Blood Pressure Management Is Only Part of the Story in Intracerebral Hemorrhage

Guidelines are also rather silent about addressing secondary mechanisms of brain injury in ICH, but not from lack of trying. Trials targeting inflammatory cascades with statins13 and intra-lesional alteplase14 have shown some promise. Current trials investigating the use of iron chelation,15 therapeutic hypothermia,16 and fingolimod17 are underway with other targets being investigated in animal models.2

Dr Qureshi and colleagues have demonstrated that in contrast to current guidelines, intensive SBP lowering alone in acute ICH is likely not effective. Despite trial evidence to the contrary, it is hard to believe that therapies that reduce hematoma expansion and peri-hematomal edema have zero effect. Perhaps what we are observing is that complex secondary cascades causing damage beyond the initial hemorrhage contribute more to long-term functional outcomes.  What may be required to ensure the best outcome for patients suffering acute intracerebral hemorrhage is a multi-faceted medical and surgical approach targeting more than one mediator of injury. In the meantime, we wait for further evidence.


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