Definitions of the recommendation classes (I, II, III) and levels of evidence (A, B, C) are provided at the end of the "Major Recommendations" field.
Recommendations for Emergency Diagnosis and Assessment of Intracerebral Hemorrhage (ICH)
Class I
- ICH is a medical emergency, with frequent early, ongoing bleeding and progressive deterioration, severe clinical deficits, and subsequent high mortality and morbidity rates, and it should be promptly recognized and diagnosed (Class I, Level of Evidence A).
- Computed tomography (CT) and magnetic resonance are each first-choice initial imaging options (Class I, Level of Evidence A); in patients with contraindications to magnetic resonance, CT should be obtained (Class I, Level of Evidence A).
Recommendations for Initial Medical Therapy
Class I
- Monitoring and management of patients with an ICH should take place in an intensive care unit setting because of the acuity of the condition, frequent elevations in intracranial pressure (ICP) and blood pressure, frequent need for intubation and assisted ventilation, and multiple complicating medical issues (Class I, Level of Evidence B).
- Appropriate antiepileptic therapy should always be used for treatment of clinical seizures in patients with ICH (Class I, Level of Evidence B).
- It is generally agreed that sources of fever should be treated and antipyretic medications should be administered to lower temperature in febrile patients with stroke (Class I, Level of Evidence C).
- As for patients with ischemic stroke, (See the National Guideline Clearinghouse (NGC) summary of the American Stroke Association Guidelines for the Early Management of Adults with Ischemic Stroke) early mobilization and rehabilitation are recommended in patients with ICH who are clinically stable (Class I, Level of Evidence C).
Class II
- Treatment of elevated ICP should include a balanced and graded approach that begins with simple measures, such as elevation of the head of the bed and analgesia and sedation. More aggressive therapies to decrease elevated ICP, such as osmotic diuretics (mannitol and hypertonic saline solution), drainage of cerebrospinal fluid (CSF) via ventricular catheter, neuromuscular blockade, and hyperventilation, generally require concomitant monitoring of ICP and blood pressure with a goal to maintain cerebral perfusion pressure (CPP) >70 mm Hg (Class IIa, Level of Evidence B).
- Evidence indicates that persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke is associated with poor outcomes, and thus it is generally agreed that hyperglycemia should be treated in patients with acute stroke. Guidelines for ischemic stroke suggest that elevated glucose concentrations (>185 mg/dL and possibly >140 mg/dL) probably should trigger administration of insulin, similar to the procedure in other acute situations accompanied by hyperglycemia. Use of these guidelines for ICH as well is reasonable. The results of ongoing research should clarify the management of hyperglycemia after stroke (Class IIa, Level of Evidence C).
- Until ongoing clinical trials of blood pressure intervention for ICH are completed, physicians must manage blood pressure on the basis of the present incomplete evidence. Current suggested recommendations for target blood pressures in various situations and potential medications are listed in the tables below and may be considered (Class IIb, Level of Evidence C).
Table: Intravenous Medications That May Be Considered for Control of Elevated Blood Pressure in Patients With ICH
| Drug |
Intravenous Bolus Dose |
Continuous Infusion Rate |
| Labetalol |
5 to 20 mg every 15 min |
2 mg/min (maximum 300 mg/d) |
| Nicardipine |
NA |
5 to 15 mg/h |
| Esmolol |
250 micrograms/kg IVP loading dose |
25 to 300 micrograms · kg -1 · min-1 |
| Enalapril |
1.25 to 5 mg IVP every 6 h* |
NA |
| Hydralazine |
5 to 20 mg IVP every 30 min |
1.5 to 5 micrograms · kg -1 · min-1 |
| Nipride |
NA |
0.1 to 10 micrograms · kg -1 · min-1 |
| Nitroglycerin |
NA |
20 to 400 micrograms/min |
IVP indicates intravenous push; NA, not applicable.
*Because of the risk of precipitous blood pressure lowering, the enalapril first test dose should be 0.625 mg.
Table: Suggested Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH
| 1. If SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of blood pressure with continuous intravenous infusion, with frequent blood pressure monitoring every 5 minutes. |
| 2. If SBP is >180 mm Hg or MAP is >130 mm Hg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous medications to keep cerebral perfusion pressure >60 to 80 mm Hg. |
| 3. If SBP is >180 mm Hg or MAP is >130 mm Hg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of blood pressure (e.g., MAP of 110 mm Hg or target blood pressure of 160/90 mm Hg) using intermittent or continuous intravenous medications to control blood pressure, and clinically reexamine the patient every 15 minutes. |
SBP indicates systolic blood pressure; MAP, mean arterial pressure.
- Treatment with recombinant activated factor VII (rFVIIa) within the first 3 to 4 hours after onset to slow progression of bleeding has shown promise in one moderate-sized phase II trial; however, the efficacy and safety of this treatment must be confirmed in phase III trials before its use in patients with ICH can be recommended outside of a clinical trial (Class IIb, Level of Evidence B).
- A brief period of prophylactic antiepileptic therapy soon after ICH onset may reduce the risk of early seizures in patients with lobar hemorrhage (Class IIb, Level of Evidence C).
Recommendations for Prevention of Deep Vein Thrombosis and Pulmonary Embolism
Class I
- Patients with acute primary ICH and hemiparesis/hemiplegia should have intermittent pneumatic compression for prevention of venous thromboembolism (Class I, Level of Evidence B).
- Treatment of hypertension should always be part of long-term therapy because such therapy decreases the risk of recurrent ICH (Class I, Level of Evidence B).
Class II
- After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered in patients with hemiplegia after 3 to 4 days from onset (Class IIb, Level of Evidence B).
