Future Trials

The trials discussed in this chapter indicate that emergent, targeted medical interventions have the potential to greatly improve the outcome of some patients with ICH. However, more research is needed before any of these novel therapies will be ready for introduction in daily clinical practice. A recent National Institute of Neurological Disorders and Stroke ICH workshop identified priorities for clinical research (Table 2) (16). It is hoped that additional trials that test optimized protocols of early hemostasis with rFVIIa, and intraventricular thrombolysis with rtPA, will offer robust data to support their approval for clinical application. Infusion of rFVIIa should also be evaluated for the treatment of ICH induced by excessive anticoagulation. Techniques of minimally invasive surgery in combination with local infusion of a thrombolytic drug deserve further exploration. New studies that test the role of surgery exclusively on patients with superficial hematomas are justified. Prompt administration of neuroprotectants to limit neuronal death is an option that must continue to be studied regardless of the disappointing results so far observed in patients with ischemic infarction. The value of aggressive reduction of blood pressure as soon as ICH is diagnosed should also be formally investigated. It is only reasonable to expect that these clinical trials will hold the key to providing a better outlook for future patients with ICH.

Table 2 Priorities for Clinical Research in ICH

Medical priorities Blood-pressure management Treatment of hyperglycemia Normalization of body temperature Prophylactic use of antiepileptic agents Safety of prophylactic anticoagulants Reversal of antithrombotic- and fibrinolytic-induced ICH Evaluation of hemostatic agents in coagulopathy-associated ICH Surgical priorities Mechanical clot removal devices Surgical targeting Perioperative imaging

Local delivery of protective restorative agents Regional hypothermia

Intracavitary microdialysis for markers of ongoing injury Polymer-based sustained release technology Delayed restorative surgical procedures Delayed implantation of bionic interfaces

Abbreviation: ICH, intracerebral hemorrhage. Source: From Ref. 16.

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