Spontaneous non-traumatic cerebral hemorrhage (ICH) continues to be a significant cause of disability and death worldwide. Recently the American Heart Association/American Stroke Association (AHA/ASA) published updated guidelines for the treatment of ICH. The guidelines are intended to update the AHA/ASA ICH guidelines published in 2010 to include the most recent research literature published in the last five years, and to remind clinicians of the importance of treating cerebral hemorrhage.
The guidelines, which were endorsed by the American Academy of Neurology, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons and the Society of Neurological Intensive Care, were published in a recent issue of Stroke. It is a comprehensive, evidence-based guide to the care of patients with acute ICH, including diagnosis, treatment of coagulation disorders, blood pressure management, prevention and treatment of secondary brain injury, intracranial pressure control, surgery, prediction of prognosis, rehabilitation, secondary prevention and future thinking.
The recommendations of the 14 areas introduced by the guidelines are summarized below.
I. Emergency diagnosis and assessment.
1. Baseline severity assessment should be part of the initial evaluation of patients with ICH (Class I recommendation, Level B evidence; new recommendation);
2. Perform rapid imaging (CT or MRI) to differentiate ischemic stroke from ICH (Class I recommendation, Level A evidence; as in previous guideline);
3. CT angiography and enhanced CT to screen patients at risk of hematoma expansion (Class IIb recommendation, Level B evidence); CT angiography, venography, enhanced CT, enhanced MRI, MR angiography, and venography are valuable in detecting underlying organic lesions (including vascular malformations and tumors) if the clinical presentation and imaging are suspicious (Class IIa recommendation, Level B evidence; Same as the previous guideline).
II. Hemostasis and coagulation disorders/antiplatelet agents/prevention of deep vein thrombosis.
1. Patients with severe coagulation factor deficiency or severe thrombocytopenia should be appropriately supplemented with coagulation factors or platelets (Class I recommendation, Level C evidence; same as previous guideline);
2. Patients with ICH with elevated INR due to VKA (vitamin K antagonist) should discontinue VKA, supplement with vitamin K-dependent coagulation factors, correct INR values, and apply vitamin K intravenously (Class I recommendation, Level C evidence); the use of PCCs (prothrombin complexes) has fewer complications than FFP (frozen fresh plasma), corrects INR more rapidly, and is considered as rFVIIa does not correct all coagulation abnormalities, although it does reduce INR and thus does not fully restore normal thrombogenic mechanisms. Therefore, rFVIIa is not recommended for routine use (Class III recommendation, Level C evidence; revised from the previous guideline);
3. For patients with ICH taking dabigatran, rivaroxaban, or apixaban, patients may be given individualized consideration for treatment with FEIBA (FVIII inhibitor bypass activity), other PCCs, or rFVIIa. Activated charcoal may be considered if the patient has taken dabigatran, rivaroxaban, or apixaban within 2 hours prior to onset. Consider hemodialysis in patients taking dabigatran (Class IIb recommendation, Level C evidence; new recommendation);
4. Consider fisetin therapy for acute ICH patients taking heparin (Class IIb recommendation, Level C evidence; new recommendation);
5. The effectiveness of platelet transfusion is uncertain in patients with ICH who have been treated with antiplatelet agents (Class IIb recommendation, Level B evidence; revised from the previous guideline);
6. Although rFVIIa may limit hematoma expansion in patients with ICH with normal coagulation, evidence suggests that in unscreened patients, rFVIIa increases the risk of thrombosis and lacks evidence of clinical benefit; therefore, rFVIIa is not recommended (Class III recommendation, Level A evidence; same as previous guideline);
7. Patients with ICH should be treated with intermittent inflation compression during the first few days of hospitalization to prevent DVT (Class I recommendation, Level B evidence); compression stockings are not beneficial in reducing DVT or improving prognosis (Class III recommendation, Level A evidence; revised from the previous guideline);
8. In patients with low activity within 1-4 days of symptom onset, low-dose low molecular weight heparin or normal heparin may be administered subcutaneously to prevent venous thrombosis if there is evidence of cessation of bleeding (Class IIb recommendation, Level B evidence; as in previous guideline);
9. For patients with ICH with symptomatic DVT or PE (pulmonary embolism), systemic anticoagulation or IVC (inferior vena cava) filter placement may be considered (Class IIa recommendation, Level C evidence); the choice of treatment requires consideration of many factors, including time of onset, hematoma stability, cause of bleeding, and overall patient status (Class IIa recommendation, Level C evidence; new recommendation). (Class IIa recommendation, Level C evidence; new recommendation).
