Journal Pre-proofs

Review article

Intracerebral Hemorrhage in Translational Research

Ruiyi Zhang, Qian Bai, Yang Liu, Yan Zhang, Zhaofu Sheng, Mengzhou Xue,
V. Wee Yong

PII: S2589-238X(20)30015-2
DOI: https://doi.org/10.1016/j.hest.2020.02.003
Reference: HEST 18

To appear in: Brain Hemorrhages

Received Date: 25 December 2019

Revised Date: 10 February 2020
Accepted Date: 11 February 2020

Please cite this article as: R. Zhang, Q. Bai, Y. Liu, Y. Zhang, Z. Sheng, M. Xue, V. Wee Yong, Intracerebral
Hemorrhage in Translational Research, Brain Hemorrhages (2020), doi: https://doi.org/10.1016/j.hest.2020.02.003

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover
page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will
undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing
this version to give early visibility of the article. Please note that, during the production process, errors may be
discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

© 2020 Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd.
Intracerebral Hemorrhage in Translational Research

Ruiyi Zhang1, Qian Bai1, Yang Liu1, Yan Zhang1, Zhaofu Sheng1, Mengzhou

Xue1, V. Wee Yong2

The Department of Cerebrovascular Diseases, The Second Affiliated

Hospital of Zhengzhou University, Henan Joint International Laboratory
of Intracerebral Hemorrhagic Brain Injury and Henan Medical Key
Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, Henan,
China (1); Hotchkiss Brain Institute and Department of Clinical
Neurosciences, University of Calgary, Calgary, Alberta, Canada (2)

Running title: Intracerebral hemorrhage and translational research

Correspondence to:

Mengzhou Xue*, MD, PhD, 2 Jingba Road, Zhengzhou, Henan, China,

450001; E-mail: xuemengzhou@zzu.edu.cn

V. Wee Yong*, PhD, Hotchkiss Brain Institute and Department of Clinical

Neurosciences, University of Calgary, Calgary, Alberta, Canada

E-mail:vyong@ucalgary.ca
Abstract

Intracerebral hemorrhage (ICH) is a serious stroke subtype with high

morbidity and mortality. The prognosis of ICH is poor. In recent years,

there have been many studies on how to improve the prognosis of ICH.

This article mainly summarizes the research progress of ICH in

translational research, including its risk factors and pathogenesis, course of

disease, primary and secondary ICH brain injury, its prevention and

treatment strategies.

Key words:

Intracerebral hemorrhage; brain injury; neuroinflammation;

neuroimmunology; neuronal death

 Intracerebral hemorrhage (ICH) can be induced by a variety of causes,

including hypertension, cerebral amyloid angiopathy, brain trauma,

vascular malformations and drugs. The study of global disease burden

showed that the number of ICH increased by 47% in past 20 years, mostly

gathered in low income and middle-income countries1. Understanding the

pattern of brain injury induced by ICH is a great significance to find the

effective treatment. Here we summarize the research progress of ICH from

the view of translational medicine.

1. Risk factors and pathogenesis of ICH

Hypertension is the most common risk factor for ICH. About 80% of

ICH patients have elevated blood pressure on admission, and most of them

have a history of hypertension2. Long-term hypertension makes cerebral

arterioles suffer higher stress of blood flow, triggers smooth muscle cell

proliferation and death followed by collagen replacement, weakens the

strength of artery wall, and makes it easy to occlusion and rupture.

Perforating arteries such as bean striation, thalamus and brainstem

perforating artery bifurcation are the most common sites of bleeding, and

the degree of bleeding mainly depends on the size of arteriole wall space,

blood pressure and hemostatic mechanism. In non-hypertensive

individuals, especially in the elderly, amyloid angiopathy is an important

cause of ICH. The deposition of amyloid protein in the media and

adventitia of capillaries, arterioles, cortex and pia meningeal arteries

causes vascular wall brittleness. The unique features of this lesion are that

hemorrhage tends to occur in the lobes of the brain (especially in the

posterior part of the brain), multifocal and recurrent3. The traditional view

believes that the difference between hypertensive vascular disease and

amyloid vascular disease lies in the site of bleeding. ICH associated with

amyloid angiopathy is usually located in the lobe, and the hypertensive

ICH is usually located in the deep part of the brain. However, hypertension

can also lead to lobar hemorrhage, and hypertensive vascular disease and

amyloid vascular disease may be a co-disease, so the pathogenesis of ICH

is sometimes difficult to determine.

Smoking, alcohol abuse, low total and low-density lipoprotein

cholesterol levels all increased the risk of ICH. Warfarin increases the

risk of ICH by 2 to 5 times, and the risk of bleeding depends on

anticoagulant strength. The increase in the number of elderly people taking

oral anticoagulant drugs has led to an increasing number of anticoagulant-

related ICH. Antiplatelet therapy also increases the risk of ICH. Although

several case-control studies did not prove that the use of antiplatelet drugs

increased the risk of ICH, Meta-analysis showed that platelet therapy

slightly significantly increased the risk of ICH. In addition, Meta-analysis

showed that the history of antiplatelet drugs increased the risk of death after

ICH, and another study showed that the history of antiplatelet drugs was
associated with an increase in early hematoma in ICH. Compared with

antiplatelet monotherapy, double anti-platelet therapy may further increase

the risk of ICH. In patients with atrial fibrillation, the risk of ICH in the

aspirin combined with clopidogrel group was almost twice as high as that

in the aspirin alone group4,5

There have been many reports of associations between sympathetic

drugs such as cocaine, heroin, amphetamine and ephedrine with ICH,

especially in young patients. Especially in women, relatively high doses of

phenylpropanolamine are an independent factor for ICH, and low doses of

phenylpropanolamine in cold cures is also associated with ICH risk6,7. In

addition, chronic kidney disease increases the risk of ICH, and chronic

kidney disease may be a marker of cerebral microvascular disease 4,8.

