The American Heart Association/American Stroke Association (AHA/ASA) has released a new guideline on the diagnosis and treatment of spontaneous intracerebral hemorrhage (ICH).
"Although ICH has traditionally lagged behind ischemic stroke and aneurysmal subarachnoid hemorrhage in terms of evidence from clinical trials to guide management, the past decade has seen a dramatic increase in studies of ICH intervention," notes the guideline writing group, led by J. Claude Hemphill, III, MD, director of the Neurocritical Care Program at San Francisco General Hospital Medical Center in California.
"Population-based studies show that most patients present with small ICHs that are readily survivable with good medical care," the authors say. "This suggests that excellent medical care likely has a potent, direct impact on ICH morbidity and mortality."
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, the Congress of Neurological Surgeons, and the Neurocritical Care Society, was published online May 29 and will appear in the July issue of Stroke.
The guideline updates the last AHA/ASA ICH guideline published in 2010 and incorporates the results of new studies published in the interim. The guideline update was purposely delayed for 1 year from the intended 3-year review cycle so that results of two pivotal phase 3 ICH clinical trials could be incorporated, the authors note.
The 30-page document presents comprehensive evidence-based guidelines for the care of patients with acute ICH, including diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations.
Class I recommendations are as follows:
Emergency Diagnosis and Assessment
Perform a baseline severity score as part of the initial evaluation of patients with ICH (Class I; level of evidence B; new recommendation).
Rapid neuroimaging with computed tomography or MRI is recommended to distinguish ischemic stroke from ICH (Class I; level of evidence A; unchanged from the previous guideline).
Hemostasis and Coagulopathy, Antiplatelet Agents, and Deep-Vein Thrombosis Prophylaxis
Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively (Class I; level of evidence C; unchanged from the previous guideline).
Patients with ICH whose international normalized ratio (INR) is elevated because of vitamin K antagonists (VKAs) should have their VKA withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K (Class I; level of evidence C; unchanged from the previous guideline).
Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission (Class I; level of evidence A; revised from the previous guideline).
Blood Pressure
For patients with ICH presenting with systolic blood pressure (SBP) between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe (Class I; level of evidence A) and can be effective for improving functional outcome (Class IIa; level of evidence B; revised from the previous guideline).
General Monitoring and Nursing Care
Initial monitoring and management of patients with ICH should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise (Class I; level of evidence B; revised from the previous guideline).
Glucose Management
Glucose should be monitored. Both hyperglycemia and hypoglycemia should be avoided (Class I; level of evidence C; revised from the previous guideline).
Seizures and Antiseizure Drugs
Clinical seizures should be treated with antiseizure drugs (Class I; level of evidence A; unchanged from the previous guideline).
Patients with a change in mental status who are found to have electrographic seizures on electroencephalography should be treated with antiseizure drugs (Class I; level of evidence C; unchanged from the previous guideline).
Management of Medical Complications Surgical Treatment of ICH
A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk for pneumonia (Class I; level of evidence B; new recommendation).
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 (Class I; level of evidence B; unchanged from the previous guideline).
Prevention of Recurrent ICH
BP should be controlled in all patients with ICH (Class I; level of evidence A; revised from the previous guideline); measures to control BP should begin immediately after ICH onset (Class I; level of evidence A; new recommendation).
Rehabilitation and Recovery
Given the potentially serious nature and complex pattern of evolving disability and the increasing evidence for efficacy, it is recommended that all patients with ICH have access to multidisciplinary rehabilitation (Class I; level of evidence A; revised from the previous guideline).
Stroke. Published online May 29, 2015. Full text
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Cite this: New AHA/ASA Guideline on Spontaneous ICH - Medscape - May 29, 2015.
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