2010 Guidelines for Management of Spontaneous ICH

2010 Guidelines for Management of Spontaneous ICH from Sun YaiCheng

AHA/ASA Guideline for the Management of Spontaneous Intracerebral Hemorrhage
Stroke September 1, 2010;41:2108-29

Emergency Diagnosis and Assessment of ICH

• Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from ICH (Class I; Level of Evidence: A).
• CT angiography and contrast CT may be considered to help identify patients at risk for hematoma expansion (Class IIb; Level of Evidence: B), and CT angiography,CT venography,contrast-enhanced CT, contrast MRI, MRA, and magnetic resonance venography can be useful to evaluate for underlying structural lesions,including vascular malformations and tumors when there is clinical or radiological suspicion (Class IIa; Level of Evidence: B).(New recommendation)

Medical Treatment of ICH

• 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). (New recommendation)
• Patients with ICH whose INR is elevated due to on oral anticoagulants (OACs) should have their warfarin withheld, receive therapy to replace vitamin K-dependent factors and correct the INR, and receive intravenous vitamin K (Class I; Level of Evidence: C).
• 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 routinely recommended as a sole agent for OAC reversal in ICH (Class III;Level of Evidence: C). (Revised from the previous guideline).

Suggested Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH (Class IIb, Level of Evidence C)

• If SBP >200 mmHg or MAP >150 mmHg, then consider aggressive reduction of BP with continuous intravenous infusion, with frequent BP monitoring every 5 minutes.
• If SBP >180 mmHg or MAP >130 mmHg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing BP using intermittent or continuous intravenous medications to keep cerebral perfusion pressure > 60-80 mmHg.
• If SBP >180 mmHg or MAP >130 mmHg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of BP (eg, MAP of 110 mmHg or target BP of 160/90 mmHg) using intermittent or continuous intravenous medications to control BP, and clinically reexamine the patient every 15 minutes.
• In patients presenting with SBP 150-220 mmHg, acute lowering of SBP to 140 mmHg is probably safe (Class IIa; Level of Evidence: B). (New recommendation)

Management of Glucose

• Glucose should be monitored and normoglycemia (range 80 to 110 mg/dL) is recommended(Class I: Level of Evidence: C). (New recommendation)

Seizures and Antiepileptic Drugs

• Clinical seizures should be treated with antiepileptic drugs(Class I; Level of Evidence: A). (Revised from the previous guideline) Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury (Class IIa; Level of Evidence:B). Prophylactic anticonvulsant medication should not be used (Class III; Level of Evidence:B). (New recommendation)

Procedure/Surgery

• Patients with a GCS 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 cerebral perfusion pressure of 50 to 70 mmHg maybe reasonable to maintain depending on the status of cerebral autoregulation (Class IIb; Level of Evidence: C). (New recommendation)
• Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness(Class IIa;Level of Evidence: B). (New recommendation)

Clot Removal

• For most patients with ICH, the usefulness of surgery is uncertain (Class IIb; Level of Evidence: C). (New recommendation). Specific exceptions to this recommendation follow:
• 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). (Revised from the previous guideline) Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended (Class III; Level of Evidence: C). (New recommendation)
• For patients presenting with lobar clots >30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered (Class IIb; Level of Evidence:B). (Revised from the previous guideline)

Prevention of Recurrent ICH

• In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E ε2 or ε4 alleles, and greater number of microbleeds on MRI (Class IIa; Level of Evidence:B). (New recommendation)
• After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy (Class I;Level of Evidence: A). (New recommendation)
• After the acute ICH period, a goal target of a normal BP of <140/90 mmHg (<130/80 mmHg if diabetes or chronic kidney disease) is reasonable (Class IIa; Level of Evidence: B). (New recommendation)
• Avoidance of long-term anticoagulation as treatment for non-valvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence (Class IIa; Level of Evidence: B).