive treatment. It requires management in a specialized unit, where hypertension, hyperglycemia, seizures, and elevated intracranial pressure can be expertly managed. However, the exact target range of hypertensive therapy is uncertain. Extraventricular drainage and surgery for cerebellar hemorrhage can both be life-saving. The role of craniotomy for hematoma resection remains unclear. Surgery for deep or pontine hemorrhages has questionable value. The reduction of clot expansion acutely may lead to improved outcomes. One option to this end, the tight control of hypertension acutely, may be difficult to prove effective. Another, the use of factor VIIa, eluded validation in one trial. Efforts are under way to reduce intraventricular hemorrhage, and with it, hydrocephalus. The role of clot evacuation in the subset of individuals with lobar hemorrhage is also being studied. In all likelihood, the key to acute treatment of this condition will be early intervention, with implementation of blood pressure control, administration of clotting factors in the emergency department, or both. This treatment will be followed by transfer to a specialized unit, with appropriate interventions in selected patients. However, morbidity and mortality will remain high, pointing out the importance of prevention through management of hypertension.

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References and Recommended Reading

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

  1. Dennis MS, Burn JP, Sandercock PA, et al.: Long-term survival after first-ever stroke. The Oxfordshire Community Stroke Project. Stroke 1993, 24(6):796–800.

    CAS  PubMed  Google Scholar 

  2. Brott T, Thalinger K, Hertzberg V: Hypertension as a risk factor for spontaneous intracerebral hemorrhage. Stroke 1986, 17(6):1078–1083.

    CAS  PubMed  Google Scholar 

  3. Thrift AG, McNeil JJ, Forbes A, Donnan GA: Three important subgroups of hypertensive persons at greater risk of intracerebral hemorrhage. Hypertension 1998, 31(6):1223–1229.

    CAS  PubMed  Google Scholar 

  4. Rincon F, Mayer SA: Current treatment options for intracerebral hemorrhage. Curr Treat Opt Cardiovasc Med 2008, 10:229–240.

    Article  Google Scholar 

  5. 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):635–640.

    Article  CAS  PubMed  Google Scholar 

  6. Andaluz N, Zuccarello M: Recent trends in the treatment of spontaneous intracerebral hemorrhage: analysis of a nationwide inpatient database. J Neurosurg 2009, 110(3):411–417.

    Article  Google Scholar 

  7. Hemphill 3rd JC, Bonovich DC, Besmertis L, et al.: The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001, 32(4):891–897.

    PubMed  Google Scholar 

  8. Brott T, Broderick J, Kothari R, et al.: Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997, 28(1):1–5.

    CAS  PubMed  Google Scholar 

  9. Davis SM, Broderick J, Hennerici M, et al.: Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology 2006, 66(8):1175–1181.

    Article  CAS  PubMed  Google Scholar 

  10. Ohwaki K, Yono E, Nagashima H, et al.: Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement. Stroke 2004, 35(8):1364–1367.

    Article  PubMed  Google Scholar 

  11. Terayama Y, Tanahashi N, Fikuuchi Y, Gotoh F: Prognostic value of admission blood pressure in patients with intracerebral hemorrhage. Stroke 1997, 28(6):1185–1188.

    CAS  PubMed  Google Scholar 

  12. Vemmos KN, Tsivgoulis G, Spengos K, et al.: Association between 24-hr. blood pressure monitoring variable and brain oedema in patients with hyperacute stroke. J Hypertens 2003, 21(11):2167–2173.

    Article  CAS  PubMed  Google Scholar 

  13. 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(6):2001–2023. This is a thorough reference on the management of spontaneous intracerebral hemorrhage.

    Article  PubMed  Google Scholar 

  14. Anderson CS, Huang Y, Arima H, et al.: Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke 2010, 41(2):307–312. This study compares standard versus intensive blood pressure management in acute ICH.

    Article  PubMed  Google Scholar 

  15. INTERACT 2 (The Second Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial). http://www.strokecenter.org/trials/TrialDetail.aspx?tid=751. Accessed August 15, 2010.

  16. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Investigators: Antihypertensive treatment of acute cerebral hemorrhage. Crit Care Med 2010, 38(2):637–648. This is a dose-finding study of nicardipine in acute ICH.

