Management of Intracerebral Hemorrhage: JACC Focus Seminar

Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.     

Intracerebral Hemorrhage from Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with the incidence of 0.5 % from all strokes. The clinical presentation with cerebral hemorrhage constitutes a diagnostic challenge. Approximately one- third of CVT patients developed intracerebral hemorrhage (ICH). Associated factors include older age, female sex, acute onset (48 h), headache, decreased level of consciousness, seizure, elevated blood pressure and papilledema. MRI and MR venogram is the most recommend diagnostic modality in CVT. Anticoagulation therapy is the most commonly accepted treatment even in patients with ICH related CVT. Mechanical thrombectomy/thrombolysis may be considered in patients with neurological deterioration despite intensive medical treatment. Intracerebral hemorrhage in the context of CVT is usually associated with poorer outcomes compared to CVT without ICH.     

Etiologies of Intracerebral Hematomas

Intracerebral hemorrhage (ICH) remains a life-threatening disease that carries significant morbidity and mortality despite recent diagnostic and management advances. Various conditions are associated with increased risk of intracerebral hemorrhage. Understanding the etiology of these conditions and their pathophysiological contribution to ICH will likely lead to better therapeutic and preventative measures and improve the morbidity and mortality associated with intracerebral hemorrhage. We will review the current literature regarding important etiologies/risk factors of intracerebral hemorrhage.     

Essential Topics About the Imaging Diagnosis and Treatment of Hemorrhagic Stroke: A Comprehensive Review of the 2022 AHA Guidelines

Intracerebral hemorrhage (ICH) is a severe stroke with a high death rate (40% mortality). The prevalence of hemorrhagic stroke has increased globally, with changes in the underlying cause over time as anticoagulant use and hypertension treatment have improved. The fundamental etiology of ICH and the mechanisms of harm from ICH, particularly the complex interaction between edema, inflammation, and blood product toxicity, have been thoroughly revised by the American Heart Association (AHA) in 2022. Although numerous trials have investigated the best medicinal and surgical management of ICH, there is still no discernible improvement in survival and functional tests.Small vessel diseases, such as cerebral amyloid angiopathy (CAA) or deep perforator arteriopathy (hypertensive arteriopathy), are the most common causes of spontaneous non-traumatic intracerebral hemorrhage (ICH). Even though ICH only causes 10%-15% of all strokes, it contributes significantly to morbidity and mortality, with few acute or preventive treatments proven effective.Current AHA guidelines acknowledge up to 89% sensitivity for unenhanced brain CT and 81% for brain MRI. The imaging findings of both methods are helpful for initial diagnosis and follow-up, sometimes necessary a few hours after admission, especially for detecting hemorrhagic transformation or hematoma expansion.This review summarized the essential topics on hemorrhagic stroke epidemiology, risk factors, physiopathology, mechanisms of injury, current management approaches, findings in neuroimaging, goals and outcomes, recommendations for lifestyle modifications, and future research directions ICH. A list of updated references is included for each topic.     

The Relationship Between Nocturnal Blood Pressure and Hemorrhagic Stroke in Chinese Hypertensive Patients

To study the relationship between nocturnal blood pressure (BP) variation and spontaneous intracerebral hemorrhage (ICH) among Chinese hypertensive patients and its clinical significance, the authors retrospectively screened 371 patients with primary hypertension (189 patients with ICH, 182 patients without ICH) in Shanghai and analyzed their demographics, clinical information, nocturnal blood pressure variability and medication. Compared with the control group, the levels of blood glucose, triglycerides, and creatinine were significantly increased in the ICH group, along with a marked reduction in nocturnal BP drop (P<.05). Multivariate logistic regression indicated that blood glucose, creatinine, and nocturnal mean arterial pressure were risk factors for ICH, and the magnitude of nocturnal BP drop was negatively related to the risk for ICH. There was no significant difference in the prevalence of reverse dippers between the large hematoma volume group and the small hematoma volume group (χ²=2.529, P=.112), nor among the patients taking angiotensin‐converting enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers (χ²=1.981, P=.371). Reverse dipping is associated with the risk for ICH, suggesting that appropriate antihypertensive drug and chronotherapy might be effective to normalize the rhythm of abnormal circadian variation in hypertensive patients.     

Risk factors for intracerebral hemorrhage in patients with COVID-19

Journal of Thrombosis and Thrombolysis - Intracerebral hemorrhage (ICH) can be a devastating complication of coronavirus disease (COVID-19). We aimed to assess risk factors associated with ICH in...     

Management of Acute Hypertensive Response in Patients with Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is intra-parenchymal bleeding that may lead to localized hematoma formation. The hematoma can enlarge over a period of time, and directly contribute to neurological deterioration and death. Several studies have shown a relationship between acute hypertensive response and poor prognosis among patients with ICH; however, it is somewhat unclear whether hematomal expansion, is a cause or a result of elevated blood pressure (BP). Current AHA guidelines state MAP should be maintained <130 mmHg and systolic blood pressure (SBP) <180 mmHg. Two major clinical trials demonstrating tolerability and safety of aggressive BP management to BP <140 mmHg in the acute phase of ICH were the ATACH (2004-2008) and INTERACT (2005-2007) trials. ATACH II and INTERACT 2 trials are currently being conducted to demonstrate the efficacy of SBP reduction as the next step to the ATACH and INTERACT pilot trials.     

