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Seminar

Intracerebral haemorrhage
Adnan I Qureshi, A David Mendelow, Daniel F Hanley
Lancet 2009; 373: 1632–44 Zeenat Qureshi Stroke Research Center, Department of Neurology and Neurosurgery, University of Minnesota, MN, Minnesota, USA (A I Qureshi MD); Department of Neurosurgery, University of Newcastle, Newcastle, UK (A D Mendelow FRCS); and Division of Brain Injury Outcomes, JohnsHopkins Medical Institutions, Baltimore, MD, USA (D F Hanley MD) Correspondence to: Dr Adnan I Qureshi, Department of Neurology, University of Minnesota, 12-100 PWB, 516 Delaware St SE, Minneapolis, MN 55455, USA qureshi@umn.edu

Intracerebral haemorrhage is an important public health problem leading to high rates of death and disability in adults. Although the number of hospital admissions forintracerebral haemorrhage has increased worldwide in the past 10 years, mortality has not fallen. Results of clinical trials and observational studies suggest that coordinated primary and specialty care is associated with lower mortality than is typical community practice. Development of treatment goals for critical care, and new sequences of care and specialty practice can improve outcome afterintracerebral haemorrhage. Specific treatment approaches include early diagnosis and haemostasis, aggressive management of blood pressure, open surgical and minimally invasive surgical techniques to remove clot, techniques to remove intraventricular blood, and management of intracranial pressure. These approaches improve clinical management of patients with intracerebral haemorrhage and promise toreduce mortality and increase functional survival.

Introduction
Non-traumatic intracerebral haemorrhage results from rupture of blood vessels in the brain. It is a major public health problem1 with an annual incidence of 10–30 per 100 000 population,1,2 accounting for 2 million (10–15%)3 of about 15 million strokes worldwide each year.4 Hospital admissions for intracerebral haemorrhage haveincreased by 18% in the past 10 years,5 probably because of increases in the number of elderly people,6 many of whom lack adequate blood-pressure control, and the increasing use of anticoagulants, thrombolytics, and antiplatelet agents. Mexican Americans, Latin Americans, African Americans, Native Americans, Japanese people, and Chinese people have higher incidences than do white Americans.2,7–9 Thesedifferences are mostly seen in the incidence of deep intracerebral haemorrhage and are most prominent in young and middle-aged people. Incidence might have decreased in some populations with improved access to medical care and blood-pressure control.8–10 Primary and secondary (anticoagulant-induced) intracerebral haemorrhage have similar underlying pathological changes.11 Intracerebralhaemorrhage commonly affects cerebral lobes, the basal ganglia, the thalamus, the brainstem (predominantly the pons), and the

Search strategy and selection criteria We based our review on personal knowledge of the subject supplemented by data derived from multicentre randomised trials, and selected non-randomised or observational clinical studies. The information was identified with multiple searches onMedline from 2002 to the present by cross referencing the following keywords: “cerebral haemorrhage”, “intracerebral hemorrhage”, “neuroimaging”, “clinical studies”, “randomised trials”, “cytotoxicity”, “oedema”, “haemostatic treatment”, “factor VII”, “acute hypertension”, “surgery”, “endoscopic evacuation”, “stereotactic surgery”, “intraventricular catheter”, “hydrocephalus”, and “oralanticoagulants”. Other pertinent articles were identified through review of bibliography from selected articles. We also reviewed abstracts from pertinent scientific meetings.

cerebellum as a result of ruptured vessels affected by hypertension-related degenerative changes or cerebral amyloid angiopathy.1 Most bleeding in hypertensionrelated intracerebral haemorrhage is at or near the bifurcation of small...