2. Progression of ICH

After vascular rupture, the formation of hematoma begins and

progresses within 60 min. The sudden influx of blood flow into the brain

leads to mechanical destruction of the brain parenchyma, distortion and

displacement of the brain tissue, increases the risk of cerebral hernia and

ischemia, and triggers brain cell death including necrosis and apoptosis,

inflammation and edema9. About 1/3 of the patients had enlarged

hematoma within 3 h, and about 2/3 of them occurred within 1 h after ICH10.

Even without the coagulation disorders, the hematoma will increase too,
and the mechanism of hematoma increase is not clear, which may be

related to the continued bleeding at the initial bleeding site and the satellite

bleeding around the blood clot caused by the destruction of adjacent small

blood vessels. Alcohol abuse, irregular bleeding, low levels of fibrinogen

and prothrombin, diabetes and liver diseases are all risk factors for

hematoma enlargement3. Computed tomographic angiography (CTA) can

predict the risk of hematoma enlargement. The spot sign of CTA is highly

correlated with hematoma enlargement10. CTA spot sign was first described

in 2007, it was defined as focal or multifocal enhancer spillover from

normal or abnormal blood vessels around hematoma after ICH, which

predicted hematoma enlargement and became an independent indicator of

poor clinical prognosis11. Subsequent large clinical studies found that about

30% of ICH patients had spot sign. Multiple CTA tests could further help

predict hematoma enlargement, and the clinical prognosis of patients with

spot sign within 23 s? of enhancer injection was poor12. Intraventricular

hemorrhage (IVH) can occur with ICH or within 24~72 h after ICH,

accounting for about 20% to 55% of patients with ICH, which is another

important factor in the poor prognosis of ICH. Compared with patients

without IVH, the prognosis of patients with IVH was worse13.

ICH patients developed brain edema within a few hours after the onset

of symptoms and reached the peak at 1 to 2 weeks. The blood composition

is closely related to the brain edema around the hematoma.

 Within 1 hour after ICH, the blood clot contracts and the plasma move

out from the clot to the tissue around the hematoma, forming edema

adjacent to hematoma. 24 hours after bleeding, thrombin cascade reaction

and thrombin production are involved in the formation of early edema.

Erythrocyte lysis, hemoglobin and its decomposition products, and

carbonic anhydrase-1, another component of erythrocytes, lead to late

edema. The blood-brain barrier (BBB) remained intact within a few hours

after ICH, but the permeability of BBB increased after 8 to 12 hours.

Although there are many forms of edema after ICH, angiogenic edema is

the main form of ICH10. The imaging findings of brain edema were low

density on CT scan and high signal on T2 weighted or Flair of magnetic

resonance imaging (MRI). The most severe edema was located around the

clot, mainly along the white matter3.

The degree of cerebral ischemia around hematoma after ICH is still

controversial. Large hematoma increases intracranial pressure, resulting in

cerebral hernia and slow blood flow velocity, which may lead to a further

decrease in blood flow if the supply of collateral circulation in the brain

area supplied by ruptured blood vessels is poor. However, few clinical and

animal studies have reported whether changes in blood flow around the

hematoma can lead to ischemic injury. It should be noted that the changes

of blood flow velocity around the hematoma mix metabolism and

hematoma formation and other factors. In ICH patients, the blood flow and
oxygen metabolic rate around the hematoma decreased, resulting in the

decrease of oxygen uptake fraction, indicating that there is a low perfusion

area around the hematoma. Recent data have shown that the decline in

brain metabolism may reflect mitochondrial damage rather than cerebral

ischemia14.

ICH may also trigger the protective defense mechanism of the body.

Up-regulation of a variety of endogenous proteins after ICH may help

protect the brain from damage. For example, ferritin and nuclear factor 2

related factor 2 (NF-E2 related factor 2, Nrf 2) were significantly up-

regulated and participated in the mechanism of antioxidant defense. In

Nrf2 knockout mice, collagenase leads to more brain injury by inducing

ICH than that in wild-type mice14.

3. Primary brain injury induced by ICH and its prevention and

treatment strategy

ICH firstly destroys the brain structure. Hematoma may increase

intracranial pressure, oppress brain areas, potentially affect blood flow and

cause cerebral hernia. In view of the physical compression of hematoma,

many clinical trials have explored the effect of surgical removal of blood

clots, but no clinical trials have confirmed the benefits of ICH patients. One

possible explanation is that the side effects of surgery offset the beneficial

effects of blood clot removal. It is worth noting that the location of ICH
affects the prognosis, and surgical decompression can save lives in patients

