2022-Guideline-for-the-Management-of-Patients-With-Spontaneous-ICH-Clinical-Update-Slides.pptx

AHAClinical Update
ADAPTED FROM:
2022GuidelinefortheManagement of
PatientsWithSpontaneous
I
ntracerebral Hemorrhage: AGuideline
FromtheAmericanHeart Association/
AmericanStrokeAssociation

PopulationHealth Implications
Early-term
I
CHMortality
is30-4
0
%
I
ncidence of I
CH by Race
• ≈1.6-fold greater among Black
than White people
• ≈1.6-fold greater among Mexican
American than non-Hispanic
White people
I
schemicStrokes,
690K
Annual I
schemic Stroke&I
CH I
ncidence
SAH,
1
6
K I
CH,79K
Total Strokes:
~795K
Abbreviations:ICH indicates intracerebral hemorrhage; and SAH, subarachnoid hemorrhage.
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.

Mechanismsof I
CH I
njury
Hematom
a
Expansion
↑
ICP
Hydrocephalus
Herniation
0- 6hours
Primary I
njury
>
6hours
SecondaryI
njury
Cerebral Edema
Inflammation
T
oxicityfromBloodProducts
GeneralPrinciple:Acute ICH management targets these mechanisms.
Abbreviations:ICHindicates intracerebral hemorrhage; and ICP, intracranial pressure.

I
CH Etiology Determines HemorrhageLocation
Deep/
PosteriorFossa
I
CHEtiologies
Arteriolosclerosis
• Penetratingarteriolelipohyalinosis
dueto HTN,DM, Age
Macrovascular
• AVM
• Aneurysm
• Dural AVF
• CavernousMalformation/Cavernoma
• Cerebral Venous Thrombosis
LobarI
CHEtiologies
Cerebral Amyloid Angiopathy
• Amyloid deposition in vessel
walls
Arteriolosclerosis
Macrovascular
DiagnosticReasoning:CAA typically causesonly lobar (or superficial cerebellar)
hemorrhages. Arteriolosclerosismay cause both deep and lobar hemorrhages.
Coexistentpathology is possible.
Abbreviations:AVF indicates arteriovenous fistula; AVM, arteriovenous malformation; CAA, cerebral amyloid angiopathy; DM, diabetes mellitus; HTN, hypertension; and ICH, intracerebral hemorrhage.

Diagnosis &Assessment |Work-Up for Acute ICH Course
Timeof
symptomonset
• Headache
• Focalneurologic
deficits
• Seizures
• Decreasedlevel
of consciousness
• Ischemic Stroke
• PriorICH
• Hypertension
• Hyperlipidemia
• Diabetesmellitus
• Metabolic
syndrome
• Imagingbiomarkers
o Cerebral
microbleeds
• Antithrombotics:
• Anticoagulants,
thrombolytics,
antiplatelet agents,
NSAIDS
• Vasoconstrictive
Agents:
o Triptans,SSRIs,
decongestants,
stimulants,
phentermine,
sympathomimetic
drugs
• Antihypertensives:
• Estrogen-containing
oral contraceptives
Associatedwith
(but not specific
for)amyloid
angiopathy
• Smoking
• Alcohol use
• Marijuana
• Sympathomimetic
drugs
• Amphetamines,
methamphetamin
es,cocaine
May beassociated
withcoagulopathy
History
Time Symptoms
Vascular
RiskFactors
Medications Cognitive
Impairment
orDem
entia
SubstanceUse Liverdisease,
Uremia,
Malignancy
and
Hematologic
disorders
Abbreviations:ICH indicates intracerebral hemorrhage; NSAIDS, non-steroidal anti-
inflammatory drugs, and SSRI,selective serotonin reuptake inhibitors.

Diagnosis&Assessment |Work-Up in AcuteICH
PhysicalExamination
• Airw
ay,Breathing&Circulation
• Vitalsigns
• General:Focusedonthehead,
heart,lungs,abdomen,and
extremities
• FocusedNeurologicalExam
(NIHSS,GCS)
Serum
• CBC
• BUNandCreatinine
• LFTs
• Glucose
• Inflammatory markers
• (ESRand/orCRP)
• PT(withINR)
• aPTT
• SpecifictestsforDOACs
Urine
• Urinetoxicologyscreen
• Pregnancytest
Cardiac-specific
• T
roponin
• ECG
Abbreviations:aPTTindicates activated partial thromboplastin time; BUN, blood urea nitrogen; CRP, C-reactive protein; DOAC, direct oral anticoagulant; ECG, electrocardiogram; ESR,erythrocytesedimentation
rate; GCS, Glasgow coma scale; ICH, intracerebral hemorrhage; INR, international normalized ratio; LFTs, liver function tests; NIHSS, National Institutes of Health Stroke Scale; and PT,prothrombin time.

