Last updated May 18, 2022

Management of Spontaneous Intracerebral Hemorrhage

TOP 10 TAKE-HOME MESSAGES

1. The organization of health care systems is increasingly recognized as a key component of optimal stroke care. This guideline recommends development of regional systems that provide initial intracerebral hemorrhage (ICH) care and the capacity, when appropriate, for rapid transfer to facilities with neurocritical care and neurosurgical capabilities.

2. Hematoma expansion is associated with worse ICH outcome. There is now a range of neuroimaging markers that, along with clinical markers such as time since stroke onset and use of antithrombotic agents, help to predict the risk of hematoma expansion. These neuroimaging markers include signs detectable by noncontrast computed tomography, the most widely used neuroimaging modality for ICH.

3. ICHs, like other forms of stroke, occur as the consequence of a defined set of vascular pathologies. This guideline emphasizes the importance of, and approaches to, identifying markers of both microvascular and macrovascular hemorrhage pathogeneses.

4. When implementing acute blood pressure lowering after mild to moderate ICH, treatment regimens that limit blood pressure variability and achieve smooth, sustained blood pressure control appear to reduce hematoma expansion and yield better functional outcome.

5. ICH while anticoagulated has extremely high mortality and morbidity. This guideline provides updated recommendations for acute reversal of anticoagulation after ICH, highlighting use of protein complex concentrate for reversal of vitamin K antagonists such as warfarin, idarucizumab for reversal of the thrombin inhibitor dabigatran, and andexanet alfa for reversal of factor Xa inhibitors such as rivaroxaban, apixaban, and edoxaban.

6. Several in-hospital therapies that have historically been used to treat patients with ICH appear to confer either no benefit or harm. For emergency or critical care treatment of ICH, prophylactic corticosteroids or continuous hyperosmolar therapy appears to have no benefit for outcome, whereas the use of platelet transfusions outside the setting of emergency surgery or severe thrombocytopenia appears to worsen outcome. Similar considerations apply to some prophylactic treatments historically used to prevent medical complications after ICH. Use of graduated knee- or thigh-high compression stockings alone is not an effective prophylactic therapy for prevention of deep vein thrombosis, and prophylactic antiseizure medications in the absence of evidence for seizures do not improve long-term seizure control or functional outcome.

7. Minimally invasive approaches for evacuation of supratentorial ICHs and intraventricular hemorrhages‚ compared with medical management alone‚ have demonstrated reductions in mortality. The clinical trial evidence for improvement of functional outcome with these procedures is neutral, however. For patients with cerebellar hemorrhage, indications for immediate surgical evacuation with or without an external ventricular drain to reduce mortality now include larger volume (>15 mL) in addition to previously recommended indications of neurological deterioration, brainstem compression, and hydrocephalus.

8. The decision of when and how to limit life-sustaining treatments after ICH remains complex and highly dependent on individual preference. This guideline emphasizes that the decision to assign do not attempt resuscitation status is entirely distinct from the decision to limit other medical and surgical interventions and should not be used to do so. On the other hand, the decision to implement an intervention should be shared between the physician and patient or surrogate and should reflect the patient’s wishes as best as can be discerned. Baseline severity scales can be useful to provide an overall measure of hemorrhage severity but should not be used as the sole basis for limiting life-sustaining treatments.

9. Rehabilitation and recovery are important determinants of ICH outcome and quality of life. This guideline recommends use of coordinated multidisciplinary inpatient team care with early assessment of discharge planning and a goal of early supported discharge for mild to moderate ICH. Implementation of rehabilitation activities such as stretching and functional task training may be considered 24 to 48 hours after moderate ICH; however, early aggressive mobilization within the first 24 hours after ICH appears to worsen 14-day mortality. Multiple randomized trials did not confirm an earlier suggestion that fluoxetine might improve functional recovery after ICH. Fluoxetine reduced depression in these trials but also increased the incidence of fractures.

10. A key and sometimes overlooked member of the ICH care team is the patient’s home caregiver. This guideline recommends psychosocial education, practical support, and training for the caregiver to improve the patient’s balance, activity level, and overall quality of life.

