Intracerebral hemorrhage accounts for 10-15% of strokes with high mortality. Primary injury from hematoma formation can induce brain edema, which is associated with poor outcomes. The inflammation, thrombin activation, and erythrocyte lysis caused by primary injury can promote brain edema formation. Guidelines recommend measures to lower intracranial pressure such as head elevation and sedation. Mannitol or hypertonic saline may be used to treat acute pressure elevations. However, evidence for treatments to lower pressure is limited.

1. BRAIN EDEMA AFTER INTRACEREBRAL HEMORRHAGE
ADE WIJAYA, MD – OCTOBER 2020

2. INTRODUCTION
• Intracerebral hemorrhage (ICH) accounts for about 10–15% of all strokes with high
mortality
• 1-month mortality of ICH is approximate 40% and it increases with age
• In the first few hours after ICH onset, primary brain injury by ICH is mainly caused
by the oppression and destruction to the near tissue by hematoma formation. And
hematoma could also increase the intracranial pressure; it can even induce brain
herniation
• The inflammation, thrombin activation, and erythrocyte lysis caused by primary
injury could promote the formation of brain edema, which is associated with poor
outcome, and could cause more severe and durable injury
Flower O, Smith M: The acute management of intracerebral hemorrhage. Curr Opin Crit Care 2011;17:106–114.
van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ: Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet
Neurol 2010; 9: 167– 176.
Keep RF, Hua Y, Xi G: Intracerebral haemorrhage: mechanisms of injury and therapeutic targets. Lancet Neurol 2012;11:720–731.

3. MECHANISM OF VASOGENIC EDEMA
Zheng H, Chen C, Zhang J, Hu Z. Mechanism and therapy of brain edema after intracerebral hemorrhage. Cerebrovascular diseases. 2016;42(3-4):155-69.
Ziai WC: Hematology and inflammatory signaling of intracerebral hemorrhage. Stroke 2013;44(6 suppl 1):S74–S78.

4. MECHANISM OF INFLAMMATION INDUCES EDEMA
Zheng H, Chen C, Zhang J, Hu Z. Mechanism and therapy of brain edema after intracerebral hemorrhage. Cerebrovascular diseases. 2016;42(3-4):155-69.
Ziai WC: Hematology and inflammatory signaling of intracerebral hemorrhage. Stroke 2013;44(6 suppl 1):S74–S78.

5. MECHANISM OF THROMBIN INDUCES EDEMA
Zheng H, Chen C, Zhang J, Hu Z. Mechanism and therapy of brain edema after intracerebral hemorrhage. Cerebrovascular diseases. 2016;42(3-4):155-69.
Ziai WC: Hematology and inflammatory signaling of intracerebral hemorrhage. Stroke 2013;44(6 suppl 1):S74–S78.

6. MECHANISM OF RBC LYSIS PRODUCTION INDUCES EDEMA
Zheng H, Chen C, Zhang J, Hu Z. Mechanism and therapy of brain edema after intracerebral hemorrhage. Cerebrovascular diseases. 2016;42(3-4):155-69.
Ziai WC: Hematology and inflammatory signaling of intracerebral hemorrhage. Stroke 2013;44(6 suppl 1):S74–S78.

7. TREATMENT
Sonni S, Lioutas VA, Selim MH: New avenues for treatment of intracranial hemorrhage. Curr Treat Options Cardiovasc Med 2014;16: 277.
Zheng H, Chen C, Zhang J, Hu Z. Mechanism and therapy of brain edema after intracerebral hemorrhage. Cerebrovascular diseases. 2016;42(3-4):155-69.

8. AHA/ASA GUIDELINES
• Basic principles include elevation of the head of the bed to 30°, the use of mild
sedation, and avoidance of collar-endotracheal tube ties that might constrict cervical
veins
• Mannitol or hypertonic saline may be used to treat acute ICP elevations, and
hypertonic saline may be more effective
• In patients with CSF outflow obstruction caused by hydrocephalus or a trapped
ventricle, CSF drainage should be considered. Hematoma evacuation and
decompressive craniectomy (DC) are options for treating elevated ICP
• Salvage therapies might include barbiturate coma or mild hypothermia.
• Corticosteroids should not be used, because they are not effective in ICH and
increase complications
Morgenstern LB, Hemphill III JC, Anderson C, Becker K, Broderick JP, Connolly Jr ES, Greenberg SM, Huang JN, Macdonald RL, Messe SR, Mitchell PH. Guidelines for the management of spontaneous intracerebral hemorrhage: a
guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010 Sep 1;41(9):2108-29.

9. ESO GUIDELINES
• Recommendation
There is insufficient evidence from RCTs to make strong recommendations on
measures to lower intracranial pressure for adults with acute ICH.
Quality of evidence: Low
Strength of recommendation: Weak
Steiner T, Salman RA, Beer R, Christensen H, Cordonnier C, Csiba L, Forsting M, Harnof S, Klijn CJ, Krieger D, Mendelow AD. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral
hemorrhage. International journal of stroke. 2014 Oct;9(7):840-55.

10. ESO GUIDELINES
• Hypertonic saline (3%) was tested in one nonrandomized feasibility study in
patients with supratentorial ICH, leading to less perihematomal edema and a trend
in mortality figures in favor of treatment when compared with 64 historical controls
• Invasive mild hypothermia (35°C) started within 12 h of symptom onset for 10 days
in 10 patients with ICH resulted in reduced peri-hematomal edema volumes and
increased the chance of survival when compared with 25 patients who were not
treated
• Several nonrandomized studies compared decompressive craniectomy plus
hematoma evacuation with hematoma evacuation alone with conflicting results
Steiner T, Salman RA, Beer R, Christensen H, Cordonnier C, Csiba L, Forsting M, Harnof S, Klijn CJ, Krieger D, Mendelow AD. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral
hemorrhage. International journal of stroke. 2014 Oct;9(7):840-55.

11. THANK YOU