New AHA/ASA Guidelines on Management of Intracerebral Hemorrhage

Susan Jeffrey

July 30, 2010

July 30, 2010 — The American Heart Association/American Stroke Association has released a new guideline on the management of spontaneous intracerebral hemorrhage (ICH).

ICH has long been recognized as one of the most severe forms of stroke, among the most devastating neurologic injuries, and the view of many has been that there is not much to be done for these patients, said lead study author Lewis B. Morgenstern, MD, from the University of Michigan, Ann Arbor.

"The clear message that we want to send with this guideline is that intracerebral hemorrhage is a very treatable disorder, with very guideline-concordant, aggressive critical care," Dr. Morgenstern told Medscape Medical News. "There's a lot of evidence in the guideline of things that are shown to be effective and improve outcome."

There's also a lot of evidence that if care is not aggressive, "outcome is very bad," he added. "So the hope of the writing committee is that clinicians will use this to guide their appropriate and aggressive treatment for patients who have intracerebral hemorrhage."

The guideline, which has been reviewed and the educational content affirmed by the American Academy of Neurology, as well as the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, was published online July 22 and will appear in the September issue of Stroke. The guideline applies only to spontaneous ICH, not ICH subsequent to trauma.

Unchanged, Modified, and New Recommendations

To help clinicians, the recommendations in the document are flagged as unchanged from the previous guidelines, modified, or new, Dr. Morgenstern noted.

"In general, I would say that there are many recommendations that are either completely new or updated since the last version 3 years ago based on additional new research that has come about or additional deliberations by the writing group that considered the evidence to guide clinical practice," he said.

Among the new and revised recommendations:

  • For the emergency diagnosis and assessment of ICH, the committee's recommendation for rapid neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is unchanged, but they have added a new recommendation that other imaging modalities, such as CT angiography or contrast-enhanced CT, may be considered to help identify patients at risk for hematoma expansion or to evaluate for underlying structural lesions, such as vascular malformations and tumors.

  • Under medical treatment of ICH, 1 new recommendation is that patients with a severe coagulation factor deficiency or severe thrombocytopenia should received appropriate factor replacement therapy or platelets, respectively. Another revision in this section recommends patients with ICH whose international normalized ratio (INR) is elevated due to the use of oral anticoagulants should have warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K.

  • Among new recommendations for inpatient management and prevention of secondary brain injury, the writing committee has included new and revised recommendations that glucose be monitored and normoglycemia maintained and that clinical seizures and those with depressed mental status found to have seizures on electroencephalograms should be treated with antiepileptic drugs. Prophylactic anticonvulsants are not recommended.

The clear message that we want to send with this guideline is that intracerebral hemorrhage is a very treatable disorder.

  • Under procedures and surgery, 1 new recommendation is that patients with a Glasgow Coma Scale score of less than 8, as well as those with clinical evidence of transtentorial herniation, or those with significant intraventricular hemorrhage or hydrocephalus might be considered for intracranial pressure monitoring and treatment, they write. It may be "reasonable" to maintain a cerebral perfusion pressure of 50 to 70 mm Hg, depending on the status of cerebral autoregulation. Ventricular drainage as treatment for hydrocephalus is also seen as reasonable in patients with a decreased level of consciousness.

  • Results of the Clot Lysis: Evaluating Accelerated Resolution of IVH (CLEAR-IVH) open-label trial of intraventricular recombinant tissue plasminogen activator in IVH suggested a low complication rate, but the efficacy and safety of this treatment are "uncertain and considered investigational," they note.

  • In terms of clot removal, the committee has provided a new recommendation that for most patients with ICH, the usefulness of surgery is "uncertain." Exceptions to this conclusion are patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction, who should undergo surgical removal of the hemorrhage as soon as possible, the study authors note. A new recommendation is that initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended.

The effectiveness of minimally invasive clot evacuation via stereotactic or endoscopic aspiration with or without thrombolytics is "uncertain and considered investigational," they note. "Although theoretically attractive," they add, "no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding."

Decisions to Limit Care "Self-fulfilling Prophecy?"

  • Another recommendation that has been revised relates to outcome prediction and the decision to withdraw technological support, a concern due to the severity of these events. Although it is understandable that patients' families want to know what may happen with their loved one, several new studies have identified withdrawal of medical support or do not resuscitate (DNR) orders within the first day of hospitalization as independent outcome predictors.

"It is likely that current outcome prediction models as well as more informal methods of early prognostication after ICH are biased by the failure to account for these care limitations," the writing committee notes. "Concern has been raised that decisions by physicians to limit care early after ICH are resulting in self-fulfilling prophecies of poor outcome due to inaccurately pessimistic prognostication and failure to provide initial aggressive therapy in severely ill ICH patients who nonetheless still have the possibility of favorable outcome."

In light of this, the committee writes that aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is "probably recommended." This recommendation does not apply to those with preexisting DNR orders. Those who are given DNR status at any point should still receive all other appropriate medical and surgical interventions "unless otherwise explicitly indicated."

  • Prevention of recurrent ICH includes several new recommendations. When stratifying risk for recurrence, they conclude it is "reasonable" to consider risk factors including lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E2 or E4 alleles, and the presence of a greater number of microbleeds on MRI. After the acute period, they recommend blood pressure be well controlled, particularly for those whose bleed was in a location typical of hypertensive vasculopathy; the goal target of less than 140/90 or less than 130/80 mm Hg for diabetes or kidney disease is "reasonable." Avoidance of alcohol use can be "beneficial," but there is insufficient evidence to recommend restrictions on the use of statins or physical or sexual activity, they conclude.

  • Finally, they recommend that "given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation." Where possible, it should be begun as early as possible and continued in the community as part of a well coordinated, "seamless" program of accelerated hospital discharge and home-based resettlement to promote ongoing recovery, they write.

They also review some priorities for future research, among them future prevention, advanced imaging techniques, hemostatic agents, interfering with oxidative injury, minimally invasive methods of clot removal, or treatments to dissolve and drain intraventricular blood, all currently being studied.

"An aggressive, collaborative approach to both basic and clinical research in this field is likely to promote the highest yield," the study authors conclude. "In the meantime, it is clear that our ability to prognosticate about ICH is limited and that aggressive care now, and hope for the future, are both clearly indicated."

Dr. Morgenstern reports he has received research grants from that National Institutes of Health and National Institute of Neurological Disorders and Stroke and is a Medical Adjudication Board Member for Wyeth. Disclosures for other writing committee members appear in the publication.

Stroke. Published online July 22, 2010.

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