[Systematic review and Meta-analysis of efficacy and safety of acupuncture therapy on hypertensive intracerebral hemorrhage].

To systematically review the efficacy and safety of acupuncture combined with minimally invasive surgery or basic the-rapy in treating hypertensive intracerebral hemorrhage(HICH) patients compared with minimally invasive surgery or basic treatment. In this study, the four Chinese databases, the four English databases, Chinese Clinical Trial Registry and ClinicalTrail.gov, all above were systematically and comprehensively retrieved from the time of database establishment to September 10, 2020. Rando-mized controlled trials(RCTs) were screened out according to inclusion criteria and exclusion criteria established in advanced. The methodological quality of included studies was evaluated by the tool named "Cochrane bias risk assessment 6.1". Meta-analysis of the included studies was performed using RevMan 5.4, and the quality of outcome indicators was evaluated by the GRADE system. Finally, 17 studies were included, involving 1 852 patients with HICH, and the overall quality of the included studies was not high. According to Meta-analysis,(1)CSS score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=-3.50,95%CI[-4.39,-2.61],P<0.000 01);(2)NIHSS score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=-4.78,95%CI[-5.55,-4.00],P<0.000 01);(3)the cerebral hematoma volume of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=-4.44,95%CI[-5.83,-3.04],P<0.000 01);(4)ADL score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=20.81,95%CI[17.25,24.37],P<0.000 01);(5)the GCS score of the group of acupuncture combined with minimally invasive surgery or basic therapy was superior to the group of minimally invasive surgery or basic therapy(MD=2.41,95%CI[1.90,2.91],P<0.000 01). The GRADE system showed an extremely low level of evidence for the above outcome indicators. Adverse reactions were mentioned only in two literatures, with no adverse reactions reported. The available evidence showed that acupuncture combined with minimally invasive surgery or basic therapy had a certain efficacy in patients of HICH compared with minimally invasive surgery or basic therapy. However, due to the high risk of bias in the included studies, its true efficacy needs to be verified by more high-quality studies in the future.

Hypertension is a Leading Cause of Nontraumatic Intracerebral Hemorrhage in Young Adults.

OBJECTIVE: To evaluate the etiology and discharge outcome of nontraumatic intracerebral hemorrhage (ICH) in young adults admitted to a comprehensive stroke center. METHODS: A retrospective chart review was performed on patients with a discharge diagnosis of nontraumatic ICH admitted from 7/1/2011 to 6/30/2016. Data was collected on demographics, clinical history, ICH score, hemorrhage location, do-not-resuscitate (DNR) orders, likely etiology, and discharge disposition. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH, and ICH score with the discharge outcome. RESULTS: Sixty-three patients met the study criteria, with mean age 35.4 ± 6.4 years including 26 (41%) women and 40 (64%) whites. Headache (65%) and change in mental status (48%) were the most common presenting symptoms. Hemorrhage was most commonly seen in the deep structures in 29 (46%) patients followed by lobar ICH in 14 (22%) patients. The most common etiology of ICH was hypertension in 23 (37%) patients, followed by vascular abnormalities in 18 (29%) patients. Forty-two (67%) had good outcome defined as discharge to home (n = 25) or acute inpatient rehabilitation (n = 17). Twenty-one (33%) patients had bad outcome with discharge to skilled nursing facility (n = 6), hospice (n = 1) or died in the hospital (n = 14). Hospital DNR orders were noted in 11 (18%) patients. Higher ICH score (P < .0001) and use of DNR orders (P < .0001) were associated with bad outcome. All 11 patients with DNR orders died in the hospital. Location or etiology of hemorrhage were not associated with discharge outcome. CONCLUSIONS: Hypertension, a modifiable risk factor, is a major cause of nontraumatic ICH in young adults. Aggressive management of hypertension is essential to halt the recent increased trends of ICH due to hypertension. Early DNR orders may need to be cautiously used in the hospital.

Intracranial Hypertension and Cerebral Perfusion Pressure Insults in Adult Hypertensive Intraventricular Hemorrhage: Occurrence and Associations With Outcome.

