AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage-2010 Update

Despite the absence of a specific treatment for spontaneous, nontraumatic, intracerebral hemorrhage, early, aggressive medical management can improve patient outcome. To update physicians on state of the art care, the American Heart Association (AHA) and American Stroke Association (ASA) have published a new evidence-based guideline that covers diagnosis, hemostasis, blood pressure management, inpatient and nursing management, prevention of medical comorbidities, surgical treatment, prognosis, rehabilitation, prevention of recurrence, and other considerations (Morgenstern et al 2010). All of the recommendations summarized below are Class I ("conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective").

Early diagnosis is important, as >20% of patients deteriorate from the time they are seen by prehospital emergency medical services and arrival in the emergency room. While many hospitals have critical pathways for acute ischemic stroke, they may be less adept at managing the less frequently seen acute hemorrhagic stroke. Emergency management includes neurosurgery and/or neurology consultation, and may include blood pressure management, intubation, hematoma evacuation, external ventricular drainage, intracranial pressure monitoring, and reversal of coagulopathy.

Initial assessment includes prompt neuroimaging with CT or MRI. CT angiography and contrast-enhanced CT may be considered to help identify patients at risk of hematoma expansion. In addition, MRI/angiogram/venogram and CT angiogram/venogram are reasonable to identify underlying causes of hemorrhage such as arteriovenousmalformations, cerebral vein thrombosis, moyamoya disease or tumors.

Patients with underlying coagulopathies need to be identified, whether due to oral anticoagulants, acquired or congenital factor deficiencies, or quantitative or qualitative platelet deficiencies. Coagulopathies should be corrected if possible. Patients should be initially managed in the intensive care unit, and should receive elastic stockings and intermittent pneumatic compression to prevent venous thromboembolism. Normoglycemia should be maintained, blood pressure controlled, and clinical epileptic seizures treated with antiepileptic medications. Electrographic seizures should also be treated in patients with altered mental status. Prompt surgical removal of the hemorrhage is indicated for patients with cerebellar hemorrhage with neurological deterioration, brainstem compression, and/or hydrocephalus from ventricular obstruction.

Conclusions

Predicting prognosis for patients with intracerebral hemorrhage remains imperfect, justifying aggressive initial treatment. These updated recommendations provide a solid framework for a comprehensive clinical approach. Information regarding ongoing clinical trials for intracerebral hemorrhage.

References

Morgenstern LB et al. Guidelines for the management of spontaneous intracerebral hemorrhage. A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010;41:00-00. DOI:10.1161/STR.ObO13e3181ec611b