New Guidelines for Treatment of Spontaneous ICH

Mark J. Alberts, MD


July 23, 2015

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Hello, and welcome to this Medscape stroke update. My name is Mark Alberts. I am vice-chair of Neurology at UT Southwestern Medical Center in Dallas, Texas. Today I want to review new guidelines[1] for the diagnosis and treatment of patients with spontaneous intracerebral hemorrhage (ICH). Because of time limitations, I cannot review all of the guidelines, but I want to share some of the new or revised recommendations that are of particular clinical importance.

One new recommendation is to calculate a baseline severity score on everyone admitted to the hospital with an ICH. This is important so that we can severity-adjust our outcomes. The guidelines recommend using the ICH Score, although others may be acceptable.

To reverse the effects of anticoagulation therapy, the guidelines recommend using:

  • Prothrombin complex concentrate (PCC) to treat cerebral hemorrhages related to warfarin therapy;

  • PCC, factor 8 inhibitor bypass activity (FEIBA), or recombinant factor 7 for hemorrhages related to the new oral anticoagulants (NOACs);

  • Hemodialysis for patients who are taking dabigatran;

  • Protamine to treat patients with ICH associated with heparin therapy.

They recommend avoiding anticoagulation for at least 4 weeks after ICH unless the patient has a mechanical valve, but they do say that aspirin therapy may be okay a few days after the bleed, assuming that everything is stable.

The guidelines suggest using electroencephalography to monitor patients with altered mental status if changes appear to be out of proportion to the size and location of the hemorrhage. They now recommend screening for myocardial infarction for admitted patients either with electrocardiogram alone or ECG and cardiac enzymes. They now also say to wait at least 2 days before instituting a "do not resuscitate" order in patients with an ICH.

Blood Pressure and Surgical Interventions

What about blood pressure control? They suggest a target systolic blood pressure of around 140 mm Hg for acute blood pressure control and a target of less than 130/80 mm Hg for long-term blood pressure control.

Regarding surgical interventions, the guidelines cite findings that early hematoma evacuation is not beneficial for the majority of patients, with the exception of those with a large cerebellar hemorrhage that is causing mass effects in the posterior fossa. For patients with a large ICH that is causing coma, shift, and increase in intracranial pressure, they recommend decompressive hemicraniotomy and hemicraniectomy. Again, they do not recommend routine clot removal in most cases unless it is a cerebellar hematoma.

Those are some of the new or important revisions to guidelines for managing spontaneous ICH. There are many others that you may want to read online and in the July issue of Stroke.

Thank you very much for tuning in for this Medscape stroke update. Have a good day.


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