Advances in intracerebral haemorrhage management

Intracerebral haemorrhage accounts for 10-15% of strokes and is associated with high mortality and severe disability in survivors. Despite its seriousness, the treatment options for intracerebral haemorrhage are limited. Measures aimed at decreasing elevated intracranial pressure are of limited effectiveness. This has stimulated an interest in attempting to improve the prognosis of intracerebral haemorrhage by addressing the haematoma directly, either removing it by surgical means or limiting its early spontaneous growth. The international Surgical Trial in Intracerebral Haemorrhage (STICH), which randomized subjects with intracerebral haemorrhage within 72 h of symptom onset to medical management vs. surgery, failed to document the superiority of one treatment over the other, when compared with regard to mortality and functional outcome at 90 days. The subgroup of patients with lobar haematomas located at a depth of 1 cm or less from the cortical surface fared better with surgery than with medical management. A similar comparison trial is planned for this subgroup of patients. The neutral results of The international Surgical Trial in Intracerebral Haemorrhage (STICH) prompted the assessment of haemostatic therapies, based on the observation that haematomas often enlarge substantially in the hours that follow the onset of symptoms. Recombinant activated factor VII has been shown in a phase IIb, dose-finding trial to result in a significant reduction of haematoma growth, and both mortality and functional scales trended in favour of recombinant activated factor VIIa. The main complication of this therapy was arterial thromboembolic events (myocardial infarction and ischaemic stroke). A phase III randomized trial has recently been completed.