ORGANIZATION OF PREHOSPITAL AND INITIAL SYSTEMS OF CARE

Recommendations for Organization of Prehospital and Initial Systems of Care

In patients with stroke, including spontaneous ICH, design and implementation of stroke public education programs for diverse populations focused on early recognition and the need to seek emergency care rapidly is useful to reduce time to diagnosis and treatment. (I, B-R)
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In patients with sudden onset of neurological symptoms or signs attributable to potential spontaneous ICH, use of stroke recognition and severity tools is recommended for dispatch personnel and first responders to identify potential stroke and facilitate rapid transport to reduce time to diagnosis and treatment. (I, B-R)
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In patients with stroke symptoms attributable to potential spontaneous ICH, immediate activation of the emergency response system (9-1-1 in North America) is recommended to reduce time to diagnosis and treatment. (I, B-NR)
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In patients with potential spontaneous ICH, early notification by emergency medical services (EMS) staff to the receiving hospital is recommended to improve time to diagnosis and treatment. (I, B-NR)
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In patients with spontaneous ICH, regional systems of stroke care are recommended so all potentially beneficial therapies can be made available when appropriate as rapidly as possible‚ including, at minimum, (a) health care facilities that provide initial spontaneous ICH care, including diagnosis and treatment, and (b) health care facilities with neurocritical care and neurosurgical capabilities. (I, C-LD)
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In patients with potential stroke, including spontaneous ICH, in geographic regions where mobile stroke units (MSUs) operate, such mobile units are reasonable to enable more rapid diagnosis and treatment than achievable by ambulance transfer to the closest stroke-capable facility. (IIa, B-R)
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In patients with potential spontaneous ICH, first responder training in stroke evaluation and care with the ability to provide airway and circulatory support when necessary is reasonable to detect and manage prehospital neurological deterioration (ND). (IIa, C-LD)
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DIAGNOSIS AND ASSESSMENT

4.1. Diagnostic Assessment of Acute ICH Course

4.1.1. Physical Examination and Laboratory Assessment

In patients with spontaneous ICH, focused history, physical examination, and routine labo-ratory work and tests on hospital admission (eg, complete blood count, prothrombin time/international normalized ratio [INR]/partial thromboplastin time, creatinine/estimated glomerular filtration rate, glucose, cardiac tro-ponin and ECG, toxicology screen, and inflam-matory markers) should be performed to help identify the type of hemorrhage, active medical issues, and risk of unfavorable outcomes (I, C-LD)
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In patients with spontaneous ICH, focused history, physical examination, and routine laboratory work and tests on hospital admission (eg, complete blood count, prothrombin time/ international normalized ratio [INR]/partial thromboplastin time, creatinine/estimated glomerular filtration rate, glucose, cardiac troponin and ECG, toxicology screen, and inflammatory markers) should be performed to help identify the type of hemorrhage, active medical issues, and risk of unfavorable outcomes. (I, C-LD)
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4.1.2. Neuroimaging for ICH Diagnosis and Acute Course

In patients presenting with stroke-like symptoms, rapid neuroimaging with CT or MRI is recommended to confirm the diagnosis of spontaneous ICH. (I, B-NR)
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In patients with spontaneous ICH and/or IVH, serial head CT can be useful within the first 24 hours after symptom onset to evaluate for hemorrhage expansion. (IIa, B-NR)
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In patients with spontaneous ICH and/or IVH and with low GCS score or ND, serial head CT can be useful to evaluate for hemorrhage expansion, development of hydrocephalus, brain swelling, or herniation. (IIa, C-LD)
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In patients with spontaneous ICH, CT angiography (CTA) within the first few hours of ICH onset may be reasonable to identify patients at risk for subsequent HE. (IIb, B-NR)
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In patients with spontaneous ICH, using noncontrast computed tomography (NCCT) markers of HE to identify patients at risk for HE may be reasonable. (IIb, B-NR)
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4.2. Diagnostic Assessment for ICH Pathogenesis