    Article  Google Scholar 

  17. Qureshi AI, Wilson DA, Hanley DF, Traystman RJ: Pharmacologic reduction of mean arterial pressure does not adversely affect regional cerebral blood flow and intracranial pressure in experimental intracerebral hemorrhage. Crit Care Med 1999, 27(5):965–971.

    Article  CAS  PubMed  Google Scholar 

  18. Powers WJ, Zazulia AR, Videen TO, et al.: Autoregulation of cerebral blood flow surrounding acute (6 to 22 hours) intracerebral hemorrhage. Neurology 2001, 57(1):18–24.

    CAS  PubMed  Google Scholar 

  19. Mayer SA, Rincon F: Treatment of intracerebral haemorrhage. Lancet Neurol 2005, 4(10):662–672.

    Article  PubMed  Google Scholar 

  20. Reddy P, Yeh YC: Use of injectable nicardipine for neurovascular indications. Pharmacotherapy 2009, 29(4):398–409.

    Article  CAS  PubMed  Google Scholar 

  21. Qureshi AI, Harris-Lane P, Kirmani JF, et al.: Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines. Crit Care Med 2006, 34(7):1975–1980.

    Article  PubMed  Google Scholar 

  22. Morgenstern LB, Demchuk AM, Kim DH, et al.: Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology 2001, 56(10):1294–1299.

    CAS  PubMed  Google Scholar 

  23. Morgenstern LB, Frankowski RF, Shedder P, et al.: Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized controlled trial. Neurology 1998, 51(5):1359–1363.

    CAS  PubMed  Google Scholar 

  24. Tan SH, Ng PY, Yeo TT, et al.: Hypertensive basal ganglia hemorrhage: a prospective study comparing surgical and nonsurgical treatment. Surg Neurol 2001, 56(5):287–292.

    Article  CAS  PubMed  Google Scholar 

  25. Juvela S, Heiskanen O, Poranen A, et al.: The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment. Neurosurgery 1989, 70(5):755–758.

    Article  CAS  Google Scholar 

  26. Naff NJ, Hanley DF, Keyl PM, et al.: Intraventricular thrombolysis speeds blood clot resolution. Results of a pilot, prospective, randomized, double-blind, controlled trial. Neurosurgery 2004, 54(3):577–583.

    Article  PubMed  Google Scholar 

  27. Batjer HH, Reisch JS, Allen BC, et al.: Failure of surgery to improve outcome in hypertensive putaminal hemorrhage: a prospective randomized trial. Arch Neurol 1990, 47(10):1103–1106.

    CAS  PubMed  Google Scholar 

  28. Kaufman HH: Treatment of deep spontaneous intracerebral hemorrhages: a review. Stroke 1993, 24(suppl):I-101–I-106.

    CAS  Google Scholar 

  29. Kaneko M, Tanaka K, Shiamada T, et al.: Long-term evaluation of ultra-early operation for hypertensive hemorrhage in 100 cases. J Neurosurg 1983, 58(6):838–842.

    Article  CAS  PubMed  Google Scholar 

  30. Teernstra OP, Evers SM, Lodder J, et al.: Stereotactic treatment of intracerebral hemorrhage by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke 2003, 34(4):968–974.

    Article  CAS  PubMed  Google Scholar 

  31. 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(9457):387–397.

    PubMed  Google Scholar 

  32. 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.

    Article  CAS  PubMed  Google Scholar 

  33. Mendelow AD, Gregson B, Mitchell P, et al.: Surgical Trial in Lobar Intracerebral Haemorrhage Protocol STICH II Version 1.3, 10 August 2006. Available at http://research.ncl.ac.uk/stich/. Accessed August 3, 2010.

  34. Liliang P-C, Liang C-L, Lu C-H, et al.: Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage. Stroke 2001, 32(5):1195–1200.

    CAS  PubMed  Google Scholar 

  35. Adams RE, Diringer MN: Response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus. Neurology 1998, 50(2):519–523.