with cerebellar hemorrhage. Because it is more difficult to remove

hematoma in small animals, there are relatively few preclinical studies on

the effect of removing blood clots, and most studies use pigs, which

confirms that early removal of hematoma may benefit, but there are many

problems with ultra-early clearance of blood clots. In clinical, some

patients will continue to bleed or easily bleed again10. Moreover, a clinical

trial shows that removing acute intracerebral hematomas in early phase by

minimally invasive surgery which has been widely used recently is safe

and effective to bring better neurological prognosis in ICH patients.15

Preventing hematoma enlargement may be another way to reduce the

space occupying effect. Many patients suffered rapid elevated blood

pressure after ICH which could result in further bleeding and edema. Some

clinical trials exhibit that although there are no differences between

intensive lowering of systolic pressure under 140 mmHg and under 180

mmHg as guideline in death or severe disability, rapid reduction of the

blood pressure may contributes to improved functional outcomes. 16,17

And many studies have focused on finding drugs that change the process

of coagulation cascade or fibrinolysis. Clinical trials have confirmed that

activated coagulation factor Ⅶ (Ⅶa), which can reduce hematoma

enlargement but cannot improve prognosis and may induce

thromboembolic complications. There are also some clinical trials to

explore which patients are suitable for the treatment of activated

coagulation factor Ⅶa18. Some studies have shown that patients with

enlarged hematoma or patients with ICH who take anticoagulant or

antiplatelet drugs benefit the most. Other methods are also being tested

clinically, such as platelet transfusion in patients receiving antiplatelet

therapy, or the use of aminocaproic acid, an antifibrinolytic agent. Early

platelet transfusion can benefit from low platelet activity or antiplatelet

therapy. In the rat model of ICH induced by collagenase, activated

coagulation factor Ⅶa reduced early hematoma enlargement 19.

Vasodilator in plasma can inhibit platelet aggregation and inhibit

vasodilator can reduce the enlargement of hematoma. In the mouse ICH

model induced by warfarin anticoagulant and collagenase, prothrombin

complex concentrate and frozen plasma could reduce bleeding, and the

effects of activated coagulation factor Ⅶa and tranexamic acid were

poor14,20.

The increase of blood pressure after ICH is the result of the

superposition of many mechanisms, including pre-onset hypertension,

increased intracranial pressure, autonomic nerve and neuroendocrine

activation. Clinical trials to reduce hematoma also include lowering blood

pressure. There is a dilemma in the treatment of elevated blood pressure.

On the one hand, acute hypertension may be protective, ensuring cerebral

blood flow supply in the case of elevated intracranial pressure to prevent

ischemic stroke, on the other hand, hypertension increases the risk of

edema. Promote hematoma enlargement by continuing bleeding and

rebleeding. According to the American Heart and Stroke Association

guidelines, blood pressure is safe at 150 to 220 mmHg after ICH. Some

clinical trials have confirmed that the target value of blood pressure

reduction within 1 h after ICH is not less than 140 mmHg, which has no

obvious negative effect on neural state and has nothing to do with serious

adverse events. Recent clinical trials have shown that the target value of

hypotension at 110 mmHg is still safe 21. It is not known whether

antihypertensive treatment has long-term benefits, but there is evidence

that it can reduce hematoma enlargement. There are few preclinical studies

on the effect of blood pressure on hematoma enlargement. After injection

of collagenase, there was no significant difference in bleeding volume

between spontaneously hypertensive rats and normal blood pressure rats.

However, the injury induced by ICH in spontaneously hypertensive rats is

more serious, indicating that hypertension does not mediate ICH-induced

injury by regulating the volume of hematoma. Rapid changes in blood

pressure may have a greater impact on hematoma enlargement than

persistent hypertension. Pathological examination of ICH rat model

showed that there was no significant difference in bleeding volume

between spontaneously hypertensive rats and normal hypertensive rats, but

there was more bleeding in normotensive rats with sharply elevated blood
pressure14.

Many studies have focused on the application of drug-enhanced

defense mechanisms. Nrf2 can be up-regulated by a range of drugs,

including sulforaphane, a component of broccoli, which reduces ICH-

induced brain injury in rats and mice through a Nrf2-dependent mechanism.

Peroxisome proliferator-activated receptor-γ (PPAR-γ) agonists can also

play a beneficial role by up-regulating cellular defense mechanisms,

including hydrogen peroxide 14.

4. Secondary brain injury induced by ICH and its prevention and

treatment strategy

Secondary brain injury after ICH may be caused by a series of events

induced by primary injury, including body / tissue responses to hematoma,

such as inflammation, microglia/macrophage activation and neutrophil

infiltration22, release of clot components (e.g. hemoglobin / iron) 14

.

Following factors are involved in secondary brain injury induced by ICH.

The initial response of the body to ICH is the activation of the

hemostatic mechanism to limit bleeding. Thrombin plays an important role

in homeostasis, but there is also a lot of evidence that thrombin can be

23
involved in ICH-induced brain injury . The most important role of

thrombin is to break down fibrinogen into fibrin, while the other effects are

mediated by three protease-activated receptors (PARs). PAR-1, PAR-3 and

PAR-4 are thrombin receptors24. It has been found that neurons and

astrocytes express mRNA of thrombin receptors and the immunoreactivity

of which in human brain. Studies have shown that PAR-1 mediates some

pathological effects of thrombin and participates in the pathophysiological

mechanism induced by ICH25. Infusion of high doses of thrombin directly

into the brain can cause inflammatory cell infiltration, mesenchymal cell

proliferation, scar formation, brain edema and seizures 23,24,26,27. Thrombin

acts on many cell types, including endothelial cells, which leads to the

destruction of BBB and the formation of brain edema. Neurons and

astrocytes are activated by Src kinase and can be killed by high

concentration of thrombin in vitro. Microglia can be activated by thrombin.

Animal experiments showed that inhibition of thrombin by hirudin, a

specific thrombin inhibitor23,24,27, could reduce the damage induced by ICH.

Clinical trials have also confirmed that thrombin mediated brain injury.

Argatroban, a thrombin inhibitor, can significantly reduce brain edema

around the hematoma following ICH. In addition, there is evidence that

thrombin is associated with brain recovery and neuronal regeneration after

ICH27-29.

There are obvious inflammatory reactions after ICH, including

microglia activation, leukocyte infiltration and inflammatory mediator

formation, which play an important role in ICH-induced injury and brain

recovery 30. In ICH animal model, the activation of microglia was an early
reaction, which appeared within 1 hour after ICH, reached the peak at 3 to

7 days after ICH, and maintained for 3 to 4 weeks23,24,26. Tuftsin or

minocycline plays a protective role after ICH by inhibiting microglia

31-33
activation . A meta-analysis including 4 clinical trials and 14 rodent

studies displays therapeutic effects on acute ischemic stroke. But the study

about minocycline treatment on ICH remains less. A pilot study of

minocycline in ICH patients shows that 400 mg dose can produce

neuroprotective effects34, but further study in different doses or usage still

need to be done. For brain injury after ICH, microglia/macrophage are a

double-edged sword, which can promote inflammation reactions leading

secondary injury or mediate inflammation and dissolve blood clots 22, and

the net effect may change with time 35. Neutrophils are the first leukocytes

to enter the brain after ICH. Neutrophils participate in ICH-induced brain

injury by producing reactive oxygen species (ROS), pro-inflammatory

proteases and destroying BBB. Monocytes also enter the brain after ICH,

and recent studies have shown that consumption of neutrophils reduces the

number of monocytes entering the brain. Toll-like receptor 4 on leukocytes

mediates the infiltration of neutrophils and monocytes. The two types of

cells that have received little attention in the ICH study are mast cells and

infiltrating lymphocytes in the brain. Recent studies have shown that the

both may mediate ICH-induced brain injury31. In animals and humans,

brain injury induced by ICH is associated with the significant upregulation

of a variety of inflammatory mediators, such as tumor necrosis factor-α

(TNF-α) and interleukin-1 β (IL-1β), chemokines, adhesion molecules, and

matrix metalloproteinase (MMPs) such as MMP-9 and -327,29,36,37. The

secondary reaction of inflammation after ICH leads to the destruction of

BBB, which can aggravate inflammation by promoting leukocyte

infiltration. ROS, pro-inflammatory cytokines, chemokines and MMPs

from leukocytes are all involved in the destruction of BBB38. In addition to

promoting inflammation, the destruction of BBB also leads to the

formation of vascular edema after ICH. There have been clinical trials to

verify whether cyclooxygenase inhibitor celecoxib, anti-inflammatory

hypoglycemic drug pioglitazone can reduce brain injury after ICH, but no

clear conclusion has been drawn. Some clinical trials focused on two kinds

of lipid-lowering drugs, rosuvastatin and simvastatin, which had anti-

inflammatory effects. Rosuvastatin had a positive effect, but simvastatin

trial could not continue because of difficulty in recruiting volunteers 39,40.

The complement system involves immune responses, including cell

lysis and inflammation. The plasma protein components of the complement

system are usually blocked out of the brain by the BBB, but they may enter

the brain after ICH as part of the blood or after BBB is damaged.

Membrane attack complex (MAC, C5b-9) is formed after ICH and

complement activation. MAC participates in the cleavage of red blood cells

and mediates the release of hemoglobin and iron, resulting in damage to

surrounding tissues. It may also cause direct damage to neurons, glial cells

and blood vessels around the hematoma. In addition, complement cascade

activation produces C3a and C5a, leukocyte chemokines, microglia and

mast cell activators, which promotes inflammation after ICH. Several

studies have confirmed that consumption of complements using

antagonists or gene knockout can reduce ICH-induced brain injury41.

However, the conclusions on C5 are not consistent. C5a inhibitors are

protective, while the brain injury induced by ICH in C5 gene deficient mice

is significantly increased, which may reflect the compensatory changes in

C5 gene deficient mice. Similar to inflammation, although complement

activation after ICH promotes brain damage, there is also evidence that

complement is beneficial to the long-term recovery of the brain42.

There is growing evidence that hemoglobin and iron released from

hematoma are the main causes of brain damage caused by ICH. Injection

of lysed red blood cells into the rodent brain induces brain damage, and

infusion of hemoglobin and iron into the brain has a similar effect. After

ICH, iron accumulates in the tissues around the hematoma. In rat and pig

models, the use of iron chelator deferoxamine can reduce brain damage

induced by ICH43. Deferoxamine has shown protective effects and

reduction of injuries in ICH rats and piglets 44,45, and deferoxamine

mesylate has been used in clinical trials46. Heme oxygenase breaks down

blood into bilirubin, carbon dioxide and iron. Inhibition of heme oxygenase
or knockout serum heme oxygenase-1 can reduce brain damage caused by

ICH47. One possible mechanism of tissue damage caused by iron is the

production of free radicals. Free radical mediated ICH injury, animal

experiments showed that free radical scavengers reduce the damage

induced by ICH. However, it should be pointed out that there may be a

variety of sources of free radicals after ICH. NXY-059 is a free radical spin

trap used in clinical trials in patients with ICH48. It has not been confirmed

whether patients benefit or not. The cause of this negative result has not

yet been determined, but it may reflect that the increase in the permeability

of BBB after ICH is not sufficient to neutralize a large number of free

radicals49. Although hemoglobin is the main component of red blood cells,

it is not the only one. A recent study has shown that intracerebral injection

of carbonic anhydrase 1, another major component of red blood cells, may

lead to brain damage, and carbonic anhydrase inhibitors reduce ICH-

induced damage in rats50.

Although glutamate-induced excitability plays an important role in cell

death after cerebral ischemia, there is some evidence that glutamate may

also be involved in ICH-induced brain injury and through specific potential

mechanisms. The primary hemorrhage leads to glutamate outflow, and the

production of thrombin after ICH leads to the activation of Src kinase. Src

kinase can phosphorylate NMDA receptor and enhance its function.

Compared with cerebral ischemia, there are few clinical trials to verify the
role of glutamate receptor antagonists in ICH, except for a small clinical

trial of NMDA antagonist CP-101606, which focuses on traumatic brain

injury51,52.

ICH causes brain cell death and brain atrophy around the hematoma.

The pathway of cell death involves apoptosis, necrosis and autophages,

which the dominant way is controversial. The necrosis of the brain around

the blood clot may be related to the mechanical pressure of hematoma, the

composition of blood clot and its degradation. Although apoptosis is

associated with peri-hematoma brain cell death, the importance of

apoptosis in ICH-induced brain injury is not clear10. A large number of

studies have used ICH model to find possible ways to reduce apoptosis and

brain injury, such as taurodeoxycholic acid, membrane stabilizer cytidine

diphosphate choline14. There is also evidence that autophagy occurs after

ICH14. Autophagy is the degradation process of cells. Proteins and

organelles are isolated in bilayer vesicles and transported to lysosomes,

which are digested by lysosomal hydrolases. ICH can induce programmed

cell death in the form of autophagy, and iron plays an important role in the

process of autophagy53. As with other neurological diseases, it is necessary

to further confirm whether autophagy is protective (removing dead cells)

or nociceptive (inducing multiple cell deaths)54. In clinical and animal

experiments, cell death after ICH can lead to brain atrophy10,55.

 5. From bench to clinic

Due to absence of effective treatment for ICH56, many researchers

devote into discover new therapeutic targets and pathophysiology with the

help of different animal models including microballoon insertion57,

autologous whole blood injection58, collagenase59, thrombin23,

hypertensive stroke model60, neonatal PVH/IVH61 and other newly

developed models. But none of these animal models can completely mimic

the condition of human ICH. Each of them has advantages and

disadvantages. Autologous blood injection model may imitate the effects

of hematoma most accurately but cannot reproduce the process of

bleeding62. Collagenase can disrupt capillary basal lamina and cause

bleeding63, but it is artificial and may lead to direct damage of brain tissue

besides the effects of hemorrhage64. Thrombin released after ICH activates

microglia and promotes cytokine production that causes

neuroinflammation and brain cell death, but this model may be not suitable

for research other than effects of thrombin. Hence, an animal model needs

to be selected deliberately according to the purpose and condition of a

preclinical research of ICH.

Many preclinical studies focused on inflammation response after ICH

and as the most important immune cells in central nerval system,

microglia/macrophage are very popular and promising65. As a double

side’s sword, activated pro-inflammatory microglia increase their

production of numerous proinflammatory and potentially neurotoxic

mediators which may contribute to ICH neuronal injury while increasing

evidence indicates that activated microglia in the later phase of ICH

phagocytose/resorb hematoma and resolve edema, contributing to

improved white matter integrity, repair and functional recovery66. Some

promising drugs targeting on shift the balance between pro-inflammatory

and regulatory phenotypes of microglia/macrophage after ICH achieved

therapeutic effects in preclinical or clinical trials. Some of these

medications focus on inhibit the generation of pro-inflammatory cells

including minocycline67, C5aRA, rCTRP9, NLRP3 blocker68, LTB4

receptor antagonist, TLR4 inhibitors69, Fingolimod70 and bortezomib71

while others dedicate to promote the transformation of regulatory

microglia/macrophage such as SIPR agonists 72, Statins73, CB2R agonist,

PPARγ activators74, mTOR inhibiters75 and sinomenine76. All of these

promising candidates still need to be further discovered in mechanism and

tested in usage and doses in both laboratory and clinical situation.

6. Conclusion

In summary, our understanding of the mechanism of brain damage

caused by ICH has increased over the past 20 years, and the conduct of

many clinical trials offers hope for the relief of severe ICH. However, it

should be noted that ICH covers a variety of hematoma in different

locations and sizes. As a result, there is probably no treatment that is most

suitable for all patients77. For different individuals, the combination of

different treatments may provide the best way to alleviate ICH brain

injury77,78.

Acknowledgments

The authors acknowledge operating grant support from the National

Natural Science Foundation of China (grants no: 81870942, 81471174 and

81520108011), National Key Research and Development Program of

China (grant no: 2018YFC1312200), and Innovation Scientists and

Technicians Troop Constructions Projects of Henan Province of China (for

MX); and from the Canadian Institutes of Health Sciences (VWY).

Competing interests

The authors have no conflict of interest to declare.

Reference

1. Kang D-W. Intracerebral hemorrhage: large disease burden but less therapeutic

progress. Journal of stroke. 2017;19(1):1-2.

2. Sessa M. Intracerebral hemorrhage and hypertension. Neurological Sciences.

2008;29:258.

3. Godoy DA, Piñero GR, Koller P, Masotti L, Di Napoli M. Steps to consider in the

approach and management of critically ill patient with spontaneous intracerebral

hemorrhage. World journal of critical care medicine. 2015;4(3):213.

4. An SJ, Kim TJ, Yoon B-W. Epidemiology, risk factors, and clinical features of

intracerebral hemorrhage: an update. Journal of stroke. 2017;19(1):3.

5. Suzuki Y, Sato T, Sakuma J, et al. Intracranial hemorrhage and platelet transfusion

after administration ofanti-platelets agents: Fukushima Prefecture. Fukushima journal

of medical science. 2016:2015-2026.

6. Tormoehlen LM, Blatsioris AD, Moser EA, et al. Disparities and guideline adherence in

drugs of abuse screening in intracerebral hemorrhage. Neurology. 2017;88(3):252-258.

7. Klys M, Konopka T, Rojek S. Intracerebral hemorrhage associated with amphetamine.

Journal of analytical toxicology. 2005;29(6):577-581.

