Intracerebral Hemorrhage (ICH) Therapy: Current Status and Future directions MM Mehndiratta, Rajeev Nayak INTRODUCTION I ntracerebral haemorrhage (ICH) can be defined as acute spontaneous extravasation of blood into the brain parenchyma that can extend into ventricles or subarachnoid space. Intracerebral haemorrhage accounts for approximately 10% of all cases of strokes 1 , and one of the leading cause of morbidity and mortality throughout the world .Worldwide incidence of intracerebral haemorrhage is 12 to 15 cases per 100,000 per year. Mortality in hemorrhagic stroke is higher than ischemic stroke 1 .Mortality rate in ICH at one month is 30-40% and at one year, it is approximately 50%. Recent population based studies suggest that most patient presents with small ICH are readily survivable with good medical care, so excellent and aggressive medical care has direct impact on ICH related morbidity and mortality. 2,3 As early deterioration is common in initial hours after ICH, rapid diagnosis and management of patients with ICH is crucial. More than 20% of patient will experience a decrease in the Glasgow coma scale score of >2 points between the prehospital emergency medical service assessment and the initial evaluation in the emergency department 4 .Within the irst hour of presentation to a hospital,15% of patients demonstrate a decrease in the GCS score of >2 points. 5 CAUSES Hypertension: is the most common cause of intracerebral haemorrhage and hypertension related ICH is also called primary ICH. In African Americans and Hispanics the incidence of stroke is directly proportional to high prevalence of hypertension. Uncontrolled hypertension leads to small vessel vasculopathy characterised by fragmentation, and degeneration of vessel wall, known as lipohyalinosis and false micro aneurysm formation (aneurysm of Charcot-Bouchard). Rupture of these micro aneurysm is proposed to be responsible for hypertensive intracerebral haemorrhage. Common sites of hypertensive cerebral haemorrhage in decreasing order are putamen (35%), lobar (25%), thalamus (10-15%), cerebellum(5-10%), pontine(5%), and caudate nucleus (5%). Table I shows non-hypertensive causes of ICH: Intracranial aneurysm and arteriovenous malformation: Site of bleeding in intracranial aneurysm is usually subarachnoid space, intraparenchymal or rarely subdural space, whereas in arteriovenous malformation the site of bleeding is lobar, intraventricular or subarachnoid space. Annual risk of rupture for aneurysm less than 10 mm is 0.1% and for those larger than 10 mm risk of rupture is 0.5-1%. Rate of rupture in AV malformation is 2-4% per year. Trauma : Primary sites for traumatic intracerebral haemorrhage are anterior temporal, basal frontal lobe, subarachnoid, subdural and epidural space. Acceleration- deceleration type of injury by a coup and countercoup mechanism leads to multiple supericial brain Intracranial haemorrhages. Tumours: Intracranial tumour bleed is an uncommon cause of ICH, but carries a very poor prognosis with a 30 day mortality of more than 90%.Common intracranial tumours that develop ICH are glioblastoma multiforme, and metastatic brain tumours with primary from lung carcinoma, renal cell carcinoma, malignant melanoma,