Advances in Acute Stroke Treatment 2020

Joseph P. Broderick, MD; Michael D. Hill, MD, MSc, FRCPC


Stroke. 2021;52(2):729-734. 

Intracerebral Hemorrhage

Intracerebral hemorrhage remains the most challenging stroke type. STOP-AUST (Spot Sign and Tranexamic Acid On Preventing ICH Growth—Australasia Trial) randomized 100 patients with acute intracerebral hemorrhage <70 cc, a spot sign on computed tomography angiography to receive intravenous tranexamic acid 1 g over 10 minutes followed by 1 g over 8 hours or matching placebo, started within 4.5 hours of symptom onset and within 1 hour of the qualifying computed tomography scan.[26] There was no observed difference in the primary surrogate outcome of hemorrhage growth (odds ratio, 0.72 [95% CI, 0.32–1.59]). A post hoc analysis of the ATACH-2 study (Antihypertensive Treatment of Acute Cerebral Hemorrhage 2) reported that dropping the blood pressure by very large absolute amounts (>220 mm Hg systolic down to <140 mm Hg systolic) may result in both poorer neurological outcomes and a greater chance of acute renal failure.[27] However, a subgroup of patients (about one-third of the trial population), treated within 2 hours of onset showed reduced hematoma growth and better outcomes with intensive blood pressure lowering comparing to control.[28] New studies are planned for intracerebral hemorrhage that will focus on the ultra-early treatment window, including a return to the assessment of recombinant factor VIIa within 2 hours of onset.[1]