Has your competent? hospital implemented any of these? Better ask now before you need this.
Treatment for intracerebral hemorrhage: Dawn of a new era
Abstract
Intracerebral
hemorrhage (ICH) is a devastating disease, causing high rates of death,
disability, and suffering across the world. For decades, its treatment
has been shrouded by the lack of reliable evidence, and consequently,
the presumption that an effective treatment is unlikely to be found.
Neutral results arising from several major randomized controlled trials
had established a negative spirit within and outside the stroke
community. Frustration among researchers and a sense of nihilism in
clinicians has created the general perception that patients presenting
with ICH have a poor prognosis irrespective of them receiving any form
of active management. All this changed in 2023 with the positive results
on the primary outcome in randomized controlled trials showing
treatment benefits for a hyperacute care bundle approach (INTERACT3),
early minimal invasive hematoma evacuation (ENRICH), and use of factor
Xa-inhibitor anticoagulation reversal with andexanet alfa (ANNEXa-I).
These advances have now been extended in 2024 by confirmation that
intensive blood pressure lowering initiated within the first few hours
of the onset of symptoms can substantially improve outcome in ICH
(INTERACT4) and that decompressive hemicraniectomy is a viable treatment
strategy in patients with large deep ICH (SWITCH). This evidence will
spearhead a change in the perception of ICH, to revolutionize the care
of these patients to ultimately improve their outcomes. We review these
and other recent developments in the hyperacute management of ICH. We
summarize the results of randomized controlled trials and discuss
related original research papers published in this issue of the International Journal of Stroke. These exciting advances demonstrate how we are now at the dawn of a new, exciting, and brighter era of ICH management.
Intracerebral hemorrhage—the deadly sibling of ischemic stroke
Intracerebral
hemorrhage (ICH) is caused by the rupture of cerebral vessels which
results in bleeding within the brain parenchyma and/or ventricles.1
Overall, ICH comprises approximately 10–15% of all strokes worldwide,
but the rates are higher in low- and middle-income countries.2 Compared to ischemic stroke, the incidence of ICH has increased in recent years and the prognosis remains poor.3,4
Current estimates predict a significant increase in the incidence of
ICH in Europe related to aging and greater use of anticoagulants, with
major implications for health care systems and societies.5
Treatment of ICH before 2023—widespread frustration and nihilism
For
decades, treatment of ICH has been overshadowed by limited evidence and
a presumed lack of effective treatment options reflected by neutral and
restrictive guideline recommendations.6,7
Several randomized controlled trials of surgical treatment (i.e.
different approaches to evacuation of parenchymal or intraventricular
hematoma),8–11 blood pressure (BP) control,12,13 and hemostatic therapies,14–16 resulted in either borderline significant or neutral results. The evidence was persuasive from INTERACT2,12 and stronger when pooled with other trials as part of an individual patient data meta-analysis,17
for a beneficial effect of early intensive BP lowering. Although a
study-level meta-analysis of hematoma evacuation also found a potential
benefit,18
there is ongoing uncertainty over which patients have the most to gain
from neurosurgery along with the optimal timing and technique of
intervention. Collectively, these efforts have contributed to somewhat
of a negative spirit within (and outside) the stroke community, and in
turn degrees of frustration and nihilism regarding treatment approaches
and the perception of a uniformly poor prognosis for patients with ICH.19
Treatment targets in ICH
Several promising treatment targets exist for ICH (Figure 1).
In the hyperacute phase, the primary aim is to stop the bleeding which
grows from the original site in “domino” or “avalanche” fashion through
the secondary shearing of neighboring vessels.20
Restricting the ongoing bleeding cascade—usually depicted as hematoma
expansion on follow-up imaging—is paramount as it is consistently
identified as a major predictor of poor outcome from ICH.21–23
The other key predictors of outcome are an early time-window (i.e.
<6 h of onset), high BP, baseline hematoma volume (medium to large),
intraventricular extension, and prior use of oral anticoagulation
therapy.24,25 Even a small initial hematoma may evolve into a devastating large lesion (Figure 2).
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