Baru saja diterbitkan guideline manajemen stroke ICH 2015 oelh AHA/ASA, meng-update guideline sebelumnya yang dirilis tahun 2010. Penasaran, saya langsung lompat ke bagian manajemen blood pressure & surgical treatment (membandingkan dengan guideline 2010, guideline yang diterbitkan Eropa dan Korea tahun 2014), dan ternyataaa.... (Tunggu aja info lengkapnya, akan diuraikan di: https://neurobsession.wordpress.com/2015/08/02/intracerebral-hemorrhage-stroke-guidelines-2015-the-enigma/ --mungkin lebih seperti "curhat" sih jadinya..) Yak, selamat membaca!

1. 1. For most patients with ICH, the usefulness of
surgery is uncertain (Class IIb; LOE C). (New
recommendation). Specific exceptions to this
recommendation follow.
2. Patients with cerebellar hemorrhage who are
deteriorating neurologically or who have
brainstem compression and/or hydrocephalus
from ventricular obstruction should undergo
surgical removal of the hemorrhage as soon as
possible (Class I; LOE B). (Revised from the
previous guideline) Initial treatment of these
patients with ventricular drainage alone rather
than surgical evacuation is not recommended
(Class III; LOE C). (New recommendation)
3. For patients presenting with lobar clots >30mL
and within 1 cm of the surface, evacuation of
supratentorial ICH by standard craniotomy
might be considered (Class IIb; LOE B). (Revised
from the previous guideline)
4. The effectiveness of minimally invasive clot
evacuation utilizing either stereotactic or
endoscopic aspiration with or without
thrombolytic usage is uncertain and is
considered investigational (Class IIb; LOE B).
(New recommendation)
5. Although theoretically attractive, no clear
evidence at present indicates that ultra-early
removal of supratentorial ICH improves
functional outcome or mortality rate. Very early
craniotomy may be harmful due to increased
risk of recurrent bleeding (Class III; LOE B).
(Revised from the previous guideline)
6. Although intraventricular administration of
recombinant tissue-type plasminogen activator
in IVH appears to have a fairly low complication
rate, efficacy and safety of this treatment is
uncertain and is considered investigational
(Class IIb; LOE B). (New recommendation)
1. If there is deterioration of consciousness due to mass effect from the
hematoma, an early craniotomy may be considered (LOE IV, GOR C)
(revised recommendation).
2. A craniotomy should be considered for a lobar hemorrhage located
within 1 cm from the surface with a consciousness level of 9–12 on the
GCS (LOE IIb, GOR B).
3. For supratentorial ICH with a GCS score of 9 or over, with a hematoma
volume between 25 and 40 mL, and within 72 hours after onset of
symptoms, minimally invasive surgery for evacuation of the hematoma
is recommended (LOE IIb, GOR B) (new recommendation).
4. A craniotomy is recommended for a cerebellar hemorrhage with a
maximal diameter of 3 cm or longer or for symptoms suggestive of
brainstem compression or hydrocephalus (LOE IIb, GOR B) (revised
recommendation).
5. For IVH, thrombolysis via the ventricular puncture may be considered
(LOE IV, GOR C)
1. Patients with cerebellar hemorrhage who are
deteriorating neurologically or who have brainstem
compression and/or hydrocephalus from ventricular
obstruction should undergo surgical removal of the
hemorrhage as soon as possible (Class I; LOE B). Initial
treatment of these patients with ventricular drainage
rather than surgical evacuation is not recommended
(Class III; LOE C). (Unchanged from the previous
guideline)
2. For most patients with supratentorial ICH, the
usefulness of surgery is not well established (Class IIb;
LOE A). (Revised from the previous guideline) Specific
exceptions and potential subgroup considerations are
outlined below in recommendations 3 through 6.
3. A policy of early hematoma evacuation is not clearly
beneficial compared with hematoma evacuation when
patients deteriorate (Class IIb; LOE A). (New
recommendation)
4. Supratentorial hematoma evacuation in deteriorating
patients might be considered as a life-saving measure
(Class IIb; LOE C). (New recommendation)
5. DC with or without hematoma evacuation might reduce
mortality for patients with supratentorial ICH who are in
a coma, have large hematomas with significant midline
shift, or have elevated ICP refractory to medical
management (Class IIb; LOE C). (New recommendation)
6. The effectiveness of minimally invasive clot evacuation
with stereotactic or endoscopic aspiration with or with-
out thrombolytic usage is uncertain (Class IIb; LOE B).
