Therapeutic management of acute intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is a stroke resulting from spontaneous rupture of an intracranial vessel and is associated with high early mortality and long-term morbidity rates. With the exception of dedicated stroke units or neurocritical care, no surgical or medical intervention has been proven to effectively improve outcome following ICH. Pharmacotherapeutic considerations include optimal blood pressure control and the choice of antihypertensive agents. Acute haematoma expansion represents the most obvious acute treatment target. The use of haemostatic agents may have a role in ICH management; although it appears improved patient selection may be required before the use of these agents can be demonstrated clinically. In patients with anticoagulant-associated ICH, a number of therapeutic agents may be used to urgently reverse the coagulopathy, although further clinical trials are required. Recurrent bleeding and future thrombo-embolic event rates in patients who require anticoagulation following ICH risks are difficult to determine accurately, although risk stratification data are emerging. This article reviews the pathophysiology, natural history and the evidence supporting present therapeutic management practices for ICH. The authors' practice based on best available evidence is provided.