OBJECTIVES: Elevated intracranial pressure and inadequate cerebral perfusion pressure may contribute to poor outcomes in hypertensive intraventricular hemorrhage. We characterized the occurrence of elevated intracranial pressure and low cerebral perfusion pressure in obstructive intraventricular hemorrhage requiring extraventricular drainage. DESIGN: Prospective observational cohort. SETTING: ICUs of 73 academic hospitals. PATIENTS: Four hundred ninety-nine patients enrolled in the CLEAR III trial, a multicenter, randomized study to determine if extraventricular drainage plus intraventricular alteplase improved outcome versus extraventricular drainage plus saline. INTERVENTIONS: Intracranial pressure and cerebral perfusion pressure were recorded every 4 hours, analyzed over a range of thresholds, as single readings or spans (≥ 2) of readings after adjustment for intracerebral hemorrhage severity. Impact on 30- and 180-days modified Rankin Scale scores was assessed, and receiver operating curves were analyzed to identify optimal thresholds. MEASUREMENTS AND MAIN RESULTS: Of 21,954 intracranial pressure readings, median interquartile range 12 mm Hg (8-16), 9.7% were greater than 20 mm Hg and 1.8% were greater than 30 mm Hg. Proportion of intracranial pressure readings from greater than 18 to greater than 30 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 70 mm Hg were associated with day-30 mortality and partially mitigated by intraventricular alteplase. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and intracranial pressure greater than 20 mm Hg in spans were associated with both 30-day mortality and 180-day mortality. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 60 mm Hg were associated with poor day-30 modified Rankin Scale, whereas cerebral perfusion pressure less than 65 and less than 75 mm Hg were associated with poor day-180 modified Rankin Scale. CONCLUSIONS: Elevated intracranial pressure and inadequate cerebral perfusion pressure are not infrequent during extraventricular drainage for severe intraventricular hemorrhage, and level and duration predict higher short-term mortality and long-term mortality. Burden of low cerebral perfusion pressure was also associated with poor short- and long-term outcomes and may be more significant than intracranial pressure. Adverse consequences of intracranial pressure-time burden and cerebral perfusion pressure-time burden should be tested prospectively as potential thresholds for therapeutic intervention.

Serum calcium levels at admission is associated with the outcomes in patients with hypertensive intracerebral hemorrhage.

BACKGROUND/OBJECTIVE: Hypertensive spontaneous intracerebral hemorrhages (ICH) cause significant morbidity and mortality. In this study, we aimed to investigate the association between calcium level at admission and outcome in hypertensive ICH patients. METHODS: 658 hypertensive ICH patients were enrolled from January 2012 to January 2016 in this retrospective study, and demographic, clinical, laboratory, radiographic, and outcome data were collected. The associations between serum calcium level and initial hematoma volume, hematoma enlargement and functional outcome were assessed. RESULTS: Lower calcium level at admission was associated with larger initial hematoma volumes, baseline NIHSS and mRSscore (p < .05), but not with platelet count, activated partial thromboplastin time and international normalized ratio on admission (p > .05). For outcome assessment, 30 days mortality and 6 months mRS were adjusted for age, gender and time from onset to admission, cigarette smoking, alcohol drinking, history of hypertension, baseline NIHSS score, Baseline mRS score and hematoma position, lower calcium level at admission was associated with worse outcomes. CONCLUSION: Low calcium level at admission is associated with worse outcome and might be a prognostic factor for acute ICH.

Clinical analysis and treatment of symptomatic intracranial hemorrhage after deep brain stimulation surgery.

