Updated US guidelines based on findings from several clinical trials: some management strategies for spontaneous hemorrhagic stroke are not as effective as previously believed
The American Heart Association/American Stroke Association have updated their 2015 guidance on the management of intracerebral hemorrhage; key new and updated aspects include:
Acute computed tomography angiography (CTA) is recommended, with consideration of CT venography (CTV), to exclude macrovascular causes of cerebral venous thrombosis, in the following groups:
Lobar spontaneous intracerebral hemorrhage, age <70 years, or
Deep/posterior fossa spontaneous intracerebral hemorrhage, age <45 years, or
Deep/posterior fossa, age 45 to 70 years, without history of hypertension.
Antihypertensive medications should be carefully titrated in patients with spontaneous intracerebral hemorrhage requiring acute blood pressure lowering. This is to ensure continuous smooth and sustained control of blood pressure (BP), avoiding peaks and large variability in systolic BP.
In nonambulatory patients, intermittent pneumatic compression should be started on the day of intracerebral hemorrhage diagnosis for deep venous thrombosis (DVT) prophylaxis. Graduated knee- or thigh-high compression stockings are ineffective in preventing DVT in this patient group.
Platelet transfusions are not recommended for patients with spontaneous intracerebral hemorrhage being treated with aspirin and not scheduled for emergency surgery. Outside the setting of emergency surgery or severe thrombocytopenia, routine use appears to worsen outcome.
In patients with vitamin K antagonist-associated spontaneous intracerebral hemorrhage and international normalized ratio (INR) ≥2.0, 4-factor prothrombin complex concentrate is preferable to fresh-frozen plasma for rapid correction of INR and to limit hematoma expansion.
For patients with cerebellar hemorrhage, indications for immediate surgical evacuation with or without external ventricular drain (EVD) now include cerebellar intracerebral hemorrhage volume ≥15 mL in addition to previously recommended indications of neurologic deterioration, brainstem compression, and hydrocephalus. Surgical intervention in these patients has been shown to reduce mortality, compared with medical management alone.
Early aggressive mobilization within the first 24 hours following intracerebral hemorrhage should be avoided since this appears to worsen 14-day mortality.
Hemorrhagic stroke accounts for approximately 10% of strokes.
Computed tomography (CT) or magnetic resonance imaging (MRI), with high sensitivity for intracerebral hemorrhage, are essential in diagnosis.
The primary treatment for people with hemorrhagic stroke involves supportive care and optimization of intracranial hemodynamics.
Surgical resection of intracerebral hematomas may be of benefit in select cases, such as cerebellar hematomas >3 cm in diameter causing brain stem compression or hydrocephalus.
Patients treated in dedicated stroke units have improved survival and reduced disability at 1 year.
Stroke is an acute neurologic deficit caused by cerebrovascular etiology. It is further subdivided into ischemic stroke and hemorrhagic stroke.
Hemorrhagic stroke is due to rupture of a cerebrospinal artery, resulting in intraparenchymal, subarachnoid, and intraventricular hemorrhage.
Intracerebral hemorrhage is further subdivided into primary and secondary etiology: primary spontaneous intracerebral hemorrhage is defined as hemorrhage in the absence of vascular malformations or associated diseases; secondary intracerebral hemorrhage is from an identifiable vascular malformation or as a complication of other medical or neurologic diseases that either impair coagulation or promote vascular rupture.
History and exam
Key diagnostic factors
- neck stiffness
- history of atrial fibrillation
- history of liver disease
- visual changes
- sudden onset followed by progression
- altered sensation
- sensory loss
- history of hematologic disorder
- altered level of consciousness/coma
- gaze paresis
- advanced age
- male sex
- Asian, black, and/or Hispanic ethnicity
- family history of hemorrhagic stroke
- cerebral amyloid angiopathy
- autosomal dominant mutations in the COL4A1 gene
- hereditary hemorrhagic telangiectasia
- autosomal dominant mutations in the KRIT1, CCM2, or PDCD10 genes
- illicit sympathomimetic drugs
- vascular malformations
- nonsteroidal anti-inflammatory drugs (NSAIDs)
- diabetes mellitus
- heavy alcohol abuse
- cerebral vasculitis
- Moyamoya disease
1st investigations to order
- noncontrast head CT
- chemistry panel
- clotting tests
- platelet function test
- urine drug screen
- pregnancy test in women of childbearing age
- liver function test
- intracerebral hemorrhage (ICH) score
Investigations to consider
- CT angiography and venography
- magnetic resonance angiography and venography
- conventional (invasive) angiography
- MRI brain with diffusion-weighted imaging (DWI) and gradient-echo sequence (GRE)
- MRI brain with susceptibility-weighted imaging
presumed hemorrhagic stroke
noncerebellar bleed: stable and alert
noncerebellar bleed: decompensating
<3 cm cerebellar bleed: alert
>3 cm cerebellar bleed or drowsy/unstable
Fernando D. Goldenberg, MD
Clinical Associate of Neurology
Medical Director, Neuroscience ICU
Director, Neurocritical Care Education
Co-Director, Stroke Center
University of Chicago
FDG has provided expert testimony in medical legal cases, unrelated to the article topic.
Raisa C. Martinez, MD
Neurocritical Care Unit
Department of Neurosciences
Wellstar Health System, Kennestone
RCM declares that she has no competing interests.
Dr Fernando Goldenberg and Dr Raisa Martinez would like to gratefully acknowledge Dr Alejandro Hornik, Dr Eric E. Smith, and Dr T. Dion Fung, the previous contributors to this topic.
EES is an author of a number of references cited in this topic. AH and TDF declare that they have no competing interests.
Louis R. Caplan, MD
Lecturer in Neurology
Beth Israel Deaconess Medical Center
Division of Cerebrovascular/Stroke
LRC declares that he has no competing interests.
Julien Morier, MD
Centre Hospitalier Universitaire Vaudois (CHUV)
JM declares that he has no competing interests.
- Ischemic stroke
- Hypertensive encephalopathy
- Guideline for the management of patients with spontaneous intracerebral hemorrhage
- Clinical guidelines for stroke management
Stroke caused by a blood clot: preventing another stroke
Stroke: treatmentMore Patient leaflets
NIH Stroke ScoreMore Calculators
Venepuncture and phlebotomy: animated demonstration
How to perform an ECG: animated demonstrationMore videos
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer