Therapeutic strategies in intracerebral hemorrhage: from hematoma stabilization to alleviating secondary brain injury

A state-of-the-art lecture titled, "New Treatment Targets in Intracerebral Hemorrhage," was presented at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2025. Intracerebral hemorrhage remains one of the most devastating forms of stroke, with high rates of mortality and long-term disability. Unlike ischemic stroke, treatment options remain limited, but advances in pathophysiological understanding and clinical trials have expanded the range of potential therapeutic strategies. This review synthesizes current evidence across 3 major interdependent domains. First, hematoma stabilization focuses on preventing hematoma expansion through intensive blood pressure control, hemostatic agents, and reversal of antithrombotic therapies, with recent prehospital and care bundle trials demonstrating promise. Second, strategies to reduce hematoma burden and the mass effect include both surgical evacuation and enhancement of endogenous clearance mechanisms. While minimally invasive surgery has shown selective benefits in carefully chosen patients, increasing attention is being directed toward accelerating natural hematoma resolution via microglial and macrophage-mediated phagocytosis, as well as modulating iron toxicity. Third, mitigation of secondary brain injury targets perihematomal edema, oxidative stress, and neuroinflammation. Recent trials of glibenclamide, anti-inflammatory agents, COX-2 inhibitors, and antioxidants have indicated both the challenges and opportunities of modulating secondary injury. Together, these developments represent a transition from therapeutic nihilism toward optimism but emphasize a need for multimodal and time-sensitive interventions. Finally, we summarize relevant new data on this topic presented during the 2025 ISTH Congress.