Guideline sources The following summarized guidelines for the evaluation and management of intracerebral hemorrhage (ICH) are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ASA 2022), the European Society of Intensive Care Medicine (ESICM 2021), the Canadian Stroke Best Practice Recommendations (CSBPR 2021), the European Stroke Organisation (ESO 2021; 2019; 2017; 2014), the Neurocritical Care Society (NCS 2020), and the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018). 1 2 3 4 5 6 7 8 9 https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 1/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway CalculatorFunctional Outcome in Patients CalculatorIntracerebral hemorrhage score CalculatorNIH Stroke Guidelines 1. Classification and risk stratification Severity grading: obtain a baseline measurement of overall hemorrhage severity as part of the initial evaluation of patients with spontaneous ICH to provide an overall measure of clinical severity. B Show 2 more 2. Diagnostic investigations Initial evaluation: As per AHA 2022 guidelines: Elicit focused medical history, perform a physical examination, and obtain routine laboratory tests (such as CBC, proTT/INR/PTT, creatinine/estimated GFR, glucose, cardiac troponin, toxicology screen, and inflammatory markers) on hospital admission in patients with spontaneous ICH to help identify the type of hemorrhage, active medical issues, and risk of unfavorable outcomes. B Obtain an ECG in all patients on hospital admission. B As per CSBPR 2021 guidelines, elicit medication history including antithrombotic agents in the evaluation of patients with ICH. B Show 3 more Diagnostic imaging (CT/MRI): obtain rapid neuroimaging with CT or MRI to confirm the diagnosis of spontaneous ICH in patients presenting with stroke-like symptoms. B Diagnostic imaging (CTA/MRA): Obtain acute CT angiography with consideration of venography to exclude macrovascular causes or cerebral venous thrombosis in patients with any of the following: lobar spontaneous ICH and age < 70 years deep/posterior fossa spontaneous ICH and age < 45 years deep/posterior fossa and age 45-70 years with no history of hypertension. B Show 2 more Diagnostic imaging (DSA): obtain catheter intra-arterial digital subtraction angiography to exclude a macrovascular cause in patients with spontaneous intraventricular hemorrhage and no https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 2/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway detectable parenchymal hemorrhage. B Show 2 more 3. Medical management Prehospital care: as per AHA 2022 guidelines, use stroke recognition and severity tools by dispatch personnel and first responders in patients with sudden onset of neurological symptoms or signs attributable to potential spontaneous ICH to identify potential stroke and facilitate rapid transport to reduce time to diagnosis and treatment. B Show 4 more Setting of care: As per AHA 2022 guidelines, admit patients with spontaneous ICH to a specialized inpatient (stroke) unit with a multidisciplinary team to improve outcomes and reduce mortality. A Show 7 more As per ESO 2014 guidelines, admit patients with ICH to an acute stroke unit to reduce mortality and dependency. A Management of blood pressure: As per AHA 2022 guidelines, consider ensuring continuous smooth and sustained control of BP with careful titration and avoiding peaks and large variability in systolic BP to improve functional outcomes in patients with spontaneous ICH requiring acute BP lowering. C Show 4 more As per ESO 2021 guidelines, insufficient evidence regarding the benefits and risks (advantages/disadvantages) of intensive BP lowering on functional outcome in patients with acute (< 24 hours) ICH. I Show 5 more As per ACC 2018 guidelines: Consider initiating continuous IV drug infusions to lower systolic BP in patients presenting with systolic BP > 220 mmHg. C Avoid initiating immediate lowering of systolic BP to < 140 mmHg in adult patients with spontaneous ICH presenting within 6 hours of the acute event and having a systolic BP of 150-220 mmHg. D Landmark trials: ATACH II In patients with intracerebral hemorrhage, intensive BP lowering, as compared to standard treatment, did not result in a decreased rate of death or disability (38.7% vs. 37.7%; RR 1.04, 95% CI 0.85-1.27). Enrollment was stopped because of futility after a prespecified interim analysis. Serious treatment-related adverse events were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within 7 days after randomization was significantly higher in the intensive-treatment group than in the standard-treatment group (9.0% vs. 4.0%, p = 0.002). https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 3/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway Qureshi AI et al. N Engl J Med. 2016 Sep 15. As per ESO 2014 guidelines: Consider initiating intensive BP reduction with a systolic target of < 140 mmHg in < 1 hour in patients with acute ICH within 6 hours of onset. C Lower BP for secondary prevention after ICH. B Landmark trials: INTERACT2 In patients who had had a spontaneous intracerebral hemorrhage within the previous 6 hours and who had elevated systolic BP, intensive blood-pressure lowering was not superior to guideline-recommended BP lowering with respect to