Medical management of intracerebral hemorrhage

Primary intracerebral hemorrhage (ICH) accounts for 10% to 20% of all strokes, with higher incidence rates among African and Asian populations. The major risk factors are hypertension and age. In addition to focal neurologic findings, patients frequently present with symptoms of elevated intracranial pressure (ICP). The diagnosis of ICH can only be made through neuroimaging. A computed tomography scan is presently standard, although magnetic resonance imaging is increasingly important in the evaluation of acute cerebrovascular disease. A significant number of intracerebral hematomas expand in the first hours after ictus. Clinical and experimental evidence demonstrates that the perihematomal region is compromised in ICH. This tissue is edematous, although the precise pathogenesis is controversial. It is unknown whether elevated arterial pressure contributes to hematoma enlargement or edema formation. Only a trial of antihypertensive therapy in acute ICH can answer this important question. ICH is associated with a high early mortality rate, although a significant number of survivors make a functional recovery. Medical management is aimed at controlling elevated ICP and prevention of complications, including pneumonia and peripheral venous thromboembolism. To date, investigations of surgical intervention have been inconclusive, although technical improvements warrant further trials. Aggressive treatment of hypertension is the most important primary and secondary preventive measure.