In patients with lobar spontaneous ICH and age <70 years, deep/posterior fossa spontaneous ICH and age <45 years, or deep/posterior fossa and age 45 to 70 years without history of hypertension, acute CTA plus consideration of venography is recommended to exclude macrovascular causes or cerebral venous thrombosis. (I, B-NR)
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In patients with spontaneous IVH and no detectable parenchymal hemorrhage, catheter intra-arterial digital subtraction angiography (DSA) is recommended to exclude a macrovascular cause. (I, B-NR)
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In patients with spontaneous ICH and a CTA or magnetic resonance angiography (MRA) suggestive of a macrovascular cause, catheter intra-arterial DSA should be performed as soon as possible to confirm and manage underlying intracranial vascular malformations. (I, C-LD)
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In patients with (a) lobar spontaneous ICH and age <70 years, (b) deep/posterior fossa ICH and age <45 years, or (c) deep/posterior fossa and age 45 to 70 years without history of hypertension and negative noninvasive imaging (CTA±venography and MRI/MRA), catheter intra-arterial DSA is reasonable to exclude a macrovascular cause. (IIa, B-NR)
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In patients with spontaneous ICH with a negative CTA/venography, it is reasonable to perform MRI and MRA to establish a nonmacrovascular cause of ICH (such as CAA, deep perforating vasculopathy, cavernous malformation, or malignancy). (IIa, B-NR)
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In patients with spontaneous ICH who undergo CT or MRI at admission, CTA plus consideration of venography or MRA plus consideration of venography performed acutely can be useful to exclude macrovascular causes or cerebral venous thrombosis. (IIa, C-LD)
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In patients with spontaneous ICH and a negative catheter intra-arterial DSA and no clear microvascular diagnosis or other defined structural lesion, it may be reasonable to perform a repeat catheter intra-arterial DSA 3 to 6 months after ICH onset to identify a previously obscured vascular lesion. (IIb, C-LD)
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MEDICAL AND NEUROINTENSIVE TREATMENT FOR ICH

5.1. Acute BP Lowering

In patients with spontaneous ICH requiring acute BP lowering, careful titration to ensure continuous smooth and sustained control of BP, avoiding peaks and large variability in SBP, can be beneficial for improving functional outcomes. (IIa, B-NR)
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In patients with spontaneous ICH in whom acute BP lowering is considered, initiating treatment within 2 hours of ICH onset and reaching target within 1 hour can be beneficial to reduce the risk of HE and improve functional outcome. (IIa, C-LD)
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In patients with spontaneous ICH of mild to moderate severity presenting with SBP between 150 and 220 mm Hg, acute lowering of SBP to a target of 140 mm Hg with the goal of maintaining in the range of 130 to 150 mm Hg is safe and may be reasonable for improving functional outcomes. (IIb, B-R)
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In patients with spontaneous ICH presenting with large or severe ICH or those requiring surgical decompression, the safety and efficacy of intensive BP lowering are not well established. (IIb, C-LD)
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In patients with spontaneous ICH of mild to moderate severity presenting with SBP >150 mm Hg, acute lowering of SBP to <130 mm Hg is potentially harmful. (III - Harm, B-R)
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5.2. Hemostasis and Coagulopathy

5.2.1. Anticoagulant-Related Hemorrhage

In patients with anticoagulant-associated spontaneous ICH, anticoagulation should be discontinued immediately and rapid reversal of anticoagulation should be performed as soon as possible after diagnosis of spontaneous ICH to improve survival. (I, C-LD)
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VKAs
In patients with VKA-associated spontaneous ICH and INR ≥2.0, 4-factor (4-F) prothrombin complex concentrate (PCC) is recommended in preference to fresh-frozen plasma (FFP) to achieve rapid correction of INR and limit HE. (I, B-R)
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In patients with VKA-associated spontaneous ICH, intravenous vitamin K should be administered directly after coagulation factor replacement (PCC or other) to prevent later increase in INR and subsequent HE. (I, C-LD)
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In patients with VKA-associated spontaneous ICH with INR of 1.3 to 1.9, it may be reasonable to use PCC to achieve rapid correction of INR and limit HE. (IIb, C-LD)
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DOACs
In patients with direct factor Xa inhibitor–associated spontaneous ICH, andexanet alfa is reasonable to reverse the anticoagulant effect of factor Xa inhibitors. (IIa, B-NR)
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In patients with dabigatran-associated spontaneous ICH, idarucizumab is reasonable to reverse the anticoagulant effect of dabigatran. (IIa, B-NR)
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In patients with direct factor Xa inhibitor–associated spontaneous ICH, a 4-F PCC or activated PCC (aPCC) may be considered to improve hemostasis. (IIb, B-NR)
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In patients with dabigatran- or factor Xa inhibitor–associated spontaneous ICH, when the DOAC agent was taken within the previous few hours, activated charcoal may be reasonable to prevent absorption of the DOAC. (IIb, C-LD)
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In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available, aPCC or PCCs may be considered to improve hemostasis. (IIb, C-LD)
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In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available, renal replacement therapy (RRT) may be considered to reduce dabigatran concentration. (IIb, C-LD)
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Heparins
In patients with unfractionated heparin (UFH)–associated spontaneous ICH, intravenous protamine is reasonable to reverse the anticoagulant effect of heparin. (IIa, C-LD)
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In patients with low-molecular-weight heparin (LMWH)–associated spontaneous ICH, intravenous protamine may be considered to partially reverse the anticoagulant effect of heparin. (IIb, C-LD)
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5.2.2. Antiplatelet-Related Hemorrhage

