AHA/ASA Release Updated Guidelines for Management of Spontaneous Intracerebral Hemorrhage

The American Heart Association and American Stroke Association have released updated guidelines for the management of individuals with spontaneous intracerebral hemorrhage (ICH).

The update includes 10 key points for managing spontaneous ICH, including:

1. Developing regional health care systems to provide initial ICH care with the ability to transfer patients to facilities that include neurocritical and neurosurgical care.

2. Addressing hematoma, which is associated with worse ICH outcomes. In addition to clinical markers, there are neuroimaging markers that can help predict the risk of hematoma expansion, including signs detectable by noncontrast computed tomography.

3. Emphasizing the importance of identifying markers of macrovascular and microvascular hemorrhage pathogeneses, which can help identify ICHs.

4. Implementing treatment regimens that limit blood pressure (BP) variability and achieve sustained BP control to help reduce hematoma expansion. These regimens can help better outcomes to occur.

5. Recommending acute reversal of anticoagulation after ICH, highlighting the use of protein complex concentrate for the reversal of vitamin K antagonists, including warfarin, idarucizumab for the reversal of the thrombin inhibitor dabigatran, and andexanet for the reversal of factor Xa inhibitors, including apixaban, endoxaban, and rivaroxaban.

6. Addressing previous in-hospital therapies that had been used to treat individuals with ICH. The authors said that for critical or emergency care treatment, continuous hyperosmolar therapy or prophylactic corticosteroids could have no benefit to the outcome.

Further, the use of platelet transfusions, excluding use for emergency surgery or severe thrombocytopenia, could actually worsen outcomes. Similar consideration can also apply to prophylactic treatments that are normally given to individuals after ICH to prevent medical complications.

The use of knee- or thigh-high compression socks alone as a prophylactic therapy for the prevention of deep vein thrombosis and prophylactic antiseizure medications, when there is an absence of seizures, did not improve long-term seizure control or functional outcomes.

7. Using minimally invasive approaches for evacuation of supratentorial ICHs and intraventricular hemorrhages demonstrated reduced mortality and the clinical trial showed that improvement of functional outcomes remains neutral.

Additionally, for individuals with cerebella hemorrhage, the immediate surgical evacuation with or without an external ventricular drain reduced mortality and now includes a larger volume of greater than 15 mL, in addition to previous recommended indications.

8. Life-sustaining treatments after ICH are dependent on an individual’s preference, but the decision for resuscitation status is independent from other medical and surgical interventions and should not be used to do so. The decision for an intervention should be shared between the physician and patient or surrogate, according to the authors.

They suggest using baseline severity scales to provide an overall measure of hemorrhage severity, though these should not be the sole basis for life-sustaining treatments.

9. Using coordinated multidisciplinary inpatient care teams for the early assessment of discharge planning and early supported discharge for mild to moderate to ICH. The authors also recommend that rehabilitation activities, including stretching and functional task training, can be considered 24 to 48 hours after moderate ICH, but early aggressive mobilization during the first 24 hours worsens the 14-day mortality.

Additionally, there is no evidence from trials to support that giving a patient fluoxetine earlier could improve functional recovery. However, it did decrease depression but increase the incidence of fractures.

10. Giving psychosocial education, practical support, and training to caregivers to improve patients’ activity level, balance, and overall quality of life.

Reference

Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, et al. American Heart Association/American Stroke Association. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;101161STR0000000000000407 doi:10.1161/STR.0000000000000407