Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Abstract

Purpose The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage (ICH). Methods A formal literature search of Medline was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data derived recommendations. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time. Results Evidence-based guidelines are presented for the care of patients presenting with ICH. The focus was sub-divided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations. Conclusions ICH is a serious medical condition where outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal directed treatment of the ICH patient.

Declining mortality in neurocritical care patients: a cohort study in Southern Alberta over eleven years

“…[9][10][11][12][13][14] Many of the treatments that are recommended in consensus guidelines and incorporated into protocols are, by necessity, based on low-quality evidence derived largely from observational studies. [15][16][17][18][19] For example, over the past decade it has become common practice to prevent/treat aggressively even relatively mild derangements in core body temperature, blood glucose levels, and serum sodium and hemoglobin concentrations. [20][21][22][23] With increasing use of electroencephalography, it has been recognized that many neurocritical care patients develop non-convulsive seizures, which most experts believe should be prevented or expeditiously diagnosed and treated.…”

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage

“…For the outcome of case fatality by 30 days, Kaplan–Meier estimates and the log‐rank test were used for univariate analysis and Cox proportional hazard models for multivariate analysis, with the multivariate comparison predefined as the primary outcome measure. We adjusted for prespecified baseline characteristics known to be associated with case fatality in ICH: age, log‐transformed ICH volume, INR, and GCS as continuous variables, and sex, infratentorial location, and intraventricular extension as binary variables 10. We confirmed the assumption of proportional hazards by visual examination of the log (minus log) curves.…”

“…This group was relatively small (131 patients vs >350 patients in each of the other 3 groups), and it is of note that the combination group had slightly higher rates of surgery (15% vs 10–13%). Surgery was not adjusted for in our prespecified Cox regression model, given the existing uncertainty around the impact of surgery on outcome 10, 12, 30. However, adding surgery into the model post hoc did not markedly change our findings.…”

“…Allocation to treatment group was dictated by the preferences of the attending physician in consultation with the patient and/or their family, guided by local and national policies. One of the main determinants of outcome in ICH is the decision to palliate early, which often forms a so‐called self‐fulfilling prophecy 10. Half of the patients without any reversal fell into this category.…”

“…Although PCC is more expensive, it has practical advantages including more rapid administration, smaller infusion volume, and no need for ABO blood type match. This has led to PCC being recommended as a reasonable alternative to FFP in the USA10 and the first‐line treatment in the United Kingdom 11. The 2014 European consensus‐based ICH guidelines do not provide a recommendation, citing lack of evidence 12.…”