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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/1\\\/29\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/1\\\/29\u0022}],\u0022ac\u0022:{\u0022spmdc;10\\\/1\\\/29\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;10\\\/1\\\/29\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EThis article discusses the prevention, management, and processing of intracerebral hemorrhage (ICH), as well as key clinical trials concerning the surgical management of ICH. This article also reviews the tools and procedures for recovery and prevention of ICH recurrence.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eischemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003ECraig Anderson, MD, University of Sydney, Sydney, Australia, noted that the best \u201ctreatment\u201d for intracerebral hemorrhage (ICH) is prevention but that a good understanding of the early natural history of ICH and subsequent bleeding is needed before specific treatment remedies can be applied. To illustrate, he noted that there is substantial growth in the volume of parenchymal hemorrhage between baseline and 24-hour CT scans in more than one-third of ICH patients and that this early clot growth is associated with more frequent neurological deterioration [Brott T et al. \u003Cem\u003EStroke\u003C\/em\u003E 1997]. Within days of the initial hemorrhage, intracranial pressure increases, followed by hydrocephalus and chemical meningitis, and later, toxicity from iron and hemoglobin breakdown products occurs. The degree and growth in perihematomal edema are strongly related to the size of the underlying hematoma following acute ICH [Arima H et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2008]. Given this scenario, medical management of ICH patients involves active, well-organized\/ coordinated management that includes assessment and monitoring, acute management (physiological control, early mobilization, managing complications, and skilled nursing), multidisciplinary rehabilitation, and discharge planning. An early CT scan (\u0026lt;24 hours) for diagnostic assessment is crucial. Dr. Anderson cautioned that ICH patients must be managed according to the timeline of events (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/29\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Management According to the Time of Events in ICH.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1760314499\u0022 data-figure-caption=\u0022Management According to the Time of Events in ICH.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/29\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/29\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/29\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11246\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-3\u0022 class=\u0022first-child\u0022\u003EManagement According to the Time of Events in ICH.\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from C. Anderson, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-4\u0022\u003EJoseph P. Broderick, MD, University of Cincinnati, Cincinnati, OH, used data from some of the key clinical trials in ICH [Mendelow AD et al. \u003Cem\u003ELancet\u003C\/em\u003E 2005; Teernstra O et al. \u003Cem\u003EStroke\u003C\/em\u003E 2003; Wang WZ et al. \u003Cem\u003EInt J Stroke\u003C\/em\u003E 2009; Morgan T et al. \u003Cem\u003EActa Neurochir\u003C\/em\u003E Suppl 2008; Cho DY et al. \u003Cem\u003ESurg Neurol\u003C\/em\u003E 2006; Hanley DF. \u003Cem\u003EStroke\u003C\/em\u003E 2009] to answer important questions that concern the surgical management of ICH\u2014such as when surgical removal of ICH is indicated, the role of the location of the ICH in the surgical decision, the best surgical approach to remove the hemorrhage, and whether the timing of surgery matters.\u003C\/p\u003E\u003Cp\u003EDr. Broderick concluded that clinical trial evidence and expert opinion currently indicate that:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\u003Cp id=\u0022p-6\u0022\u003EPatients with cerebellar hemorrhage who are deteriorating neurologically or who have brain stem compression and\/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\u003Cp id=\u0022p-7\u0022\u003EIn those patients who present in coma with deep hemorrhages, removal of ICH by standard craniotomy is not recommended. Use of minimally invasive approaches in these patients is under study. For patients who present with lobar clots \u22641 cm from the surface, evacuation of supratentorial ICH by standard craniotomy might be considered.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\u003Cp id=\u0022p-8\u0022\u003EThe effectiveness of minimally invasive clot evacuation, utilizing either stereotactic or endoscopic aspiration with\/without thrombolytic usage, is uncertain. Although intraventricular administration of rt-PA in IVH appears to have a fairly low complication rate, efficacy, and safety of this treatment is uncertain.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\u003Cp id=\u0022p-9\u0022\u003EThere is no clear evidence that ultraearly removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be associated with an increased risk of recurrent bleeding.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EWe still need a lot more information, which may come from the clinical trials that are currently in progress, concluded Dr. Broderick.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003E\u201cPrognostication matters,\u201d said J. Claude Hemphill III, MD, University of California, San Francisco, CA. He noted, however, that prediction models and scoring systems are developed on, and apply to, populations of ICH patients, and while they are useful, their point scores can not be used with certainty in individual patients. Approximately half of all ICH-associated deaths occur in the first 2 days, and the majority (60% to 78%) of these is due to withdrawal of medical support [Hemphill JC et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2009; Zurasky JA et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2005]. Additionally, other care limitations, short of actual withdrawal of medical support, may impact outcome. For example, being treated in a hospital that uses do-not-resuscitate (DNR) orders within the first 24 hours after ICH as little as 10% more often than another hospital with a similar case mix has been shown to increase a patient\u0027s odds of dying during hospitalization by 13% (p\u0026lt;0.001). This is likely because early DNR use is probably a surrogate for overall aggressiveness of care [Hemphill JC et al. \u003Cem\u003EStroke\u003C\/em\u003E 2004].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EWhile the use of DNR orders is unlikely to invalidate existing prediction models overall, it may very well impact the point estimates of outcome that are often used for individual patients. This has prompted American Heart Association ICH guidelines to recommend careful consideration of aggressive full care during the first 24 hours after ICH onset and postponement of new DNR orders during that time (Class IIb, Level of Evidence B). Dr. Hemphill concluded by repeating one of the basic tenets of care: \u201cYou have to survive in order to improve.\u201d\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003ESteven M. Greenberg, MD, Massachusetts General Hospital, Boston, MA, reviewed the tools and procedures for recovery and prevention of ICH recurrence.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EICH recurrence (2.1% to 3.7%\/patient-year in population-based studies) is a significant factor in the recovery process. Lobar hemorrhages have a significantly higher risk of recurrence (p=0.007) than deep hemispheric or brain stem ICH [Viswanathan A et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2006]. Other possible risk factors for recurrence include older age, prior ICH, anticoagulation, APOE genotype, and number of microbleeds.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EBlood pressure (BP) control is an important factor in preventing ICH recurrence. The Perindopril Protection Against Recurrent Stroke (PROGRESS) study established that a BP-lowering regimen of an angiotensin-converting enzyme and a diuretic can reduce stroke risk by 67% [Tzourio et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2008]. A reasonable BP target is \u0026lt;140\/90 mm Hg. The recommendations for whether to use anticoagulant or antiplatelet therapy in ICH patients with indications for these treatments are not clear cut. There is a relatively strong contraindication to anticoagulants following ICH and a weaker one for antiplatelets, since antiplatelet agents are associated with a lower risk of catastrophic ICH than anticoagulants. The most favorable risk-benefit ratio is when there is a strong indication (such as the presence of atrial fibrillation) and the contraindication is weak (eg, a patient with a deep hemispheric ICH with well-controlled BP). Heavy alcohol use (\u0026gt;1 drink per day) should also be avoided, but there is currently insufficient evidence to withhold statins or restrict physical activity. Rehabilitation efforts should begin early, take a multidisciplinary approach, and continue as part of accelerated hospital discharge and reintegration to home environment.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/10\/1\/29.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmulq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmulq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}