For patients with spontaneous ICH being treated with aspirin and who require emergency neurosurgery, platelet transfusion might be considered to reduce postoperative bleeding and mortality. (IIb, C-LD)
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For patients with spontaneous ICH being treated with antiplatelet agents, the effectiveness of desmopressin with or without platelet transfusions to reduce the expansion of the hematoma is uncertain. (IIb, C-LD)
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For patients with spontaneous ICH being treated with aspirin and not scheduled for emergency surgery, platelet transfusions are potentially harmful and should not be administered. (III - Harm, B-R)
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5.2.3. General Hemostatic Treatments

In patients with spontaneous ICH (with or without the spot sign), the effectiveness of recombinant factor VIIa to improve functional outcome is unclear. (IIb, B-R)
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In patients with spontaneous ICH (with or without the spot sign, black hole sign, or blend sign), the effectiveness of TXA to improve functional outcome is not well established. (IIb, B-R)
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5.3. General Inpatient Care

5.3.1. Inpatient Care Setting

In patients with spontaneous ICH, provision of care in a specialized inpatient (eg, stroke) unit with a multidisciplinary team is recommended to improve outcomes and reduce mortality. (I, A)
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In patients with spontaneous ICH, provision of care at centers that can provide the full range of high-acuity care and expertise is recommended to improve outcomes. (I, B-NR)
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In patients with spontaneous ICH and clinical hydrocephalus, transfer to centers with neurosurgical capabilities for definitive hydrocephalus management (eg, EVD placement and monitoring) is recommended to reduce mortality. (I, B-NR)
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In patients with spontaneous ICH, care delivery that includes multidisciplinary teams trained in neurological assessment is recommended to improve outcomes. (I, C-LD)
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In hospitalized patients with spontaneous ICH who require hospital transfer but do not have adequate airway protection, cannot support adequate gas exchange, and/or do not have a stable hemodynamic profile, appropriate life-sustaining therapies should be initiated before transportation to prevent acute medical decompensation in transport. (I, C-EO)
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In patients with spontaneous ICH without indications for ICU admission at presentation, initial provision of care in a stroke unit compared with a general ward is reasonable to reduce mortality and improve outcomes. (IIa, B-NR)
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In patients with moderate to severe spontaneous ICH, IVH, hydrocephalus, or infratentorial location, provision of care in a neuro-specific ICU compared with a general ICU is reasonable to improve outcomes and reduce mortality. (IIa, B-NR)
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In patients with IVH or infratentorial ICH location, transfer to centers with neurosurgical capabilities might be reasonable to improve outcomes. (IIb, B-NR)
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In patients with larger supratentorial ICH, transfer to centers with neurosurgical capabilities may be reasonable to improve outcomes. (IIb, C-LD)
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5.3.2. Prevention and Management of Acute Medical Complications

