Intracerebral Hemorrhage 2022 Guideline Update

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK)

The American Heart Association/American Stroke Association (AHA/ASA) 2022 Guideline for managing spontaneous intracerebral hemorrhage (ICH) was recently released. This post will focus on the key parts of the guideline that affect ED evaluation and management.


Background

ICH is defined as acute blood extravasation into brain parenchyma. There are approximately 795,000 strokes per year, with 10% of these being an ICH. Unfortunately, ICH disproportionately affects low resource populations worldwide. In the U.S., there is a 1.6-fold higher risk of ICH in Black and Mexican Americans compared to non-Hispanic White people.

Early mortality is severe, approximating 30-40%, and the incidence drastically increases with age. The increasing use of anticoagulants has also resulted in greater numbers of ICH. ICH is often the consequence of several factors, including trauma, cancer, AVMs, aneurysm, venous pathology (cerebral venous thrombosis), hemorrhagic conversion of ischemic stroke, and microvascular disease including arteriolosclerosis and cerebral amyloid angiopathy. Once blood extravasates, it can cause direct pressure effects as well as physiological and cellular damage.

The remainder of this post will provide a brief synopsis of the guidelines, with some editorial thoughts as well.


The Recommendations

All recommendations are designated with a class of recommendation (COR) and level of evidence (LOE).  COR is the strength of the recommendation, while the LOE is the quality of scientific evidence.


Physical Examination and Laboratory Assessment

Obtain focused history, exam, and routine laboratory testing to assist with identifying the type of hemorrhage, active medical issues, and risk of unfavorable outcomes. COR 1, LOE C-LD


Neuroimaging

In patients presenting with stroke-like symptoms, rapid neuroimaging with CT or MRI is recommended to confirm the diagnosis of spontaneous ICH. COR 1, LOE B-NR

In patients with spontaneous ICH and/or IVH, serial head CT can be useful within the first 24 hours after symptom onset to evaluate for hemorrhage expansion. COR 2a, LOE B-NR

In patients with spontaneous ICH and/or IVH and with low GCS score or ND, serial head CT can be useful to evaluate for hemorrhage expansion, development of hydrocephalus, brain swelling, or herniation. COR 2a, LOE C-LD

In patients with spontaneous ICH, CT angiography (CTA) within the first few hours of ICH onset may be reasonable to identify patients at risk for subsequent HE. COR 2b, LOE B-NR

In patients with spontaneous ICH, using noncontrast computed tomography (NCCT) markers of HE to identify patients at risk for HE may be reasonable. COR 2b, LOE B-NR

Editorial Comment: The guideline incorporates CTA, which may assist with diagnosis and prognostication. The spot sign may be associated with mortality and poor mRS, score, but the data are heterogenous and have significant limitations.


Diagnostic Assessment for Pathogenesis

In patients with lobar spontaneous ICH and age <70 years, deep/posterior fossa spontaneous ICH and age <45 years, or deep/posterior fossa and age 45 to 70 years without history of hypertension, acute CTA plus consideration of venography is recommended to exclude macrovascular causes or cerebral venous thrombosis. COR 1, LOE B-NR

In patients with spontaneous ICH who undergo CT or MRI at admission, CTA plus consideration of venography or MRA plus consideration of venography performed acutely can be useful to exclude macrovascular causes or cerebral venous thrombosis. COR 2a, LOE C-LD

Editorial Comment: They incorporate venography in a select subset of patients to evaluate for CVT. This is an important consideration, as CVT requires anticoagulation even in the setting of ICH.


