Guidelines for the Management of Spontaneous Intracerebral Hemorrhage | Ten Points to Remember

Hemphill JC III, Greenberg SM, Anderson CS, et al., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Clinical Cardiology.
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015;May 28:[Epub ahead of print].

The American Heart Association/American Stroke Association updated the guidelines for the management of patients with spontaneous intracerebral hemorrhage (ICH). The following are 10 key points to remember from the guidelines:

  1. When a patient has the acute onset of neurologic symptoms attributed to a vascular cause, neuroimaging is required to distinguish ICH from ischemic stroke. Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is acceptable. At most centers, CT is the test of choice given cost, timing, patient tolerance, and availability issues. When there is clinical or radiographic suspicion for tumor or vascular malformation as the etiology of the hemorrhage, additional imaging with CT angiography/CT venography, MRI/MR venography, and catheter angiography may be useful.
  2. Active bleeding can occur for hours after symptom onset and may explain the high frequency of early deterioration in ICH patients. More than 20% of patients will have a clinical decline between emergency medical system (EMS) and emergency department (ED) assessments, and another approximately 20% of patients will have continued deterioration in the hours after hospital arrival.
  3. Due to the risk of early decline, protocols should be in place so ICH patients receive rapid treatment in the ED. These patients should be admitted to an intensive care unit or stroke unit with physician and nursing expertise in stroke care.
  4. New oral anticoagulants are likely associated with a lower rate of ICH than vitamin K antagonists, such as warfarin. For patients taking warfarin who have an ICH, the international normalized ratio (INR) should be rapidly corrected. This correction should be done with vitamin K (5-10 mg intravenous) in addition to fresh frozen plasma (FFP) or prothrombin complex concentrates (PCCs). Correction of the INR with PCCs occurs more rapidly and with less volume than FFP, and therefore, may be preferred. There are no randomized trials of reversing agents for the new oral anticoagulants, although activated charcoal (if the last dose was within 2 hours) and PCCs may be considered.
  5. Elevated blood pressure (BP) is common after ICH and is associated with poor outcomes. Recent trials have suggested that BP lowering to a systolic BP of <140 mm Hg is safe, and may be effective in patients presenting with systolic BP of 150-220 mm Hg.
  6. Seizures occur in about 15% of ICH patients, and are associated with a cortical hemorrhage location. While clinical seizures should be treated with an anticonvulsant agent, prophylactic antiseizure medication is not recommended. Subclinical seizures are common after ICH, but their impact on outcome is unclear. Patients with a mental status that is decreased out of proportion to the degree of brain injury should undergo continuous electroencephalogram (EEG) monitoring, and if seizure activity is present, the patient should receive antiseizure medication.
  7. Dysphagia is common after ICH, and is a risk factor for pneumonia. Since screening for dysphagia can reduce the risk of pneumonia, all ICH patients should have a formal swallow screen before taking food, drink, or medication by mouth.
  8. Surgical treatment of cerebellar ICH is recommended for patients with brainstem compression or hydrocephalus. Trials have not shown a benefit for surgery in supratentorial ICH, but this could be considered as a lifesaving measure in deteriorating patients. In patients who are comatose or have significant mass effect from a supratentorial hematoma, decompressive craniectomy may be lifesaving. Surgical treatment of ICH is an area of ongoing active research.
  9. Prognostic models in ICH are limited because they do not account for early do not resuscitate (DNR) orders and withdrawal of care. In patients without existing DNR orders, it is reasonable to provide aggressive care and postpone new DNR orders until the second full day of hospitalization.
  10. Risk factors for recurrent ICH include older age, location of the index ICH (deep versus lobar), antithrombotic drug use, and hypertension. BP control reduces the risk of future ICH, and it is reasonable to target a systolic BP of <130 mm Hg and a diastolic BP of <80 mm Hg. When the indication for antithrombotic therapy is strong, anticoagulation can likely be restarted after nonlobar ICH, and antiplatelet monotherapy can likely be restarted after any ICH. While there may be an association between statin use and ICH, the data are insufficient to recommend withholding statins after ICH.

Keywords: Angiography, Anticoagulants, Anticonvulsants, Blood Coagulation Factors, Blood Pressure, Brain Injuries, Brain Stem, Cerebral Hemorrhage, Decompressive Craniectomy, Intracranial Hemorrhage, Hypertensive, Deglutition Disorders, Electroencephalography, Emergency Service, Hospital, Hematoma, Hydrocephalus, Hypertension, Intensive Care Units, International Normalized Ratio, Magnetic Resonance Imaging, Neoplasms, Neuroimaging, Phlebography, Seizures, Stroke, Tomography, Vascular Malformations, Vitamin K, Warfarin

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