Intracerebral Hemorrhage

Primary spontaneous intracerebral hemorrhage (ICH), or extravasation of blood into the brain parenchyma, typically results from either hypertension or cerebral amyloid angiopathy (CAA). This is in contrast to secondary ICH that results from underlying vascular lesions including aneurysms or malformations as well as pathologies like venous thrombosis, neoplasms, coagulopathies, or antithrombotic use. The management of primary ICH for many years has emphasized medical management as opposed to surgical intervention based on the failure of several large, randomized trials to show a benefit of open craniotomy with hematoma evacuation [1]. The treatment of ICH is a multidisciplinary effort, with neurologists, neurosurgeons, neurointensivists, internists, and rehabilitation specialists all playing critical roles in the care of these patients. The most recent guidelines from the American Heart Association/American Stroke Association in 2022 served as an update to the previous 2015 guidelines [2]. Even with recent advances in medical care and technology, the short-term case fatality still approaches 50%, indicating a continued treatment gap that further trials with novel therapies must seek to overcome [3]. This chapter will focus on the diagnosis and management of primary ICH, with particular attention to recent advances in surgical management including minimally invasive evacuation.