Treatment: Acute BP Lowering

In patients with spontaneous ICH requiring acute BP lowering, careful titration to ensure continuous smooth and sustained control of BP, avoiding peaks and large variability in SBP, can be beneficial for improving functional outcomes. COR 2a, LOE B-NR

In patients with spontaneous ICH in whom acute BP lowering is considered, initiating treatment within 2 hours of ICH onset and reaching target within 1 hour can be beneficial to reduce the risk of HE and improve functional outcome. COR 2a, LOE C-LD

In patients with spontaneous ICH of mild to moderate severity presenting with SBP between 150 and 220 mm Hg, acute lowering of SBP to a target of 140 mm Hg with the goal of maintaining in the range of 130 to 150 mm Hg is safe and may be reasonable for improving functional outcomes. COR 2b, LOE B-R

HARM: In patients with spontaneous ICH of mild to moderate severity presenting with SBP >150 mm Hg, acute lowering of SBP to <130 mm Hg is potentially harmful. COR 3, LOE B-R

Editorial Comment: The guideline recommends a range between 130-150 for a BP target in those with a presenting BP between 150-220, while avoiding drops less than 130.  For those with higher BPs, decrease that BP by 20% in the first hour. If you drop these patients by too much and too rapidly, end organ injury can occur (ie, renal injury), and cerebral perfusion pressure will also decrease.  The key is a steady, early decrease in BP. Most of the studies included in the guideline included patients where BP treatment was initiated at least 3 hours after onset of the ICH (ATACH-2, INTERACT). Decreasing BP within the first hour can improve patient outcomes. Use a reliable antihypertensive infusion such as nicardipine or clevidipine.  An arterial line can be helpful in these critical patients, but if this is not feasible, make sure the blood pressure cuff is routinely recycled (less than every 10 minutes).


Treatment: Anticoagulant-related hemorrhage

In patients with anticoagulant-associated spontaneous ICH, anticoagulation should be discontinued immediately and rapid reversal of anticoagulation should be performed as soon as possible after diagnosis of spontaneous ICH to improve survival. COR 1, LOE C-LD

VKAs

In patients with VKA-associated spontaneous ICH and INR ≥2.0, 4-factor (4-F) prothrombin complex concentrate (PCC) is recommended in preference to fresh-frozen plasma (FFP) to achieve rapid correction of INR and limit HE. COR 1, LOE B-R

In patients with VKA-associated spontaneous ICH, intravenous vitamin K should be administered directly after coagulation factor replacement (PCC or other) to prevent later increase in INR and subsequent HE. COR 1, LOE C-LD

In patients with VKA-associated spontaneous ICH with INR of 1.3 to 1.9, it may be reasonable to use PCC to achieve rapid correction of INR and limit HE. COR 2b, LOE C-LD

Editorial Comment: Fixed dose 4-F PCC with vitamin K is the optimal reversal in this setting. However, the third recommendation of reversing an INR of 1.3-1.9 is questionable.

DOACs

In patients with direct factor Xa inhibitor–associated spontaneous ICH, andexanet alfa is reasonable to reverse the anticoagulant effect of factor Xa inhibitors. COR 2a, LOE B-NR

In patients with dabigatran-associated spontaneous ICH, idarucizumab is reasonable to reverse the anticoagulant effect of dabigatran. COR 2a, LOE B-NR

In patients with direct factor Xa inhibitor–associated spontaneous ICH, a 4-F PCC or activated PCC (aPCC) may be considered to improve hemostasis. COR 2b, LOE B-NR

In patients with dabigatran- or factor Xa inhibitor–associated spontaneous ICH, when the DOAC agent was taken within the previous few hours, activated charcoal may be reasonable to prevent absorption of the DOAC. COR 2b, LOE C-LD

In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available, aPCC or PCCs may be considered to improve hemostasis. COR 2b, LOE C-LD

In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available, renal replacement therapy (RRT) may be considered to reduce dabigatran concentration. COR 2b, LOE C-LD

Editorial Comment: There is limited evidence supporting improved patient-centered outcomes with andexanet alfa. 4-F PCC and aPCC are effective reversal agents, with more literature support compared to anexanet alfa for DOAC reversal. An institutional protocol utilizing aPCC is recommended.