Diagnosis&Assessment |Work-Up in AcuteICH
I
ndicatorsof I
ncreasedMorbidity &Mortality:
• Thrombocytopenia
• AcuteKidneyI
njury
• Hyperglycemia
• Elevatedtroponin
I
ndicatorsof I
ncreasedHE:
• Anemia •
• Anticoagulant-related
hemorrhages
Identificationofaspot
signonCTAor
contrast-enhancedOR
certainimaging
featuresonNCCTsuch
asheterogeneous
densitiesw
ithinthe
hematomaor
irregularitiesat its
margins.
Abbreviations: CTA indicates computed tomography angiography; HE, hematoma expansion; ICH, intracerebral hemorrhage; and NCCT, noncontrast computed tomography .

Diagnosis&Assessment |Neuroimaging to Diagnose ICH
Timeofpresentationw
ith
stroke-likesymptoms:
Obtainrapid CTorMRIto
confirmthediagnosisof
spontaneousICH (1
)
SerialheadCTscanscanbeusefulfor:
• Patientswithspontaneousintracerebraland/or
intraventricularhemorrhagewithinthefirst24hours
aftersymptomonsettoevaluateforHE
• PatientswithlowGCS scoreorneurologicaldeterioration
toevaluate forHE,hydrocephalus,perihematomal
edema orherniation
(2a)
CTangiographyw
ithinthefirst
fewhoursofI
CHonset:
May bereasonableto detect
somestructural causesof
secondaryICH (2b)
UtilizingCTmarkersofHEtoidentifypatientsatrisk
forHEmaybereasonable.
Imagingfindings:
• Noncontrast CT
:
o Heterogeneousdensitieswithinthehematoma
o I
rregularitiesat thehematomamargins
• CTangiography/ Contrast enhancedCT
:
o Spotsign
(2b)
Beyondfirst24hours: Serial
imaging is generally guided by
clinical picture of the patient
Abbreviations:CT indicates computed tomography; HE, hematoma expansion; ICH, intracerebral hemorrhage; and MRI,magnetic resonance imaging.

Diagnosis &Assessment |Strategyto Determine ICHEtiology
Abbreviations:CT indicates computed tomography; CTA, computed tomography angiogram; HTN, hypertension; ICH, intracerebral
hemorrhage; IVH, intraventricular hemorrhage; MRA,magnetic resonance angiogram; and MRI,magnetic resonance imaging.
ForPatientsWith… UtilizeThisDiagnosticStrategy…
Deep/PosteriorFossaI
CH
• Age <
45
• Age 45-70 yrs, NOHTN
LobarI
CH
• Age <70yrs
-OR-
CTAngiogram
/VenogramRecom
m
ended(1
)
MR
I+MRAngiogramReasonable(2a)
Cerebral AngiogramReasonable(2a)
- AND-
- AND-
CTA/MRAsuggestiveofmacrovascular
I
CHetiology (anyage)
SpontaneousI
VHw
ithNOparenchymal
hemorrhage(anyage)
-OR- CerebralAngiogramRecom
m
ended (1
)

Medical and NeurointensiveTreatment forI
CH
Acute Blood PressureLowering in Spontaneous ICH
To improvefunctional outcomes.
Medicationtitrationtoensurecontinuoussmooth&sustainedcontrolofBP
,
avoidingpeaksandlargevariabilityinSBP
,can bebeneficial.(2a)
Initiatingtxwithin2hrsofICHonsetandreachingtargetwithin1-hrcanbe
beneficialtoreducetheriskofHE. (2a)
InICHofmildto moderateseveritypresentingwithSBPbetween150and220
mmHg,acuteloweringofSBPto a targetof140mmHgwiththegoalofmaintaining
in therangeof130to150mmHgissafeandmaybereasonable.(2b)
IfpresentingwithlargeorsevereICHorthoserequiringsurgicaldecompression,the
safetyandefficacyofintensiveBPloweringarenotwellestablished.(2b)
IfICHismild tomoderateseveritypresentingwithSBP>150mmHg,acutelowering
ofSBPto hrs.<130mmHgispotentiallyharmful.(3:Harm)
Abbreviations:HEindicates hematoma expansion; ICH, intracerebral hemorrhage; mmHg, millimeters of mercury; SBP, systolic blood pressure;and tx, treatment.

