Medical Book

Buy Textbooks | Autoclaves | stethoscopes | Buy Books Online | Buy Medical Textbooks | Textbooks | Equipment | Nutrition | USMLE | MRCP | MRCS | Dental | Sport Medicine | Cardiology | Medical Textbook | Surgery | Pregnancy | Anatomy | Radiation | Pedia |
 
HomeCalendarFAQSearchMemberlistUsergroupsRegisterLog in
Reply to topicShare | 
 

 Advances in the Management of Intracerebral Hemorrhage

View previous topic View next topic Go down 
AuthorMessage
john



Membership NO: 1
Male Posts: 1676
Join date: 2011-03-27

PostSubject: Advances in the Management of Intracerebral Hemorrhage   Thu Jun 09, 2011 1:45 pm

Advances in the Management of Intracerebral Hemorrhage

Abstract and Introduction

                       Abstract

                       Intracerebral hemorrhage (ICH) is a major
public-health problem worldwide. No proven treatments are available for
this condition, which is associated with high rates of morbidity and
mortality. Only 20% of individuals who survive ICH are independent at 6
months. Hypertension, cerebral amyloid angiopathy (CAA) and
anticoagulation are known to be associated with such hemorrhages. No
effective preventive therapies exist specifically for CAA-related ICH.
The incidence of hypertension-related ICH might be decreasing in some
populations with improvements in the treatment of hypertension; however,
the incidence of anticoagulant-related ICH is increasing, as the use of
anticoagulants rises. Many questions remain unanswered regarding the
clinical management of ICH, although in the past 10 years completed
medical and surgical clinical trials—examining hemostatic therapy, blood
pressure control and/or hematoma evacuation—have refined our
understanding of the goals of such management. Ongoing clinical trials,
which have built on the lessons of past studies, hold promise for the
development of effective, scientifically proven treatments for ICH. In
this Review, we discuss clinical trials for ICH that have been completed
in the past 10 years, the contributions of these studies to the
clinical management of ICH, and the ongoing trials that might further
improve clinical care.
                   
Introduction
                       

                       Spontaneous nontraumatic intracerebral hemorrhage (ICH) occurs in ≈2 million people worldwide every year[1-4] and represents a major global public-health problem. ICH is associated with a 30 day mortality rate of 32-50%,[2,5,6] and 6 month functional independence is only achieved in 20% of individuals who survive such hemorrhages.[6] ICH
represents 10-15% of all strokes that occur in the US, Europe and
Australia, and 20-30% of all strokes that occur in Asian countries.[7] In the US alone, ICH accounts for ≈US$12.7 billion of the US$74 billion in direct costs related to stroke care annually.[8,9]
                       
                       The most important risk factor for ICH is
age. Each advancing decade from 50 years of age is associated with a
twofold increase in ICH incidence. The most notable modifiable risk
factor for ICH is hypertension, which is present in 50-70% of patients
who develop such hemorrhages.[10]
Hypertension is primarily associated with ICH that occurs in deep
cerebral and brainstem locations and, to a lesser extent, lobar
locations,[11] and confers a higher risk of ICH in younger individuals (aged ≤45 years) than in older people (aged >45 years).[12]
Evidence indicates that the incidence of ICH might have decreased in
some populations with improvements in hypertension control.[13,14]
In a study of cardiovascular disease in three cohorts of Japanese
people from 1961, 1974 and 1988, the incidence of ICH in men but not in
women was found to have declined (by 61%) from the first to the second
cohort, although from the second to third cohorts the incidence remained
stable in both sexes.[13]
In a Chinese study conducted from 1991-2000, the incidence of ICH
decreased by 12.0% per year in Beijing, 4.4% per year in Shanghai and
7.7% per year in Changsha.[14]
                       
                       Anticoagulant-related ICH is associated with a
higher mortality rate and a more-prolonged period of continued bleeding
than non-anticoagulant-related ICH,[15-17] and has risen in incidence over the past decade.[18]
Indeed, a study conducted in the Greater Cincinnati region of the US
found that the annual incidence of anticoagulant-related ICH per 100,000
people increased significantly (P <0.001) from 0.8 (95% CI
0.3-1.3) in 1988, to 1.9 (95% CI 1.1-2.7) in 1993-1994, and to 4.4 (95%
CI 3.2-5.5) in 1999. Since warfarin distribution in the US quadrupled on
a per capita basis from 1988-1999, the investigators who conducted this
study suggested that most of the increase in anticoagulant-related ICH
could be attributed to the increase in use of this agent.[18]
                       
                       Cerebral amyloid angiopathy (CAA) has emerged as an increasingly important cause of ICH, particularly in the elderly.[19]
CAA-related ICH rarely occurs in people aged <60 years but markedly
increases in incidence thereafter, and is nearly always associated with a
lobar location of the hemorrhage.[19]
No specific preventive therapies exist for CAA-related ICH, although
evidence suggests that control of hypertension might reduce the risk of
such hemorrhages.[20]
                       
                       To date, no medical or surgical clinical
trials have unequivocally demonstrated improvements in functional
outcome after ICH. Thus, this condition remains a challenging clinical
and public-health problem. In this Review, we discuss the natural
history of acute ICH, clinical trials for this condition that were
completed and/ or initiated in the past 10 years, and prospective novel
therapies and future clinical trials that might improve functional
outcomes and reduce the overall societal burden of ICH.





Natural History


                       Clinically, patients with ICH present with a
focal neurological deficit that might be associated with headache,
nausea, vomiting or other symptoms. After the initial presentation,
early (within hours) neurological deterioration can occur. Historically,
the 'hemorrhage' in ICH was thought to be a static process, and the
observed neurological deterioration was believed to result from cerebral
edema.[21]
A sentinel prospective study demonstrated, however, that early
neurological deterioration in ICH was due to ongoing bleeding and
hematoma expansion (Figure 1).[22]
In this study, which involved 103 patients with ICH who presented
within 3 h of symptom onset, head CT scans were obtained at presentation
(baseline), 1 h later, and then at 20 h. 26% of patients had a
significant increase in hematoma volume (defined as a >33% increase
in volume) within 1 h of the baseline CT, and an additional 12% of
patients exhibited further hematoma expansion at 20 h. Hematoma
expansion was associated with neurological deterioration, as measured by
the Glasgow Coma Scale (GCS) and the NIH Stroke Scale.[22]
Subsequently, other large prospective studies have confirmed the early
dynamic changes observed in hemorrhages in patients with ICH (
Table 1
).[23-25]
                       

                                                   

(Enlarge Image)



                                   Figure 1.
                               

