New Treatment Strategies in the Management of Large Hemispheric Strokes and Intracerebral Hemorrhages

Large ischemic strokes and intracerebral hemorrhage continue to have significant morbidity and mortality. Changes in our understanding of the cerebral hemodynamics of pressure volume shifts after expanding hemispheric mass lesions led to the development of hemicraniectomy to allow for expansion of edematous cerebral tissue outside of the skull. This technique has had considerable impact on morbidity and mortality. Patient identification and timing of surgery remain under investigation. Recent studies have revealed that ICH is a dynamic event with hematoma expansion occurring over the first few hours. Strategies to prevent or limit this expansion have focused on decreasing post-hemorrhage hypertension and inducing thrombosis. Similarly, secondary injury after hemorrhage may account for a noted increased neurological deficit compared to anatomic cellular loss. Medical strategies to prevent secondary neurological damage currently being studied include the use of iron chelators. The failure of surgical trials to reveal any benefit post-ICH has renewed interest in minimally invasive strategies to initiate clot removal. This combined with thrombolytics is currently being investigated with both intracerebral and intraventricular hemorrhage. The changing demographics of intracerebral hemorrhage with an increased incidence of hemorrhages secondary to anticoagulation may also shape future studies.