In patients with spontaneous ICH, the use of standardized protocols and/or order sets is recommended to reduce disability and mortality. (I, B-R)
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In patients with spontaneous ICH, a formal dysphagia screening protocol should be implemented before initiation of oral intake to reduce disability and the risk of pneumonia. (I, B-NR)
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In patients with spontaneous ICH, continuous cardiac monitoring for the first 24 to 72 hours of admission is reasonable to monitor for cardiac arrhythmias and new cardiac ischemia. (IIa, C-LD)
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In patients with spontaneous ICH, diagnostic laboratory and radiographic testing for infection on admission and throughout the hospital course is reasonable to improve outcomes. (IIa, C-LD)
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5.3.3. Thromboprophylaxis and Treatment of Thrombosis

Prophylaxis
In nonambulatory patients with spontaneous ICH, intermittent pneumatic compression (IPC) starting on the day of diagnosis is recommended for VTE (DVT and pulmonary embolism [PE]) prophylaxis. (I, B-R)
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In nonambulatory patients with spontaneous ICH, low-dose UFH or LMWH can be useful to reduce the risk for PE. (IIa, C-LD)
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In nonambulatory patients with spontaneous ICH, initiating low-dose UFH or LMWH prophylaxis at 24 to 48 hours from ICH onset may be reasonable to optimize the benefits of preventing thrombosis relative to the risk of HE. (IIb, C-LD)
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In nonambulatory patients with spontaneous ICH, graduated compression stockings of knee-high or thigh-high length alone are not beneficial for VTE prophylaxis. (III - No Benefit, B-R)
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Treatment
For patients with acute spontaneous ICH and proximal DVT who are not yet candidates for anticoagulation, the temporary use of a retrievable filter is reasonable as a bridge until anticoagulation can be initiated. (IIa, C-LD)
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For patients with acute spontaneous ICH and proximal DVT or PE, delaying treatment with UFH or LMWH for 1 to 2 weeks after the onset of ICH might be considered. (IIb, C-LD)
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5.3.4. Nursing Care

In patients with spontaneous ICH, frequent neurological assessments (including GCS) should be performed by ED nurses in the early hyperacute phase of care to assess change in status, neurological examination, or level of consciousness. (I, C-LD)
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In patients with spontaneous ICH, frequent neurological assessments in the ICU and stroke unit are reasonable for up to 72 hours of admission to detect early ND. (IIa, C-LD)
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In patients with spontaneous ICH, specialized nurse stroke competencies can be effective in improving outcome and mortality. (IIa, C-LD)
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5.3.5. Glucose Management

In patients with spontaneous ICH, monitoring serum glucose is recommended to reduce the risk of hyperglycemia and hypoglycemia. (I, C-LD)
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In patients with spontaneous ICH, treating hypoglycemia (<40–60 mg/d, <2.2–3.3 mmol/L) is recommended to reduce mortality. (I, C-LD)
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In patients with spontaneous ICH, treating moderate to severe hyperglycemia (>180–200 mg/dL, >10.0–11.1 mmol/L) is reasonable to improve outcomes. (IIa, C-LD)
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5.3.6. Temperature Management

In patients with spontaneous ICH, pharmacologically treating an elevated temperature may be reasonable to improve functional outcomes. (IIb, C-LD)
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In patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICHIn patients with spontaneous ICH, the usefulness of therapeutic hypothermia (<35° C/95 °F) to decrease peri-ICH edema is unclear. (IIb, C-LD)
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5.4. Seizures and Antiseizure Drugs

In patients with spontaneous ICH, impaired consciousness, and confirmed electrographic seizures, antiseizure drugs should be administered to reduce morbidity. (I, C-LD)
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In patients with spontaneous ICH and clinical seizures, antiseizure drugs are recommended to improve functional outcomes and prevent brain injury from prolonged recurrent seizures. (I, C-EO)
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In patients with spontaneous ICH and unexplained abnormal or fluctuating mental status or suspicion of seizures, continuous electroencephalography (≥24 hours) is reasonable to diagnose electrographic seizures and epileptiform discharges. (IIa, C-LD)
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In patients with spontaneous ICH without evidence of seizures, prophylactic antiseizure medication is not beneficial to improve functional outcomes, long-term seizure control, or mortality. (III - No Benefit, B-NR)
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5.5. Neuroinvasive Monitoring, ICP, and Edema Treatment