BACKGROUND: Symptomatic intracranial hemorrhage (ICH) may lead to permanent neurological disability of patients and has impeded the extensive clinical application of deep brain stimulation (DBS). The present study was conducted to discuss the incidence, prevention, and treatment of symptomatic ICH after DBS surgery. METHODS: From January 2009 to December 2014, 396 patients underwent DBS with a total of 691 implanted leads. In all, 10 patients had symptomatic ICH. We analyzed these cases' clinical characteristics, including comorbid diagnoses and coagulation profile. We described the onset of ICH, imaging features, clinical manifestations, treatment, neurological impairment, and outcome of DBS. RESULTS: Of the 10 patients with symptomatic ICH, 2 had hypertension. Three cases of ICH occurred within 12 h of the procedure; four cases within 24 h. Five experienced grand mal seizures concurrently with hemorrhage. Unilateral frontal lobe hemorrhage occurred in all cases. In seven cases, hematomas occurred around the electrodes. Some hematomas were not well-circumscribed and had perihematomal edema. Conservative therapy was administered to 8 patients, and 2 patients underwent craniotomy and hematoma evacuation. All electrodes were successfully preserved. Neurological dysfunction in all patients gradually improved. Nine patients ultimately experienced effective symptom relief of Parkinson's disease with DBS. CONCLUSIONS: Symptomatic ICH should be identified as soon as possible after implantation surgery and treated effectively to limit neurological deficit and preserve DBS leads.

Clinical syndromes and management of intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) is a devastating disease with high morbidity and mortality. Acutely, ICH is associated with a sudden surge in intracranial pressure (ICP), as the volume of hematoma increases the pressure in the closed head, leading to non-specific symptoms of ICP: headache, nausea, vomiting, and alterations in consciousness. In the early phase, damage to the brain tissues surrounding the hematoma causes progression of neurologic symptoms. Expansion of supratentorial ICHs may result in transtentorial herniation, causing mental status deterioration and loss of pupillary light reflex. Compared to ischemic stroke, seizure is more common in ICH.

Emergency neurological life support: intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is a subset of stroke resulting from bleeding within the brain parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an emergency neurological life support (ENLS) protocol because intervention within the first critical hour may improve outcome, and it is helpful to have a protocol to drive care quickly and efficiently.

[Hypertensive intracerebral hemorrhage in isolated islands in Nagasaki Prefecture: a remote teleradiology and helicopter transportation system].

Hypertensive intracerebral hemorrhage (HICH) causes significant morbidity and mortality. The time required to transport the patients to a specialized hospital can influence the prognosis. In the isolated islands in Nagasaki prefecture, there is no medical institution which can offer emergent neurosurgical intervention. We reviewed the cases of HICH in this region from January 2006 to September 2010, who were transferred to Nagasaki Medical Center by a helicopter after consultation via teleradiology. Eighty four cases (23%) were transferred via helicopter to our institution from isolated islands. In three of them (4%), re-hemorrhage was demonstrated on computed tomography after helicopter transportation, and one of three had been administered an anti-coagulant agent. Only one case (1%) has deteriorated during helicopter transportation because of acute obstructive hydrocephalus. The outcome at discharge was as follows: modified Rankin Scale (mRS) I: 3 cases (4%), II: 5 cases (6%), III: 3 cases (4%), IV: 30 cases (36%), V: 31 cases (37%), VI: 12 cases (14%), 43 cases (51%) showed poor outcome (mRS V, VI). For medical management in isolated islands, a remote teleradiology system is indispensable to decide a strategy of treatment rapidly, and a helicopter transportation system is very useful in cases requiring emergent neurosurgical intervention, particular in cases of impending cerebral herniation or acute hydrocephalus. However, we may need to expand logistical supporting hospitals or secure other transportation facilities because many of the patients with poor outcome can not return to their home islands.

Clinical Research of Early Hyperbaric Oxygen Therapy on Patients with Hypertensive Cerebral Hemorrhage After Craniotomy.

AIM: To observe the effect of early hyperbaric oxygen (HBO) therapy on the improvement of consciousness and prognosis of patients with severe brain damages after craniocerebral craniotomy. MATERIAL AND METHODS: Eighty-one patients who had cerebral hemorrhage and underwent clearance of hematoma and decompressive craniectomy from August 2013 to August 2016 were retrospectively analyzed. The patients were divided into HBO and non-HBO therapy groups. The treatment effects were scored and subjected to corresponding statistical analysis. RESULTS: There were significant differences in the Glasgow coma scale (GCS) scores at 3 and 5 weeks (t=2.293 and t=3.014, respectively, p < 0.05), and in Glasgow outcome scale (GOS) scores at 5 weeks and 3 months between the two groups (p < 0.05). CONCLUSION: Early HBO therapy could improve the consciousness and prognosis of patients with cerebral hemorrhage after craniotomy.