Hematoma Expansion Revealed by CT. Head CT scans were obtained from a
63 year-old woman who presented within 3 h of the onset of stroke
symptoms. a | The scan taken on the patient's arrival at the hospital showed a right basal ganglion intracerebral hemorrhage. b |
As a result of a deterioration in the neurological status of the
patient, a second scan was obtained 4 h after the initial CT. In this
image hematoma expansion can be observed.
[ CLOSE WINDOW ]

<blockquote>

</blockquote>

                                   Figure 1.
                               

Hematoma Expansion Revealed by CT. Head CT scans
were obtained from a 63 year-old woman who presented within 3 h of the
onset of stroke symptoms. a | The scan taken on the patient's arrival at the hospital showed a right basal ganglion intracerebral hemorrhage. b |
As a result of a deterioration in the neurological status of the
patient, a second scan was obtained 4 h after the initial CT. In this
image hematoma expansion can be observed.

                       In addition to the volume of the parenchymal
hematoma, the presence and expansion of intraventricular hemorrhage
(IVH) are powerful and independent predictors of ultimate outcomes in
cases of ICH. IVH occurs in 45% of patients with spontaneous ICH,[26] and contributes to early neurological deterioration and poor functional outcomes.[27,28]
In a secondary analysis of data from a prospective study of 1,033
patients with ICH, the presence of IVH was associated with a lower
probability of favorable outcomes than was an absence of IVH (15% versus
31%, P <0.00001).[27]
Another study showed that a >2 ml increase in IVH volume in the
first 24 h from baseline was associated with an odds ratio (OR) of a
poor outcome of 4.21 (95% CI 1.06-16.63, P = 0.0405).[28]
Thus, hematoma expansion in the brain parenchyma or into the
ventricular system might have dire consequences for patient outcomes.
                       In addition to the influence of IVH, early
deterioration in ICH might also be affected by cerebral edema. In a
prospective observational cohort of 142 patients with ICH, baseline and
24 h absolute and relative (to the hematoma volume) edema volumes were
measured.[29]
Baseline relative edema volume was found to be the strongest predictor
of outcome, with a large relative volume being associated with lower
odds of a poor 3 month functional outcome than a small baseline relative
volume. By contrast, patients with a low level of baseline edema were
more likely to develop increases in edema volume during the subsequent
24 h than individuals with a high level of baseline edema.[29] Another
prospective study (INTERACT) of 270 patients with ICH that described
the evolution of perihematomal edema in the first 72 h after ICH
(baseline, 24 h and 72 h CT scans were reviewed) reported different
results.[30]
In this study, baseline perihematomal edema volume was highly
correlated with baseline hematoma volume (coefficient of determination
0.45). In multivariate analysis, both absolute (OR 1.85, 95% CI
1.30-2.65, P = 0.001) and relative (OR 1.48, 95% CI 1.13-1.94, P =
0.004) increases in perihematomal edema volume were associated with
death or dependency at 90 days before adjustment for baseline hematoma
volume. Once this adjustment had been made, however, neither the
absolute nor the relative increases in perihematomal edema were
associated with the 90 day outcomes. The investigators concluded that
the degree and growth of perihematomal edema were strongly related to
the volume of the underlying hematoma, and that these factors did not
seem to have an independent effect on ICH outcome.[30]
Given the variability in the results described above, the contribution
of early changes in edema to overall ICH-related morbidity remains
unclear.
                       Delayed edema can occur 3 days to 2 weeks after ictus in ICH. Zazulia et al.
studied the progression of mass effect or the increase in midline shift
during hospitalization in 76 patients with supratentorial ICH.[31]
Early development of mass effect (within 48 h of symptom onset)
occurred in 13% of cases and was associated with hematoma expansion,
while delayed mass effect (9-21 days after ictus) was thought to be
independently related to edema and occurred in 9% of cases.[31]
                       
                       Sansing and colleagues studied 80 patients
with supratentorial ICH. Peak edema volume was found to occur 5-6 days
after ICH onset.[32]
In this study, edema growth was correlated with platelet counts, and
the investigators suggested that interactions between activated
platelets and thrombin might contribute to edema development.[32]
                       
                       Delayed mass effect is thought to be induced
by red blood cell lysis and hemoglobin-induced neurotoxicity. Slow
thrombin release over time has also been suggested as the basis for
delayed edema.[33]
No established means exists for predicting hematoma expansion, early
edema or delayed edema in patients with ICH; however, the results of
published and ongoing clinical trials suggest that targeted therapy to
improve outcomes in such patients might become available in the near
future.
Clinical Trials

                       Therapy for ICH can be described as medical or surgical. To date, data from one large surgical[34] and five large medical[23-25,35,36] interventional clinical trials for ICH have been published (
Table 2
). None of these trials has shown a definite functional benefit from the
tested therapy; however, refinements to research questions and
improvements in patient selection for the studied interventions in
ongoing and future clinical trials should lead to effective therapies
for ICH.




                   
                       Medical Management Trials

                                                   Hemostatic Therapy.
To date, only two
large prospective interventional studies targeting hematoma expansion
in ICH by administration of recombinant factor VIIa (rFVIIa) have been
published.[24,25] In
the phase IIb study, 399 patients with ICH, who were diagnosed by CT
within 3 h of symptom onset, were randomized to receive placebo (n = 96) or 40 µg/kg (n = 108), 80 µg/kg (n = 92) or 160 µg/kg (n = 103) rFVIIa within 1 h after the baseline scan.[25] The primary outcome measure was the percentage change in ICH volume at 24 h.
The mean increase in ICH volume was 29% in the placebo group and 16%,
14%, and 11% in the groups receiving 40 µg/kg, 80 µg/kg, and 160 µg/kg
rFVIIa, respectively (a comparison of all three rFVIIa groups combined
with the placebo group revealed a significant difference in volume; P =
0.01). ICH volume expansion was reduced by 3.3 ml, 4.5 ml and 5.8 ml in
the 40 µg/kg, 80 µg/kg and 160 µg/kg rFVIIa treatment groups,
respectively, compared with the placebo group (P = 0.01 for all
three rFVIIa groups combined compared with placebo). The study was
underpowered to detect differences in mortality rates or functional
outcomes; however, mortality and severe disability rates (defined as a
modified Rankin Scale [mRS] score of 4-6) were significantly higher in
the placebo group than in all rFVIIa treatment groups combined ([i]P
                           [/i]= 0.004). The investigators who
conducted this study concluded, therefore, that in patients with ICH,
rFVIIa treatment within 4 h of symptom onset leads to reductions in
hematoma expansion and mortality rate and to improvements in functional
outcomes.[25]
                       