In patients with spontaneous ICH or IVH and hydrocephalus that is contributing to decreased level of consciousness, ventricular drainage should be performed to reduce mortality. (I, B-NR)
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In patients with moderate to severe spontaneous ICH or IVH with a reduced level of consciousness, ICP monitoring and treatment might be considered to reduce mortality and improve outcomes. (IIb, B-NR)
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In patients with spontaneous ICH, the efficacy of early prophylactic hyperosmolar therapy for improving outcomes is not well established. (IIb, B-NR)
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In patients with spontaneous ICH, bolus hyperosmolar therapy may be considered for transiently reducing ICP. (IIb, C-LD)
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In patients with spontaneous ICH, corticosteroids should not be administered for treatment of elevated ICP. (III - No Benefit, B-R)
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SURGICAL INTERVENTIONS

6.1. Hematoma Evacuation

6.1.1. MIS Evacuation of ICH

For patients with supratentorial ICH of >20- to 30-mL volume with GCS scores in the moderate range (5–12), minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration with or without thrombolytic use can be useful to reduce mortality compared with medical management alone. (IIa, B-R)
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For patients with supratentorial ICH of >20 to 30-mL volume with GCS scores in the moderate range (5–12) being considered for hematoma evacuation, it may be reasonable to select minimally invasive hematoma evacuation over conventional craniotomy to improve functional outcomes. (IIb, B-R)
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For patients with supratentorial ICH of >20 to 30-mL volume with GCS scores in the moderate range (5–12), the effectiveness of minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration with or without thrombolytic use to improve functional outcomes is uncertain. (IIb, B-R)
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6.1.2. MIS Evacuation of IVH

For patients with spontaneous ICH, large IVH, and impaired level of consciousness, EVD is recommended in preference to medical management alone to reduce mortality. (I, B-NR)
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For patients with a GCS score >3 and primary IVH or IVH extension from spontaneous supratentorial ICH of <30-mL volume requiring EVD, minimally invasive IVH evacuation with EVD plus thrombolytic is safe and is reasonable compared with EVD alone to reduce mortality. (IIa, B-R)
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For patients with a GCS score >3 and primary IVH or IVH extension from spontaneous supratentorial ICH of <30-mL volume requiring EVD, the effectiveness of minimally invasive IVH evacuation with EVD plus thrombolytic use to improve functional outcomes is uncertain. (IIb, B-R)
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For patients with severe spontaneous ICH‚ large IVH, and impaired level of consciousness, the efficacy of EVD for improving functional outcomes is not well established. (IIb, B-NR)
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For patients with spontaneous supratentorial ICH of <30-mL volume and IVH requiring EVD, the usefulness of minimally invasive IVH evacuation with neuroendoscopy plus EVD, with or without thrombolytic, to improve functional outcomes and reduce permanent shunt dependence is uncertain. (IIb, C-LD)
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6.1.3. Craniotomy for Supratentorial Hemorrhage

For most patients with spontaneous supratentorial ICH of moderate or greater severity, the usefulness of craniotomy for hemorrhage evacuation to improve functional outcomes or mortality is uncertain. (IIb, A)
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In patients with supratentorial ICH who are deteriorating, craniotomy for hematoma evacuation might be considered as a lifesaving measure. (IIb, C-LD)
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6.1.4. Craniotomy for Posterior Fossa Hemorrhage

For patients with cerebellar ICH who are deteriorating neurologically, have brainstem compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL, immediate surgical removal of the hemorrhage with or without EVD is recommended in preference to medical management alone to reduce mortality. (I, B-NR)
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6.2. Craniectomy for ICH

In patients with supratentorial ICH who are in a coma, have large hematomas with significant midline shift, or have elevated ICP refractory to medical management, decompressive craniectomy with or without hematoma evacuation may be considered to reduce mortality. (IIb, C-LD)
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In patients with supratentorial ICH who are in a coma, have large hematomas with significant midline shift, or have elevated ICP refractory to medical management, effectiveness of decompressive craniectomy with or without hematoma evacuation to improve functional outcomes is uncertain. (IIb, C-LD)
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OUTCOME PREDICTION AND GOALS OF CARE