What did Joseph Stalin really die of? A reappraisal of his illness, death, and autopsy findings.

Joseph Stalin was one of the most important world leaders during the first half of the 20th century. He died suddenly in early March 1953 after a short illness, which was described in a series of medical bulletins in the Soviet newspaper Pravda. Based on both the clinical history and autopsy findings, it was concluded that Stalin had died of a massive hemorrhagic stroke involving his left cerebral hemisphere. However, almost 50 years later, a counter-narrative developed suggesting a more nefarious explanation for his sudden death, namely, that a "poison," warfarin, a potent anticoagulant, had been administered surreptitiously by one or more of his close associates during the early morning hours prior to the onset of his stroke. In the present report, we will examine this counter-narrative and suggest that his death was not due to the administration of warfarin but rather to a hypertension-related cerebrovascular accident resulting in a massive hemorrhagic stroke involving his left cerebral hemisphere. The counter-narrative was based on the misunderstanding of certain specific autopsy findings, namely, the presence of focal myocardial and petechial hemorrhages in the gastric and intestinal mucosa, which could be attributed to the extracranial pathophysiologic changes that can occur as a consequence of a stroke rather than the highly speculative counter-narrative that Stalin was "poisoned" by the administration of warfarin.

Aspects of intracerebral hematomas--an update.

BACKGROUND: In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status. MATERIAL AND METHODS: This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas. RESULTS AND DISCUSSION: Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.

Changes of TXA2 and PGI2 during postoperative hypertensive crisis in patients with hypertensive intracerebral hemorrhage.

In order to explore the changes and the roles of TXA2 and PGI2 during postoperative hypertensive crisis in patients with hypertensive intracerebral hemorrhage, 31 cases subject to craniotomy were divided into three groups: group A, 9 patients with postoperative hypertensive crisis; group B, 13 patients without postoperative hypertensive crisis; and group C, 9 patients without history of hypertension and hypertensive intracerebral hemorrhage. TXA2, TXB2, 6-keto-PGF1 alpha and PGI2 were measured after operation in the three groups respectively. The postoperative blood pressure in group A, including SBP and DBP, was elevated more obviously than that in the other two groups. TXA2 and PGI2 in group A were significantly higher than those in other two groups (P<0.01). Moreover, the ratio of TXB2 to 6-keto-PGF1 alpha in group A was significantly higher than that in other two groups (P<0.05). The increase of TXA2 and the relative inadequacy of prostacyclin, especially 6-keto-PGF1 alpha, may play roles in the postoperative hypertensive crisis. And the increased value of TXB2 to 6-keto-PGF1 alpha could provide the basis for diagnosis of postoperative hypertensive crisis.

[Treatment of great hematoma in brain hemorrhage with multi-point puncture and continuous irrigation-draining].

OBJECTIVE: To investigate the clinical effect of multi-point aspiration combined with continuous irrigation with urokinase in treating great hematoma as the result of brain hemorrhage due to hypertension. METHODS: Ninety-four patients with great hematoma as the result of brain hemorrhage due to hypertension, aged 70, were randomly divided into 2 equal groups: one point puncture group and multi-point puncture group. Both groups underwent puncture under local or general anesthesia and were irrigated with urokinase continually. The outcomes were recorded and analyzed. RESULTS: The case-fatality rate of the multi-point puncture group was 10.87, significantly lower than that of the one-point puncture group (20.83, P < 0.05). The superiority rate of recovery of the multi-point group was 78.26%, significantly higher than that of the one-point puncture group (64.58%, P < 0.05). In 15 days, the resolution rate of brain hematoma of the multi-point group was 67.43%, significantly higher than that of the one point puncture group (23.68%, P < 0.01). The re-hemorrhage rate of the multi-point puncture group was 8.95%, significantly lower than that of the one-point puncture group (12.5%, P < 0.05). CONCLUSION: Multi-point puncture and continuous irrigation decrease the intracranial pressure quickly and suck the hematoma more effectively, especially for the great and irregular hematoma of brain. Continuous urokinase irrigation-drainage is able to keep the concentration of urokinase at an effective level, thus continuously washing, liquefying, draining, and resolving the brain hematoma.