death or major disability at day 90. Craig S Anderson et al. N Engl J Med. 2013 Jun 20. Management of blood glucose: As per AHA 2022 guidelines, monitor serum glucose to reduce the risk of hyperglycemia and hypoglycemia in patients with spontaneous ICH. B Show 2 more As per ESO 2017 guidelines, avoid administering IV insulin routinely to achieve tight glycemic control in order to improve functional outcomes or survival in patients with hemorrhagic stroke. D Management of coagulopathy, antocoagulant reversal: As per ASA/AHA 2022 guidelines, discontinue anticoagulation immediately and perform rapid reversal of anticoagulation as soon as possible after diagnosis to improve survival in patients with anticoagulant-associated spontaneous ICH. B Show 11 more As per ESO 2019 guidelines, administer PCC to decrease mortality and normalize INR in adult patients with ICH occurring during the use of vitamin K antagonists (with an INR above normal). B Show 9 more Management of coagulopathy, antiplatelet reversal: As per ASA/AHA 2022 guidelines, consider administering platelet transfusion to reduce postoperative bleeding and mortality in patients with spontaneous ICH treated with aspirin and requiring emergency neurosurgery. C Show 2 more As per ESICM 2021 guidelines, do not administer platelet transfusion in patients with spontaneous intracranial hemorrhage treated with antiplatelet therapy. D Management of coagulopathy (rFVIIa): insufficient evidence to support the use of recombinant factor VIIa to improve functional outcomes in patients with spontaneous ICH (with or without the https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 4/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway spot sign). I Management of coagulopathy, tranexamic acid: As per ASA/AHA 2022 guidelines, insufficient evidence to support the use of tranexamic acid to improve functional outcomes in patients with spontaneous ICH (with or without the spot sign, black hole sign, or blend sign). I As per ESICM 2021 guidelines, insufficient evidence to support the use of tranexamic acid in critically ill patients with spontaneous intracranial hemorrhage. I Management of intracranial pressure: As per AHA 2022 guidelines, perform ventricular drainage to reduce mortality in patients with spontaneous ICH or intraventricular hemorrhage and hydrocephalus contributing to a reduced level of consciousness. B Show 4 more As per NCS 2020 guidelines, consider administering hypertonic sodium solutions over mannitol for the management of intracranial pressure or cerebral edema in patients with ICH. C Show 2 more As per ESO 2014 guidelines, do not use dexamethasone in patients with acute ICH outside of a clinical trial. D Management of seizures: as per AHA 2022 guidelines, consider obtaining continuous electroencephalography ( 24 hours) to diagnose electrographic seizures and epileptiform discharges in patients with spontaneous ICH and unexplained abnormal or fluctuating mental status or suspicion of seizures. C Show 3 more Management of fever: As per AHA 2022 guidelines: Consider treating an elevated temperature pharmacologically to improve functional outcomes in patients with spontaneous ICH. C Insufficient evidence to support the use of therapeutic hypothermia (< 35 C/95 F) to decrease peri-ICH edema in patients with spontaneous ICH. I Management of comorbidities: Insufficient evidence regarding the risks and benefits of statin therapy on ICH outcomes and recurrence relative to overall prevention of cardiovascular events in patients with spontaneous ICH and an established indication for statin pharmacotherapy. I Do not use regular long-term NSAIDs in patients with spontaneous ICH because of the increased risk of ICH. D Withdrawal of care: as per AHA 2022 guidelines, consider initiating aggressive care, including postponement of new do not attempt resuscitation orders or withdrawal of medical support until at least the second full day of hospitalization, to decrease mortality and improve functional outcome in patients with spontaneous ICH not having preexisting documented requests for life-sustaining therapy limitations. C https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 5/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway Show 2 more 4. Inpatient care Serial clinical assessment: As per AHA 2022 guidelines: Obtain frequent neurological assessments (including Glasgow Coma Scale) by emergency department nurses in the early hyperacute phase of care to assess change in status, neurological examination, or level of consciousness in patients with spontaneous ICH. B Consider obtaining frequent neurological assessments in the ICU and stroke unit for up to 72 hours of admission to detect early neurological deterioration in patients with spontaneous ICH. C As per CSBPR 2021 guidelines: Repeat Glasgow Coma Scale and neurological assessment at least hourly for the first 24 hours, depending on the patient's stability. B Reassess BP every 15 minutes after presentation until desired BP target is achieved and maintained for the first 24 hours. Tailor subsequent BP monitoring to the individual patients according to the stability of the vital signs and intracranial pressure. B Serial imaging assessment: consider obtaining serial head CT within the first 24 hours after symptom