Intracerebral hemorrhage (ICH) can be prevented by adequate treatment of
hypertension.
Angiotensin-converting enzyme inhibitors,
angiotensin receptor blockers, and
calcium channel blockers seem particularly effective. ICH also is associated with
apolipoprotein E 4 genotype and with low
cholesterol, but not
statin therapy for high
cholesterol. Microbleeds identified on magnetic resonance imaging scans also confer increased risk of ICH. Experimental
drug regimens that target
metalloproteinases and
inflammation reduce damage in animal models of ICH, but none are proven effective in humans.
Cerebral edema after ICH has varied mechanisms and significance, and may be another target for
therapy. Cerebral blood flow is not substantially reduced in most patients with ICH. Lowering systolic blood pressure below 160 mm Hg in the first hours after ICH may prevent additional
bleeding. Activated
factor 7 is a promising new
therapy to limit
hematoma enlargement and consequently reduce morbidity and mortality after ICH. Dosages of 80 to 160 μg/kg given within the first 3 to 4 hours after symptom onset, or in patients at risk of additional
bleeding such as those with coagulopathy, is logical but is unapproved. The role of activated
factor 7 hopefully will be clarified by additional study. Open surgical evacuation of most spontaneous supratentorial
hematomas has been shown to be ineffective in reducing mortality or disability except in certain circumstances, such as large or enlarging superficially located clots in patients who are awake. Stereotactic and endoscopic clot aspiration, often using instillation of lytic agents to liquefy the
hematoma, is the most active area of surgical intervention research. Such minimally invasive approaches have been shown to safely produce more rapid removal of blood compared with standard treatment. This is particularly true for intraventricular
hemorrhages. Future research will focus on the use of stem cells to restore the damaged architecture around the
hematoma. The impressive scope and progress of ongoing clinical and basic research show that there is no longer a place for nihilism in the approach to ICH.