Hemorrhagic stroke

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.

See Diagnosis: approach

See Management: approach

Original source of update