Intracerebral haemorrhage — mechanisms, diagnosis and prospects for treatment and prevention

Intracerebral haemorrhage (ICH) is a devastating condition associated with high mortality and substantial residual disability among survivors. Effective treatments for the acute stages of ICH are limited. However, promising findings from randomized trials of therapeutic strategies, including acute care bundles that target anticoagulation therapies, blood pressure control and other physiological parameters, and trials of minimally invasive neurosurgical procedures have led to renewed optimism that patient outcomes can be improved. Currently ongoing areas of research for acute treatment include anti-inflammatory and haemostatic treatments. The implementation of effective secondary prevention strategies requires an understanding of the aetiology of ICH, which involves vascular and brain parenchymal imaging; the use of neuroimaging markers of cerebral small vessel disease improves classification with prognostic relevance. Other data underline the importance of preventing not only recurrent ICH but also ischaemic stroke and cardiovascular events in survivors of ICH. Ongoing and planned randomized controlled trials will assess the efficacy of prevention strategies, including antiplatelet agents, oral anticoagulants or left atrial appendage occlusion (in patients with concomitant atrial fibrillation), and optimal management of long-term blood pressure and statin use. Together, these advances herald a new era of improved understanding and effective interventions to reduce the burden of ICH. Effective treatments for the acute stages of intracerebral haemorrhage are currently limited. In this Review, the authors consider advances in therapeutic strategies and neurosurgical procedures, including acute care bundles, that promise a new era of interventions. Key points Intracerebral haemorrhage (ICH) is a common and severe type of stroke associated with severe morbidity and mortality. Advances in acute treatment of ICH, including ultra-early blood pressure control, anticoagulation reversal and minimally invasive neurosurgical procedures, have great potential to improve patient outcomes; bundled approaches might have particular value in acute settings. Diagnosis of the underlying aetiology of ICH is crucial for understanding the cause; diagnosis usually requires both vascular and structural (magnetic resonance) imaging. The most important aetiologies of ICH include arteriolosclerosis, cerebral amyloid angiopathy and macrovascular causes. ICH aetiology must be determined