In the FAST trial, a phase III efficacy and safety study of rFVIIa
for acute ICH, 841 patients with such hemorrhages were randomly assigned
to receive placebo (n = 268), 20 µg/kg rFVIIa (n = 276) or 80 µg/kg rFVIIa (n = 297) within 4 h of symptom onset.[24]
The primary end point of this trial was rate of poor outcome, which was
defined as death or severe disability (according to the mRS) 90 days
after the stroke. The phase IIb trial initially excluded patients with
symptomatic thrombotic or vaso-occlusive disease (that is, angina,
claudication, deep vein thrombosis, or cerebral or myocardial
infarction) within 30 days before ICH onset. Midway through the trial,
however, patients with any history of thrombotic or vaso-occlusive
disease were excluded.[25]
By contrast, the FAST trial allowed participation of patients with a
history of vaso-occlusive disease but excluded individuals with symptoms
within 30 days of ICH.[24]
Treatment with 80 µg/kg rFVIIa led to a significant reduction in
hematoma expansion at 24 h (11% increase in volume with 80 µg/kg rFVIIa
versus 26% with placebo, P <0.001), and a nonsignificant
decrease in hematoma expansion was observed in patients who received 20
µg/kg rFVIIa (18% versus 26% in placebo, P = 0.09). No
differences in functional outcomes were observed, however, among the
three treatment groups (rate of poor clinical outcomes was 24% in the
placebo group, 26% in the 20 µg/kg rFVIIa group and 29% in the 80 µg/kg
rFVIIa group).[24]
                       
The posited explanations for the discrepant results between the phase
IIb and phase III trials included randomization imbalances (a higher
rate of IVH was present in patients treated with rFVIIa than occurred in
patients receiving placebo in the FAST study), an increase in arterial
thromboembolic events in patients receiving rFVIIa, inclusion of very
elderly patients (aged >80 years) and patients with very large
(>60 ml) ICHs, and better than expected outcomes in the placebo arm
of the FAST trial.[24]
A subgroup analysis of the FAST trial suggested that patients aged ≤70
years who had an ICH <60 ml and an IVH <5 ml, and arrived within
2.5 h of symptom onset, might benefit from rFVIIa.[37]
Nevertheless, in contrast to the 5% absolute increase in arterial
thromboembolic events initially reported in both rFVIIa trials, a
follow-up study found a 19% absolute increase in arterial thrombotic
events with such therapy.[38]
Accurate prediction of the probability of hematoma expansion before
administration of hemostatic therapy is, therefore, important for
harnessing the potential benefits of limiting hematoma expansion while
avoiding the potential thromboembolic complications associated with
rFVIIa therapy.
The appearance of contrast extravasation on CT angiography (the 'spot
sign') early after symptom onset represents a promising tool for the
prediction of hematoma expansion in ICH (Figure 1). In two case series,
patients with a spot sign had a greater risk of hematoma expansion than
patients without extravasation.[39,40] Wada et al.
prospectively studied 39 patients with ICH by CT angiography within 3 h
of symptom onset. Hematoma expansion occurred in 11 patients (28%), and
13 patients (33%) had the spot sign. In multiple regression analysis,
the spot sign independently predicted hematoma expansion (P = 0.0003).[40] Goldstein et al.
retrospectively reviewed images from 104 patients with ICH who
underwent CT angiography. Contrast extravasation was present in 56% of
patients, and was associated with an increased risk of hematoma
expansion compared with the absence of such signs (22% versus 2%, P = 0.003).[39] Taken
together, these studies suggest that the spot sign has a sensitivity of
91-93% and a specificity of 50-89% for the prediction of hematoma
expansion. Follow-up studies have found, however, that spot sign mimics
can confound interpretation of CT angiography in ICH.[41] Thus, the role of the spot sign in the clinical care of patients with ICH requires further study.
The STOP-IT study is an ongoing two-arm prospective study of patients
with ICH who present within 6 h of symptom onset. The first arm is a
randomized, double-blind, placebo-controlled trial comparing rFVIIa with
placebo for treatment of patients who have acute ICH and a spot sign on
CT angiography. The second arm is a prospective observational study of
hematoma expansion among patients without a spot sign. The STOP-IT study
will, therefore, determine the predictive value of the spot sign for
ICH growth, and the capability of CT angiography to guide administration
of hemostatic therapy in the acute clinical setting. The trial should
be completed in the next 3-5 years.
Another 'imaging' modality that has been proposed for monitoring
hematoma expansion is transcranial duplex sonography (TDS). In a small
prospective study, 34 patients with supratentorial ICH presenting <3 h
after symptom onset were evaluated by CT and TDS at baseline and 6 h
later.[42]
The data generated from TDS were shown to correlate with the results of
CT in terms of total hematoma volume (coefficient of correlation 0.82, P = 0.001).[42] Further studies are warranted to establish the utility of TDS for monitoring hematoma expansion after ICH.
To our knowledge, only one published study has explored blood
biomarkers for the prediction of hematoma expansion in ICH. In this
multicenter prospective study, blood samples were obtained from 183 ICH
patients within 12 h of symptom onset, and the concentrations of
interleukin 6 (IL-6), tumor necrosis factor (TNF), matrix
metalloproteinase-9 (MMP-9), and cellular fibronectin (cFN) were
determined.[43]
CT scans were performed at baseline and at 48 ± 6 h, and 54 patients
(29.5%) were found to exhibit hematoma expansion. A cFN concentration
>6 µg/ml (OR 92, 95% CI 22-381, P <0.0001) and an IL-6 level >24 pg/ml (OR 16, 95% CI 2.3-119, P =
0.005) were independently associated with hematoma expansion in the
logistic regression analysis. These findings are yet to be independently
validated.
In addition to the markers examined in the study described above,
glial fibrillary acidic protein, activated protein C-protein C inhibitor
complex, and a panel of markers, including S100, MMP-9, D-dimer and brain natriuretic peptide, might have diagnostic utility in the differentiation of ICH from ischemic stroke.[44-46] Confirmation of these findings and exploration of the capacity of these markers to predict hematoma expansion are warranted.
                           Anticoagulant-related ICH. In
anticoagulant-related ICH, rapid correction of the underlying
coagulopathy is the goal of therapy. A retrospective study of 69
patients with anticoagulant-related ICH found that the median time from
symptom onset to first dose of fresh frozen plasma (FFP) had been
shorter in patients who showed successful normalization of their
international normalized ratio (INR) at 24 h than in individuals whose
INR failed to normalize (90 min versus 210 min, P = 0.02).
Moreover, this study found that every 30 min of delay in FFP
administration was associated with a 20% decrease in probability of INR
normalization within 24 h (OR 0.8, 95% CI 0.63-0.99).[47]
                       