8. Kim JK, Shin JJ, Park SK, Hwang YS, Kim TH, Shin HS. Prognostic factors and clinical

outcomes of acute intracerebral hemorrhage in patients with chronic kidney disease.

Journal of Korean Neurosurgical Society. 2013;54(4):296.

9. Brouwers HB, Greenberg SM. Hematoma expansion following acute intracerebral

hemorrhage. Cerebrovascular diseases. 2013;35(3):195-201.

10. Xi G, Strahle J, Hua Y, Keep RF. Progress in translational research on intracerebral

hemorrhage: is there an end in sight? Progress in neurobiology. 2014;115:45-63.

11. Wada R, Aviv RI, Fox AJ, et al. CT angiography “spot sign” predicts hematoma

expansion in acute intracerebral hemorrhage. Stroke. 2007;38(4):1257-1262.

12. Bates T, Phatourous C, Van Heerden J. Spot sign, prognosis and intracerebral

haemorrhage. QJM: An International Journal of Medicine. 2017;110(1):51-52.

13. Chen S, Zeng L, Hu Z. Progressing haemorrhagic stroke: categories, causes,

mechanisms and managements. Journal of neurology. 2014;261(11):2061-2078.

14. Keep RF, Hua Y, Xi G. Intracerebral haemorrhage: mechanisms of injury and

therapeutic targets. The Lancet Neurology. 2012;11(8):720-731.

15. Vespa P, Hanley D, Betz J et al. ICES (Intraoperative Stereotactic Computed

Tomography-Guided Endoscopic Surgery) for Brain Hemorrhage: A Multicenter

Randomized Controlled Trial. Stroke. 2016;47(11):2749-2755.

16. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with

acute intracerebral hemorrhage. N Engl j Med. 2013;368:2355-2365.

17. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in

patients with acute cerebral hemorrhage. New England Journal of Medicine.

2016;375(11):1033-1043.

18. Diringer MN, Skolnick BE, Mayer SA, et al. Thromboembolic events with recombinant

activated factor VII in spontaneous intracerebral hemorrhage: results from the Factor

Seven for Acute Hemorrhagic Stroke (FAST) trial. Stroke. 2010;41(1):48-53.

19. Kawai N, Nakamura T, Nagao S. Early hemostatic therapy using recombinant factor
 VIIa in a collagenase-induced intracerebral hemorrhage model in rats. In: Brain Edema

XIII. Springer; 2006:212-217.

20. Illanes S, Zhou W, Schwarting S, Heiland S, Veltkamp R. Comparative effectiveness

of hemostatic therapy in experimental warfarin-associated intracerebral hemorrhage.

Stroke. 2011;42(1):191-195.

21. Lattanzi S, Silvestrini M. Blood pressure in acute intra-cerebral hemorrhage. Annals of

translational medicine. 2016;4(16).

22. Bai Q, Xue M, Yong VW. Microglia and macrophage phenotypes in intracerebral

haemorrhage injury: therapeutic opportunities. Brain. 2020 Jan 9. pii: awz393, doi:

10.1093/brain/awz393. [Epub ahead of print]

23. Xue M, Del Bigio MR. Injections of blood, thrombin, and plasminogen more severely

damage neonatal mouse brain than mature mouse brain. Brain pathology.

2005;15(4):273-280.

24. Xue M, Balasubramaniam J, Parsons KA, McIntyre IW, Peeling J, Del Bigio MR. Does

thrombin play a role in the pathogenesis of brain damage after periventricular

hemorrhage? Brain pathology. 2005;15(3):241-249.

25. Xue M, Hollenberg MD, Demchuk A, Yong VW. Relative importance of proteinase-

activated receptor-1 versus matrix metalloproteinases in intracerebral hemorrhage-

mediated neurotoxicity in mice. Stroke. 2009;40(6):2199-2204.

26. Xue M, Del Bigio MR. Acute tissue damage after injections of thrombin and plasmin

into rat striatum. Stroke. 2001;32(9):2164-2169.

27. Xue M, Hollenberg MD, Yong VW. Combination of thrombin and matrix
 metalloproteinase-9 exacerbates neurotoxicity in cell culture and intracerebral

hemorrhage in mice. Journal of Neuroscience. 2006;26(40):10281-10291.

28. Babu R, Bagley JH, Di C, Friedman AH, Adamson C. Thrombin and hemin as central

factors in the mechanisms of intracerebral hemorrhage–induced secondary brain injury

and as potential targets for intervention. Neurosurgical focus. 2012;32(4):E8.

29. Xue M, Fan Y, Liu S, Zygun DA, Demchuk A, Yong VW. Contributions of multiple

proteases to neurotoxicity in a mouse model of intracerebral haemorrhage. Brain.

2009;132(Pt 1):26-36.

30. Aronowski J, Zhao X. Molecular pathophysiology of cerebral hemorrhage: secondary

brain injury. Stroke. 2011;42(6):1781-1786.

31. Xue M, Mikliaeva EI, Casha S, Zygun D, Demchuk A, Yong VW. Improving outcomes

of neuroprotection by minocycline: guides from cell culture and intracerebral

hemorrhage in mice. The American journal of pathology. 2010;176(3):1193-1202.

32. Wang G, Li Z, Li S, et al. Minocycline Preserves the Integrity and Permeability of BBB

by Altering the Activity of DKK1-Wnt Signaling in ICH Model. Neuroscience.

2019;415:135-146.

33. Sheng Z, Liu Y, Li H, et al. Efficacy of Minocycline in Acute Ischemic Stroke: A

Systematic Review and Meta-Analysis of Rodent and Clinical Studies. Frontiers in

neurology. 2018;9:1103.