7.1. Outcome Prediction

In patients with spontaneous ICH, administering a baseline measure of overall hemorrhage severity is recommended as part of the initial evaluation to provide an overall measure of clinical severity. (I, B-NR)
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In patients with spontaneous ICH, a baseline severity score might be reasonable to provide a general framework for communication with the patient and their caregivers. (IIb, B-NR)
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In patients with spontaneous ICH, a baseline severity score should not be used as the sole basis for forecasting individual prognosis or limiting life-sustaining treatment. (III - No Benefit, B-NR)
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7.2. Decisions to Limit Life-Sustaining Treatment

In patients with spontaneous ICH who do not have preexisting documented requests for lifesustaining therapy limitations, aggressive care, including postponement of new DNAR orders or withdrawal of medical support until at least the second full day of hospitalization, is reasonable to decrease mortality and improve functional outcome. (IIa, B-NR)
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In patients with spontaneous ICH who are unable to fully participate in medical decisionmaking, use of a shared decision-making model between surrogates and physicians is reasonable to optimize the alignment of care with patient wishes and surrogate satisfaction. (IIa, C-LD)
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In patients with spontaneous ICH who have DNAR status, limiting other medical and surgical interventions, unless explicitly specified by the patient or surrogate, is associated with increased patient mortality. (III - Harm, B-NR)
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POST-ICH RECOVERY, REHABILITATION, AND COMPLICATIONS

8.1. Rehabilitation and Recovery

In patients with spontaneous ICH, multidisciplinary rehabilitation, including regular team meetings and discharge planning, should be performed to improve functional outcome and reduce morbidity and mortality. (I, A)
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In patients with spontaneous ICH with mild to moderate severity, early supported discharge is beneficial to increase the likelihood of patients living at home at 3 months. (I, A)
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In patients with spontaneous ICH with moderate severity, early rehabilitation beginning 24 to 48 hours after onset (including ADL training, stretching, functional task training) may be considered to improve functional outcome and reduce mortality. (IIb, B-R)
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In patients with spontaneous ICH without depression, fluoxetine therapy is not effective to enhance poststroke functional status. (III - No Benefit, A)
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In patients with spontaneous ICH, very early and intense mobilization within the first 24 hours is associated with lower likelihood of good recovery. (III - Harm, B-R)
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8.2. Neurobehavioral Complications

In patients with spontaneous ICH and moderate to severe depression, appropriate evidence-based treatments including psychotherapy and pharmacotherapy are useful to reduce symptoms of depression. (I, B-R)
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In patients with spontaneous ICH, administration of depression and anxiety screening tools in the postacute period is recommended to identify patients with poststroke depression and anxiety. (I, B-NR)
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In patients with spontaneous ICH, administration of a cognitive screening tool in the postacute period is useful to identify patients with cognitive impairment and dementia. (I, B-NR)
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In patients with spontaneous ICH and cognitive impairment, referral for cognitive therapy is reasonable to improve cognitive outcomes. (IIa, B-NR)
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In patients with spontaneous ICH and preexisting or new mood disorders requiring pharmacotherapy, continuation or initiation of SSRIs after ICH can be beneficial for the treatment of mood disorders. (IIa, B-NR)
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In patients with spontaneous ICH and cognitive impairment, treatment with cholinesterase inhibitors or memantine might be considered to improve cognitive outcomes. (IIb, C-LD)
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PREVENTION

9.1. Secondary Prevention

9.1.1. Prognostication of Future ICH Risk

In patients with spontaneous ICH in whom the risk for recurrent ICH may facilitate prognostication or management decisions, it is reasonable to incorporate the following risk factors for ICH recurrence into decision-making: (a) lobar location of the initial ICH; (b) older age; (c) presence, number, and lobar location of microbleeds on MRI; (d) presence of disseminated cortical superficial siderosis on MRI; (e) poorly controlled hypertension; (f) Asian or Black race; and (g) presence of apolipoprotein E ε2 or ε4 alleles. (IIa, B-NR)
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9.1.2. BP Management

In patients with spontaneous ICH, BP control is recommended to prevent hemorrhage recurrence. (I, B-R)
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In patients with spontaneous ICH, it is reasonable to lower BP to an SBP of 130 mm Hg and diastolic BP (DBP) of 80 mm Hg for longterm management to prevent hemorrhage recurrence. (IIa, B-NR)
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9.1.3. Management of Antithrombotic Agents

