8th ESSW Garmisch Session Report: Session III – ICH

Friday afternoon started with the intracerebral haemorrhage (ICH) session, highlighting recent progress and future directions in ICH treatment.

Surgery for ICH
In the keynote lecture, Professor Karin Klijn (Radboud University Nijmegen, Netherlands) reviewed the history and current status of surgical treatment for ICH. Since the first major trial (STICH) was published in 2005, many studies have examined whether surgery improves outcomes, yet clear evidence is still lacking. A 2025 Cochrane review suggested a small benefit. However, results should be interpreted with caution due to small sample sizes and a high risk of bias (Wilting et al., Cochrane Library, 2025).
Professor Klijn outlined ongoing international trials in China, Canada, and the Netherlands. Apart from hopefully providing a definitive answer on whether or not to operate on ICH patients, these studies may refine patient selection, optimal timing, surgical techniques, and supportive treatments. However, assessing surgery for lobar ICH remains difficult because most trials focus on deep ICH.

Standardising Acute Care
Assistant Professor Teresa Ullberg (Lund University, Sweden) showed how ICH management varies widely even in high-quality healthcare systems. In Sweden, only 4–22% of ICH patients are treated in dedicated stroke units. She highlighted the value of structured care bundles, which typically include anticoagulation reversal, blood pressure control, neurosurgical referral, fever management, and glucose regulation. Although individual bundles differ, standardisation improves overall care when teams implement it effectively, suggesting that care bundles are more than the sum of their parts.

Treatment of Cerebral Amyloid Angiopathy (CAA)
Professor Marieke Wermer (Leiden University, Netherlands) discussed emerging therapies for CAA, a major cause of lobar ICH. CAA develops over many years as amyloid accumulates in cerebral vessels. No proven treatment exists, and some past approaches (e.g., the antibody Ponezumab) have worsened outcomes.
Several new trials are now targeting different disease mechanisms. The cAPPricorn study is testing whether Mivelsiran, an RNA molecule interfering with transcription of the amyloid precursor protein, can slow microbleed progression. She also presented two academic trials led at Leiden University: CLEAR-BRAIN, a factorial 2×2 trial combining vagus nerve stimulation and low-sodium oxybate to enhance amyloid-beta clearance, and the recently completed BATMAN trial investigating whether Minocycline can slow CAA progression.

Neuroinflammation after ICH
The final speaker, Neshika Samarasekara (University of Edinburgh, United Kingdom), focused on neuroinflammation as a key driver of secondary injury following ICH. She described how inflammation results in perihaematomal oedema, which develops within minutes to hours. Many potential biomarkers and therapeutic targets exist, but the optimal timing and approach to treating inflammation remain unclear. One striking statistic underscored the importance of pursuing research in this area: every 1 mL increase in perihaematomal oedema raises the risk of death or dependence by 4%.

Conclusion
The session highlighted meaningful advances but also major unanswered questions in ICH care. Progress will likely require combining mechanistic insights with system-level improvements to achieve better outcomes for patients.

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