Blood Pressure Goals in Acute Stroke—How Low Do You Go?

Purpose of Review

Elevations in systolic blood pressure (BP) greater than 140 mmHg are reported in the majority (75%) of patients with acute ischemic stroke and in 80% of patients with acute intracerebral hemorrhages (ICH). This paper summarizes and updates the current knowledge regarding the proper management strategy for elevated BP in patients with acute stroke.

Recent Findings and Summary

Recent studies have generally showed a neutral effect of BP reduction on clinical outcomes among acute ischemic stroke patients. Thus, because of the lack of convincing evidence from clinical trials, aggressive BP reduction in patients presenting with acute ischemic stroke is currently not recommended. Although in patients treated with intravenous tissue plasminogen activator, guidelines are recommending BP?<?180/105 mmHg but currently, the optimal BP management after reperfusion therapy still remains unclear. In acute ICH, the evidence from randomized clinical trials supports the immediate BP lowering targeting systolic BP to 140 mmHg, which is now recommended by guidelines.

     

Management of hemorrhagic stroke

Fifty thousand Americans suffer an intracerebral hemorrhage (ICH) annually, one third of whom die as a result. Poorly controlled hypertension is the most important risk factor for ICH. Over time it results in pathologic changes to small intracranial vessels, leading to their rupture. All stroke patients, including those with suspected ICH, require emergent evaluation. Surgical intervention is appropriate for some ICH patients, although intensive medical management of intracranial pressure and the systemic consequences of ICH can reduce morbidity in all. Innovative medical and surgical therapeutic approaches hold promise for improved treatment in the future, but prevention is the key for reducing morbidity in the short term.     

The Effect of Admission Blood Pressure on the Prognosis of Patients with Intracerebral Hemorrhage That Occurred during Treatment with Aspirin,Warfarin, or No Drugs

Background. Hypertension is the most important modifiable risk factor for intracerebral hemorrhage (ICH), but blood pressure (BP) management during the acute phase of ICH is still controversial. Approximately one-fourth of ICHs occur during treatment with warfarin or aspirin. Aim. This study was designed to determine the effect of admission BP on the early prognosis of ICH patients by dividing them into three groups (warfarin, aspirin, and no drugs). Methods. Three hundred and sixty-nine patients with supratentorial ICH were divided into three groups according to medication. Each group was evaluated in terms of prognosis and the risk for mortality based on the modified Rankin Scale (mRS) score at discharge (good prognosis: mRS ≤ 3; poor prognosis: mRS > 3). The effect of admission BP on prognosis was evaluated for each group. Results. The inhospital mortality rate was 72% for ICH patients treated with warfarin, 41.6% for ICH patients treated with aspirin, and 35% for ICH patients treated with no drugs. Admission mean arterial blood pressure (MABP) values were higher in patients with poor prognosis compared with patients with good prognosis for the aspirin (P = .002) and no-drug (P = .001) groups, but not in the warfarin (P = .067) group. Conclusion. A high MABP at admission was found to be an independent predictor of poor prognosis for ICH patients treated with aspirin or with no drugs, but not for ICH patients treated with warfarin.     

Intracerebral hemorrhage: a life-threatening complication of hypertension during pregnancy

Intracerebral hemorrhage (ICH) is an infrequent but severe complication in pregnant women with hypertension. The authors describe a patient with chronic hypertension who developed superimposed preeclampsia and spontaneous ICH during the thirty-fifth week of pregnancy. ICH was diagnosed by computed tomographic scan. She underwent successful emergent cesarean section and neurosurgical decompression of the ICH. Both intraoperative surveillance and postoperative magnetic resonance angiographic examination of the cerebral vessels failed to identify an aneurysm or arteriovenous malformation. The authors discuss the diagnosis and management in this case and review the literature regarding this challenging complication of pregnancy and preeclampsia. Controversies regarding treatment of hypertension during pregnancy are discussed in light of the impact on the management of this patient.     

Intracerebral hemorrhage induces monocyte-related gene expression within six hours: Global transcriptional profiling in swine ICH

Metabolic Brain Disease - Intracerebral hemorrhage (ICH) is a severe neurological disorder with no proven treatment. Our prior research identified a significant association with monocyte level and...     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.     

铁超载与脑出血后脑损伤

脑出血(intracerebral hemorrhage,ICH)是一种常见神经系统疾病,其死亡率和致残率均很高,但目前对ICH后脑损伤的机制尚未完全阐明.最新的研究表明,铁超载在ICH后脑损伤中起着重要作用.文章对脑铁分布和功能、ICH后铁超载引起脑损伤的机制以及铁螯合剂应用等方面的研究进展进行了综述.