In patients with spontaneous ICH and conditions placing them at high risk of thromboembolic events, for example, a mechanical valve or LVAD, early resumption of anticoagulation to prevent thromboembolic complications is reasonable. (IIa, C-LD)
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In patients with spontaneous ICH with an indication for antiplatelet therapy, resumption of antiplatelet therapy may be reasonable for the prevention of thromboembolic events based on consideration of benefit and risk. (IIb, B-R)
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In patients with nonvalvular atrial fibrillation (AF) and spontaneous ICH, the resumption of anticoagulation to prevent thromboembolic events and reduce all-cause mortality may be considered based on weighing benefit and risk. (IIb, B-NR)
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In patients with AF and spontaneous ICH in whom the decision is made to restart anticoagulation, initiation of anticoagulation ≈7 to 8 weeks after ICH may be considered after weighing specific patient characteristics to optimize the balance of risks and benefits. (IIb, C-LD)
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In patients with AF and spontaneous ICH deemed ineligible for anticoagulation, left atrial appendage closure may be considered to reduce the risk of thromboembolic events. (IIb, C-LD)
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9.1.4. Management of Other Medications

In patients with spontaneous ICH and an established indication for statin pharmacotherapy, the risks and benefits of statin therapy on ICH outcomes and recurrence relative to overall prevention of cardiovascular events are uncertain. (IIb, B-NR)
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In patients with spontaneous ICH, regular long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is potentially harmful because of the increased risk of ICH. (III - Harm, B-NR)
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9.1.5. Lifestyle Modifications/Patient and Caregiver Education

In patients with spontaneous ICH, lifestyle modification is reasonable to reduce BP. (IIa, C-LD)
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In patients with spontaneous ICH, avoiding heavy alcohol consumption is reasonable to reduce hypertension and risk of ICH recurrence. (IIa, C-LD)
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In patients with spontaneous ICH, lifestyle modification, including supervised training and counseling, may be reasonable to improve functional recovery. (IIb, C-LD)
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In patients with spontaneous ICH, psychosocial education for the caregiver can be beneficial to increase patients’ activity level and participation and/or quality of life. (IIa, C-LD)
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In patients with spontaneous ICH, practical support and training for the caregiver are reasonable to improve patients’ standing balance. (IIa, C-LD)
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9.2. Primary ICH Prevention in Individuals With High-Risk Imaging Findings

When considering primary prevention of ICH, it may be reasonable to incorporate any available MRI results demonstrating cerebral microbleed burden or cortical superficial siderosis to inform shared decision-making about stroke prevention treatment plans. (IIb, C-LD)
573

Recommendation Grading

Abbreviations

  • CPP: Cerebral Perfusion Pressure
  • CT: Computed Tomography
  • DBP: Diastolic Blood Pressure
  • DOAC: Direct Oral Anticoagulants
  • DSA: Digital Subtraction Angiography
  • DVT: Deep Vein Thrombosis
  • EIBPL: Early Intensive Blood Pressure Lowering
  • ERICH: Ethnic/Racial Variations Of Intracerebral Hemorrhage
  • EVD: External Ventricular Drain/drainage
  • ICH: Intracerebral Hemorrhage
  • LVAD: Left Ventricular Assist Device
  • PE: Pulmonary Embolism
  • RRT: Renal Replacement Therapy
  • SBP: Systolic Blood Pressure
  • SSRIs: Selective Serotonin Reuptake Inhibitors
  • UFH: Unfractionated Heparin
  • VTE: Venous Thromboembolism

Overview

Title

Management of Patients With Spontaneous Intracerebral Hemorrhage

Authoring Organization

Publication Month/Year

May 17, 2022

Supplemental Implementation Tools

Quick-Reference Guide

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Operating and recovery room

Intended Users

Paramedic emt, physician, nurse, nurse practitioner, physician assistant

Scope

Diagnosis, Management, Prevention, Rehabilitation

Diseases/Conditions (MeSH)

D020201 - Brain Hemorrhage, Traumatic, D002543 - Cerebral Hemorrhage, D020202 - Cerebral Hemorrhage, Traumatic, D000074042 - Cerebral Intraventricular Hemorrhage

Keywords

intracerebral hemorrhage, ICH, Brain injury

Supplemental Methodology Resources

Data Supplement