An update on neurocritical care for intracerebral hemorrhage

ABSTRACT

Introduction: Intracerebral hemorrhage remains one of the leading causes of death and disability worldwide with few established interventions that improve neurologic outcome. Research dedicated to better understanding and treating hemorrhagic strokes has multiplied in the past decade.

Areas Covered: This review aims to discuss the current landscape of management of intracerebral hemorrhage in a critical care setting and provide updates regarding developments in therapeutic interventions and targets. PubMed was utilized to review recent literature, with a focus on large trials and meta-analyses, which have shaped current practice. Published committee guidelines were also included. A focus was placed on research published after 2015 in an effort to supplement previous reviews included in this publication.

Expert Opinion: Literature pertaining to ICH management has allowed for a greater understanding of ineffective strategies as opposed to those of benefit. Despite this, mortality has improved worldwide, which may be the result of growing research efforts. Areas of future research that will impact mortality and improve neurologic outcomes include prevention of hematoma expansion, optimization of blood pressure targets, effective coagulopathy reversal, and minimally invasive surgical techniques to reduce hematoma burden.

KEYWORDS:

• Anticoagulation
• cerebral edema
• hematoma
• hemorrhagic stroke
• intracranial pressure
• intracerebral hemorrhage

Article Highlights

• Intracerebral hemorrhage remains a significant global health issue with high rates of morbidity and mortality yet limited interventions shown to improve outcome. Chronic hypertension, cerebral amyloid angiopathy, and anticoagulant use are major risk factors.

• Initial evaluation of patients suspected to have intracerebral hemorrhage should include assessment of airway and hemodynamic stabilization. A non-contrasted head CT provides critical diagnostic information quickly and is cost effective. Vascular imaging, typically CT or MR angiogram, may reveal underlying vascular lesions which change early management.

• Early neurologic deterioration is common due to hematoma expansion and is associated with worse outcomes. Evidence of contrast extravasation on CT angiogram, termed the “spot sign,” is a predictor of hematoma growth. There are no approved hemostatic agents recommended to prevent or reduce hematoma expansion at present.

• Current guidelines from the American Heart Association/American Stroke Association (AHA/ASA) state that a target systolic blood pressure (SBP) of 140 mmHg for those who present with a SBP of 150–220 mmHg is safe. While recent studies including INTERACT-II and ATACH-II have evaluated blood pressure control in ICH, optimum targets still remain uncertain.

• Hemorrhage related to anticoagulation is associated with higher mortality. Immediate reversal of systemic medication effects is essential to restore hemostasis and limit hematoma expansion. Platelet transfusion was shown to increase risk of death or disability in the PATCH trial (2016), and the routine use of platelet transfusion for patients on antiplatelet agents is unwarranted.

• Managing complications of cerebral edema, detection, and treatment of seizures, achieving glycemic control, and avoidance of fever are critical to preventing secondary neuronal injury.

• STICH-I and STICH-II investigated surgical evacuation of supratentorial hematomas but did not find improvement in mortality or functional outcome. Cerebellar hematomas > 3cm in size with obstructive hydrocephalus or brainstem compression resulting in neurologic decline should be evacuated.

• Intraventricular thrombolysis with alteplase, investigated in both CLEAR-IVH and CLEAR-III, accelerated clot resolution in intraventricular hemorrhage but did not show improvement in functional neurologic outcomes.

• MISTIE III (2019) evaluated whether minimally invasive surgery for clot removal followed by thrombolytic irrigation would improve functional outcomes. Significant reduction in hematoma size was seen in the treatment group but functional outcomes were not significantly improved.

• While predictive of patient outcome, the ICH score is not intended to be used solely for the purpose of prognostication that may limit intervention or care. The perception of a poor neurologic outcome can be overestimated and result in limitation of care to patients who may otherwise have reasonable outcomes.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

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

Additional information

Funding

This paper was not funded.