Heparins

In patients with unfractionated heparin (UFH)–associated spontaneous ICH, intravenous protamine is reasonable to reverse the anticoagulant effect of heparin. COR 2a, LOE C-LD

In patients with low-molecular-weight heparin (LMWH)–associated spontaneous ICH, intravenous protamine may be considered to partially reverse the anticoagulant effect of heparin. COR 2b, LOE C-LD


Treatment: Antiplatelet-related hemorrhage

For patients with spontaneous ICH being treated with aspirin and who require emergency neurosurgery, platelet transfusion might be considered to reduce postoperative bleeding and mortality. COR 2b, LOE C-LD

For patients with spontaneous ICH being treated with antiplatelet agents, the effectiveness of desmopressin with or without platelet transfusions to reduce the expansion of the hematoma is uncertain. COR 2b, LOE C-LD

HARM: For patients with spontaneous ICH being treated with aspirin and not scheduled for emergency surgery, platelet transfusions are potentially harmful and should not be administered. LOE B-R

Editorial Comment: Desmopressin 0.3 mcg/kg IV  is promising, especially in patients with renal disease or those on aspirin. Many centers use platelet response testing. This may assist in determining the need for platelet transfusion in those on ASA or clopidogrel. Make sure to speak with neurosurgery as well.

From EMCrit.org


Treatment: General Hemostatic Measures

In patients with spontaneous ICH (with or without the spot sign), the effectiveness of recombinant factor VIIa to improve functional outcome is unclear. COR 2b, LOE B-R.

In patients with spontaneous ICH (with or without the spot sign, black hole sign, or blend sign), the effectiveness of TXA to improve functional outcomes is not well established. COR 2b, LOE B-R

Editorial Comment:  TXA is likely not beneficial in patients with ICH.


General Inpatient Care

In patients with spontaneous ICH, provision of care in a specialized inpatient (eg, stroke) unit with a multidisciplinary team is recommended to improve outcomes and reduce mortality. COR 1, LOE A

In patients with spontaneous ICH and clinical hydrocephalus, transfer to centers with neurosurgical capabilities for definitive hydrocephalus management (eg, EVD placement and monitoring) is recommended to reduce mortality. COR 1, LOE B-NR

In patients with moderate to severe spontaneous ICH, IVH, hydrocephalus, or infratentorial location, provision of care in a neuro-specific ICU compared with a general ICU is reasonable to improve outcomes and reduce mortality. COR 2a, LOE B-NR

In patients with IVH or infratentorial ICH location, transfer to centers with neurosurgical capabilities might be reasonable to improve outcomes. COR 2b, LOE B-NR

Editorial Comment: A dedicated care team and ICU can improve outcomes. Have a low threshold to transfer these patients to centers with a multidisciplinary care team, including neurosurgery and neurocritical care teams.


Thromboprophylaxis

In nonambulatory patients with spontaneous ICH, intermittent pneumatic compression (IPC) starting on the day of diagnosis is recommended for VTE (DVT and pulmonary embolism [PE]) prophylaxis. COR 1, LOE B-R

In nonambulatory patients with spontaneous ICH, low-dose UFH or LMWH can be useful to reduce the risk for PE. COR 2a, LOE C-LD

In nonambulatory patients with spontaneous ICH, initiating low-dose UFH or LMWH prophylaxis at 24 to 48 hours from ICH onset may be reasonable to optimize the benefits of preventing thrombosis relative to the risk of HE. COR 2b, LOE C-LD

Editorial Comment: In most situations, thromboprophylaxis can be left to the intensivist and neurosurgeon.


Glucose

In patients with spontaneous ICH, monitoring serum glucose is recommended to reduce the risk of hyperglycemia and hypoglycemia. COR 1, LOE C-LD

In patients with spontaneous ICH, treating hypoglycemia (<40–60 mg/d, <2.2–3.3 mmol/L) is recommended to reduce mortality. COR 1, LOE C-LD

In patients with spontaneous ICH, treating moderate to severe hyperglycemia (>180– 200 mg/dL, >10.0–11.1 mmol/L) is reasonable to improve outcomes. COR 2a, LOE C-LD

Editorial Comment: Avoid hypo- and hyperglycemia.