    CAS  PubMed  Google Scholar 

  36. Morgan T, Awad I, Keyl P, et al.: Preliminary report of the clot lysis evaluating accelerated resolution of intraventricular hemorrhage (CLEAR-IVH) clinical trial. Acta Neurochir Suppl 2008, 105:217–220.

    Article  CAS  PubMed  Google Scholar 

  37. CLEAR III Intraventricular Thrombolysis Trial. Available at http://biosgroup--johnshopkinsmedicine.health.officelive.com/default.aspx. Accessed August 3, 2010.

  38. Steiner T, Diringer MN, Schneider D, et al.: Dynamics of intraventricular hemorrhage in patients with spontaneous intracerebral hemorrhage: risk factors, clinical impact, and effect of hemostatic therapy with recombinant activated factor VII. Neurosurgery 2006, 59(4):767–773.

    Article  PubMed  Google Scholar 

  39. Murthy JM, Chowdary GV, Murthy TV, et al.: Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. Neurocrit Care 2005, 2(3):258–262.

    Article  CAS  PubMed  Google Scholar 

  40. Zuccarello M, Brott J, Derex L, et al.: Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke 1999, 30(9):1833–1839.

    CAS  PubMed  Google Scholar 

  41. Auer LM, Deinsberger W, Niederkorn K, et al.: Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989, 70(4):530–535.

    Article  CAS  PubMed  Google Scholar 

  42. Fisher CM, Picard EH, Polak A, et al.: Acute hypertensive cerebellar hemorrhage: diagnosis and surgical treatment. J Nerv Ment Dis 1965, 140(1):38–57.

    Article  CAS  PubMed  Google Scholar 

  43. Kobayashi S, Sato A, Kageyama Y, et al.: Treatment of hypertensive cerebellar hemorrhage—surgery or conservative management? Neurosurgery 1994, 34(2):246–251.

    Article  CAS  PubMed  Google Scholar 

  44. Rabinstein AA, Atkinson JL, Wijdicks EF: Emergency craniotomy in patients worsening due to expanded cerebral hematoma. Neurology 2002, 58(9):1367–1372.

    PubMed  Google Scholar 

  45. Mayer SA, Brun NC, Begtrup K, et al.: Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2005, 352(8):777–785.

    Article  CAS  PubMed  Google Scholar 

  46. 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, 358(20):2127–2137. So far, this is the best study of rFVIIa in ICH.

    Article  CAS  PubMed  Google Scholar 

  47. Becker KJ, Baxter AB, Bybee HM, et al.: Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage. Stroke 1999, 30(10):2025–2032.

    CAS  PubMed  Google Scholar 

  48. Goldstein JN, Fazen LE, Snider R, et al.: Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology 2007, 68(12):889–894. This is one of two recent studies on the “spot sign.”

    Article  CAS  PubMed  Google Scholar 

  49. Wada R, Aviv RI, Fox AJ, et al.: CT angiography “spot sign” predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 2007, 38(4):1257–1262. This is one of two recent studies on the “spot sign.”

    Article  PubMed  Google Scholar 

  50. 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(3):349–353.

    Article  CAS  PubMed  Google Scholar 

  51. Passero S, Ciacci G, Ulivelli M: The influence of diabetes and hyperglycemia on clinical course after intracerebral hemorrhage. Neurology 2003, 61(10):1351–1356.

    PubMed  Google Scholar 

  52. Godoy DA, Pinero GR, Svampa S, et al.: Hyperglycemia and short-term outcome in patients with spontaneous intracerebral hemorrhage. Neurocrit Care 2008, 9(2):217–229.

    Article  CAS  PubMed  Google Scholar 

  53. Stead LG, Jain A, Bellolio MF, et al.: Emergency department hyperglycemia as a predictor of early mortality and worse functional outcome after intracerebral hemorrhage. Neurocrit Care 2010, 13(1):67–74.

    Article  CAS  PubMed  Google Scholar 

  54. Lee S-H, Kim BJ, Bae H-J, et al.: Effects of glucose level on early and long-term mortality after intracerebral hemorrhage: the Acute Brain Bleeding Analysis Study. Diabetologia 2010, 53(3):429–434. This is the largest study of the effect of hyperglycemia on ICH outcome.

