This document summarizes key issues and guidelines for the management of intracerebral hemorrhage (ICH). It discusses debates around blood pressure management, timing of clot removal, use of ICP monitoring, and role of surgery. The guidelines note that while increased blood pressure may be necessary, it could also be harmful. Clot removal within 7 hours may be useful but is not significantly beneficial at later time points. ICP monitoring is not generally useful for most ICH patients but could be considered for those with GCS 8 or lower and signs of herniation or hydrocephalus. The role of surgery is uncertain and early craniotomy may be harmful. In conclusion, guidelines provide admissions that more evidence is still needed

1. ICH Guideline 2010 :
Enigma

2. “One would think that we would know exactly what to do by now,
and we should have the pathophysiology well in hand.
Unfortunately, we are left with only guidelines,
which essentially are admissions
that we don’t know what to do.”
-- Roberts JR, 2011

3. The issues
Glucose &
temperature
Seizure
Neuroimaging
control
ED
management
Prehospital
management

4. ..and the most confusing issues
BP
management
ICP
monitoring
Surgery &
Clot removal

5. Should we reduce BP in acute ICH?
No, Yes,
increased BP is increased BP is
necessary harmful
Is there evidence of Hematoma expansion
perihematoma ischemia?? is a reality

6. Best timing for Clot Removal
Recommendation:
< 7 hours, may be useful
not significant
(too) Early • Rebleeding
12 hour • Not significant
24 hour • Not significant
48 hour • Not significant
96 hour • Not significant
No Surgery ?

7. ICP monitor in Stroke, not useful?
For most patients with ICH, the Ventricular drainage as treatment for
usefulness of surgery is uncertain. hydrocephalus is “reasonable”..
GCS 8 or lower, transtentorial
herniation, significant IVH /
hydrocephalus  “might be
considered” for ICP
monitoring and treatment.
..no clear evidence at present indicates
that ultra-early removal of supratentorial
MAP >130 + increase ICP  CPP 60 ICH improves functional out- come or
mortality rate. Very early craniotomy may
be harmful..

8. Conclusion :
New “eye”
Compare
(other guidelines & literature)
Keep searching

9. Enjoy the Guidelines!