View source for AHA, ASA guidelines for the management of spontaneous intracerebral hemorrhage

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{{Intracerebral hemorrhage}}
{{CMG}} {{AE}} {{SaraM}}

==2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage<ref name=ASA/AHA-ICH-Guid> 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhagehttp://stroke.ahajournals.org/content/early/2015/05/28/STR.0000000000000069 Accessed on November 10, 2016</ref>==
===Emergency Diagnosis and Assessment: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''A baseline severity score should be performed as part of the initial evaluation of patients with [[intracerebral hemorrhage|intracerebral hemorrhage (ICH)]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''Rapid neuroimaging with [[CT]] or [[MRI]] is recommended to distinguish [[ischemic stroke]] from [[intracerebral hemorrhage|intracerebral hemorrhage (ICH)]]  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''[[CT angiography]], CT venography, contrast-enhanced CT, contrast-enhanced MRI, [[MRA]] and MRV can be useful to evaluate for underlying structural lesions including vascular malformations and [[tumors]] when there is clinical or radiologic suspicion  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''[[CT angiography]] and contrast-enhanced CT may be considered to help identify patients at risk for [[hematoma|hematoma expansion]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

===Hemostasis and Coagulopathy, Antiplatelet Agents, and DVT Prophylaxis: Recommendations===
====Patients with a severe coagulation factor deficiency or severe thrombocytopenia====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Patients with a severe [[coagulation factor deficiency]] or severe [[thrombocytopenia]] should receive appropriate factor replacement therapy or platelets, respectivel ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====Patients with ICH whose INR is elevated because of VKA====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Patients with ICH whose INR is elevated because of VKA should have their VKA withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
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|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''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 recommended for VKA reversal in ICH   ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''PCCs may have fewer complications and correct the INR more rapidly than FFP and might be considered over FFP ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

====Patients with ICH who are taking dabigatran, rivaroxaban, or apixaban====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''For patients with ICH who are taking dabigatran, rivaroxaban, or apixaban, treatment with FEIBA, other PCCs, or rFVIIa might be considered on an individual basis. Activated charcoal might be used if the most recent dose of dabigatran, apixaban, or riva- roxaban was taken <2 hours earlier. Hemodialysis might be considered for dabigatran ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Reverse heparin in patients with acute ICH====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Protamine sulfate]] may be considered to reverse [[heparin]] in patients with acute ICH ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Patients with a history of anti platelet and ICH====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====Hematoma expansion====
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus, rFVIIa is not recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}

====prevention of venous thromboembolism====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Patients with ICH should have intermittent pneu- matic compression for prevention of venous throm- boembolism beginning the day of hospital admission ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
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|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''Graduated compression stockings are not beneficial to reduce DVT or improve outcome  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''After documentation of cessation of bleeding, low- dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for pre- vention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
====ICH patients with symptom- atic DVT or PE ====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Systemic anticoagulation or IVC filter placement is probably indicated in ICH patients with symptom- atic DVT or PE ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' The decision between these 2 options should take into account several factors, including time from hem- orrhage onset, hematoma stability, cause of hemor- rhage, and overall patient condition ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

===BP-Lowering: Recommendations===
====ICH patients presenting with SBP between 150 and 220 mmHg====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg ) can be effective for improving functional outcome ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====ICH patients presenting with SBP >220 mmHg====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For ICH patients presenting with SBP >220 mm Hg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===General Monitoring and Nursing Care: Recommendation===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Initial monitoring and management of ICH patients should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertis ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

===Glucose Management: Recommendation===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Glucose should be monitored. Both [[hyperglycemia]] and [[hypoglycemi]]a should be avoided ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===Temperature Management: Recommendation===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Treatment of fever after ICH may be reasonable ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===Seizures and Antiseizure Drugs: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Clinical seizures should be treated with antiseizure drugs  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiseizure drugs ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''Prophylactic antiseizure medication is not recommended   ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status that is out of proportion to the degree of brain injury ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===Management of Medical Complications: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''A formal screening procedure for [[dysphagia]] should be performed in all patients before the initiation of oral intake to reduce the risk of [[pneumonia]]  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Systematic screening for [[myocardial ischemia]] or infarction with [[electrocardiogram]] and [[cardiac enzyme testing]] after ICH is reasonable  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===ICP Monitoring and Treatment: Recommendations===
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
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|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''[[Corticosteroids]] should not be administered for treatment of elevated ICP in ICH  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Ventricular drainage as treatment for [[hydrocephalus]] is reasonable, especially in patients with decreased level of consciousness  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Patients with a GCS score 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 CPP of 50 to 70 mm Hg may be reasonable to maintain depending on the status of cerebral autoregulation ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===IVH: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''The efficacy of endoscopic treatment of IVH is uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

===Surgical Treatment of ICH: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''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  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Initial treatment of patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction is not recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For most patients with supratentorial ICH, the usefulness of surgery is not well established ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacution when patients deteriorate ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.'''Decompressive hemicraniectomy (DC) with or without hematoma evacuation might reduce mortality for patients with supratentorial ICH who are in a [[coma]], have large hematomas with significant midline shift, or have elevated ICP refractory to medical management ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.'''  The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without [[thrombolytic]] usage is uncertain ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
===Outcome Prediction and Withdrawal of Technological Support: Recommendation===
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Current prognostic models for individual patients early after ICH are biased by failure to account for the influence of withdrawal of support and early DNAR orders. DNAR status should not limit appropriate medical and surgical interventions unless otherwise explicitly indicated  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Aggressive care early after ICH onset and postponement of new DNAR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNAR orders are not included in this recommendation ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

==References==
{{reflist|2}}


[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Neurosurgery]]
[[Category:Emergency medicine]]


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