Guidelines for the Management of Spontaneous Intracerebral Hemorrhage Stroke. 2010;41:2108

1. AHA/ASA GuidelineGuidelines for the Management of Spontaneous IntracerebralHemorrhage The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists Morgenstern et al. Stroke September 1, 2010;41:2108-29

3. Emergency Diagnosis and Assessment of ICH Rapid neuroimaging with CT or MRI is recommended to distinguishischemic stroke from ICH (Class I; Level of Evidence: A). (Unchangedfrom the previous guideline) CT angiography and contrastCT may be consideredto help identify patients at risk for hematomaexpansion (ClassIIb; Level of Evidence: B), and CT angiography,CT venography,contrast-enhanced CT, contrast MRI,MRA, and magnetic resonance venographycan be usefulto evaluate for underlying structural lesions,including vascularmalformations and tumors when there is clinicalor radiologicalsuspicion (Class IIa; Level of Evidence: B).(New recommendation)

4. Medical Treatment of ICH Patients with a severe coagulation factor deficiency or severethrombocytopenia should receive appropriate factor replacementtherapy or platelets, respectively (Class I; Level of Evidence:C). (New recommendation) Patients with ICH whose INR iselevated due to on oral anticoagulants (OACs) shouldhave their warfarin withheld, receivetherapy to replace vitaminK-dependent factors and correctthe INR, and receive intravenousvitamin K (Class I; Level ofEvidence: C). PCCshave not shownimproved outcome comparedwith FFP but may have fewer complicationscompared with FFPand are reasonable to consider as an alternativeto FFP (ClassIIa; Level of Evidence: B). rFVIIadoes not replaceall clottingfactors, and although the INR may be lowered, clottingmay notbe restored in vivo; therefore, rFVIIa is not routinelyrecommendedas a sole agent for OAC reversal in ICH (Class III;Level ofEvidence: C). (Revised from the previous guideline).

5. Medical Treatment of ICH AlthoughrFVIIa can limit the extent of hematoma expansionin noncoagulopathicICH patients, there is an increase in thromboembolicrisk withrFVIIa and no clear clinical benefit in unselectedpatients.Thus rFVIIa is not recommended in unselected patients.(ClassIII; Level of Evidence: A). (New recommendation) The usefulness of platelet transfusionsin ICH patients witha history of antiplatelet use is unclearand is considered investigational(Class IIb; Level of Evidence:B). (New recommendation) Patients with ICH should haveintermittent pneumatic compressionfor prevention of venousthromboembolism in addition to elasticstockings (Class I; Levelof Evidence: B). (Unchanged from theprevious guideline) After documentation of cessation of bleeding, low-dose subcutaneouslow-molecular-weight heparin or unfractionated heparin may beconsidered for prevention of venous thromboembolism in patientswith lack of mobility after 1 to 4 days from onset (Class IIb;Level of Evidence: B). (Revised from the previous guideline)

6. Suggested Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH(Class IIb, Level of Evidence C) If SBP >200 mmHg or MAP >150 mmHg, then consider aggressive reduction of BP with continuous intravenous infusion, with frequent BP monitoring every 5 minutes. If SBP >180 mmHg or MAP >130 mmHg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing BP using intermittent or continuous intravenous medications to keep cerebral perfusion pressure > 60-80 mmHg. If SBP >180 mmHg or MAP >130 mmHg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of BP (eg, MAP of 110 mmHg or target BP of 160/90 mmHg) using intermittent or continuous intravenous medications to control BP, and clinically reexamine the patient every 15 minutes. In patients presenting with SBP 150-220 mmHg, acute lowering of SBP to 140 mmHg is probably safe (Class IIa; Level of Evidence: B). (New recommendation)

7. Intravenous Medications That May Be Considered for Control of Elevated Blood Pressure in Patients with ICH

8. Prevention of Secondary Brain Injury Initial monitoring and management of ICH patients shouldtake place in ICU with physician and nursingneuroscience intensive care expertise (Class I; Level of Evidence:B). (Unchanged from the previous guideline)

9. Prevention of Secondary Brain Injury Management of Glucose Glucose should be monitored and normoglycemia (range 80 to 110 mg/dL) is recommended(Class I: Level of Evidence: C). (New recommendation) Seizures and Antiepileptic Drugs Clinical seizures should be treated with antiepileptic drugs(Class I; Level of Evidence: A). (Revised from the previousguideline) Continuous EEG monitoring is probably indicated inICH patients with depressed mental status out of proportionto the degree of brain injury (Class IIa; Level of Evidence:B). Patients with a change in mental status who are found tohave electrographic seizures on EEG should be treated with antiepilepticdrugs (Class I; Level of Evidence: C). Prophylactic anticonvulsantmedication should not be used (Class III; Level of Evidence:B). (New recommendation)

