Management of Primary Hypertensive Hemorrhage of the Brain

Intracerebral hemorrhage (ICH) can be prevented by adequate treatment of hypertension. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers seem particularly effective. ICH also is associated with apolipoprotein E 4 genotype and with low cholesterol, but not statin therapy for high cholesterol. Microbleeds identified on magnetic resonance imaging scans also confer increased risk of ICH. Experimental drug regimens that target metalloproteinases and inflammation reduce damage in animal models of ICH, but none are proven effective in humans. Cerebral edema after ICH has varied mechanisms and significance, and may be another target for therapy. Cerebral blood flow is not substantially reduced in most patients with ICH. Lowering systolic blood pressure below 160 mm Hg in the first hours after ICH may prevent additional bleeding. Activated factor 7 is a promising new therapy to limit hematoma enlargement and consequently reduce morbidity and mortality after ICH. Dosages of 80 to 160 μg/kg given within the first 3 to 4 hours after symptom onset, or in patients at risk of additional bleeding such as those with coagulopathy, is logical but is unapproved. The role of activated factor 7 hopefully will be clarified by additional study. Open surgical evacuation of most spontaneous supratentorial hematomas has been shown to be ineffective in reducing mortality or disability except in certain circumstances, such as large or enlarging superficially located clots in patients who are awake. Stereotactic and endoscopic clot aspiration, often using instillation of lytic agents to liquefy the hematoma, is the most active area of surgical intervention research. Such minimally invasive approaches have been shown to safely produce more rapid removal of blood compared with standard treatment. This is particularly true for intraventricular hemorrhages. Future research will focus on the use of stem cells to restore the damaged architecture around the hematoma. The impressive scope and progress of ongoing clinical and basic research show that there is no longer a place for nihilism in the approach to ICH.