Hemostasis&Coagulopathy
Management of Anticoagulant-Related Hemorrhage
Patients with I
CH onanticoagulation
Discontinue anticoagulationtherapyimmediately. Rapidreversal shouldbeperformedas soonaspossible (1)
VI
TAMI
NKANTAGONI
STS DABIGATRAN FACTORXa-INHIBIT
ORS HEPARINS
I
NR 1
.3–1
.9 I
NR >
2.0
4-FPCC
1
0
-20IU
/
kg
(2b)
4-FPCC
25-50I
U/
kg
(1)
I
VVitaminK
(1)
History: Whenlast dose taken
Activatedcharcoal ifDOAC<2hrs(potentialefficacyupto8hrs)(2b)
Unfractionated
Heparin
LowMolecular
Weight Heparin
Protamine
(2a)
Protamine
(2b)
Is
I
darucizumab
available?
I
darucizum
ab
(2a)
PCCs oraPCC and/
or
renal replacem
ent therapy
(2b)
YES NO
Is
Andexanetalfa
available?
Andexanet
alfa
(2a)
4FactorPCCs oraPCC
(2b)
YES NO
Abbreviations:4-FPCC indicates four-factor prothrombin complex concentrate; aPCC, activated prothrombin complex concentrate; DOAC, direct oral anticoagulant;
ICH, intracerebral hemorrhage; and INR, international normalized ratio.

Antiplatelet-Related Hemorrhagein Spontaneous ICH
Ifthepatientisbeing
treatedwithaspirin,
platelettransfusionmight
beconsideredtoreduce
postoperativebleedingand
mortality.
(2b)
Ifthepatientisbeing
treatedwithASA,
platelettransfusions
arepotentially
harmful andshould
not beadministered.
(3:Harm)
Doesthe
patientrequire
emergent
neurosurgery?
Patients with SpontaneousI
CH
YES
NO
Abbreviations:ASA indicates aspirin; and ICH, intracerebral hemorrhage.
Ifthepatientisbeing
treatedwith antiplatelet
agents,theeffectivenessof
desmopressinwithor
without platelet
transfusionstoreducethe
expansionofthe
hematoma isuncertain.
(2b)

General Hemostatic T
reatments
Synopsisof the Evidence
• HE occurs in up to a third of patients after ICH and is associated with poor outcome.
• Hemostatic therapy for the prevention of HE remains an attractive therapeutic target after ICH.
• Inpatients withspontaneous ICH(withor without the spot sign), the effectiveness of
recombinantfactor VIIato improvefunctional outcome isunclear. (2b)
• Inpatients with spontaneousICH (with orwithoutthespot sign, black hole sign, orblend sign),
theeffectivenessof TXAto improvefunctional outcomeisnotwell established. (2b)
• ICH expansion most commonly occurs very early after onset, and future studies need to target
earlier treatment
Abbreviations:CTA indicates computed tomography angiography; HE, hematoma expansion; and ICH, intracerebral hemorrhage.

General I
npatient Care
Considerations for Inpatient Care Setting
I
nitiationof Appropriate
LifeSustainingTherapies
(1)
Provisionof careina
specializedinpatient
unitwitha
m
ultidisciplinary
team (1)
I
f specializedunitisnot
available,thentransferto
centerswithfull rangeof high-
acuitycareandexpertise
(1)
I
npatientswithspontaneous
I
CHandclinical hydrocephalus,
transfertocenterswith
Neurosurgicalcapabilitiesfor
hydrocephalus m
anagem
ent
(e.g.EVDplacem
ent and
monitoring)
(1)
Abbreviations:EVD indicates external ventricular drain; and ICH, intracerebral hemorrhage.

I
npatient CareChecklist
I
n Non-Ambulatory SpontaneousI
CH…
Prevention&
Management
of Acute
Medical
Complications
• Use of standardizedprotocols/order sets is recommended to reduce disability and mortality. (1)
• Formal dysphagia screening protocol should be implemented prior to initiation of oralintake to reduce
disability and the risk of pneumonia. (1)
• Continuous cardiac monitoring for first 24to 72hrs is reasonable tomonitor for cardiac arrhythmias &
new cardiac ischemia. (2a)
• Laboratoryand radiographic testing for infection on admission and throughout the hospital course is
reasonable to improve outcomes. (2a)
Prioritiesfor
NursingCare
• Frequent neurological assessments (including GCS) should be performed by EDnurses in the early
hyperacute phase of careto assess change in status, neurological examination, or LOC. (1)
• Frequent neuro assessments in ICU/Strokeunit upare reasonable up to 72hrs from admission to detect
early ND.(2a)
• Nursing staff with specialized stroke competency education can be effective in improving outcome &
mortality. (2a)
Abbreviations:DVT indicates deep vein thrombosis; ED, emergency department; HE, hematoma expansion; hrs, hours; GCS, Glasgow Coma Scale; ICH, intracerebral hemorrhage; ICU, intensive care unit; LMWH, low molecular
weight heparin; LOC, level of consciousness; ND, neurological deterioration; PE,pulmonary embolism; Tx, treatment; UFH, unfractionated heparin; and VTE,venous thromboembolism.