34. Fouda AY, Newsome AS, Spellicy S, et al. Minocycline in Acute Cerebral Hemorrhage:

An Early Phase Randomized Trial. Stroke. 2017;48(10):2885-2887.

35. Yong HYF, Rawji KS, Ghorbani S, Xue M, Yong VW. The benefits of neuroinflammation
 for the repair of the injured central nervous system. Cellular & molecular immunology.

2019;16(6):540-546.

36. Dang B, Duan X, Wang Z, He W, Chen G. A Therapeutic Target of Cerebral

Hemorrhagic Stroke: Matrix Metalloproteinase- 9. Current drug targets.

2017;18(12):1358-1366.

37. Chang JJ, Emanuel BA, Mack WJ, Tsivgoulis G, Alexandrov AV. Matrix

metalloproteinase-9: dual role and temporal profile in intracerebral hemorrhage.

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke

Association. 2014;23(10):2498-2505.

38. Xue M, Yong VW. Matrix metalloproteinases in intracerebral hemorrhage. Neurological

research. 2008;30(8):775-782.

39. Wang J, Dore S. Inflammation after intracerebral hemorrhage. Journal of cerebral blood

flow and metabolism : official journal of the International Society of Cerebral Blood Flow

and Metabolism. 2007;27(5):894-908.

40. Zhou Y, Wang Y, Wang J, Anne Stetler R, Yang QW. Inflammation in intracerebral

hemorrhage: from mechanisms to clinical translation. Prog Neurobiol. 2014;115:25-44.

41. Garrett MC, Otten ML, Starke RM, et al. Synergistic neuroprotective effects of C3a and

C5a receptor blockade following intracerebral hemorrhage. Brain Res. 2009;1298:171-

177.

42. Ducruet AF, Zacharia BE, Hickman ZL, et al. The complement cascade as a

therapeutic target in intracerebral hemorrhage. Exp Neurol. 2009;219(2):398-403.

43. Sun YM, Wang YT, Jiang L, Xue MZ. The effects of deferoxamine on inhibition for
 microglia activation and protection of secondary nerve injury after intracerebral

hemorrhage in rats. Pakistan journal of pharmaceutical sciences. 2016;29(3

Suppl):1087-1093.

44. Hatakeyama T, Okauchi M, Hua Y, Keep RF, Xi G. Deferoxamine reduces neuronal

death and hematoma lysis after intracerebral hemorrhage in aged rats. Translational

stroke research. 2013;4(5):546-553.

45. Xie Q, Gu Y, Hua Y, Liu W, Keep RF, Xi G. Deferoxamine attenuates white matter

injury in a piglet intracerebral hemorrhage model. Stroke. 2014;45(1):290-292.

46. Yeatts SD, Palesch YY, Moy CS, Selim M. High dose deferoxamine in intracerebral

hemorrhage (HI-DEF) trial: rationale, design, and methods. Neurocritical care.

2013;19(2):257-266.

47. LeBlanc RH, 3rd, Chen R, Selim MH, Hanafy KA. Heme oxygenase-1-mediated

neuroprotection in subarachnoid hemorrhage via intracerebroventricular deferoxamine.

J Neuroinflammation. 2016;13(1):244.

48. Lyden PD, Shuaib A, Lees KR, et al. Safety and tolerability of NXY-059 for acute

intracerebral hemorrhage: the CHANT Trial. Stroke. 2007;38(8):2262-2269.

49. Righy C, Bozza MT, Oliveira MF, Bozza FA. Molecular, Cellular and Clinical Aspects

of Intracerebral Hemorrhage: Are the Enemies Within? Current neuropharmacology.

2016;14(4):392-402.

50. Guo F, Hua Y, Wang J, Keep RF, Xi G. Inhibition of carbonic anhydrase reduces brain

injury after intracerebral hemorrhage. Transl Stroke Res. 2012;3(1):130-137.

51. Sharp F, Liu DZ, Zhan X, Ander BP. Intracerebral hemorrhage injury mechanisms:
 glutamate neurotoxicity, thrombin, and Src. Acta neurochirurgica Supplement.

2008;105:43-46.

52. Bullock MR, Merchant RE, Carmack CA, et al. An open-label study of CP-101,606 in

subjects with a severe traumatic head injury or spontaneous intracerebral hemorrhage.

Annals of the New York Academy of Sciences. 1999;890:51-58.

53. Chen TY, Lin CL, Wang LF, Tsai KL, Lin JY, Hsu C. Targeting GPER1 to suppress

autophagy as a male-specific therapeutic strategy for iron-induced striatal injury.

Scientific reports. 2019;9(1):6661.

54. Durocher M, Ander BP, Jickling G, et al. Inflammatory, regulatory, and autophagy co-

expression modules and hub genes underlie the peripheral immune response to human

intracerebral hemorrhage. J Neuroinflammation. 2019;16(1):56.

55. Li Q, Weiland A, Chen X, et al. Ultrastructural Characteristics of Neuronal Death and

White Matter Injury in Mouse Brain Tissues After Intracerebral Hemorrhage:

Coexistence of Ferroptosis, Autophagy, and Necrosis. Frontiers in neurology.

2018;9:581.

56. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous

intracerebral hemorrhage. New England Journal of Medicine. 2001;344(19):1450-1460.

57. Sinar E, Mendelow AD, Graham DI, Teasdale GM. Experimental intracerebral

hemorrhage: effects of a temporary mass lesion. Journal of neurosurgery.

1987;66(4):568-576.

58. Xue M, Del Bigio MR. Intracerebral injection of autologous whole blood in rats: time

course of inflammation and cell death. Neuroscience letters. 2000;283(3):230-232.