The slow correction of coagulopathy with administration of FFP and
vitamin K in patients with anticoagulant-related ICH has led to an
interest in alternative agents—such as prothrombin complex concentrates
(PCCs), factor IX complex concentrate and rFVIIa—to achieve this
objective. PCCs contain high levels of factors II, VII and X, while
factor IX complex concentrate contains factors II, VII, IX and X. These
preparations require much smaller infusion volumes than FFP, and they
correct coagulopathy more rapidly.[48,49] The
INCH trial is an ongoing, multicenter, prospective randomized trial
examining the use of PCCs and FFP in patients with anticoagulant-related
ICH.[50]
                       
Two small studies have shown that rFVIIa can normalize the INR
rapidly but requires co-administration with full doses of FFP and
vitamin K, as the former has a short half-life (2.6 h) and lacks other
relevant clotting factors.[51,52]
Given the potential thrombotic complications with rFVIIa therapy and
the limited available data, this agent is not currently recommended for
routine use in cases of anticoagulant-related ICH.
                           Blood Pressure Management.

Markedly elevated blood pressure in patients who experience acute ICH has been associated with poor out-comes,[53,54] as has a rapid reduction in blood pressure in the first 24 h from symptom onset.[55]
Thus, optimal blood pressure management in ICH requires a controlled,
modest reduction in blood pressure levels for patients with
hypertension. To date, INTERACT has been the largest study of blood
pressure reduction in ICH.[23]
                       
Patients with ICH were eligible to participate in INTERACT if they
were diagnosed by CT within 6 h of symptom onset and had a systolic
blood pressure of 150-220 mmHg. Individuals meeting these criteria were
randomly assigned to receive intensive blood pressure management (n = 203) to lower systolic blood pressure to 140 mmHg, or standard guideline-based management (n =
201) to achieve a systolic blood pressure of 180 mmHg. The primary
efficacy end point was the proportional change in hematoma volume at 24
h.[23]
At 1 h postrandomization, mean systolic blood pressure was 153 mmHg in
the intensively managed group and 167 mmHg in the guideline-managed
group ([i]P
                           [/i]<0.0001). From 1 h to 24 h, the
systolic blood pressure was 146 mmHg in the intensive group and 157 mmHg
in the guideline group ([i]P
                           [/i]<0.0001). Mean hematoma expansion was markedly higher ([i]P
                           [/i]= 0.04) in the guideline group (36.3%
hematoma expansion) than in the intensive group (13.7% hematoma
expansion) at 24 h. After adjustment for baseline ICH volume and for
time from onset to CT, the median hematoma expansion was 16.2% in the
guideline group and 6.2% in the intensive group, although this
difference did not quite reach significance ([i]P
                           [/i]= 0.06). No difference in 90 day
functional outcomes was observed between the two treatment groups
(median mRS score 2 in both groups, P = 0.66). Risk of serious adverse events was not altered by intensive blood pressure reduction.[23]
INTERACT2, a phase III trial, is ongoing and aims to confirm these
findings and to determine whether intensive blood pressure reduction in
ICH is associated with improvements in functional outcomes in treated
patients.
The ATACH trial was an open-label pilot study designed to evaluate
the feasibility and safety of three escalating levels of
antihypertensive treatment in hypertensive patients with ICH.[56]
Individuals with ICH and systolic blood pressure ≥170 mmHg who
presented within 6 h of symptom onset were eligible for enrollment in
this study. Intravenous nicardipine was infused to achieve a target
systolic blood pressure of 170-200 mmHg in the first cohort of patients (n = 18), 140-170 mmHg in the second cohort (n = 20), and 110-140 mmHg in the third cohort (n =
22). The primary outcomes were feasibility of treatment, neurological
deterioration within 24 h of treatment, and serious adverse events
within 72 h of therapy. No significant adverse events above the
pre-specified safety stopping points were observed,[56] and a follow-up phase III trial is in the planning stages.
                           Neuroprotective Therapies.
As
discussed above, secondary injury in ICH can result from cerebral edema,
slow thrombin release, red blood cell lysis and/or hemoglobin-induced
neurotoxicity. The multitude of processes that occur after ICH have been
collectively termed 'neurohemoinflammation'.[33] The
pursuit of targeting these processes as a means of improving ICH
outcomes has generated notable clinical interest, and the results of two
large trials of putative neuroprotective drugs in ICH have been
published.[35,36] In
the GAIN International and GAIN Americas trials, patients with either
ischemic stroke or ICH were randomly assigned to receive gavestinel, a
glycinesite antagonist of the N-methyl-D-aspartate (NMDA)
receptor, or placebo within 6 h of symptom onset. The trials' outcomes
were death or one of the three following levels of functional ability,
as measured by the Barthel Index (BI): functionally independent (BI
score 95-100), assisted independence (BI score 60-90) or functionally
dependent (BI score 0-55). An analysis of the 571 patients with ICH
included in the two trials revealed no significant difference (P = 0.09) in the trichotomized BI scores at 3 months between patients receiving gavestinel and patients receiving placebo.[36]
                       
