Despite its severity, experts differ on the optimal management of ICH: are non-surgical, medical therapies best, or should physicians choose more invasive surgical procedures?
This is the profound, timely, and deeply vital question explored in detail during a fascinating and informative lecture by Michael M. Gezalian, MD entitled “Intracerebral Hemorrhage: Surgery vs Medical Therapy.” This 24-minute talk was recorded exclusively for AudioDigest at the 13th Annual Symposium on Neurovascular Disease: Symptoms and Solutions, held online on Jan. 29, 2022 and presented by Cedars-Sinai. It is also fully accredited for CME by the Accreditation Council for Continuing Medical Education and qualifies for AMA PRA Category 1 Credits™ for 35 months from the date of its publication.
Intracerebral hemorrhage: a closer look
Intracerebral Hemorrhage is fairly common in all strokes, but especially prevalent (at a rate of around 66 percent) in hemorrhagic strokes. The primary injury occurs in the first few hours after onset via compression and destruction of perihematomal tissue. Secondary injury is from inflammation, thrombin activation, and erythrocyte lysis—accelerating the formation of brain edema around the ICH.
“There are over two million cases of ICH each year in the U.S. and there is a disproportionately high morbidity and mortality associated with this disease,” explains Dr. Gezalian, who serves as Assistant Professor of Neurology and Neurosurgery at Cedars-Sinai Medical Center in Los Angeles, California. “The risk of seizures, including subclinical seizures, is relatively high — more so in patients with lobar hemorrhages.”
Surgical management solutions to treat ICH
In his lecture, Dr. Gezalian discusses a handful of surgical management solutions for treating ICH — addressing them head-on and in their full spectrum. His analysis and recommendations are partially summarized as follows:
- Minimally invasive surgical approaches: The effects of minimally invasive surgical approaches are still not fully understood. Current recommendations are that surgery should be performed as soon as possible for patients who present with posterior fossa hemorrhage with acute hydrocephalus, brainstem compression, or worsening neurologic condition.
- Early craniotomy for hematoma evacuation: Not recommended routinely for supratentorial ICH, especially deep ICH and small lobar ICH with a preserved level of consciousness.
- Decompressive craniotomy with or without ICH evacuation: May reduce mortality for patients in a coma who have large hematomas with significant midline shift, those with refractory intracranial hypertension, or delayed neurologic deterioration.
Non-surgical medical therapies
As is the case with many medical emergencies and problematic conditions, surgical intervention is not the sole route physicians and medical professionals can pursue when treating intracerebral hemorrhage. Dr. Gezalian addresses some non-surgical medical therapies, including:
- Hemostatic strategies: These interventions allow for immediate reversal of the underlying cause. Around 15% of ICH is associated with anticoagulant use.
- Hemostasis with antiplatelet therapies: Antiplatelet therapies increase a patient’s likelihood of secondary hematoma expansion and poor outcomes. Platelet transfusion should be avoided if the ICH is related to antiplatelet therapies but can be considered if patients have thrombocytopenia or require neurosurgical interventions.
- Acute blood pressure control: In patients with acute mild-to-moderate severity ICH and no contraindications to acute BP reduction, early intensive blood pressure reduction is safe—but does not reduce death or severe disability. If the ICH is in the basal ganglia, intensive BP reduction has been associated with a lower risk of hematoma expansion.
Options and analysis for treating patients
There are several viable options available today when it comes to treating patients who present with spontaneous ICH. Dr. Gezalian concludes his lecture by cautioning that any reliance on available data must be carefully balanced with good, old-fashioned medical practice and discernment—along with individual attention to each unique patient.
“We have data out there that gives us some guidance on how to care for these patients,” says Dr. Gezalian. “However, that data really doesn’t capture all of the patients who present with spontaneous ICH. It’s important for us to really go off of our clinical judgment, with some of that data guiding our care.”
Additional neurology lectures
Dr. Michael M. Gezalian’s lecture “Intracerebral Hemorrhage: Surgery vs Medical Therapy” is just one of several lectures you may find informative and impactful to your practice. Additional CME/CE-accredited content available anytime, anywhere you choose to listen, learn, and earn CME includes:
- Surgical Management of Spontaneous Intracerebral Hemorrhage, Part 1
- Surgical Management of Spontaneous Intracerebral Hemorrhage, Part 2
- Neurocritical Care Approaches to Intracerebral Hemorrhage
In addition to our always-available lectures, explore more of our insightful, in-depth Neurology CME/CE solutions.