onset to evaluate for hemorrhage expansion in patients with spontaneous ICH and/or intraventricular hemorrhage. C Show 3 more Thromboprophylaxis: As per AHA 2022 guidelines, perform intermittent pneumatic compression starting on the day of diagnosis for VTE (DVT and pulmonary embolism) prophylaxis in non-ambulatory patients with spontaneous ICH. B Show 3 more As per ESO 2014 guidelines: Perform intermittent pneumatic compression to improve outcomes and reduce the risk of DVT in immobile patients with ICH. B Do not offer short or long graduated compression stockings for the prevention of DVT in patients with ICH. D Prevention of inpatient complications: use standardized protocols and/or order sets to reduce disability and mortality in patients with spontaneous ICH. B Show 3 more 5. Nonpharmacologic interventions Lifestyle modifications: Consider offering lifestyle modifications to reduce BP in patients with spontaneous ICH. C https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 6/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway Advise avoiding heavy alcohol consumption to reduce hypertension and risk of ICH in patients with spontaneous ICH. B 6. Surgical interventions Indications for surgery (supratentorial hemorrhage): consider performing minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration with or without thrombolytic use to reduce mortality C , but not for improving functional outcomes, in patients with a Glasgow Coma Scale scores of 5-12 and supratentorial ICH of > 20-30 mL volume. Consider performing minimally invasive hematoma evacuation over conventional craniotomy to improve functional outcomes in these patients considered for hematoma evacuation. C Show 3 more Indications for surgery (cerebellar hemorrhage): perform immediate surgical removal of the hemorrhage with or without external ventricular drainage to reduce mortality in patients with cerebellar ICH deteriorating neurologically, having brainstem compression and/or hydrocephalus from ventricular obstruction, or having cerebellar ICH volume 15 mL. B Indications for surgery (intraventricular hemorrhage): perform external ventricular drainage to reduce mortality in patients with spontaneous ICH, large intraventricular hemorrhage, and impaired level of consciousness. B Show 4 more 7. Specific circumstances Patients with concomitant VTE: Consider placing a temporary retrievable filter as a bridge until anticoagulation in patients with acute spontaneous ICH and proximal deep vein thrombosis not yet candidates for anticoagulation. C Consider delaying UFH or LMWH for 1-2 weeks after the onset of ICH in patients with acute spontaneous ICH and proximal deep vein thrombosis or pulmonary embolism. C 8. Patient education Caregiver counseling: Consider providing psychosocial education for the caregiver to increase patients' activity level and participation and/or quality of life. C Consider providing practical support and training for the caregiver to improve patients' standing balance. C 9. Preventative measures https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 7/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway Primary prevention: consider incorporating any available MRI results demonstrating cerebral microbleed burden or cortical superficial siderosis to inform shared decision-making about stroke prevention treatment plans when considering primary prevention of ICH. C Secondary prevention: Consider incorporating the following risk factors of ICH recurrence into decision-making in patients with spontaneous ICH for recurrence prognostication or management: lobar location of the initial ICH older age presence, number, and lobar location of microbleeds on MRI presence of disseminated cortical superficial siderosis on MRI poorly controlled hypertension asian or Black race presence of apolipoprotein E 2 or 4 alleles. C Show 2 more 10. Follow-up and surveillance Stroke rehabilitation: offer multidisciplinary rehabilitation including regular team meetings and discharge planning to improve functional outcomes and reduce morbidity and mortality in patients with spontaneous ICH. A Show 5 more Landmark trials: EFFECTS In adult patients with a clinical diagnosis of ischemic or intracerebral hemorrhage in the previous 2-15 days, fluoxetine was not superior to placebo with respect to physical function as measured by the stroke impact scale score. EFFECTS Trial Collaboration. Lancet Neurol. 2020 Aug. Management of neurobehavioral complications: use depression and anxiety screening tools in the post-acute period to identify patients with post-stroke depression and anxiety. B Show 5 more Resumption of antithrombotics: as per AHA 2022 guidelines, consider resuming anticoagulation early to prevent thromboembolic complications in patients with conditions placing them at high risk of thromboembolic events, such as a mechanical valve or LV assist device. C Show 4 more Follow-up imaging: consider obtaining repeated catheter intra-arterial digital subtraction angiography 3-6 months after ICH onset to identify a previously obscured vascular lesion in patients with spontaneous ICH and a negative catheter intra-arterial digital subtraction angiography and no clear microvascular diagnosis or other defined structural lesion. C