ICH blood pressure management.
For inpatients with a systolic blood pressure of 150-220 mmHg, rapid lowering to 140 mmHg may be safe in the absence of contraindications to acute lowering (Class I recommendation, Level A evidence) and may improve the patient’s functional prognosis (Class IIa recommendation, Level B evidence; revised from the previous guideline);
For ICH patients with systolic blood pressure >220 mmHg, aggressive antihypertensive therapy is reasonable with continuous intravenous infusion and close monitoring of blood pressure (Class IIb recommendation, Level C evidence; new recommendation).
IV. General Monitoring and Care.
Initial monitoring and management of patients with ICH should be performed in an intensive care unit or well-configured stroke unit with health care staff with expertise in neurocritical care (Class I recommendation, Level B evidence; revised from previous guideline).
V. Glucose management.
Blood glucose should be monitored and over- or under-glycemia should be avoided (Class I recommendation, Level C evidence; revised from previous guideline).
Temperature management.
It is reasonable to treat febrile symptoms in patients with ICH (Class IIb recommendation, Level C evidence; new recommendation).
VII. Epilepsy and antiepileptic drugs.
1. Anti-epileptic drugs should be used in patients with clinical convulsions (Class I recommendation, Level A evidence; same as previous guideline);
2. Patients with altered mental status and EEG showing epileptiform discharges may be treated with antiepileptic drugs (Class I recommendation, Level C evidence; same as previous guideline);
3. Continuous EEG monitoring may be used in patients with ICH whose mental status is more depressed than the degree of brain damage (Class IIa recommendation, Level B evidence; revised from the previous guideline);
4. Prophylactic application of antiepileptic drugs is not recommended (Class III recommendation, Level B evidence; same as the previous guideline).
VIII. Management of medical complications.
1. All patients should be screened for dysphagia to reduce the risk of pneumonia (Class I recommendation, Level B evidence; new recommendation);
2. It is reasonable to screen for myocardial ischemia or infarction with electrocardiography or cardiac enzymes after ICH (Class IIa recommendation, Level C evidence; new recommendation).
IX. ICP (intracranial pressure) monitoring and treatment.
1. Ventricular drainage is reasonable in patients with hydrocephalus, especially in patients with decreased level of consciousness (Class IIa recommendation, Level B evidence; revised from the previous guideline);
ICP monitoring should be considered and managed accordingly in patients with ICH who have a GCS score less than or equal to 8, clinical manifestations of cerebellar herniation, severe intraventricular hemorrhage, or hydrocephalus. Maintain cerebral perfusion pressure between 50-70 mmHg according to cerebral blood flow autoregulation (Class IIb recommendation, Level C evidence; as in previous guideline);
3. Patients with ICH with elevated ICP should not be given steroid hormone therapy (Class III recommendation, Level B evidence; new recommendation).
X. IVH (intraventricular hemorrhage).
Although the complication rate of intracerebroventricular injection of r-tPA is relatively low, the efficacy and safety of this treatment remains unclear (Class IIb recommendation, Level B evidence; revised from the previous guideline);
2. The effectiveness of endoscopic treatment of IVH is unclear (Class IIb recommendation, Level B evidence; new recommendation).
