Abstract and Introduction
Abstract
Intracerebral hemorrhage (ICH) remains a common and deadly form of stroke, with virtually no greatly effective treatments aside from supportive and stroke unit care. Several surgical and medical therapies have been studied, but nothing has yet been found that greatly changes the pathophysiology. To achieve this, there will need to be substantial changes in treatment strategies. This article will focus on refinements to existing strategies and consider new approaches to the management of ICH. It will draw parallels with ischemic stroke treatments, and define the idea of 'interventional therapy' for ICH. It is suggested that reducing hematoma expansion could be compared with salvage of the ischemic penumbra, as a potential target for interventional ICH treatments. The concept of different time windows for the application of therapies according to the pathophysiology will be discussed. Finally, some novel treatment strategies are proposed, including an endovascular approach and 'external, stereotactic cautery', as future possibilities.
Introduction
Intracerebral hemorrhage (ICH) remains a common and deadly form of stroke, with virtually no greatly effective treatments aside from supportive and stroke unit care. The current management of ICH is reminiscent of ischemic stroke in the early 1990s, before the advent of stroke units and the proven benefits of aspirin and also intravenous thrombolysis. This provides an exciting challenge that will require innovative thinking in order to make substantial changes to treatment strategies, if any meaningful improvement in clinical outcome is to be achieved. The epidemiological profile of ICH has changed over the latter portion of the 20th century, from predominantly hypertensive-related ICH to an increasing percentage of ICH due to amyloid angiopathy and antithrombotic medication use in elderly patients. It is likely that this trend will continue, although it is possible that with increasing levels of obesity in young and middle-aged adults that hypertensive-related ICH may again increase. There is little doubt that ICH will continue to be a major cause of mortality, morbidity and be a major healthcare burden, particularly in Asian and low- and middle-income countries. The high overall case–fatality rate of ICH might provide the statistical opportunity (from a clinical trials perspective) for novel, effective therapies to be proven reasonably quickly; the challenge is to devise some new approaches. The optimal application of all known present strategies, including control of physiological variables (e.g., hypothermia, euglycemia and strict control of hypertension), selective hemostatic therapy (based upon vessel status), appropriate application of surgical techniques (e.g., evacuation of superficial hematomas or drainage of intraventricular clot facilitated by thrombolysis), current possible neuroprotective drugs (e.g., magnesium, minocycline and deferoxamine) and optimal stroke unit care, including early venous thromboprophylaxis and mobilization, may provide incremental improvements in overall outcome. Carefully selecting the timing of these interventions may be important, and this issue will be expanded upon later. For dramatic changes in outcome, it is likely that quite novel treatments will be required.