https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 8/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway 11. Quality improvement Public health measures: Design and implement stroke public education programs for diverse populations focused on early recognition and the need to seek emergency care rapidly to reduce time to diagnosis and treatment. B Develop regional systems of stroke care so all potentially beneficial therapies can be made available when appropriate as rapidly as possible including, at a minimum healthcare facilities providing initial spontaneous ICH care including diagnosis and treatment, and healthcare facilities with neurocritical care and neurosurgical capabilities. B References 1. Steven M Greenberg, Wendy C Ziai, Charlotte Cordonnier et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 May 17;101161STR0000000000000407. Open 2. Alexander P J Vlaar, Joanna C Dionne, Sanne de Bruin et al. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2021 Dec;47 12 1368 1392. Open 3. Ashkan Shoamanesh, M Patrice Lindsay, Lana A Castellucci et al. Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020. Int J Stroke. 2021 Apr;16 3 321 341. Open 4. Thorsten Steiner, Rustam Al-Shahi Salman, Ronnie Beer et al. European Stroke Organisation ESO guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014 Oct;9 7 840 55. Open 5. Paul K Whelton, Robert M Carey, Wilbert S Aronow et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71 6):e13-e115. Open 6. Else Charlotte Sandset, Craig S Anderson, Philip M Bath et al. European Stroke Organisation ESO guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J. 2021 Jun;6 2 XLVIII LXXXIX. Open 7. Blanca Fuentes, George Ntaios, Jukka Putaala et al. European Stroke Organisation ESO guidelines on glycaemia management in acute stroke. Eur Stroke J. 2018 Mar;3 1 5 21. Open 8. Aaron M Cook, G Morgan Jones, Gregory W J Hawryluk et al. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocrit Care. 2020 Jun;32 3 647 666. Open 9. Hanne Christensen, Charlotte Cordonnier, Janika K rv et al. European Stroke Organisation Guideline on Reversal of Oral Anticoagulants in Acute Intracerebral Haemorrhage. Eur Stroke J. 2019 Dec;4 4 294 306. Open https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 9/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway 10. Hemphill JC rd, Greenberg SM, Anderson CS et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46 7 2032 60. Open 11. Frontera JA, Lewin JJ rd, Rabinstein AA et al. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016 Feb;24 1 6 46. Open 12. Halvorsen S, Storey RF, Rocca B et al. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J. 2017 May 14;38 19 1455 1462. Open 13. RESTART Collaboration. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage RESTART a randomised, open-label trial. Lancet. 2019 Jun 29;393 10191 2613 2623. Open 14. Fred Rincon, Stephan A Mayer. The epidemiology of intracerebral hemorrhage in the United States from 1979 to 2008. Neurocrit Care. 2013 Aug;19 1 95 102. Open 15. Sang Joon An, Tae Jung Kim, Byung-Woo Yoon. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke. 2017 Jan;19 1 3 10. Open 16. Marilyn M Rymer. Hemorrhagic stroke: intracerebral hemorrhage. Mo Med. Jan-Feb 2011;108 1 50 4. Open 17. Nikola Sprigg, Katie Flaherty, Jason P Appleton et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage TICH 2 an international randomised, placebo-controlled, phase 3 superiority trial. Lancet. 2018 May 26;391 10135 2107 2115. Open 18. Adnan I Qureshi, Yuko Y Palesch, William G Barsan et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016 Sep 15;375 11 1033 43. Open 19. A David Mendelow, Barbara A Gregson, Elise N Rowan et al. Early Surgery versus Initial Conservative Treatment in Patients with Traumatic Intracerebral Hemorrhage STITCH Trauma]): The First Randomized Trial. J Neurotrauma. 2015 Sep 1;32 17 1312 23. Open 20. Natalia S Rost, Eric E Smith, Yuchiao Chang et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage: the FUNC score. Stroke. 2008 Aug;39 8 2304 9. Open 21. J C Hemphill rd, D C Bonovich, L Besmertis et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001 Apr;32 4 891 7. Open 22. J E Delgado Almandoz, P W Schaefer, J N Goldstein et al. Practical scoring system for the identification of patients with intracerebral hemorrhage at highest risk of harboring an underlying vascular etiology: the Secondary Intracerebral Hemorrhage Score. AJNR Am J Neuroradiol. 2010 Oct;31 9 1653 60. Open 23. Daniel Strbian, Stefan Engelter, Patrik Michel et al. Symptomatic intracranial hemorrhage after stroke thrombolysis: the SEDAN score. Ann Neurol. 2012 May;71 5 634 41. Open 24. M Lou, A Safdar, M Mehdiratta et al. The HAT Score: a simple grading scale for predicting hemorrhage after thrombolysis. Neurology. 2008 Oct 28;71 18 1417 23. Open 25. Saurav Chatterjee, Ido Weinberg, Robert W Yeh et al. Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE CH Score. Thromb Haemost. 2017 Jan 26;117 2 246 251. Open https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 10/11 6/24/23, 2:34 PM Intracerebral hemorrhage Pathway 26. Craig S Anderson, Emma Heeley, Yining Huang et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013 Jun 20;368 25 2355 65. Open https://web.pathway.md/diseases/recGP8CvsS9VfC26Z 11/11