59. Rosenberg GA, Mun-Bryce S, Wesley M, Kornfeld M. Collagenase-induced

intracerebral hemorrhage in rats. Stroke. 1990;21(5):801-807.

60. Liard J-F, Cowley Jr AW, McCaa RE, McCaa CS, GUYTON AC. Renin, aldosterone,

body fluid volumes, and the baroreceptor reflex in the development and reversal of

Goldblatt hypertension in conscious dogs. Circulation Research. 1974;34(4):549-560.

61. Goddard J, Lewis RM, Armstrong DL, Zeller RS. Moderate, rapidly induced

hypertension as a cause of intraventricular hemorrhage in the newborn beagle model.

The Journal of pediatrics. 1980;96(6):1057-1060.

62. Xi G, Wagner KR, Keep RF, et al. Role of blood clot formation on early edema

development after experimental intracerebral hemorrhage. Stroke. 1998;29:2580-2585.

63. Rosenberg GA, Estrada E, Kelley RO, Kornfeld M. Bacterial collagenase disrupts

extracellular matrix and opens blood-brain barrier in rat. Neuroscience letters.

1993;160(1):117-119.

64. Xue M, Del Bigio MR. Comparison of brain cell death and inflammatory reaction in three

models of intracerebral hemorrhage in adult rats. Journal of Stroke and

Cerebrovascular Diseases. 2003;12(3):152-159.

65. Poon CC, Sarkar S, Yong VW, Kelly JJ. Glioblastoma-associated microglia and

macrophages: targets for therapies to improve prognosis. Brain. 2017;140(6):1548-

1560.

66. Wan S, Cheng Y, Jin H, et al. Microglia activation and polarization after intracerebral

hemorrhage in mice: the role of protease-activated receptor-1. Translational stroke

research. 2016;7(6):478-487.
67. Kobayashi K, Imagama S, Ohgomori T, et al. Minocycline selectively inhibits M1

polarization of microglia. Cell death & disease. 2013;4(3):e525-e525.

68. Yang X, Sun J, Kim TJ, et al. Pretreatment with low-dose fimasartan ameliorates

NLRP3 inflammasome-mediated neuroinflammation and brain injury after intracerebral

hemorrhage. Experimental neurology. 2018;310:22-32.

69. Lan X, Han X, Li Q, et al. Pinocembrin protects hemorrhagic brain primarily by inhibiting

toll-like receptor 4 and reducing M1 phenotype microglia. Brain, behavior, and immunity.

2017;61:326-339.

70. Yang Z, Dong S, Zheng Q, et al. FTY720 attenuates iron deposition and glial responses

in improving delayed lesion and long-term outcomes of collagenase-induced

intracerebral hemorrhage. Brain research. 2019;1718:91-102.

71. Sinn D-I, Lee S-T, Chu K, et al. Proteasomal inhibition in intracerebral hemorrhage:

neuroprotective and anti-inflammatory effects of bortezomib. Neuroscience research.

2007;58(1):12-18.

72. Sun N, Shen Y, Han W, et al. Selective sphingosine-1-phosphate receptor 1 modulation

attenuates experimental intracerebral hemorrhage. Stroke. 2016;47(7):1899-1906.

73. Wang Y, Chen Q, Tan Q, et al. Simvastatin accelerates hematoma resolution after

intracerebral hemorrhage in a PPARγ-dependent manner. Neuropharmacology.

2018;128:244-254.

74. Chang C-F, Wan J, Li Q, Renfroe SC, Heller NM, Wang J. Alternative activation-

skewed microglia/macrophages promote hematoma resolution in experimental

intracerebral hemorrhage. Neurobiology of disease. 2017;103:54-69.

75. Lu Q, Gao L, Huang L, et al. Inhibition of mammalian target of rapamycin improves

neurobehavioral deficit and modulates immune response after intracerebral

hemorrhage in rat. Journal of neuroinflammation. 2014;11(1):44.

76. Shi H, Zheng K, Su Z, et al. Sinomenine enhances microglia M2 polarization and

attenuates inflammatory injury in intracerebral hemorrhage. Journal of

neuroimmunology. 2016;299:28-34.

77. Jiang YB, Wei KY, Zhang XY, Feng H, Hu R. White matter repair and treatment strategy

after intracerebral hemorrhage. CNS neuroscience & therapeutics. 2019;25(10):1113-

1125.

78. Shao A, Zhu Z, Li L, Zhang S, Zhang J. Emerging therapeutic targets associated with

the immune system in patients with intracerebral haemorrhage (ICH): From

mechanisms to translation. EBioMedicine. 2019;45:615-623.

Figure1. In the earliest stage of ICH, the primary brain injury made by hematoma and
edema causes blood products (Fe2+, Hb, thrombin) to leak into the damage area to
activate microglia/macrophages and other peripheral immune cells to express high
levels of IL-6, IL-1β, TNFα, GMCSF, INFγ, ROS, RNS, CCLs, HO-1, and MMPs.
These changes result in the secondary brain injury, which extend the brain damage such
as brain edema, cell death, blood–brain barrier disruption, and neurologic deficits.

Conflict of Interest

Please find enclosed the manuscript entitled “Intracerebral Hemorrhage in

Translational Research” by Ruiyi Zhang et al.

All authors have read and approved the submitted manuscript and have no
conflicts of interest to declare; the manuscript has not been submitted
elsewhere nor published elsewhere in whole or in part.

Ruiyi Zhang, Qian Bai, Yang Liu, Yan Zhang, Zhaofu Sheng, V. Wee Yong,
Mengzhou Xue