Prophylaxis
… , intermittent pneumatic compression starting onthe day of diagnosis is recommended for VTE(DVT and PE)
prophylaxis. (1)
… low-dose UFHor LMWH can be useful to reduce risk of PE(2a)
… temporaryuse of retrievable filter asbridge until anticoagulationinitiated. (2a)
… low-dose UFHor LMWH prophylaxis at 24to 48hrs from ICH onset may be reasonable tooptimize the
benefits of preventing thrombosis relative to the risk of HE. 2b)
… graduatedcompression stockings of knee-high or thigh-high length alone arenot beneficial for VTE
prophylaxis. (3:No Benefit)
Treatment
… and proximal DVTwhoarenot yet candidatesfor anticoagulation, temporary useof retrievable filter is
reasonable as a bridge until anticoagulation initiated. (2a)
… and proximal DVTor PE,delaying treatment withUFHor LMWH 1to2 weeks after onset of ICHmight be
considered. (2b)
I
npatient CareChecklist
I
n Non-Ambulatory SpontaneousI
CH…
Thromboprophylaxis&TxofThrombosis
Abbreviations:DVT indicates deep vein thrombosis; HE, hematoma expansion; hrs, hours; ICH, intracerebral hemorrhage; LMWH, low molecular weight heparin;
PE, pulmonary embolism; Tx, treatment; UFH, unfractionated heparin; and VTE,venous thromboembolism.

General I
npatient Care
Glucose and TemperatureManagement
Glucose
Management
Monitor serumglucoseto
reduceboth
hyper/hypoglycem
ia. (1
)
Treatserumglucose
<
40-60m
g/dL
toreducem
ortality. (1
)
NICE-SUGARtrialfindings:
• Incritically ill, targetof<
1
8
0mg/dLassociated with
lower mortality than target of 81-108mg/dL.
• Intensive glucose control (target 81-108mg/dL) more
likely to result insevere hypoglycemic events compared
to control.
Temperature
Management
I
npatientswithspontaneousI
CH,
pharm
acologically treatinganelevated
temperaturemaybereasonable to improve
functional outcom
es. (2b)
Theusefulnessof therapeutichypotherm
ia
(<35°C/95°F)todecreaseperi-I
CHedem
a is
unclear. (2b)
T
emperature abnormalities can occur in over 30%
of acute ICH patients, with fever associated with
higher clinical severity and worse outcomes.
Abbreviations:dL indicates deciliter; ICH, intracerebral hemorrhage; mg/dL, milligram per deciliter; mmol/L, millimoles per liter; and NICE-SUGAR,
Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose AlgorithmRegulation.
InpatientswithspontaneousICH,treating
m
oderatetoseverehyperglycem
ia (>
1
80–
200mg/dL,>
1
0
.
0
–
1
1
.
1mmol/L)isreasonabletoimprove
outcom
es. (2a)

Seizuresand AntiseizureDrugs
NewonsetseizuresinsICHarerelativelycommon(2.8-28%)andoccurwithinthefirst24hrsofhemorrhage
Confirmed clinical or
electrographicseizures
AdministerASD
(1)
sI
CH patientswithout suspicion of
seizure
Unexplainedabnormalorfluctuating
mental status,orsuspiciousofseizures,
cEEGisreasonableto
diagnoseelectrographicseizuresand
epileptiformdischarges
(24hoursorlonger)
(2a)
AvoidASD
(3:No Benefit)
Abbreviation:ASDindicates antiseizure drugs; cEEG, continuous electroencephalography; hrs, hours; and sICH,spontaneousintracerebral hemorrhage.

NeuroinvasiveMonitoring, Intracranial Pressure
&Edema Treatment
sICHorIVHand hydrocephaluswhichiscontributing to
decreasedlevelof consciousness:
Ventriculardrainageshould
beperformedtoreduce
mortality(1
)
Corticosteroidsshouldnot
beadministeredfor
treatmentofelevatedI
CP
(3:NoBenefit)
ICPmonitoringandtreatment
toreducemortalityand
improveoutcomes(2b)
Early prophylactic
hyperosmolartherapyfor
improvingoutcomesisnotw
ell
established(2b)
Bolushyperosmolartherapy
maybeconsideredfor
transientlyreducingI
CP(2b)
Abbreviation:ICP indicates intracranial pressure; IVH, intraventricular hemorrhage; and sICH, spontaneousintracerebral hemorrhage.