XI. Surgical treatment of ICH.
1. Cerebellar hemorrhage with neurological deterioration, brainstem compression and/or ventricular obstruction resulting in hydrocephalus should be treated by surgery as soon as possible to remove the hematoma (Class I recommendation, Level B evidence); ventricular drainage is not recommended as initial treatment for these patients (Class III recommendation, Level C evidence; same as the previous guideline);
2. For most patients with supratentorial ICH, the effectiveness of surgery is unclear (Class IIb recommendation, Level A evidence; revised from previous guideline), with exceptions and subgroups of patients who may be considered for surgery listed in sections 3-6 below;
3. There is no significant advantage to early hematoma debridement when the patient deteriorates (Class IIb recommendation, Level A evidence; new recommendation);
4. Patients with progressive deterioration may be considered for life-saving supratentorial hematoma removal (Class IIb recommendation, Level C evidence; new recommendation);
5. Patients with supratentorial ICH may be treated with debulking decompression (DC) with or without hematoma debridement to reduce mortality if they are comatose, have a large hematoma with significant midline shift, have elevated ICP, and have failed pharmacologic therapy (Class IIb recommendation, Level C evidence; new recommendation);
6. Minimally invasive hematoma removal using stereotactic devices, endoscopy alone or in combination with thrombolytic drugs; the efficacy of these modalities is unclear (Class IIb recommendation, Level B evidence; revised from the previous guideline).
XII. Prognostic prediction and abandonment of technical support.
Early aggressive treatment and postponement of no-resuscitation measures may not lead to abandonment of resuscitation until at least the second day of patient admission (Class IIa recommendation, Level B evidence). Patients who have previously agreed not to resuscitate are excluded. The current prediction of early prognosis for ICH may be biased because it does not take into account the impact of early abandonment of technical support and resuscitation. Appropriate medical and surgical treatment should be given even to patients for whom resuscitation is abandoned, unless there is a clear contraindication (revised from the previous edition of the guidelines).
XIII. Prevention of ICH relapse.
1. A stratified assessment of the patient’s risk of ICH recurrence will influence the treatment strategy. The risk of ICH recurrence should take into account the following factors: (1) site of bleeding of the initial ICH; (2) advanced age; (3) MRI GRE sequence showing microhemorrhagic lesions and their number; (4) taking oral anticoagulants; (5) carriers of the apolipoprotein Eε2 or ε4 allele (Class IIa recommendation, Level B evidence; revised from the previous Revised from previous guideline);
Blood pressure should be controlled in all patients with ICH (Class I recommendation, Level A evidence; revised from previous guideline). A long-term blood pressure control goal of 130/80 mmHg is reasonable (Class IIa recommendation, Level B evidence; new recommendation);
3. Lifestyle changes, including avoidance of more than 2 drinks per day, avoidance of smoking and substance abuse, and treatment of obstructive sleep apnea, may be beneficial in preventing recurrence of ICH (Class IIb recommendation, Level B evidence; revised from previous guideline);
4. Patients with non-valvular atrial fibrillation are advised to avoid long-term anticoagulants to prevent an increased risk of recurrence in patients with spontaneous lobar ICH (Class IIa recommendation, Level B evidence; as in previous guideline);
5. Anticoagulants can be used in patients with non-lobar ICH, and antiplatelet agents can be used in all patients with ICH, especially when there is a clear indication for their use;
6. The optimal time to restart oral anticoagulation in patients with anticoagulant-associated ICH is unclear. In patients with nonmechanical valves, avoid oral anticoagulants for at least 4 weeks (Class IIb recommendation, Level B evidence; new recommendation). If indicated, aspirin monotherapy may be initiated several days after the onset of ICH, although the optimal timing of its use is not known;
7. The effectiveness of dabigatran, rivaroxaban, or apixaban in reducing the risk of recurrence in patients with cerebral hemorrhage associated with atrial fibrillation is unknown;
8. There is insufficient evidence that the use of statins should be restricted in patients with ICH.
XIV. Rehabilitation and recovery.
1. Given the severity and complexity of the disability that occurs, and the growing body of research on the effectiveness of rehabilitation, all patients with ICH should receive multidisciplinary rehabilitation;
2. If possible, rehabilitation should begin early and continue in the community after discharge, forming a well coordinated program to achieve early discharge and home-based rehabilitation to promote recovery.