Medical management of intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) causes 10–15% of first ever strokes and is associated with the highest mortality of all cerebrovascular events, with 30-day mortality after ICH approaching almost 50%. Of note, most survivors never regain functional independence, with only 20% achieving a meaningful level of functional recovery at six months [1,2]. This article discusses the basic principles of management of ICH, including initial stabilization, the prevention of hematoma growth, hemodynamic goal-setting, treatment of potential complications such as cerebral edema, herniation and seizures, and identification of the underlying etiology. Newer treatment options such as minimally invasive surgery (MIS) to reduce clot size are also briefly discussed. Initial medical stabilization As in other medical emergencies, initial resuscitative measures should be directed to establishing adequacy of airway, breathing, and circulation (ABCs). Airway: indications for endotracheal intubation include the lack of adequate airway protection (Glasgow Coma Scale [GCS] Score < 8), herniation syndrome, uncontrolled seizures, and respiratory failure. Airway control might be suboptimal in patients even with GCS > 8 in the absence of a good cough/gag reflex who may be high aspiration risk especially with brainstem hemorrhages. Breathing: hyperventilation might be necessary in the event of acute herniation, but, extrapolating from brain trauma literature, its prophylactic use is unlikely to be of benefit. Due to the risk of cerebral ischemia with prolonged hyperventilation, cautious slow return to goals of normocarbia (PaCO2 35–45) after reversal of herniation is recommended.