[Local fibrinolysis of hypertensive intracerebral hematomas].

Authors presented the results of experimental and clinical studies of effects of recombinant prourokinase on brain tissue, its toxicity and safety in intracerebral administration for lysis of hypertensive intracerebral hematomas. Experiments were performed in 64 rabbits. Histological specimens were examined in different periods after injection of prourokinase into white matter and into experimental hematoma. It is revealed that dose of 615 mg/kg causes minimal changes in cerebral tissue. Clinical study was based on analysis of puncture aspiration of intracerebral hematomas with local fibrinolysis performed in 275 patients with hemorrhagic stroke. Dynamics of MRI, clinical and laboratory parameters, coagulation, analysis of aspirated products of lysis were assessed. Authors showed that recombinant prourokinase and the drug "Puroplazan" are effective for local fibrinolysis. The drugs are non-toxic and non-allergenic and do not cause cerebral edema.

[Spontaneous intracerebral hemorrhage]. / Spontan intracerebral blødning.

BACKGROUND: Cerebral stroke caused by intracerebral hemorrhage is serious. This review presents updated knowledge about the condition. MATERIAL AND METHODS: The review is based on pivotal articles published during recent years, identified through a PubMed search applying the key words "intracerebral haemorrhage", and our own clinical experience. RESULTS AND INTERPRETATION: Intracerebral hemorrhage strikes about 1,000 persons in Norway annually. Hypertension is the single most important risk factor. Cerebral CT confirms the diagnosis. Almost half of the patients die during the first month after the hemorrhage, many during the first two days. About 20% of the patients can manage without help after the first six months. Treatment includes measures against increased intracranial pressure and in selected cases surgical evacuation of the haematoma, especially in cases of bleeding into the cerebellum. Recombinant factor VIIa infused within the first three hours to stop the bleeding can play an important role in the acute phase. Patients below the age of 45, patients without hypertension, and patients with lobar haemorrhage and signs of clinical deterioration should be thoroughly investigated to disclose a potential arteriovenous malformation or an aneurysm. Neurointensive care may give better clinical results and the condition should ideally be treated in an intensive care unit.

Effect of integrated traditional Chinese and Western medicine therapy for acute hypertensive intracerebral hemorrhage: a meta-analysis.

Intracerebral hemorrhage (ICH) is an important public health problem associated with high mortality and morbidity. The aim of this study was to evaluate the clinical efficacy of integrated traditional Chinese (TCM) and Western medicine (WM) therapy for acute hypertensive ICH. Randomized controlled trials were searched in PubMed, Medline, Embase, Wanfang and CNKI database published between January 2000 and June 2016. Our results showed that integrated TCM and WM therapy appeared to be able to improve the clinical effect for patients with acute hypertensive ICH.

Therapeutic Benefits of Mesenchymal Stromal Cells in a Rat Model of Hemoglobin-Induced Hypertensive Intracerebral Hemorrhage.

