intracerebral hemorrhage medical treatment

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Abstract Intracerebral hemorrhage (ICH) accounts for

between 10% to 30% of first-ever strokes; outcomes are

significantly worse than with ischemic stroke with a

30-day mortality rate up to 50%, furthermore, half of the

deaths occur in the acute phase. Intracerebral hemorrhage

(ICH) is classified as primary or secondary according to

the underlying etiology. Primary ICH (about 80%) comes

from the spontaneous rupture of small vessels more often

in relation to long-standing or uncontrolled arterial hyper-

tension and is generally located in the basal ganglia and

internal capsula. Secondary ICH (about 20%) is often

associated with vascular abnormalities, tumors, and anti-coagulant therapy or coagulation disorders, more fre-

quently located in cerebral lobes or subtentorial (cerebel-

lum or pons). Rapid recognition and diagnosis of ICH as

well as identification of early prognostic indicators are

essential for planning the level of care and avoiding acute

rapid progression during the first hours. Hematoma size

has been identified as one of the most important predic-

tors of 30-day mortality and its expansion is highly pre-

dictive of neurological deterioration [1]. Blood pressure

management remains, although controversial, the first-

line medical approach along with possible new and effec-

tive treatments coming from the numerous between pilot

and larger randomized medical trials for ICH completed

in the past decade.

Keywords Intracerebral hemorrhage Medical management

Medical treatment of acute ICH

General treatment of ICH includes an overall supportive

medical approach through the management of airways

and ventilatory measures, circulation stabilization, fever

and glucose level control, nutrition as well as prophylax-

is for seizure and deep vein thrombosis [2].

A standardized medical approach begins with simple

measures, such as head positioning [head elevation to 30

improves jugular venous outflow and lowers intracranial

pressure (ICP)] and appropriate sedation to more aggres-

sive clinical strategies as indicated.

Increase of ICP and consequent possible mass effect

result in neurological deterioration.Specific treatments for increased ICP secondary to

head trauma may not necessarily apply to ICH patients;

cerebral perfusion pressure (CPP) should be kept as much

as possible >70 mmHg where ICP is monitored.

Hyperventilation is one of the most effective method

available for rapid reduction of ICP through the physio-

logical mechanism of cerebral blood flow (CBF) regula-

tion. However its use is limited due to its transient effect

and its simultaneous lowering of PCO2 level and CBF.

Osmotic therapy, despite little evidence of its efficacy,

is commonly used in patients with large ICH and

increased ICP; the agent most often used is mannitol,

Neurol Sci (2008) 29:S271S273

DOI 10.1007/s10072-008-0961-y

A N N U A L M E E T I N G O F S I N / S N O L O M B A R D I A

Intracerebral hemorrhage: medical treatment

Paola Santalucia

Springer-Verlag 2008

Paola Santalucia ()

Istituto Auxologico Italiano, IRCCS

U.O. Cardiologia

Ospedale San Luca

Via Spagnoletto 3, 20149 Milano, Italy

e-mail: [email protected]


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S272 Neurol Sci (2008) 29:S271S273

which acts as an intravascular osmotic agent thus

decreasing ICP through cerebral autoregulation; its use

should however be limited to a few days mostly due to

electrolyte imbalance and renal function alteration.

Invasive monitoring of ICP with intraventricular

catheter positioning, in selected critical cases, allowsCSF drainage that in turn is effective for lowering ICP

especially in case of hydrocephalus.

Acute blood pressure management and treatment

remain controversial and the association of a hyperten-

sive status to hematoma enlargement is unclear.

Persistent marked elevation of blood pressure can predis-

pose to hematoma expansion; however, it may also repre-

sent a protective response to preserve cerebral perfusion

mainly in the areas of focal ischemia around the

hematoma where reduction of blood pressure could pro-

mote further ischemia.

It is, therefore, difficult to indicate what is the limit

for aggressive blood pressure treatment. An acceptable

target blood pressure value should be tailored on the indi-

vidual patients factors such as history of hypertension

and baseline blood pressure, age, and the presumed cause

of bleeding, as well as correlated with intracranial pres-

sure. The main goal for lowering blood pressure is avoid-

ing hematoma enlargement; this is especially true for

bleeding resulting from a ruptured aneurysm or arteri-

ovenous malformation. However, in primary ICH, in

which a specific large vessel rupture is not evident, the

risk of hematoma enlargement that is blood pressure

related may be lower and must be balanced with the the-

oretical risks of inducing cerebral ischemia in the areasurrounding the hematoma.

Despite the weak evidence to support a specific blood

pressure threshold, the recommendation from the

AHA/ASA Guidelines is to maintain a systolic blood

pressure


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ge. Stroke 36:7479

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S273Neurol Sci (2008) 29:S271S273

intracerebral hemorrhage medical treatment

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