Intracerebral hemorrhage: an update on diagnosis and treatment

ABSTRACT

Introduction: Spontaneous non-traumatic intracerebral hemorrhage (ICH) is most often caused by small vessel diseases: deep perforator arteriopathy (hypertensive arteriopathy) or cerebral amyloid angiopathy (CAA). Although ICH accounts for only 10–15% of all strokes it causes a high proportion of stroke mortality and morbidity, with few proven effective acute or preventive treatments.

Areas covered: We conducted a literature search on etiology, diagnosis, treatment, management and current clinical trials in ICH. In this review, We describe the causes, diagnosis (including new brain imaging biomarkers), classification, pathophysiological understanding, treatment (medical and surgical), and secondary prevention of ICH.

Expert opinion: In recent years, significant advances have been made in deciphering causes, understanding pathophysiology, and improving acute treatment and prevention of ICH. However, the clinical outcome remains poor and many challenges remain. Acute interventions delivered rapidly (including medical therapies – targeting hematoma expansion, hemoglobin toxicity, inflammation, edema, anticoagulant reversal – and minimally invasive surgery) are likely to improve acute outcomes. Improved classification of the underlying arteriopathies (from neuroimaging and genetic studies) and prognosis should allow tailored prevention strategies (including sustained blood pressure control and optimized antithrombotic therapy) to further improve longer-term outcome in this devastating disease.

KEYWORDS:

• Non-traumatic intracerebral hemorrhage
• stroke
• diagnosis
• treatment
• current managment
• update

Article highlights

• In acute ICH ‘time is brain’: prompt treatment to target hematoma and other acute modifiable factors (e.g. perihematomal edema, inflammation) might improve the outcome

• All treatable factors (i.e. elevated blood pressure, anticoagulation reversal) should be addressed immediately and simultaneously

• Better phenotyping of ICH according to the underlying arteriopathy will help in better understanding, potentially reducing recurrence and improving understanding of acute treatment targets

• Potentially promising targets for reducing the toxic effects of hemoglobin, such as chelating agents (e.g. desferoxamine mesylate), hemoglobin scavenging agents (e.g. haptoglobin), and anti-inflammatory agents (e.g. blocking interleukin-1 receptors) are currently being evaluated

• The role of surgery remains unclear; minimally invasive surgery might play an increasingly important role

• The role of oral anticoagulation and antiplatelets agents after the acute ICH event in patients at risk of occlusive vascular events is a current topic of investigation in randomised controlled trials

Declaration of interest

DJ Werring has received speaking honoraria from Bayer in 2016, 2017 and 2018 for talks and debates on anticoagulants, intracerebral hemorrhage, atrial fibrillation or dementia. He has also received chairing honoraria from Portola (2019) and consultancy fees from Bayer (2017) and Alnylam (2019). He has also acted as UCLH principle investigator for NIHR clinical trials: NAVIGATE-ESUS (Bayer, 2016-), B2341002 (Pfizer 2014-2016), Action 2 (2016-Biogen). IC Hostettler has received funding from the Alzheimer Research UK and Dunhill Medical Trust Foundation unrelated to this review. DJ Seiffge is on scientific advisory boards for Bayer and Pfizer. He also receives for educational efforts from Stago. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.