Treatment for Intracerebral Hemorrhage: Mastering the "6-Hour Barrier" and Emergency Surgical Indications by Location (Cerebellar, Putaminal)

The treatment for Intracerebral Hemorrhage (ICH) evolves rapidly depending on the time elapsed since onset and the location of the bleeding. The first 6 hours, in particular, constitute the “Hyperacute Phase,” where treatments aimed at halting the expansion of the hemorrhage and controlling intracranial pressure have the greatest impact on prognosis.

Treatment for Intracerebral Hemorrhage: Detailed by Phase and Location

Phase	Goal	Main Treatment Contents	Key Important Points
Hyperacute Phase (Onset ∼ 6 hours)	① Stop the bleeding expansion ② Preserve life	* Blood Pressure Management (Lowering SBP to approx. 140–160 mmHg) * Reversal of Anticoagulants * Seizure prophylaxis (e.g., Levetiracetam)	This 6-hour window is the most critical factor for prognosis! Absolutely no “wait and see” approach.
Acute Phase (∼ 72 hours)	Control cerebral edema (swelling)	* Hyperosmolar agents (Glycerol, Mannitol) * Steroids (for some types of cerebellar hemorrhage) * Head elevation at 30∘, avoid excessive oxygen * Temperature management (antipyretics if >38∘C)	The peak of brain edema is typically between day 2 and day 5.
Surgical Indications (Emergency/Semi-Emergency)	Save life or reduce long-term disability (See below)

Main Types of Surgery and Indications (Current Standard 2025)

Bleeding Site/Condition	Procedure Name	Indication Guidelines	Surgical Goal	Impact on Prognosis
Cerebellar Hemorrhage	Suboccipital Decompression + Hematoma Evacuation	* Hematoma size >3 cm * Deteriorating consciousness * Compression of the 4th ventricle	Relieve brainstem compression	Survival rate significantly increases with surgery (Best within 6 hours)
Putaminal/Thalamic Hemorrhage (Large)	Open Craniotomy and Hematoma Evacuation	* Hematoma volume >30–50 mL+ Impaired consciousness * Young patient with signs of cerebral herniation	Reduce intracranial pressure	Highly effective for young patients/right-sided bleeds; cautious for the elderly.
	Neuroendoscopic Hematoma Aspiration (Trans-nasal/Trans-cranial)	* Hematoma volume >30 mL * Feasible even for elderly patients	Minimally invasive reduction of hematoma	Rapidly increasing in use (Shortens hospital stay)
Deep-seated Bleeding	Stereotactic Hematoma Aspiration	* Deep lesions where craniotomy is difficult	Least invasive option	Common for elderly and thalamic hemorrhage.
Ventricular Rupture + Acute Hydrocephalus	External Ventricular Drainage (EVD)	* Massive blood flow into the ventricles, causing reduced consciousness	Lower intracranial pressure	Performed for almost all cases.
Subarachnoid Hemorrhage + Intraventricular Hematoma	Coiling or Clipping	* Ruptured aneurysm is present (most cases)	Prevent re-bleeding	Best done within 72 hours of onset.

New Treatments Gaining Attention in 2025

Minimally Invasive Surgery (Endoscopy + Aspiration Device)
- Can aspirate nearly 100% of the hematoma through a hole approx. 2 cm in diameter.
- Can now be performed safely on patients over 70 years old.
Decompressive Craniotomy for Middle Cerebral Artery territory Putaminal Hemorrhage
- For young patients with massive bleeding: Hematoma removal + wide opening of the dura mater to relieve brain swelling.
- Data is accumulating showing clear reduction in post-stroke disability.
Advancements in Reversal Agents for Anticoagulant-Associated ICH
- Immediate-acting reversal agents for Xarelto (Rivaroxaban) and Eliquis (Apixaban) are now approved for reimbursement.
- Dramatically shortens the time to surgery.

Recovery Phase ∼ Chronic Phase Treatment (Managing Sequelae)

Type of Sequelae	Main Treatment / Rehabilitation
Hemiparesis	Early mobilization, Botulinum toxin injection (for spasticity), robotic rehabilitation
Aphasia / Higher Brain Dysfunction	Intensive training by speech-language therapists (SLP), Transcranial Magnetic Stimulation (TMS: at select facilities)
Thalamic Pain (Severe burning pain)	Pregabalin, Milogabalin, Carbamazepine, sometimes opioids
Dysphagia (Swallowing difficulty)	Videofluoroscopic swallowing study, swallowing rehabilitation, temporary gastrostomy
Epilepsy	Levetiracetam, Valproic acid, etc. (May require lifelong medication)

Summary

The first 6 hours are critical → Call 911 immediately!
Cerebellar hemorrhage or large amount of blood in the ventricle → Almost 100% require surgery.
Young patient with massive bleeding → Aggressive consideration of surgery.
Minimally invasive endoscopic surgery is often safe even for the elderly.
Rehabilitation works better the “earlier you start.”