Temperature

In patients with spontaneous ICH, pharmacologically treating an elevated temperature may be reasonable to improve functional outcomes. COR 2b, LOE C-LD

In patients with spontaneous ICH, the usefulness of therapeutic hypothermia (<35C/95F) to decrease peri-ICH edema is unclear. COR 2b, LOE C-LD

Editorial Comment: Avoid elevated temperatures, but there is no clear evidence supporting therapeutic hypothermia.


Seizures and Antiseizure Medications

In patients with spontaneous ICH, impaired consciousness, and confirmed electrographic seizures, antiseizure drugs should be administered to reduce morbidity. COR 1, LOE C-LD

In patients with spontaneous ICH and clinical seizures, antiseizure drugs are recommended to improve functional outcomes and prevent brain injury from prolonged recurrent seizures. COR 1, LOE C-EO

In patients with spontaneous ICH and unexplained abnormal or fluctuating mental status or suspicion of seizures, continuous electroencephalography (≥24 hours) is reasonable to diagnose electrographic seizures and epileptiform discharges. COR 2a, LOE C-LD

No Benefit: In patients with spontaneous ICH without evidence of seizures, prophylactic antiseizure medication is not beneficial to improve functional outcomes, long-term seizure control, or mortality. LOE B-NR

Editorial Comment: Treat seizures if they occur, but otherwise, do not provide prophylactic antiseizure medications.


ICP and Cerebral Edema

In patients with spontaneous ICH or IVH and hydrocephalus that is contributing to decreased level of consciousness, ventricular drainage should be performed to reduce mortality. COR 1, LOE B-NR

In patients with moderate to severe spontaneous ICH or IVH with a reduced level of consciousness, ICP monitoring and treatment might be considered to reduce mortality and improve outcomes. COR 2b, LOE B-NR

In patients with spontaneous ICH, the efficacy of early prophylactic hyperosmolar therapy for improving outcomes is not well established. COR 2b, LOE B-NR

In patients with spontaneous ICH, bolus hyperosmolar therapy may be considered for transiently reducing ICP. COR 2b, LOE C-LD

No Benefit:  In patients with spontaneous ICH, corticosteroids should not be administered for treatment of elevated ICP. LOE B-R

Editorial Comment: If concerned about elevated ICP and the patient decompensates, administer a bolus hyperosmolar agent such as hypertonic saline, and a bolus is probably better than a  continuous infusion. Hypertonic saline may be better than mannitol. Steroids are also not recommended.


Surgical Therapies

There are specific patient populations that may improve with surgical interventions, especially those with larger bleeds and depressed GCS. The key is to consult neurosurgery early in the care of these patients.


Outcome Prediction

In patients with spontaneous ICH, administering a baseline measure of overall hemorrhage severity is recommended as part of the initial evaluation to provide an overall measure of clinical severity. COR 1, LOE B-NR

In patients with spontaneous ICH, a baseline severity score might be reasonable to provide a general framework for communication with the patient and their caregivers. COR 2b, LOE B-NR

No Benefit:  In patients with spontaneous ICH, a baseline severity score should not be used as the sole basis for forecasting individual prognosis or limiting life-sustaining treatment. LOE B-NR

Editorial Comment: Be careful using the ICH score to prognosticate. It may be helpful with assessing disease severity. Much of the patient’s prognosis depends on their baseline status prior to the ICH.


Summary:

  • ICH is deadly and accounts for 10% of all strokes.
  • In the patient with suspected stroke, perform a rapid assessment (such as CPSS, VAN), and obtain a glucose and noncontrast head CT. CTA may be helpful, as can venography in select patients.
  • Once ICH is diagnosed on CT, our goals are to stabilize the patient, control blood pressure (rapid control with an IV infusion), prevent further injury (avoid elevated ICP, hypoxia, hypotension, hypoglycemia), and admit to an appropriate facility (ie, transfer may be needed).
  • Consult neurosurgery early in the care of these patients.

 

Reference:

Greenberg SM, Ziai WC, Cordonnier C, et al; American Heart Association/American Stroke Association. 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. doi: 10.1161/STR.0000000000000407.

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