Previous studies have shown that bone marrow mesenchymal stromal cell (MSC) transplantation significantly improves the recovery of neurological function in a rat model of intracerebral hemorrhage. Potential repair mechanisms involve anti-inflammation, anti-apoptosis and angiogenesis. However, few studies have focused on the effects of MSCs on inducible nitric oxide synthase (iNOS) expression and subsequent peroxynitrite formation after hypertensive intracerebral hemorrhage (HICH). In this study, MSCs were transplanted intracerebrally into rats 6 hours after HICH. The modified neurological severity score and the modified limb placing test were used to measure behavioral outcomes. Blood-brain barrier disruption and neuronal loss were measured by zonula occludens-1 (ZO-1) and neuronal nucleus (NeuN) expression, respectively. Concomitant edema formation was evaluated by H&E staining and brain water content. The effect of MSCs treatment on neuroinflammation was analyzed by immunohistochemical analysis or polymerase chain reaction of CD68, Iba1, iNOS expression and subsequent peroxynitrite formation, and by an enzyme-linked immunosorbent assay of pro-inflammatory factors (IL-1ß and TNF-α). The MSCs-treated HICH group showed better performance on behavioral scores and lower brain water content compared to controls. Moreover, the MSC injection increased NeuN and ZO-1 expression measured by immunochemistry/immunofluorescence. Furthermore, MSCs reduced not only levels of CD68, Iba1 and pro-inflammatory factors, but it also inhibited iNOS expression and peroxynitrite formation in perihematomal regions. The results suggest that intracerebral administration of MSCs accelerates neurological function recovery in HICH rats. This may result from the ability of MSCs to suppress inflammation, at least in part, by inhibiting iNOS expression and subsequent peroxynitrite formation.

Efficacy of lumbar cistern drainage combined with intrathecal antibiotherapy for the treatment of ventriculo-subarachnoid infections following surgery for hypertensive intracerebral hemorrhage.

OBJECTIVE: The aim of this study was to investigate the efficacy of lumbar cistern drainage combined with intrathecal injection of antibiotics (LCD-ITI) in treating postoperative intracranial infections of hypertensive intracerebral hemorrhage (pHIH-ICI). METHODS: Sixty pHIH-ICI patients were randomly divided into the control group and the treatment group, with 30 patients in each group. Conventional treatment was performed in the control group, while LCD-ITI was performed in the treatment group. The clinical outcomes, Glasgow Outcome Score (GOS), activities of daily living (ADL) scores, incidence rates of hydrocephalus and other indicators were compared. RESULTS: The improvement time of clinical symptoms, infection control time and hydrocephalus incidence of the treatment group were significantly lower than the control group (P<0.05). Also the infection control rate, GOS score and ADL score of the treatment group were significantly higher or better than the control group (P<0.05). CONCLUSION: LCD-ITI could improve clinical treatment and prognosis of pHIH-ICI patients.

Comparison of endoscopic evacuation, stereotactic aspiration and craniotomy for the treatment of supratentorial hypertensive intracerebral haemorrhage: study protocol for a randomised controlled trial.

BACKGROUND: Hypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient. METHODS/DESIGN: A multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery. DISCUSSION: The trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02811614 . Registered on 20 June 2016.

Current management of spontaneous intracerebral haemorrhage.

Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. Uncontrolled hypertension (HTN) is the most common cause of spontaneous ICH. Recent advances in neuroimaging, organised stroke care, dedicated Neuro-ICUs, medical and surgical management have improved the management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering of systolic blood pressure to <140 mm Hg is proven safe by two recent randomised trials. Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of haematoma. In patients with small haematoma without significant mass effect, there is no indication for routine use of mannitol or hypertonic saline (HTS). However, for patients with large ICH (volume > 30 cbic centmetre) or symptomatic perihaematoma oedema, it may be beneficial to keep serum sodium level at 140-150 mEq/L for 7-10 days to minimise oedema expansion and mass effect. Mannitol and HTS can be used emergently for worsening cerebral oedema, elevated intracranial pressure (ICP) or pending herniation. HTS should be administered via central line as continuous infusion (3%) or bolus (23.4%). Ventriculostomy is indicated for patients with severe intraventricular haemorrhage, hydrocephalus or elevated ICP. Patients with large cerebellar or temporal ICH may benefit from emergent haematoma evacuation. It is important to start intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for prophylaxis of venous thromboembolism. There is no benefit for seizure prophylaxis or aggressive management of fever or hyperglycaemia. Early aggressive comprehensive care may improve survival and functional recovery.