Hemostatic Treatment in the Early Stage of Intracerebral Hemorrhage

Abstract

Section Editors: Marc Fisher MD Antoni Da valos MD The treatment of intracerebral hemorrhage (ICH) has been a largely neglected item. In contrast to literally dozens of clinical trials of treatment of ischemic stroke, only a handful have addressed treatment of ICH with either medical (steroids,1 osmotic diuretics2) or surgical3 interventions. The medical intervention trials, primarily aimed at reducing brain edema surrounding the ICH, have shown lack of benefit of treatment with dexamethasone1 or glycerol solutions.2 Although some pilot data suggested a potential benefit of early surgical drainage of the hematoma,4,5 the recent publication of neutral results in the large, prospective, and randomized international Surgical Trial in Intracerebral Hemorrhage (STICH) study6 has been a disappointment. Mendelow and colleagues went for 8 years of enrollment and follow up of over 500 subjects in each treatment group, one managed “conservatively,” the other subjected to surgical drainage of the hematoma within a maximum of 4 days from symptom onset. The final results showed no benefit of one mode of treatment over the other, because a favorable outcome occurred as frequently in the “conservative” (24%) as in the surgical (26%) group when they were evaluated at 6 months. Although a prespecified subgroup analysis suggested a possible advantage of surgical treatment for superficially located (≤1 cm from the cortical surface) lobar hematomas, the overall trial results showed that only one fourth of patients with ICH can be expected to have a good clinical outcome, which cannot be improved on by surgical treatment. In the wake of the neutral STICH trial results, it is refreshing to see some hope for the treatment of this devastating stroke subtype with the publication of the results of the phase IIB trial of recombinant activated factor VIIa (rFVIIa) in ICH. …