- Patients with an ICH who develop an acute proximal venous thrombosis, particularly those with clinical or subclinical pulmonary emboli, should be considered for acute placement of a vena cava filter (Class IIb, Level of Evidence C).
- The decision to add long-term antithrombotic therapy several weeks or more after placement of a vena cava filter must take into consideration the likely cause of the hemorrhage (amyloid [higher risk of recurrent ICH] versus hypertension), associated conditions with increased arterial thrombotic risk (e.g., atrial fibrillation), and the overall health and mobility of the patient (Class IIb, Level of Evidence B).
Recommendations for the Management of ICH Related to Coagulation and Fibrinolysis
Class I
- Protamine sulfate should be used to reverse heparin-associated ICH, with the dose depending on the time from cessation of heparin (Class I, Level of Evidence B).
- Patients with warfarin-associated ICH should be treated with intravenous vitamin K to reverse the effects of warfarin and with treatment to replace clotting factors (Class I, Level of Evidence B).
Class II
- Prothrombin complex concentrate, factor IX complex concentrate, and rFVIIa normalize the laboratory elevation of the international normalized ratio (INR) very rapidly and with lower volumes of fluid than fresh frozen plasma (FFP) but with greater potential of thromboembolism. FFP is another potential choice but is associated with greater volumes and much longer infusion times (Class IIb, Level of Evidence B).
- The decision to restart antithrombotic therapy after ICH related to antithrombotic therapy depends on the risk of subsequent arterial or venous thromboembolism, the risk of recurrent ICH, and the overall state of the patient. For patients with a comparatively lower risk of cerebral infarction (e.g., AF without prior ischemic stroke) and a higher risk of amyloid angiopathy (e.g., elderly patients with lobar ICH) or with very poor overall neurological function, an antiplatelet agent may be an overall better choice for prevention of ischemic stroke than warfarin. In patients with a very high risk of thromboembolism in whom restarting warfarin is considered, warfarin therapy may be restarted at 7 to 10 days after onset of the original ICH (Class IIb, Level of Evidence B).
- Treatment of patients with ICH related to thrombolytic therapy includes urgent empirical therapies to replace clotting factors and platelets (Class IIb, Level of Evidence B).
Recommendations for Surgical Approaches
Class I
- Patients with cerebellar hemorrhage >3 cm who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible (Class I, Level of Evidence B).
Class II
- Although stereotactic infusion of urokinase into the clot cavity within 72 hours of ictus apparently reduces the clot burden and risk of death, rebleeding is more common, and functional outcome is not improved; therefore, its usefulness is unknown (Class IIb, Level of Evidence B).
- Although theoretically attractive, the usefulness of minimally invasive clot evacuation utilizing a variety of mechanical devices and/or endoscopy awaits further testing in clinical trials; therefore, its current usefulness is unknown (Class IIb, Level of Evidence B).
- For patients presenting with lobar clots within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered (Class IIb, Level of Evidence B).
Class III
- The routine evacuation of supratentorial ICH by standard craniotomy within 96 hours of ictus is not recommended (Class III, Level of Evidence A). (See possible Class II exception above for patients presenting with lobar clots within 1 cm of the surface.)
Recommendations for Timing of Surgery
Class II
- No clear evidence at present indicates that ultra-early craniotomy improves functional outcome or mortality rate. Operative removal within 12 hours, particularly when performed by less-invasive methods, has the most supportive evidence, but the number of subjects treated within this window is very small (Class IIb, Level of Evidence B). Very early craniotomy may be associated with an increased risk of recurrent bleeding (Class IIb, Level of Evidence B).
Class III
- Delayed evacuation by craniotomy appears to offer little if any benefit with a fairly high degree of certainty. In those patients presenting in coma with deep hemorrhages, removal of ICH by craniotomy may actually worsen outcome and is not recommended (Class III, Level of Evidence A).
Recommendation for Decompressive Craniectomy
Class II
- Too few data currently exist to comment on the potential of decompressive craniectomy to improve outcome in ICH (Class IIb, Level of Evidence C).
Recommendation for Withdrawal of Technological Support
Class II
- We recommend careful consideration of aggressive full care during the first 24 hours after ICH onset and postponement of new do not resuscitate (DNR) orders during that time (Class IIb, Level of Evidence B). Patients with previous DNR orders are not included in this recommendation. In all cases, physicians and nurses caring for ICH patients who are given DNR status should be reminded that the designation relates only to the circumstance of cardiopulmonary arrest and that patients should receive all other appropriate medical and surgical interventions.
Recommendations for Prevention of Recurrent ICH
Class I
- Treating hypertension in the nonacute setting is the most important step to reduce the risk of ICH and probably recurrent ICH as well (Class I, Level of Evidence A).
- Smoking, heavy alcohol use, and cocaine use are risk factors for ICH, and discontinuation should be recommended for prevention of ICH recurrence (Class I, Level of Evidence B).
Definitions:
Class I Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment
Class IIa The weight of evidence or opinion is in favor of the procedure or treatment
Class IIb Usefulness/efficacy is less well established by evidence or opinion
Class III Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful
Therapeutic Recommendation
Level of Evidence A: Data derived from multiple randomized clinical trials
Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies
Level of Evidence C: Consensus opinion of experts
Diagnostic Recommendation
Level of Evidence A: Data derived from multiple prospective cohort studies employing a reference standard applied by a masked evaluator
Level of Evidence B: Data derived from a single grade A study or 1 or more case–control studies or studies employing a reference standard applied by an unmasked evaluator
Level of Evidence C: Consensus opinion of experts
