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2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

By Currents Editor posted 08-26-2022 09:13

  

Stroke (05/17/22) DOI: 10.1161/STR.0000000000000407
Greenberg, Steven M.; Ziai, Wendy C.; Cordonnier, Charlotte; et al.
https://www.ahajournals.org/doi/10.1161/STR.0000000000000407 

The American Heart Association (AHA) and American Stroke Association (ASA) have released updated guidelines for the management of individuals with spontaneous intracerebral hemorrhage (ICH). The guidelines for the management of spontaneous ICH were last updated in 2015. The updated guidance is limited to spontaneous ICHs that are not caused by head trauma and do not have a visualized structural cause. 

The update includes 10 key points for managing spontaneous ICH, including the development of regional systems to provide initial ICH care, with the ability to rapidly transfer patients to facilities with neurocritical care and neurosurgical capabilities. The guidance also addresses hematomas, noting there are now both clinical markers and neuroimaging markers that can help predict the risk of hematoma expansion. Also stressed is the importance of identifying markers of microvascular and macrovascular hemorrhage pathogeneses. AHA and ASA further note the importance of implementing treatment regimens that limit blood pressure variability and achieve sustained blood pressure control to help reduce hematoma expansion. The guidelines include updated recommendations for acute reversal of anticoagulation after ICH, emphasizing the use of protein complex concentrate for reversal of vitamin K antagonists, idarucizumab for the reversal of the thrombin inhibitor dabigatran, and andexanet for the reversal of factor Xa inhibitors. 

However, the guidelines also discuss several in-hospital therapies that have been used to treat patients with ICH, noting that for critical or emergency care treatment, continuous hyperosmolar therapy or prophylactic corticosteroids appear to have no benefit to the outcome, while the use of platelet transfusions - except in emergency surgery or severe thrombocytopenia - appears to worsen outcome. The use of knee- or thigh-high compression stockings alone is not an effective prophylactic therapy for the prevention of deep vein thrombosis, and prophylactic antiseizure medications, in the absence of seizures, did not improve long-term seizure control or functional outcomes.  

The guidance notes that use of minimally invasive approaches for evacuation of supratentorial ICHs and intraventricular hemorrhages demonstrated reduced mortality. Additionally, the authors stress that the decision to assign do not attempt resuscitation status is separate 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 patient's surrogate. Finally, the guidelines also discuss the use of coordinated multidisciplinary inpatient team care for early assessment of discharge planning and early supported discharge for mild to moderate ICH, and they recommend psychosocial education, practical support, and training for caregivers to help enhance the patient's quality of life, activity level, and balance.

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