The CHANT trial explored the safety and efficacy of NXY-059
(disufenton sodium), a free radical-trapping agent, in patients with ICH
who presented within 6 h of symptom onset.[35]
Overall, the drug had a good safety and tolerability profile, with no
adverse effects observed. However, the OR for an improvement in the 3
month mRS score in the NXY-059 group was 1.01 (95% CI 0.75-1.35). Given
the absence of evidence for efficacy, the investigators concluded there
was "no suggestion that NXY-059 benefits ICH patients".[35]
                       
In addition to the studies described above, two smaller clinical
trials have investigated citicoline-an intermediate compound in the
synthetic pathway of structural phospholipids—as a putative
neuroprotective agent in ICH.[57,58]
A randomized study of 32 patients with supratentorial ICH found that
muscular strength was improved in patients receiving intravenous
citicoline administered twice daily for 14 days (n = 16) compared with individuals who received placebo (n = 16).[57] The
scale used to determine muscle strength was not validated; thus,
interpretation of the findings from this study is difficult. In a
randomized pilot study designed to test the safety and efficacy of
citicoline in human ICH, 1 g of oral or intravenous citicoline or
placebo was administered twice daily for 2 weeks to patients with ICH
who presented within 6 h of symptom onset.[58]
In total, 19 patients received placebo and 19 patients received
citicoline (either orally or intravenously). At 3 months, only one
patient in the placebo group was rated as functionally independent (mRS
≤2), whereas 5 patients in the citicoline group were deemed independent
(OR 5.38, 95% CI 0.55-52). No differences were observed in adverse
events between the two treatment groups. The investigators concluded
that citicoline was safe to use in humans and showed a positive trend
towards efficacy for ICH.[58] Overall, insufficient data are currently available to recommend citicoline for clinical use.
To date, no neuroprotective therapy has been shown to be effective in
ICH. Several promising agents, however, are progressing to or have
entered early-phase human ICH trials (
Table 3
).
                   
                       Surgical Management Trials

                                                   Cerebellar ICH.
The discussion below focuses largely on supratentorial ICH. Nevertheless, cerebellar ICH comprises 6-10% of all cases of ICH.[59-62]
Hematoma evacuation in cerebellar ICH can be life saving and is a class
I recommendation in patients who are deteriorating neurologically, or
who have brainstem compression and/or hydrocephalus from ventricular
obstruction due to cerebellar hemorrhage.[2,63] Thus, when feasible and necessary, emergent surgery should be performed promptly in cases of such ICH.
                           Craniotomy.
Surgical treatment
options for ICH include standard craniotomy for clot evacuation and/or
decompression, and minimally invasive endoscopic clot evacuation, with
or without thrombolysis. Craniotomy for clot evacuation is the most
extensively studied surgical treatment option for ICH. The data
generated from the STICH trial represent the best available evidence to
inform the surgical management of ICH.[34]
In this study, 1,033 patients with ICH were randomly assigned to
surgery or medical management within 96 h of symptom onset. Of note,
patients were only allocated to one of these treatment groups after the
investigators had determined that they were not candidates for urgent
neurosurgery. Hemorrhage evacuation occurred within 24 h of
randomization. The primary outcome measure was the Glasgow Outcome Scale
score at 6 months. In the STICH study, no overall benefit—in terms of
the percentage of patients with favorable outcomes—was seen from early
surgery over initial medical treatment (26% versus 24% had favorable
outcomes, P = 0.41). A preplanned subgroup analysis, however,
showed that patients with a hematoma within 1 cm of the cortical surface
who were treated with surgery showed a trend towards better outcomes
than in patients treated medically (P = 0.07).[34] The
STICH II trial is underway and aims to determine whether carefully
selected patients might benefit from surgery over medical management.
                           Minimally Invasive Endoscopic Procedures.
To
date, the largest study of minimally invasive clot evacuation in ICH
involved the random assignment of 377 patients with basal ganglion ICH
(hemorrhage volumes of 25-40 ml) to receive minimally invasive
craniopuncture therapy (n = 195) or medical control treatment (n = 182).[64]
Patients in the craniopuncture arm were treated with clot aspiration
and urokinase (10,00050,000 IU). The primary outcomes of the trial were
death or dependency at 90 days (the latter was measured by the mRS and
the BI). At 90 days, no significant difference was apparent in the
mortality rates of the two groups (6.7% in the craniopuncture group
versus 8.8% in the medically treated group, P = 0.44). The
patients in the medical treatment group were, however, significantly
less likely than the individuals who underwent clot evacuation to be
functionally independent at 90 days (63.0% versus 40.9% had an mRS score
3-6, P <0.01). The researchers concluded that minimally
invasive craniosurgery was safe and might improve independent survival
in ICH.[64] A confirmatory phase III trial is under way.
In a single-center trial, 100 patients with ICH were randomly
assigned to burr hole and continuous lavage of the hematoma cavity or
medical therapy within 48 h of symptom onset.[65] In this study, the surgical group had a significantly lower mortality rate than the medically treated group (42% versus 70%, P = 0.01).
A multicenter randomized controlled trial of 71 patients with ICH,
each of whom had a GCS score ≥5 or clots ≥10 ml in volume, examined
stereotactic infusion of urokinase infusion within 72 h of symptom
onset.[66] Urokinase
(5,000 IU) was infused every 6 h over a period of 48 h, and the primary
outcomes in this study were death and functional disability at 6
months. The median reduction in volume of ICH from baseline was 40% in
the surgical group and 18% in the medical group, while rebleeding
occurred in 35% of patients in the former group and 17% of patients in
the latter treatment group. In the logistic regression analysis, a
nonsignificant reduction was noted in mortality at 180 days in the
urokinase group (OR 0.23, 95% CI 0.05-1.20, P = 0.08).[66]
                       
Stereotactic administration of recombinant tissue plasminogen
activator (rtPA) into the hematoma cavity of parenchymal ICH has also
been studied.[67]
After CT-guided placement of a catheter via a burr hole, 28 patients
with ICH received 1 mg of rtPA infusion into the clot cavity every 8 h
over a period of 48 h. In these patients, the ICH volume was reduced by
77 ± 6 ml (13%) on final CT scans compared with baseline CT scans ([i]P
                           [/i]<0.0002). No episodes of symptomatic
hematoma expansion occurred, although one patient had asymptomatic
bleeding along the catheter tract.[67]
                       