    Article  CAS  PubMed  Google Scholar 

  55. Tetri S, Juvela S, Saloheimo P, et al.: Hypertension and diabetes as predictors of early death after spontaneous intracerebral hemorrhage. J Neurosurg 2009, 110(3):411–417. This study analyzes the effect on acute ICH mortality of two prevalent risk factors.

    Article  PubMed  Google Scholar 

  56. 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(8):1348–1353.

    PubMed  Google Scholar 

  57. Passero S, Rocchi R, Rossi S, et al.: Seizures after spontaneous supratentorial intracerebral hemorrhage. Epilepsia 2002, 43(10):1175–1180.

    Article  PubMed  Google Scholar 

  58. 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(9):1441–1446.

    CAS  PubMed  Google Scholar 

  59. Claassen J, Jette N, Chum F, et al.: Electrographic seizures and periodic discharges after intracerebral hemorrhage. Neurology 2007, 69(13):1356–1365.

    Article  CAS  PubMed  Google Scholar 

  60. Naidech AM, Garg RK, Liebling S, et al.: Anticonvulsant use and outcomes after intracerebral hemorrhage. Stroke 2009, 40(12):3810–3815. This is a useful analysis of anticonvulsant use in ICH.

    Article  CAS  PubMed  Google Scholar 

  61. Messe S, Sansing LH, Cucchiara BL, et al.: Prophylactic antiepileptic drug use is associated with poor outcome following ICH. Neurocrit Care 2009, 11(1):38–44. This paper complements reference [60•].

    Article  CAS  PubMed  Google Scholar 

  62. Schwarz S, Hafner K, Aschoff A, Schwab S: Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology 2000, 54(2):354–361.

    CAS  PubMed  Google Scholar 

  63. Linares G, Mayer SA: Hypothermia for the treatment of ischemic and hemorrhagic stroke. Crit Care Med 2009, 37(7 Suppl):S243–S249.

    Article  PubMed  Google Scholar 

  64. Mayer SA, Chong JY: Critical care management of increased intracranial pressure. J Intensive Care Med 2002, 17(3):55–67.

    Google Scholar 

  65. Qureshi AI, Suarez JI, Bhardwaj A, et al.: Use of hypertonic (3%) saline/acetate infusion in the treatment of cerebral edema: effect on intracranial pressure and lateral displacement of the brain. Crit Care Med 1998, 26(3):440–446.

    Article  CAS  PubMed  Google Scholar 

  66. Misra UK, Kalita J, Ranjan P, Mandal SK: Mannitol in intracerebral hemorrhage: a randomized controlled study. J Neurol Sci 2005, 234(1):41–45.

    Article  CAS  PubMed  Google Scholar 

  67. Koenig MA, Bryan M, Lewin JL, et al.: Reversal of transtentorial herniation with hypertonic saline. Neurology 2008, 70(13):1023–1029. This study analyses the role of 3% saline infusion in ICH.

    Article  CAS  PubMed  Google Scholar 

  68. Dutch Intraventricular Thrombolysis after Cerebral Hemorrhage study (DITCH). http://www.strokecenter.org/trials/TrialDetail.aspx?tid=581. Accessed August 4, 2010.

  69. MISTIE Clinical Trial–Intracerebral Brain Hemorrhage. http://mistietrial.com. Accessed August 4, 2010.

  70. PATCH (Platelet Transfusion in Cerebral Hemorrhage). http://www.strokecenter.org/trials/TrialDetail.aspx?tid=730. Accessed August 4, 2010.

  71. The Spot Sign for Predicting and Treating ICH Growth Study (STOP-IT). Available at ClinicalTrials.gov (http://clinicaltrials.gov/ct2/show/NCT00810888). Accessed August 4, 2010.

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  1. Division of Neurology, Cooper University Hospital-UMDNJ, 3 Cooper Plaza, Suite 320, Camden, NJ, 08103, USA

    Thomas Mirsen MD

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Mirsen, T. Acute Treatment of Hypertensive Intracerebral Hemorrhage. Curr Treat Options Neurol 12, 504–517 (2010). https://doi.org/10.1007/s11940-010-0096-3

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