Spontaneous intracerebral hemorrhage (ICH), the most devastating and debilitating form of stroke, remains a major healthcare concern all over the world. Intracerebral hemorrhage is frequently managed in critical care settings where intensive monitoring and treatment are employed to prevent and address primary and secondary brain injury as well as other medical complications that may arise. Although there has been increasing data guiding the management of ICH in the past decade, prognosis remains dismal. In this article, the authors discuss the risk factors for ICH, the role of imaging, the major targets of neurocritical care management, the etiology and management of raised intracranial pressure, as well as prevention of and prompt response to the emergence of medical complications. They also discuss the effect of early withdrawal of life-sustaining therapy on prognosis. Finally, we outline several clinical trials that hold promise in improving our management of ICH in the near future.
Spontaneous intracerebral hemorrhage (ICH) is a common neurologic emergency accounting for 15% of all strokes. High mortality rates make it the deadliest of stroke subtype.[1,2] Survivors are left with significant disability. Despite the high morbidity and mortality associated with ICH, there is considerably less evidenced-based guidance in the management of ICH when compared with ischemic stroke. In the last decade, clinical trials have targeted surgical evacuation (Surgical Trial in Intracerebral Hemorrhage: STICH trials),[5,6] augmentation of hemostasis (Recombinant Factor VIIa in Acute Intracerebral Hemorrhage [FAST]), and blood-pressure reduction (Antihypertensive Treatment of Acute Cerebral Hemorrhage [ATACH]) trial and Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial [INTERACT 1 and 2]).[8,9]Unfortunately, interventions improving functional and cognitive outcomes remain elusive.
Several trials that are currently underway or were recently completed will hopefully provide further insight into the impact of medical and surgical management of this devastating disease (Intracerebral Hemorrhage Deferoxamine [iDEF], Minimally Invasive Surgery for Intracerebral Hemorrhage [MISTIE], Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage [CLEAR III] trials)[10–13] on outcome.
In this review, we discuss the neurocritical care management of ICH based on current evidence and available guidelines. We also will discuss ongoing studies that have the potential to change the management of ICH in the critical care setting.Continue Reading