Ultra-Early Hemostatic Therapy for Intracerebral Hemorrhage: Future Directions

Hematoma expansion after initial bleeding is associated with many risk factors, such as anticoagulation, diagnosis by computed tomography (CT) shortly after symptom onset, liver disease, and a high initial blood pressure, among others, and with increased mortality and poor long-term functional outcomes. Contrast extravasation on CT angiogram, termed 'the spot sign', and on delayed-contrast CT scans (13-59%) may help to identify impending intracerebral hemorrhage growth and may open a window of opportunity for therapeutic interventions. The spot sign score, the prediction score for hematoma expansion, and the BRAIN score were developed to assess the probability of hematoma expansion at 24 h. Therapeutic interventions to promote hemostasis are currently limited to intensive blood pressure control and antagonization of the effect of antiplatelets and anticoagulation. Ultra-early hemostasis for ICH not associated with coagulopathy may include administration of recombinant factor VIIa and tranexamic acid to selected patients based on the presence of a spot sign on the CT angiogram is currently under investigation.