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Intracerebral hemorrhage (ICH) is a lingering cause of significant mortality and morbidity rates in contemporary society. Despite its established burden, considerably less investigative attention has been devoted to the study of ICH than other forms of stroke. Only a limited number of clinical studies have been performed to examine the surgical (both craniotomy and minimally invasive) and medical management of patients with ICH. No consistently efficacious strategies have been identified through such investigations. Limitations in study design and execution have universally impaired the interpretation and impact of available data. Management of ICH unfortunately remains heterogeneous across institutions, and it continues to suffer from the lack of proven medical and surgical effectiveness. Urgently needed are further prospective randomized controlled trials in which investigators consider the shortcomings of previous endeavors in the management of ICH. In the present article the authors review the current management practices of ICH, discuss the controlled trials, and highlight recent trials and future avenues of further study.
The management of ICH remains an enigma. Despite its relatively high incidence (15-35 per 100,000 persons) and its poor associated outcomes (30-40% 30-day mortality rate), neither medical nor surgical intervention has been shown consistently to improve survival or QOL significantly. Limited success in establishing efficacious therapies is due, in part, to the limited quantity and quality of clinical studies. This paucity of quality data has left current management recommendations largely based on theory and clinicians attempting to modify factors that have been associated with poor outcomes. In this report, we review the current management of ICH, discuss related controlled trials, and highlight recent trials and new theories that await investigation in ICH management.
Considerable attention has been directed toward identifying predictive factors of poor outcome. The potentially modifiable factors have been of particular interest in developing treatments for ICH, despite the fact that these factors have only been associated with rather than proven to cause poor outcomes. Several factors that have been associated with poor outcome include volume of the hematoma, neurological status (GCS score ) on admission, intraventricular extension of the clot and/or hydrocephalus, subarachnoid extension, anticoagulation agents, and relative edema. Of these, the most tangible factor on which to base therapeutic intervention is the volume of the hematoma. A reduction in hematoma volume theoretically decreases mass effect, lessens ICP, and limits the potential stimulus for edema formation and cell death. Raised ICP is also treated when appropriate. Although not clearly established as an independent predictor of poor outcome, it is postulated to have direct adverse effects on cerebral tissue but also interacts with other prognostic factors. For example, raised ICP impairs the resolution of vasogenic edema following experimental ICH. Hence, theoretical therapeutic targets emerge from the analysis of potentially modifiable predictors of poor outcome. As will be discussed, however, it is not clear whether post hoc modification of these factors is beneficial.
The methods for managing ICH are broadly divided into two categories: medical and surgical interventions. Medical management includes cardiopulmonary optimization and blood pressure control, ICP reduction (using, for example, patient positioning, hyperosmolar fluids, hyperventilation, and barbiturate coma), general medical management (including careful glucose management), and reversing coagulation defects. Surgical management has included craniotomy, stereotactic clot lysis and/or aspiration, endoscopic lysis and/or aspiration, ventriculostomy, and decompressive craniectomies or combinations thereof. Unfortunately, the division between "medical" and "surgical" management is artificial, grouping diverse methodologies together, each of which has a distinct profile of risks and benefits, making it difficult to assess the advantage of any single intervention.
This difficulty is highlighted by a randomized trial conducted by Chen and colleagues in which surgery (craniotomy, stereotactic clot evacuation, craniectomy, and ventricular drainage) was compared with medical management. Although after 1 month the patients in the medical treatment group had experienced relatively superior outcomes, this difference was not maintained at 3 months. The grouping of all surgical techniques into one category adds several uncontrolled factors into the assessment, thereby reducing the study's power to identify a difference, if present, and consequently making the results difficult to interpret. Therefore, in this review we subdivide surgical management by type of intervention and discuss the controlled trials involving each of these techniques separately.
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