Management of Spontaneous Intracerebral Hematomas

Spontaneous intracerebral hemorrhage (ICH) accounts for 10% to 15% of all strokes, and is associated with significant mortality and morbidity rates. Hypertension, age, and cerebral amyloid angiopathy are the major risk factors. Clinical presentation continues to progress with sudden onset, focal neurologic deficit to symptoms of elevated intracranial pressure (ICP), and coma. Diagnosis of ICH is established by computed tomography scan and magnetic resonance imaging; catheter angiography may exclude underlying vascular pathologies in young normotensive patients. Surrounding brain tissue is edematous, with thrombin and iron as the major culprits. In more than 30% of patients, ICH expands within the first hours after the initial bleed. The potential relationships between elevated blood pressure, hematoma enlargement, and edema formation remain unclear. Medical management attempts to control ICP and prevent complications. In a trial of ICH patients, the administration of recombinant activated coagulation factor VIIa, within 4 hours of the ictus, limited the hematoma growth and improved functional independence and neurologic impairment on day 15 after the ICH. However, the study failed to show any significant improvement in functional outcomes at 90 days. The results of a recent multicenter trial failed to demonstrate any advantage of surgical drainage of ICH when compared with conservative treatment. Open surgical intervention is largely reserved for patients harboring lobar hemorrhages with mass effect, rapid neurologic deterioration, and cerebellar hematomas >3 cm in diameter. In the future, the value of minimally invasive procedures in the evacuation of spontaneous ICH and the use of recombinant factor VIIa in prevention of hematoma growth will be validated.