Gestione dell'emorragia intracranica

Spontaneous intracerebral hemorrhage (ICH) was traditionally considered part of a general vascular damage often induced by chronic arterial hypertension. For this reason, unlike traumatic brain injury and subarachnoid hemorrhage, in the last years clinicians didn't use aggressive treatments in patients with ICH. After the initial bleeding, hematoma increases in volume in approximately one third of case. Several experimental studies have shown that the deleterious effects of intracerebral blood are due both to its mass effect and to a toxic effect. This is caused by the activation of coagulation cascade and the release of toxic substances, causing brain edema. Consequently reduction or, possibly, elimination of the hematoma would likely to be the best therapeutical approach for ICH. In 1961 the first prospective randomized trial showed that conservative treatment was associated with better outcome tha surgical treatment. In January 2005 a prospective randomized study on 1.033 patients compared early surgery with conservative treatment for ICH. Patients were elegible if the neurosurgeon was uncertain about the benefit of either treatments. This trial showed no benefit from early surgery when compared with conservative treatment. The month after a randomized, controlled trial evaluated the ability of activated factor VII to reduce hematoma expansion. Three hundred and thirty nine patients with GCS>5 were assigned to receive placebo or one of three doses of activated factor VII (40, 80 or 160 µg/kg). Treatment with activated factor VII reduces the growth of hematoma and imporves outcome, despite a small increase in the thromboembolic events. In 2004 trombolytic therapy for intraventricular hemorrhage wa sevaluated in a small randomized controlled trial. This study showed that intraventricular thrombolysis with urokinase speeds the resolution of intraventricular blood clot. In conclusion surgical treatment following ICH is still controversial. Medical treatment with activated factor VII might be successful. Careful selection of patients who might benefit from aggressive treatment, either surgical or medical, remain necessary.