Management of Intracerebral Hemorrhage

Abstract

Intracerebral hemorrhage (ICH) is a medical emergency that warrants urgent neurological evaluation including neurovascular imaging. The etiology for spontaneous ICH remains broad although hypertension remains an important comorbidity in non-traumatic cases, with anatomical location providing clues to the underlying basis. Primary and secondary injury cascades contribute to neurological insult, while tools such as the ICH score aid in prognostication. In addition to serial neurological assessments and imaging, treatment strategies in the acute setting focus on airway protection and management of hypertension, intracranial pressure, as well as correction of laboratory abnormalities. CSF diversion may be warranted in the setting of obstructive hydrocephalus and intraventricular hemorrhage. Neurosurgical decompression is of particular importance in patients with large posterior fossa hemorrhages, while endovascular strategies have a role in the treatment of aneurysmal and other vascular etiologies of ICH. Multiple large clinical trials are ongoing to assess novel management strategies. Areas of debate in the management of ICH have included choice of hyperosmotic therapy for ICP crises, goal-directed blood pressure management, seizure prophylaxis, and the utilization of systemic cooling.