(Revised from the previous guideline)
7. Although intraventricular administration of rtPA in IVH
appears to have a fairly low complication rate, the
effcacy and safety of this treatment are uncertain (Class
IIb; LOE B). (Revised from the previous
recommendation)
8. The efficacy of endoscopic treatment of IVH is uncertain
(Class IIb; LOE B). (New recommendation)
Surgical Treatment / Clot Removal for Intracerebral Hemorrhage Stroke
Update Guidelines Recommendations
Hemphill et al., AHA/ASA, 2015 Kim et al., Korea, 2014 Morgenstern et al., AHA/ASA, 2010
References:
Hemphill et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage : A Guideline for
Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, published
online May 28, 2015.
Kim et al. Clinical Practice Guidelines for the Medical and Surgical Management of Primary Intracerebral
Hemorrhage in Korea. J Korean Neurosurg Soc 56 (3) : 175-187, 2014
Morgenstern et al. Association for Healthcare Professionals From the American Heart Association/American
Stroke Guidelines for the Management of Spontaneous Intracerebral Hemorrhage : A Guideline. Stroke.
2010;41:2108-2129; originally published online July 22, 2010.
Steiner et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral
hemorrhage. Int J Stroke. 2014 Oct;9(7):840-55.
Divisi Ilmiah Kelurahan PPDS Neurologi UNAIR – RS Dr Soetomo | 2015
1. There is no evidence to support surgical intervention on a routine basis
to improve outcome after supratentorial ICH in comparison with
conservative management, but early surgery may be of value for
patients with a GCS score 9–12.
2. In the absence of RCTs, we cannot make strong recommendations about
how, when, and for whom to use EVD combined with intrathecal
thrombolysis in spontaneous ICH.
3. There is insufficient evidence from RCTs to make strong
recommendations about how, when, and for whom surgical evacuation
should be performed in adults with infratentorial ICH.
Steiner et al., ESO, 2014

2. 1. The suggested BP targets in patients with acute ICH are described below (LOE III, GOR B). Drugs
that can be used for BP control in spontaneous ICH are shown in Table 2 (revised
recommendation).
1) If the SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive BP reduction with
a continuous intravenous infusion of drugs, with frequent BP monitoring every 5 minutes.
2) If the SBP is >180 mm Hg or MAP is >130 mm Hg and there is any possibility of an ICP
elevation, then consider ICP monitoring and reducing BP using an intermittent or continuous
intravenous infusion while maintaining a CPP (MAP-ICP) of 50–70 mm Hg.
3) If the SBP is >180 mm Hg or MAP is >130 mm Hg and there is no evidence of an ICP elevation,
then consider a modest reduction of BP using an intermittent or continuous intravenous
infusion (MAP of 110 mm Hg for a BP of 160/90 mm Hg) and clinically re-examine the patient
every 15 minutes.
2. In patients with acute ICH, when the SBP is measured between 150 and 220 mm Hg, the SBP
may be safely lowered to 140 mm Hg within 1 hour (LOE Ib, GOR A) (new Recommendation).
Intracerebral Hemorrhage Stroke - The Management of Blood Pressure
Update Guideline Recommendations
1. For ICH patients presenting with SBP between 150 and 220 mm Hg and without
contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is
safe (Class I; Level of Evidence A) and can be effective for improving functional
outcome (Class IIa; Level of Evidence B). (Revised from the previous guideline)
2. For ICH patients presenting with SBP >220 mm Hg, it may be reasonable to
consider aggressive reduction of BP with a continuous intravenous infusion and
frequent BP monitoring (Class IIb; Level of Evidence C). (New recommendation)
Kim at al., Korea, 2014
1. Until ongoing clinical trials of BP
intervention for ICH are
completed, physicians must
manage BP on the basis of the
present incomplete efficacy
evidence. Current suggested
recommendations for target BP
in various situations are listed in
Table 6 and may be considered
(Class IIb; LOE C). (Unchanged
from the previous guideline)
2. In patients presenting with a
systolic BP of 150 to 220 mmHg,
acute lowering of systolic BP to
140 mmHg is probably safe (Class
IIa; LOE B). (New
recommendation)
Hemphill et al., AHA/ASA, 2015
Morgenstern et al., AHA/ASA, 2010
References:
Hemphill et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage : A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke, published online May 28, 2015.
Kim et al. Clinical Practice Guidelines for the Medical and Surgical Management of Primary Intracerebral Hemorrhage in Korea. J Korean Neurosurg Soc 56 (3) : 175-187, 2014
Morgenstern et al. Association for Healthcare Professionals From the American Heart Association/American Stroke Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage : A Guideline. Stroke. 2010;41:2108-2129; originally published online July 22, 2010.
Steiner et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014 Oct;9(7):840-55.Divisi Ilmiah Kelurahan PPDS Neurologi UNAIR – RS Dr Soetomo | 2015
In acute ICH within 6 h of onset,
intensive blood pressure reduction
(systolic target <140 mmHg in <1h) is
safe and may be superior to a systolic
target <180 mmHg. No specific agent
can be recommended.
Steiner et al., ESO, 2014