Elsevier

The Lancet

Volume 392, Issue 10154, 6–12 October 2018, Pages 1257-1268
The Lancet

Series
Intracerebral haemorrhage: current approaches to acute management

https://doi.org/10.1016/S0140-6736(18)31878-6Get rights and content

Summary

Acute spontaneous intracerebral haemorrhage is a life-threatening illness of global importance, with a poor prognosis and few proven treatments. As a heterogeneous disease, certain clinical and imaging features help identify the cause, prognosis, and how to manage the disease. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from perihaematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. A moderate level of evidence supports there being beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control of elevated blood pressure, and rapid reversal of abnormal coagulation.

Introduction

Acute spontaneous (non-traumatic) intracerebral haemorrhage is the most common type of spontaneous intracranial haemorrhage (others being subarachnoid haemorrhage and isolated intraventricular haemorrhage) and is the most serious and least treatable form of stroke that affects approximately 2 million people in the world each year.1 It is a life-threatening and disabling event, usually manifest as a rapidly expanding haematoma arising within the brain parenchyma, with potential extension into the ventricular system and subarachnoid or dural spaces. One in three patients die within the first month of onset, and survivors have varying degrees of residual disability and high risk of recurrent intracerebral haemorrhage, other serious vascular events, and neurological complications such as epilepsy and dementia. As most cases occur in working adults in large populations of low-income and middle-income countries, among whom the prevalence of hypertension and other vascular risk factors is high, intracerebral haemorrhage has enormous social and economic effects from the resultant loss of productive life years. A meta-analysis of available population-based studies showed stable early case fatality for intracerebral haemorrhage between 1980 and 2008.2 More recent data have shown favourable trends in survival from intracerebral haemorrhage in the Netherlands,3 the UK,4 and France,5 possibly related to the development of specialist-organised stroke unit care. Unfortunately, there is still no medical treatment for acute intracerebral haemorrhage that is clearly beneficial, and the role of surgery remains controversial despite its widespread use in various forms. We review the evidence and offer guidance in the management of intracerebral haemorrhage, for which recent advances provide encouraging information about reducing cerebral injury, preventing complications, and promoting recovery from this complex and challenging illness.

Section snippets

Acute assessment

Intracerebral haemorrhage is difficult to differentiate from acute ischaemic stroke at the bedside, but certain features suggest its diagnosis: rapidly progressive neurological signs and symptoms, headache, vomiting, seizures, and reduced consciousness often disproportionate to focal deficits all suggest mass effect from an underlying haematoma; neck stiffness indicates chemical meningitis from extension of intraventricular haemorrhage into the subarachnoid space. Neuroimaging should be done

Organisation of care

Intracerebral haemorrhage is a medical emergency in which most patients benefit from an early active management plan. Various studies of health record data show that premature use of orders for do-not-resuscitate, withdrawal of care, or palliative care (which includes narcotic use) independently predict mortality, after adjustment for conventional clinical prognostic factors.45, 46 Active care includes monitoring, early screening for dysphagia, maintenance of physiological control, including

Blood pressure control

Hypertension after intracerebral haemorrhage is common and multiple factors contribute to the hypertensive response, including stress of the acute event, or prior variability and peaks in systolic blood pressure that might trigger the event. Because hypertension, defined as elevated systolic blood pressure (>140 mm Hg), is modifiable and associated with haematoma growth and poor recovery, it seems reasonable that early intensive lowering of blood pressure could improve clinical outcomes through

Seizures

The risk of seizures is relatively high (around 5–10%) after intracerebral haemorrhage, more so than it is for acute ischaemic stroke,72 and even higher if subclinical seizures are also considered.73 Early seizures (<7 days after intracerebral haemorrhage onset) are due to the cerebral trauma of intracerebral haemorrhage and do not seem to influence recovery.74 Prophylactic use of antiepilepsy drugs is not recommended because of uncertainty over the balance of potential benefits (eg, improved

Craniectomy for evacuation of the haematoma

Surgical evacuation of cerebellar intracerebral haemorrhage in patients who are rapidly deteriorating from brainstem compression is accepted practice despite there being no randomised assessment of this strategy.91, 92 For supratentorial intracerebral haemorrhage, early evacuation (<24 h after onset of haemorrhage) with standard craniotomy is considered life saving in deteriorating patients, but is not clearly beneficial in deeply comatose or otherwise stable patients. In the first large

Secondary prevention

Intracerebral haemorrhage has a high risk of recurrence—about 5% per year.40 Several trials have shown long-term benefits from blood pressure lowering (systolic target <140 mm Hg) for the secondary prevention of intracerebral haemorrhage and other serious vascular events, and the effects on recurrent intracerebral haemorrhage are much greater than for prevention of ischaemic stroke for the same degree of blood pressure reduction.108 The stronger effect of blood pressure lowering on

Conclusion

We recognise that this Series paper including practice recommendations is constrained by our interpretation of the evidence in a critical illness that is particularly challenging to study. Research indicates several therapeutic avenues of benefit in intracerebral haemorrhage modelled around an active management plan, aggressive supportive care, early blood pressure control, and targeted surgery as a life-preserving strategy. Emerging data support a shift in management towards much earlier

Search strategy and selection criteria

We searched PubMed for papers published between Dec 1, 1945, and April 1, 2018. We used the search terms: “intracerebral haemorrhage” or “haemorrhagic stroke” or “intracranial haemorrhage”. Two authors independently reviewed all the retrieved articles. In case of disagreements regarding the literature search results, another author was consulted to formulate a mutual consensus. The search focused on articles published in English. We mostly selected publications from the past 5 years but did not

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