Seby John, MD

Di Napoli M, Parry-Jones AR, Smith CJ, Hopkins SJ, Slevin M, Masotti L, et al. C-Reactive Protein Predicts Hematoma Growth in Intracerebral Hemorrhage. Stroke. 2013

Intracerebral hemorrhage remains the most deadly form of stroke with high morbidity and mortality. Approximately 40% of ICHs will expand and this is an independent predictor of poor clinical outcomes. How this expansion occurs is unknown and several studies have attempted to predict which hemorrhages will expand. 

Di Napoli et al. studied the link between plasma C-reactive protein (CRP) and early hematoma growth (EHG) after spontaneous ICH (sICH). CRP was measured within 6 hours in patients with primary or vitamin-K antagonist associated sICH, without infection. ICH volume was measured at baseline and within 24 hour using CT brain imaging. They found that median CRP levels were significantly higher in patients who developed EHG compared to those who didn’t. A CRP level >10 mg/l was independently predictive of EHG and early neurological worsening, both of which were associated with increased 30-day mortality. High CRP was also more frequently associated with larger hematomas, severe clinical presentation, IVH, and death at follow-up. The authors conclude that CRP maybe able to identify patients at risk for EHG, thus helping with patient care and prognostication.
This study offers support for the inflammation hypothesis causing primary and secondary injury in ICH. 

Much has been learnt in recent years regarding the pathophysiology of injury, and seems to be mediated by a complex intertwined progression of inflammatory cascades, red cell lysis and thrombin production. Although complicated, interruption of any players in these cascades can be feasible therapeutic targets to prevent injury. The trials of steroid use for ICH in the 1970s and ‘80s showed no benefit, but may have been off set by adverse effects. 

With a better understanding of inflammatory signaling molecules, the dawn of targeted treatment for ICH may be in sight.