The MISTIE study is an ongoing, multicenter, randomized clinical
trial that is testing whether early minimally invasive surgery plus
administration of rtPA is a safe treatment for ICH and, by comparison
with medically treated patients, leads to a reduction in clot size.[68] The study began in 2006 and is expected to reach completion in 2013.
Interest has been expressed in the use of thrombolytic therapy in
conjunction with ventriculostomy in cases of IVH. In the open-label
CLEAR-IVH trial, 52 patients with IVH were treated prospectively with
intraventricular rtPA. The 30 day mortality rate in this study was 17%,
and symptomatic bleeding occurred in 4% of treated individuals.[69]
In a small randomized trial, patients with IVH who had undergone
ventriculostomy received intraventricular injections of normal saline
solution (5 patients) or urokinase (25,000 IU; 7 patients) at 12 h
intervals. Clot resolution occurred at a faster rate in the
urokinase-treated group than in the saline-treated group (P = 0.02).[70]
The CLEAR III study is an international, multicenter, double-blind,
randomized phase III trial comparing the use of ventriculostomy plus
rtPA with ventriculostomy plus placebo for the treatment of IVH. The
primary aim is to determine whether the former improves mRS scores at 6
months, and enrollment is expected to be completed in 2012.
Conclusions

                       The clinical trials discussed above have
broadly been described as medical or surgical. Medical trials in the
acute phase of ICH are aimed mainly at attenuation of hematoma expansion
(hemostasis), while surgical trials require cessation of bleeding
before evacuation of a stable hematoma.
                       Evacuation of the hematoma might decrease
mass effect, and reduce neurotoxicity resulting from red blood cell
lysis and delayed thrombin release, but the trauma associated with
surgery or rebleeding due to surgery can worsen outcomes. These
contrasting effects might account for the equivocal findings in trials
of surgery for ICH to date.
                       Both medical and surgical trials require
consistently excellent neurocritical care of enrolled patients, if such
studies are to be successful in testing the efficacy of a given approach
to treatment. If CT angiography or bio-markers are proven to predict
hematoma expansion accurately, patients who are destined to have ongoing
bleeding might be considered for appropriate medical therapies, while
individuals who are unlikely to have hematoma expansion might be
operated on more quickly than would otherwise be the case. An early time
to surgery has been associated with not only an improvement in
mortality rate in patients with ICH, but also an increase in the risk of
bleeding.[71,72]
The accurate identification of the 60% of patients with ICH who will
not have marked hematoma expansion in the first few hours after symptom
onset might allow selected individuals to undergo early evacuation of
the hematoma by surgical techniques that minimize brain injury.
Combination therapies such as early administration of hemostatic agents
followed by surgical evacuation could also be pursued if early accurate
stratification of patients can be achieved.
                       A scientifically proven and effective
treatment for ICH remains elusive; however, trials in the past 10 years
have led to improvements in our understanding of the goals of clinical
care for the various subpopulations of patients who develop this
condition. Careful selection of patients for enrollment in ongoing
trials should lead to proven therapies for ICH in the coming years.
Key Points

  • Globally, ≈2 million people every year
    develop intracerebral hemorrhage (ICH), which is associated with high
    morbidity and mortality rates and has no effective treatment
  • Medical trials conducted for acute ICH
    in the past decade have included trials of hemostasis with recombinant
    factor VIIa and trials of blood pressure control
  • Surgical trials for ICH of the past 10
    years have included studies of craniotomy with clot evacuation, and
    minimally invasive clot aspiration with or without thrombolysis
  • Data generated from medical and surgical
    trials have led to improvements in our understanding of the strategies
    to undertake for effective clinical management of ICH
  • Ongoing trials show promise for the development of a therapy that improves ICH outcomes