10. Procedure/Surgery Patients with a GCS of 8, those with clinical evidenceof transtentorialherniation, or those with significant IVHor hydrocephalus might be considered for ICP monitoring andtreatment. A cerebral perfusion pressure of 50 to 70 mmHg maybe reasonable to maintain depending on the status of cerebralautoregulation(Class IIb; Level of Evidence: C). (New recommendation) Ventricular drainage as treatment for hydrocephalus isreasonablein patients with decreased level of consciousness(Class IIa;Level of Evidence: B). (New recommendation) Although intraventricular administration of rt-PA in IVH appears to have a fairly low complicationrate, efficacy and safety of this treatment is uncertain andis considered investigational (Class IIb; Level of Evidence:B). (New recommendation)

11. Clot Removal For most patients with ICH, the usefulness of surgery isuncertain (Class IIb; Level of Evidence: C). (New recommendation)Specific exceptions to this recommendation follow Patientswith cerebellar hemorrhage who are deterioratingneurologicallyor who have brainstem compression and/or hydrocephalusfromventricular obstruction should undergo surgical removalof thehemorrhage as soon as possible (Class I; Level of Evidence:B). (Revised from the previous guideline) Initial treatmentof these patients with ventricular drainage alone rather thansurgical evacuation is not recommended (Class III; Level ofEvidence: C). (New recommendation)

12. Clot Removal For patients presentingwith lobar clots >30 mLand within1 cm of the surface, evacuationof supratentorial ICH by standardcraniotomy might be considered(Class IIb; Level of Evidence:B). (Revised from the previousguideline) The effectiveness of minimally invasive clotevacuation utilizingeither stereotactic or endoscopic aspirationwith or withoutthrombolytic usage is uncertain and is consideredinvestigational(Class IIb; Level of Evidence: B). (New recommendation) Although theoretically attractive, no clear evidence atpresentindicates that ultra-early removal of supratentorialICH improvesfunctional outcome or mortality rate. Very earlycraniotomymay be harmful due to increased risk of recurrentbleeding (ClassIII; Level of Evidence: B). (Revised from theprevious guideline)

13. Withdrawal of Technological Support Aggressive full care early after ICH onset and postponementof new DNR orders until at least the second full day of hospitalizationis probably recommended (Class IIa; Level of Evidence: B). Patientswith preexisting DNR orders are not included in this recommendation.Current methods of prognostication in individual patients earlyafter ICH are likely biased by failure to account for the influenceof withdrawal of support and early DNR orders. Patients whoare given DNR status at any point should receive all other appropriatemedical and surgical interventions unless otherwise explicitlyindicated. (Revised from the previous guideline)

14. Prevention of Recurrent ICH In situations where stratifying a patient’s risk ofrecurrent ICH may affect other management decisions, it is reasonableto consider the following risk factors for recurrence: lobarlocation of the initial ICH, older age, ongoing anticoagulation,presence of the apolipoprotein E ε2 or ε4 alleles, and greaternumber of microbleeds on MRI (Class IIa; Level of Evidence:B). (New recommendation) After the acute ICH period, absentmedical contraindications,BP should be well controlled, particularlyfor patients withICH location typical of hypertensive vasculopathy(Class I;Level of Evidence: A). (New recommendation) Afterthe acute ICH period, a goal target of a normal BPof <140/90(<130/80 if diabetes or chronic kidney disease)is reasonable(Class IIa; Level of Evidence: B). (New recommendation)

15. Prevention of Recurrent ICH Avoidance of long-term anticoagulation as treatment for nonvalvularatrial fibrillation is probably recommended after spontaneouslobar ICH because of the relatively high risk of recurrence(Class IIa; Level of Evidence: B). Anticoagulation after nonlobarICH and antiplatelet therapy after all ICH might be considered,particularly when there are definite indications for these agents(Class IIb; Level of Evidence: B). (Unchanged from the previousguideline) Avoidance of heavy alcohol use can be beneficial(Class IIa;Level of Evidence: B). There is insufficient datato recommendrestrictions on use of statin agents or physicalor sexual activity(Class IIb; Level of Evidence: C). (New recommendation)