Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Abstract

2032Purpose-The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. Methods-A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. Results-Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. Conclusions-Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted.These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Persistent Hyperglycemia Is Associated With Increased Mortality After Intracerebral Hemorrhage

“…These results were derived from a small sample size with a point estimate that approached 1 and a wide confidence interval. The negative association needs to be considered in this context and late hyperglycemia should still be managed as per current best practice guidelines 1. Although our secondary analyses showed increasing glucose levels in both epochs to be associated with mortality, it is likely the outcome association is driven by patients with persistent rather than transient hyperglycemia as demonstrated in the primary analysis.…”

“…The current American Stroke Association guidelines endorse avoidance of hyperglycemia in patients with intracerebral hemorrhage (ICH) 1. The recommendation was based on association of hyperglycemia and poor outcome in observational studies 2, 3, 4, 5.…”

Evaluation of Acute Kidney Injury and Mortality After Intensive Blood Pressure Control in Patients With Intracerebral Hemorrhage

“…Our onset time for initiating intensive SBP treatment (within 24 hours) also differed when compared with INTERACT 2 (6 hours) and ATACH 2 trial (4.5 hours). Although this may have improved the clinical efficacy of intensive SBP reduction by reducing the probability of hematoma expansion, the role of delayed intensive SBP reduction on renal function is unclear, with no clear guidelines 5. In addition, the duration of review for blood pressure measurements was shortened in our study.…”

“…Current randomized‐controlled clinical trials and international recommendations acknowledge the importance of reducing SBP in acute ICH but focus on specific SBP targets without considering systemic organ autoregulation17 or providing recommendations for patients who present with SBPs >220 mm Hg 5. The ATACH 2 trial complicated the benefit of intensive SBP reduction in acute ICH by demonstrating a significant increase in adverse renal events in patients randomized to intensive antihypertensive therapy 6.…”

“…The multicenter randomized INTERACT 2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial) showed a trend suggesting intensive SBP reduction targeted to <140 mm Hg leads to improved clinical outcome 4. As a result, this goal was adopted by the American Heart Association/American Stroke Association recommendations for acute ICH management 5. However, this blood pressure goal has been disputed by the more recent ATACH 2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage 2) trial that compared an intensive SBP goal (<140 mm Hg) to a standard SBP goal (140–179 mm Hg) and found no improvement in primary outcome 6.…”