References

  1. Qureshi, A. I., Mendelow, A. D. & Hanley, D. F. Intracerebral haemorrhage. Lancet 373, 1632-1644 (2009).
  2. Broderick, J. et al. Guidelines for the
    management of spontaneous intracerebral hemorrhage in adults: 2007
    update: a guideline from the American Heart Association/American Stroke
    Association Stroke Council, High Blood Pressure Research Council, and
    the Quality of Care and Outcomes in Research Interdisciplinary Working
    Group. Circulation 116, e391-e413 (2007).
  3. Lloyd-Jones, D. et al. Heart disease and
    stroke statistics—2009 update: a report from the American Heart
    Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 119, e21-e181 (2009).
  4. Sudlow, C. L. & Warlow, C. P. Comparable studies
    of the incidence of stroke and its pathological types: results from an
    international collaboration. International Stroke Incidence
    Collaboration. Stroke 28, 491-499 (1997).
  5. Flaherty, M. L. et al. Long-term mortality after intracerebral hemorrhage. Neurology 66, 1182-1186 (2006).
  6. Fogelholm, R., Murros, K., Rissanen, A. &
    Avikainen, S. Long term survival after primary intracerebral
    haemorrhage: a retrospective population based study. J. Neurol. Neurosurg. Psychiatry 76, 1534-1538 (2005).
  7. Cheung, R. T. Update on medical and surgical management of intracerebral hemorrhage. Rev. Recent Clin. Trials. 2, 174-181 (2007).
  8. Lloyd-Jones, D. et al. Heart disease and stroke statistics—2010 update. A report from the American Heart Association. Circulation 121, e46-e215 (2010).
  9. Earnshaw, S. R., Joshi, A. v., Wilson, M. R. &
    Rosand, J. Cost-effectiveness of recombinant activated factor VII in the
    treatment of intracerebral hemorrhage. Stroke 37, 2751-2758 (2006).
  10. Ariesen, M. J., Claus, S. P, Rinkel, G. J. &
    Algra, A. Risk factors for intracerebral hemorrhage in the general
    population. A systematic review. Stroke 34, 2060-2066 (2003).
  11. Flaherty, M. L., Woo, D. & Broderick, J. The
    incidence of deep and lobar intracerebral hemorrhage in whites, blacks
    and hispanics. Neurology 66, 956-957 (2006).
  12. Jackson, C. A. & Sudlow, C. L. Is hypertension a
    more frequent risk factor for deep than for lobar supratentorial
    intracerebral haemorrhage? J. Neurol. Neurosurg. Psychiatry 77, 1244-1252 (2006).
  13. Kubo, M. et al. Trends in the incidence, mortality, and survival rate of cardiovascular disease in a Japanese community: the Hisayama study. Stroke 34, 2349-2354 (2003).
  14. Jiang, B. et al. Incidence and trends of stroke and its subtypes in China: results from three large cities. Stroke 37, 63-68 (2006).
  15. Flaherty, M. L. et al. Location and outcome of anticoagulant-associated intracerebral hemorrhage. Neurocrit. Care 5, 197-201 (2006).
  16. Flaherty, M. L. et al. Warfarin use leads to larger intracerebral hematomas. Neurology 71, 1084-1089 (2008).
  17. Flibotte, J. J., Hagan, N., O'Donnell, J.,
    Greenberg, S. M. & Rosand, J. Warfarin, hematoma expansion, and
    outcome of intracerebral hemorrhage. Neurology 63, 1059-1064 (2004).
  18. Flaherty, M. L. et al. The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology 68, 116-121 (2007).
  19. McCarron, M. O. & Nicoll, J. A. Apolipoprotein E genotype and cerebral amyloid angiopathy-related hemorrhage. Ann. NY Acad.Sci. 903, 176-179 (2000).
  20. Arima, H. et al. Effects of
    perindopril-based lowering of blood pressure on intracerebral hemorrhage
    related to amyloid angiopathy: the PROGRESS trial. Stroke 41, 394-396 (2010).
  21. Ropper, A. H. Lateral displacement of the brain and level of consciousness in patients with an acute hemispheral mass. N. Engl. J. Med. 314, 953-958 (1986).
  22. Brott, T. et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 28, 1-5 (1997).
  23. Anderson, C. S. et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 7, 391-399 (2008).
  24. Mayer, S. A. et al. Efficacy and safety of recombinant activated factor vII for acute intracerebral hemorrhage. N. Engl. J. Med. 358, 2127-2137 (2008).
  25. Mayer, S. A. et al. Recombinant activated factor vII for acute intracerebral hemorrhage. N. Engl. J. Med. 352, 777-785 (2005).
  26. Hallevi, H. et al. Intraventricular hemorrhage: Anatomic relationships and clinical implications. Neurology 70, 848-852 (2008).
  27. Bhattathiri, P S., Gregson, B., Prasad, K. S. &
    Mendelow, A. D. Intraventricular hemorrhage and hydrocephalus after
    spontaneous intracerebral hemorrhage: results from the STICH trial. Acta Neurochir. Suppl. 96, 65-68 (2006).
  28. Steiner, T. et al. Dynamics of
    intraventricular hemorrhage in patients with spontaneous intracerebral
    hemorrhage: risk factors, clinical impact, and effect of hemostatic
    therapy with recombinant activated factor vII. Neurosurgery 59, 767-773 (2006).
  29. Gebel, J. M. Jr et al. Relative edema volume is a predictor of outcome in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke 33, 2636-2641 (2002).
  30. Arima, H. et al. Significance of perihematomal edema in acute intracerebral hemorrhage: the INTERACT trial. Neurology 73, 1963-1968 (2009).
  31. Zazulia, A. R., Diringer, M. N., Derdeyn, C. I? & Powers, W. J. Progression of mass effect after intracerebral hemorrhage. Stroke 30, 1167-1173 (1999).
  32. Sansing, L. H. et al. Edema after intracerebral hemorrhage: correlations with coagulation parameters and treatment. J. Neurosurg. 98, 985-992 (2003).
  33. Xi, G., Keep, R. F. & Hoff, J. T. Mechanisms of brain injury after intracerebral haemorrhage. Lancet Neurol. 5, 53-63 (2006).
  34. Mendelow, A. D. et al. Early surgery versus
    initial conservative treatment in patients with spontaneous
    supratentorial intracerebral haematomas in the International Surgical
    Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 365, 387-397 (2005).
  35. Lyden, I? D. et al. Safety and tolerability of NXY-059 for acute intracerebral hemorrhage: the CHANT Trial. Stroke 38, 2262-2269 (2007).
  36. Haley, E. C. Jr et al. Gavestinel does not
    improve outcome after acute intracerebral hemorrhage: an analysis from
    the GAIN International and GAIN Americas studies. Stroke 36, 1006-1010 (2005).
  37. Mayer, S. A. et al. Can a subset of intracerebral hemorrhage patients benefit from hemostatic therapy with recombinant activated factor VII? Stroke 40, 833-840 (2009).
  38. Diringer, M. N. et al. Thromboembolic
    events with recombinant activated factor VII in spontaneous
    intracerebral hemorrhage: results from the Factor Seven for Acute
    Hemorrhagic Stroke (FAST) trial. Stroke 41, 48-53 (2010).
  39. Goldstein, J. N. et al. Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology 68, 889-894 (2007).
  40. Wada, R. et al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 38, 1257-1262 (2007).
  41. Gazzola, S. et al. Vascular and nonvascular mimics of the CT angiography "spot sign" in patients with secondary intracerebral hemorrhage. Stroke 39, 1177-1183 (2008).
