Stokes caused by non-traumatic intracerebral haemorrhage (IH) are caused by a rupture of blood vessels in the brain. This is a major public health problem which accounts for 2 million (10-15%) of a total of 15 million strokes worldwide each year. The causes and the future treatment of this condition are discussed in a Seminar in this week's edition of The Lancet, written by Dr Adnan I. Qureshi, (Zeenat Qureshi Stroke Research Center, University of Minnesota, USA); Dr A David Mendelow (University of Newcastle, UK); and Dr Daniel F Hanley (Johns Hopkins Medical Institutions, Baltimore, USA).
Hospital admissions for IH have increased by 18% in the past 10 years, probably because of increases in the number of elderly people, many of whom lack adequate blood-pressure control, and the increasing use of anticoagulants, thrombolytics, and antiplatelet agents. Oral anticoagulant (anti-clotting) use comprised 5% of all IH in 1988, 9% in 1993, and 17% in 1999, with the observed increase presumably due to increasing prevalence of atrial fibrillation and higher rates of warfarin use. Mexican Americans, Latin Americans, African Americans, Native Americans, Japanese people, and Chinese people have higher incidences than do white Americans. These differences are mostly seen in the incidence of deep IH and are most prominent in young and middle-aged people.
The authors say: "Although the number of hospital admissions for intracerebral haemorrhage has increased worldwide in the past 10 years, mortality has not fallen. Results of clinical trials and observational studies suggest that coordinated primary and specialty care is associated with lower mortality than is typical community practice. Development of treatment goals for critical care, and new sequences of care and specialty practice can improve outcome after intracerebral haemorrhage. Specific treatment approaches include early diagnosis and haemostasis, aggressive management of blood pressure, open surgical and minimally invasive surgical techniques to remove clot, techniques to remove intraventricular blood, and management of intracranial pressure. These approaches improve clinical management of patients with intracerebral haemorrhage and promise to reduce mortality and increase functional survival."
They discuss the importance of three management tasks in IH — stopping the bleeding, removing the clot, and controlling the resulting pressure on the brain. The relative benefits of each goal will likely be determined when the results of several ongoing trials, such as the Surgical Trial in Intracerebral Haemorrhage (STICH) II; Clot Lysis: Evaluating Accelerated Resolution of IVH (CLEAR-IVH); Minimally Invasive Surgery plus Tissue plasminogen activator for Intracerebral haemorrhage Evacuation (MISTIE); and Antihypertensive Treatment of Acute Cerebral Haemorrhage (ATACH), are known. They conclude: "Use of real-time, high-field MRI with three-dimensional imaging and high-resolution tissue probes is another priority. Trials of acute blood-pressure treatment and coagulopathy reversal are also medical priorities. And trials of minimally invasive surgical techniques including mechanical and pharmacological adjuncts are surgical priorities."
Dr Adnan Qureshi, Department of Neurology, University of Minnesota, USA T) +1 612-626-8221 E) qureshi@umn.edu
Dr Daniel F. Hanley, Director, Division of Brain Injury Outcomes, The Johns Hopkins Medical Institutions, Baltimore, USA T) +1 410-614-6996 E) dhanley@jhmi.edu
Prof David Mendelow, Department of Neurosurgery, Newcastle General Hospital and University of Newcastle, UK T) +44 (0) 191 256 3151 a.d.mendelow@newcastle.ac.uk
For full Seminar, see: http://press.thelancet.com/ih.pdf
Journal
The Lancet