AHA, ASA guidelines for the management of spontaneous intracerebral hemorrhage

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Emergency Diagnosis and Assessment: Recommendations

Class I

"1.A baseline severity score should be performed as part of the initial evaluation of patients with intracerebral hemorrhage (ICH) (Level of Evidence: B)"

"2.Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from intracerebral hemorrhage (ICH) (Level of Evidence: A)"

Class IIa

"1.CT angiography, CT venography, contrast-enhanced CT, contrast-enhanced MRI, MRA and MRV can be useful to evaluate for underlying structural lesions including vascular malformations and tumors when there is clinical or radiologic suspicion (Level of Evidence: B)"

Class IIb

"1.CT angiography and contrast-enhanced CT may be considered to help identify patients at risk for hematoma expansion (Level of Evidence: B)"

Hemostasis and Coagulopathy, Antiplatelet Agents, and DVT Prophylaxis: Recommendations

Patients with a severe coagulation factor deficiency or severe thrombocytopenia

Class I

"1.Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectivel (Level of Evidence: C)"

Patients with ICH whose INR is elevated because of VKA

Class I

"1.Patients with ICH whose INR is elevated because of VKA should have their VKA withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K (Level of Evidence: C)"

Class III (Harm)

"1.rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not recommended for VKA reversal in ICH (Level of Evidence: C)"

Class IIb

"1.PCCs may have fewer complications and correct the INR more rapidly than FFP and might be considered over FFP (Level of Evidence: B)"

Patients with ICH who are taking dabigatran, rivaroxaban, or apixaban

Class IIb

"1.For patients with ICH who are taking dabigatran, rivaroxaban, or apixaban, treatment with FEIBA, other PCCs, or rFVIIa might be considered on an individual basis. Activated charcoal might be used if the most recent dose of dabigatran, apixaban, or riva- roxaban was taken <2 hours earlier. Hemodialysis might be considered for dabigatran (Level of Evidence: C)"

Reverse heparin in patients with acute ICH

Class IIb

"1. Protamine sulfate may be considered to reverse heparin in patients with acute ICH (Level of Evidence: C)"

Patients with a history of anti platelet and ICH

Class IIb

"1.The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is uncertain (Level of Evidence: C)"

Hematoma expansion

Class III (Harm)

"1. Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus, rFVIIa is not recommended (Level of Evidence: A)"

prevention of venous thromboembolism

Class I

"1.Patients with ICH should have intermittent pneu- matic compression for prevention of venous throm- boembolism beginning the day of hospital admission (Level of Evidence: A)"

Class III (Harm)

"1.Graduated compression stockings are not beneficial to reduce DVT or improve outcome (Level of Evidence: A)"

Class IIb

"1.After documentation of cessation of bleeding, low- dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for pre- vention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset (Level of Evidence: B)"

ICH patients with symptom- atic DVT or PE

Class IIa

"1.Systemic anticoagulation or IVC filter placement is probably indicated in ICH patients with symptom- atic DVT or PE (Level of Evidence: C)"

"2. The decision between these 2 options should take into account several factors, including time from hem- orrhage onset, hematoma stability, cause of hemor- rhage, and overall patient condition (Level of Evidence: C)"

BP-Lowering: Recommendations

ICH patients presenting with SBP between 150 and 220 mmHg

Class I

"1.For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe (Level of Evidence: A)"

Class IIa

"1.For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg ) can be effective for improving functional outcome (Level of Evidence: C)"

ICH patients presenting with SBP >220 mmHg

Class IIb

"1. For ICH patients presenting with SBP >220 mm Hg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring (Level of Evidence: C)"

General Monitoring and Nursing Care: Recommendation

Class I

"1.Initial monitoring and management of ICH patients should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertis (Level of Evidence: B)"

Glucose Management: Recommendation

Class I

"1.Glucose should be monitored. Both hyperglycemia and hypoglycemia should be avoided (Level of Evidence: C)"

Temperature Management: Recommendation

Class IIb

"1.Treatment of fever after ICH may be reasonable (Level of Evidence: C)"

Seizures and Antiseizure Drugs: Recommendations

Class I

"1.Clinical seizures should be treated with antiseizure drugs (Level of Evidence: A)"

"2.Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiseizure drugs (Level of Evidence: C)"

Class III (Harm)

"1.Prophylactic antiseizure medication is not recommended (Level of Evidence: B)"

Class IIa

"1.Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status that is out of proportion to the degree of brain injury (Level of Evidence: C)"

Management of Medical Complications: Recommendations

Class I

"1.A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk of pneumonia (Level of Evidence: B)"

Class IIa

"1. Systematic screening for myocardial ischemia or infarction with electrocardiogram and cardiac enzyme testing after ICH is reasonable (Level of Evidence: C)"

ICP Monitoring and Treatment: Recommendations

Class III (Harm)

"1.Corticosteroids should not be administered for treatment of elevated ICP in ICH (Level of Evidence: B)"

Class IIa

"1.Ventricular drainage as treatment for hydrocephalus is reasonable, especially in patients with decreased level of consciousness (Level of Evidence: B)"

Class IIb

"1. Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A CPP of 50 to 70 mm Hg may be reasonable to maintain depending on the status of cerebral autoregulation (Level of Evidence: C)"

IVH: Recommendations

Class IIb

"1.Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncertain (Level of Evidence: B)"

"2.The efficacy of endoscopic treatment of IVH is uncertain (Level of Evidence: B)"

Surgical Treatment of ICH: Recommendations

Class I

"1.Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible (Level of Evidence: B)"

Class III (Harm)

"1. Initial treatment of patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction is not recommended (Level of Evidence: C)"

Class IIb

"1. For most patients with supratentorial ICH, the usefulness of surgery is not well established (Level of Evidence: A)"

"2. A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacution when patients deteriorate (Level of Evidence: A)"

"3. Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure (Level of Evidence: C)"

"4.Decompressive hemicraniectomy (DC) with or without hematoma evacuation might reduce mortality for patients with supratentorial ICH who are in a coma, have large hematomas with significant midline shift, or have elevated ICP refractory to medical management (Level of Evidence: C)"

"5. The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain (Level of Evidence: B)"

Outcome Prediction and Withdrawal of Technological Support: Recommendation

Class III (Harm)

"1. Current prognostic models for individual patients early after ICH are biased by failure to account for the influence of withdrawal of support and early DNAR orders. DNAR status should not limit appropriate medical and surgical interventions unless otherwise explicitly indicated (Level of Evidence: C)"

Class IIa

"1. Aggressive care early after ICH onset and postponement of new DNAR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNAR orders are not included in this recommendation (Level of Evidence: B)"

References

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