Hemorrhagic Stroke: Introduction

Daniel F. Hanley, MD; Issam A. Awad, MD; Paul M. Vespa, MD; Neil A. Martin, MD;
Mario Zuccarello, MD

Downloaded from http://stroke.ahajournals.org/ by guest on November 2, 2016

he last form of stroke without a primary treatment is intracerebral hemorrhage (ICH).1 The past decade has brought
significant understanding of hematoma expansion, ICH volume, and intraventricular hemorrhage extension as independent severity factors.2 The Surgical Treatment for Ischemic
Heart Failure (STICH) trials indicate that craniotomy is not
the answer for deep hematomas but has created enthusiasm
for site-selective surgery; a subsequent post hoc analysis suggests that limited craniotomy for lobar ICH to reduce volume
of hematomas within 1 cm of the surface may be promising.3
The Fluid Accumulation Status Trial (FAST) trial achieved
stability by 24 hours, but was insufficient to alter either
72-hour edema volume or 90-day functional outcome. A subsequent meta-analysis proposes that reductions of 12.5 mL
are much more likely to lead to favorable shifts of important
outcomes, such as modified Rankin Scale4 in a group with
large expansions that account for 11% of the ICHs at presentation. With this background, Gonzales5 describes a full range
of clinical trial targets with the potential to limit secondary
damage begun by bleeding. Of these targets, 2 are particularly promising: (1) early reduction of blood pressure to limit
hematoma volume growth, and (2) minimally invasive surgery to reduce hematoma volume in subjects not experiencing active hematoma growth.5 These targets are not mutually
exclusive, as blood pressure control is needed at ICH presentation, and the time window for surgery seems to be long (up
to 72 hours)6,7 and may be enhanced by early blood pressure
control. Both offer the possibility of reducing brain injury
by limiting growth (12.5 mL) of clot volume size. Qureshi8
describes the evolution of data supporting early treatment of
blood pressure. Ziai9,10 describes the cascade of inflammatory
factors, which drives the progression of mass effect over several weeks when blood products alter the blood brain barrier.
This is followed by Vespa11 describing 2 different minimally
invasive methods for hematoma volume reduction and limitation of inflammation/edema. Data presented from Minimally
Invasive Surgery + rtPA for Intracerebral Hemorrhage
(MISTIE) and Intraoperative CT-Guided Endoscopic Surgery
for Intracerebral Hemorrhage (ICES) demonstrate that minimally invasive reduction of clot volume is effective at the deep
basal ganglia sites where STICH was not beneficial.

When these presentations are considered together, the

total evidence suggests the strategic priority for ICH is to
(1) determine the value of early stability and (2) acquire scientific knowledge about the volume reduction hypothesis.
Vespa11 presents a biologically plausible argument that minimally invasive techniques limit tissue damage and maximize
reduction of the inflammatory triggers. From the pending
Interventions to Reduce Acute Care Transfers II (INTERACT
II) and Antihypertensive Treatment of Acute Cerebral
Hemorrhage II (ATTACH) results and the potential MISTIE
III trials, it can be expected that improved knowledge of disease severity factors, patient selection, and timing of interventions will occur. Thus, these presentations demonstrate that
independent investigation of well-defined disease factors, and
interventions designed to mitigate these factors, can produce
new knowledge that will likely unravel the disease process of
the last untreated form of stroke.

Disclosures
None.

References
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Final Report of Stroke Progress Review Group (SPRG) on the Priorities
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Accessed May 15, 2012.
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MC. Neurosurgical outcomes after intracerebral hemorrhage: results of
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From the Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD (D.F.H.); Department of Neurovascular Surgery,
University of Chicago Medicine and Biological Sciences, Chicago, IL (I.A.A.); Department of Neurosurgery and Neurology, Division of Neurocritical Care
(P.M.V.) and Department of Neurosurgery (N.A.M.), David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA;
and Mayfield Clinic, University of Cincinnati, Cincinnati, OH (M.Z.).
Correspondence to Daniel F. Hanley, MD, Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, 1550 Orleans St 3M-S, Baltimore,
MD 21231. E-mail dhanley@jhmi.edu
(Stroke. 2013;44[suppl 1]:S65-S66.)
2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org

DOI: 10.1161/STROKEAHA.113.000856

S65

S66StrokeJune 2013
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10. Ziai WC. Hematology and Inflammatory Signaling of ICH, Princeton

Conference, May 2012. In: Summary of the XXVIII Princeton Conference,
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et al. Frameless stereotactic aspiration and thrombolysis of deep
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274281.
Key Words: blood pressure craniotomy intracerebral hemorrhage rt-PA
stroke

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Hemorrhagic Stroke: Introduction

Daniel F. Hanley, Issam A. Awad, Paul M. Vespa, Neil A. Martin and Mario Zuccarello

Downloaded from http://stroke.ahajournals.org/ by guest on November 2, 2016

Stroke. 2013;44:S65-S66
doi: 10.1161/STROKEAHA.113.000856
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2013 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628

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