Intracerebral haemorrhage is an important public health problem leading to high rates of death and disability in adults. Although the number of hospital admissions for intracerebral haemorrhage has increased worldwide in the past 10 years, mortality has not fallen. Results of clinical trials and observational studies suggest that coordinated primary and specialty care is associated with lower mortality than is typical community practice. Development of treatment goals for critical care, and new sequences of care and specialty practice can improve outcome after intracerebral haemorrhage. Specific treatment approaches include early diagnosis and haemostasis, aggressive management of blood pressure, open surgical and minimally invasive surgical techniques to remove clot, techniques to remove intraventricular blood, and management of intracranial pressure. These approaches improve clinical management of patients with intracerebral haemorrhage and promise to reduce mortality and increase functional survival.

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fall is peculiar to our population. Himal et a14 recently reported a similar decrease in Montreal in the number of patients with acute peptic ulceration secondary to ulcerogenic drugs. Analysis of our figures over the past year has shown one death in 107 admissions, a mortality rate of under 1 %O. We believe that our improved results are due to several factors, ranging from early diagnosis and vigorous resuscitation to strict criteria for surgical intervention. Possibly the most important factor has been the formation of a unit with a combined medical and surgical approach in which patients are cared for by the same personnel familiar with all aspects of upper gastrointestinal haemorrhage.We therefore conclude that a prospective system of management with regular review of results and formation of a unit certainly improve mortality rate in patients with upper gastrointestinal bleeding. The results emphasise the need for immediate operation in patients deteriorating with extradural haematomas. Direct admission of all head-injured patients to a head and spinal injuries unit staffed by neurosurgeons resulted in minimal delay times as well as a reduction in morbidity and mortality.

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Clinicians are encouraged to discover if the suspected beneficial role of surgery truly exists by randomizing patients with intracerebral haemorrhage in the ongoing prospective randomized controlled trials in the following circumstances: lobar intracerebral haemorrhage (clot reaches to within 1 cm of the cortical surface), STICH II; intraventricular haemorrhage (clot maximum size of 30 ml), CLEAR IVH; deep intracerebral haemorrhage and minimal invasive surgery, MISTIE.