Spontaneous intracerebral hemorrhage: a review.
Spontaneous intracerebral hemorrhage (SICH) is a blood clot that arises in the brain parenchyma in the absence of trauma or surgery. This entity accounts for 10 to 15% of all strokes and is associated with a higher mortality rate than either ischemic stroke or subarachnoid hemorrhage. Common causes include hypertension, amyloid angiopathy, coagulopathy, vascular anomalies, tumors, and various drugs. Hypertension, however, remains the single greatest modifiable risk factor for SICH. Computerized tomography scanning is the initial diagnostic modality of choice in SICH, and angiography should be considered in all cases except those involving older patients with preexisting hypertension in thalamic, putaminal, or cerebellar hemorrhage. Medical management includes venous thrombosis prophylaxis, gastric cytoprotection, and aggressive rehabilitation. Anticonvulsant agents should be prescribed in supratentorial SICH, whereas the management of hypertension is controversial. To date, nine prospective randomized controlled studies have been conducted to compare surgical and medical management of SICH. Although definitive evidence favoring surgical intervention is lacking, there is good theoretical rationale for early surgical intervention. Surgery should be considered in patients with moderate to large lobar or basal ganglia hemorrhages and those suffering progressive neurological deterioration. Elderly patients in whom the Glasgow Coma Scale score is less than 5, those with brainstem hemorrhages, and those with small hemorrhages do not typically benefit from surgery. Patients with cerebellar hemorrhages larger than 3 cm, those with brainstem compression and hydrocephalus, or those exhibiting neurological deterioration should undergo surgical evacuation of the clot. It is hoped that the forthcoming results of the International Surgical Trial in IntraCerebral Hemorrhage will help formulate evidence-based recommendations regarding the role of surgery in SICH.
Fewel
Matthew E
ME
Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan 48109-0338, USA. fewelm@umich.edu
Thompson
B Gregory
BG
Hoff
Julian T
JT
D000328:Adult; D000368:Aged; D001778:Blood Coagulation Disorders / Q000150:complications; D001932:Brain Neoplasms / Q000150:complications; D016657:Cerebral Amyloid Angiopathy / Q000150:complications; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D002561:Cerebrovascular Disorders / Q000150:complications; D002986:Clinical Trials as Topic; D003131:Combined Modality Therapy; D003399:Craniotomy; D003952:Diagnostic Imaging / Q000379:methods; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D011250:Pregnancy Complications, Hematologic; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D012422:Rupture, Spontaneous; D012640:Seizures / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome