The acute management of intracerebral hemorrhage

Purpose of review Spontaneous intracerebral hemorrhage (ICH) is associated with high morbidity and mortality, providing substantial scope for improvements in outcome. This review will discuss recent developments and present consensus evidence for the management of ICH. Recent findings Intracranial management strategies focus on preventing further bleeding and minimizing the risk of hematoma expansion and cerebral ischemia. Known coagulopathies should be corrected and oral anticoagulation reversed, but there is no evidence for the routine transfusion of platelets in patients taking aspirin or clopidogrel. Recombinant factor VIIa reduces hematoma expansion after ICH, but does not improve outcome and is associated with thromboembolic complications. The role and type of surgical interventions remain controversial. Early aggressive treatment, including meticulous control of blood pressure and other systemic physiological variables, improves outcome as does management in a specialized neurointensive care unit. Thromboembolic prophylaxis is routine but prophylactic antiepileptic drugs confer no benefit. Ongoing research seeks to define optimal blood pressure, glucose and temperature targets, the role and type of surgery, and potential neuroprotective strategies. Summary Well organized, multimodal therapy optimizing intracranial and systemic physiological variables improves outcome after ICH. Recent guidelines provide a useful consensus evidence-based framework for the management of acute ICH.