  42. Perez, E. S. et al. Transcranial duplex sonography for monitoring hyperacute intracerebral hemorrhage. Stroke 40, 987-990 (2009).
  43. Silva, Y. et al. Molecular signatures of vascular injury are associated with early growth of intracerebral hemorrhage. Stroke 36, 86-91 (2005) .
  44. Foerch, C. et al. Serum glial fibrillary acidic protein as a biomarker for intracerebral haemorrhage in patients with acute stroke. J. Neurol. Neurosurg. Psychiatry 77, 181-184 (2006) .
  45. Laskowitz, D. T., Kasner, S. E., Saver, J., Remmel,
    K. S. & Jauch, E. C. Clinical usefulness of a biomarker-based
    diagnostic test for acute stroke: the Biomarker Rapid Assessment in
    Ischemic Injury (BRAIN) study. Stroke 40, 77-85 (2009).
  46. Unden, J. et al. Explorative investigation of biomarkers of brain damage and coagulation system activation in clinical stroke differentiation. J. Neurol. 256, 72-77 (2009).
  47. Goldstein, J. N. et al. Timing of fresh
    frozen plasma administration and rapid correction of coagulopathy in
    warfarin-related intracerebral hemorrhage. Stroke 37, 151-155 (2006).
  48. Lankiewicz, M. W., Hays, J., Friedman, K. D.,
    Tinkoff, G. & Blatt, P M. Urgent reversal of warfarin with
    prothrombin complex concentrate. J. Thromb. Haemost. 4, 967-970 (2006).
  49. Baker, R. I. et al. Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. Med. J. Aust. 181, 492-497 (2004).
  50. Steiner, T. et al. INR normalization in
    patients with coumadin related intracranial hemorrhages—the INCH trial: a
    randomized controlled trial to compare safety and preliminary efficacy
    of fresh frozen plasma versus prothrombin complex [abstract 13]. Cerebrovasc. Dis. 27 (Suppl. 6), 185 (2009).
  51. Freeman, W. D. et al. Recombinant factor VIIa for rapid reversal of warfarin anticoagulation in acute intracranial hemorrhage. Mayo Clin. Proc. 79, 1495-1500 (2004).
  52. Brody, D. L., Aiyagari, V., Shackleford, A. M. &
    Diringer, M. N. Use of recombinant factor VIIa in patients with
    warfarin-associated intracranial hemorrhage. Neurocrit. Care 2, 263-267 (2005).
  53. Leonardi-Bee, J., Bath, P. M., Phillips, S. J. &
    Sandercock, P. A. Blood pressure and clinical outcomes in the
    International Stroke Trial. Stroke 33, 1315-1320 (2002).
  54. Vemmos, K. N. et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J. Intern. Med. 255, 257-265 (2004).
  55. Qureshi, A. I. et al. Rate of 24-hour blood
    pressure decline and mortality after spontaneous intracerebral
    hemorrhage: a retrospective analysis with a random effects regression
    model. Crit. Care Med. 27, 480-485 (1999).
  56. Antihypertensive Treatment of Acute Cerebral
    Hemorrhage (ATACH) investigators. Antihypertensive treatment of acute
    cerebral hemorrhage. Crit. Care Med. 38, 637-648 (2010).
  57. Iranmanesh, F. & Vakilian, A. Efficiency of
    citicoline in increasing muscular strength of patients with nontraumatic
    cerebral hemorrhage: a double-blind randomized clinical trial. J. Stroke Cerebrovasc. Dis. 17, 153-155 (2008).
  58. Secades, J. J. et al. Citicoline in intracerebral haemorrhage: a double-blind, randomized, placebo-controlled, multi-centre pilot study. Cerebrovasc. Dis. 21, 380-385 (2006).
  59. Adeoye, O. et al. Surgical management and case-fatality rates of intracerebral hemorrhage in 1988 and 2005. Neurosurgery 63, 1113-1117 (2008).
  60. Broderick, J. et al. Management of intracerebral hemorrhage in a large metropolitan population. Neurosurgery 34, 882-887 (1994).
  61. Inagawa, T., Ohbayashi, N., Takechi, A., Shibukawa,
    M. & Yahara, K. Primary intracerebral hemorrhage in Izumo City,
    Japan: incidence rates and outcome in relation to the site of
    hemorrhage. Neurosurgery 53, 1283-1297 (2003).
  62. Morioka, J. et al. Surgery for spontaneous intracerebral hemorrhage has greater remedial value than conservative therapy. Surg. Neurol. 65, 67-72 (2006).
  63. Steiner, T. et al. Recommendations for the
    management of intracranial haemorrhage— part I: spontaneous
    intracerebral haemorrhage. The European Stroke Initiative Writing
    Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc. Dis. 22, 294-316 (2006).
  64. Wang, W. Z. et al. Minimally invasive
    craniopuncture therapy vs. conservative treatment for spontaneous
    intracerebral hemorrhage: results from a randomized clinical trial in
    China. Int. J. Stroke 4, 11-16 (2009).
  65. Auer, L. M. et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J. Neurosurg. 70, 530-535 (1989).
  66. Teernstra, O. P. et al. Stereotactic
    treatment of intracerebral hematoma by means of a plasminogen activator:
    a multicenter randomized controlled trial (SICHPA). Stroke 34, 968-974 (2003).
  67. Vespa, P. et al. Frameless stereotactic
    aspiration and thrombolysis of deep intracerebral hemorrhage is
    associated with reduction of hemorrhage volume and neurological
    improvement. Neurocrit. Care 2, 274-281 (2005).
  68. Morgan, T. et al. Preliminary findings of
    the minimally-invasive surgery plus rtPA for intracerebral hemorrhage
    evacuation (MISTIE) clinical trial. Acta Neurochir. Suppl. 105, 147-151 (2008).
  69. Morgan, T., Awad, I., Keyl, P, Lane, K. &
    Hanley, D. Preliminary report of the clot lysis evaluating accelerated
    resolution of intraventricular hemorrhage (CLEAR-IVH) clinical trial. Acta Neurochir. Suppl. 105, 217-220 (2008).
  70. Naff, N. J. et al. Intraventricular
    thrombolysis speeds blood clot resolution: results of a pilot,
    prospective, randomized, double-blind, controlled trial. Neurosurgery 54, 577-583 (2004).
  71. Morgenstern, L. B., Demchuk, A. M., Kim, D. H.,
    Frankowski, R. F. & Grotta, J. C. Rebleeding leads to poor outcome
    in ultra-early craniotomy for intracerebral hemorrhage. Neurology 56, 1294-1299 (2001).
  72. Zuccarello, M. et al. Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke 30, 1833-1839 (1999).
  73. Leira, R. et al. Early neurologic deterioration in intracerebral hemorrhage: predictors and associated factors. Neurology 63, 461-467 (2004).
  74. Miller, C. M. et al. Image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage. Surg. Neurol. 69, 441-446 (2008).
  75. Mayer, S. A. et al. Recombinant activated factor VII for acute intracerebral hemorrhage: US phase IIA trial. Neurocrit. Care 4, 206-214 (2006).
  76. Misra, U. K., Kalita, J., Ranjan, P& Mandal, S. K. Mannitol in intracerebral hemorrhage: a randomized controlled study. J. Neurol. Sci. 234, 41-45 (2005).
  77. US NIH ClinicalTrials.gov[online], http:// www.clinicaltrials.gov/ (2010)

_________________


Share
Back to top Go down
View user profile
 

Advances in the Management of Intracerebral Hemorrhage

View previous topic View next topic Back to top 
Page 1 of 1

Permissions in this forum:You can reply to topics in this forum
Medical Book ::  :: -
Reply to topic