Surgical I
nterventions
Minimally InvasiveSurgical Evacuationof ICH
Intervention
Patient Selection
MISforICH
Supratentorial ICH,hematoma
volume >20-30mL,GCS5-12
MIS±hematoma
thrombolysistoimprove
mortalitycanbeuseful
(2a)
MIS±hematoma
thrombolysistoimprove
functionaloutcomeisof
uncertaineffectiveness
(2b)
ChoosingMISratherthan
craniotomytoimprove
functionaloutcomesmay
bereasonable
(2b)
I 0-
Abbreviations:GCS indicates Glasgow Coma Scale; ICH, intracerebral hemorrhage; and MIS, minimally invasive surgery.

Surgical I
nterventions
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 21
Minimally Invasive Surgical Evacuation of Intraventricular Hemorrhage
IVH
SurgicalManagem
ent
SpontaneousI
VH+
ObstructiveHydrocephalus
SpontaneousI
CH<30mL
GCS>
3
I
VHrequiringEVD
SpontaneousI
CH<
3
0mL
I
VHrequiringEVD
EVD EVD+thrombolytic
Neuroendoscopy
+EVD
+
/
-thrombolytic
Functional
Outcome
Benefit
(2b*)
Mortality
Reduction
(I)
Functional
Outcome
Benefit
(2b†)
Functional
Outcome
Benefit
(2b†)
Reduced
Permanent
Shunt
Dependence
(2b†)
Note:*Not well established. †Uncertain
Abbreviations:EVD indicates external ventricular drain; GCS, Glasgowcoma scale; ICH, Intracerebral hemorrhage, and IVH, intraventricular hemorrhage.
Mortality
Reduction
(2a)

Surgical I
nterventions
Craniotomy forSupratentorial Hemorrhage
Craniotomyforhemorrhage
evacuationtoimprovemortality
or functional outcomesisof
uncertainusefulness
(2b)
Craniotomyforhemorrhage
evacuationmaybeconsideredas
a life-savingmeasureinpatients
whoaredeteriorating
(2b)
SupratentorialICHof moderateorgreaterseverity*
Note: *>10 cc with asignificant neurologic
deficit
Abbreviations:ICH indicates intracerebral hemorrhage.

Surgical I
nterventions
Craniotomy for Posterior Fossa Hemorrhage
I
mmediatesurgicalremovalof
hemorrhage±EVDisrecomm
endedto
reducemortality(1
)
CerebellarI
CH
I
fanyof thefollow
ingpresent
Neurologic
deterioration
Brainstem
compression
Obstructive
hydrocephalus
I
CHvolume≥1
5cc
Abbreviations:EVD indicates external ventricular drain; and ICH, intracerebral hemorrhage.

Surgical I
nterventions
Craniectomy for ICH
Abbreviation:ICH indicates intracerebral hemorrhage; and ICP, intracranial pressure.
Inpatients with supratentorial ICHwhoare ina coma, havelarge
hematomas withsignificant midline shift, or have elevated ICP
refractory to medical management:
….decompressivecraniectomy
withorwithout hematoma
evacuationmaybeconsidered
toreducemortality.(2b)
….effectivenessofdecompressive
craniectomy withorwithout
hematoma evacuationto
improvefunctionaloutcomesis
uncertain.(2b)

OutcomePredictionand Goalsof Care
I
CH
… a baseline
severity score might be
reasonable to provide
a generalfram
eworkfor
com
m
unication with
thepatientandtheir
caregivers.(2b)
… a baseline
severity score should
NOTbeusedasthesole
basisforforecasting
individual prognosis or
limiting life-sustaining
treatment. (3:Harm)
Abbreviations:ICH indicates intracerebral hemorrhage.
… administering a
baseline measure of
overall hem
orrhage
severityis recommended
aspart of theinitial
evaluation to provide an
overall measure of clinical
severity. (1)
Examples:
• ICH-score
• Max-ICH
Clic
ktovie
wMeas
ur
e
sforE
valuating
Ove
r
allH
e
m
or
r
hageS
e
ve
r
ity

Decisions to Limit Life-SustainingTreatment
I
CH
Cannotfully
participateinmedical
decision-making
Shareddecision-making
between surrogates and
physicians is reasonable
(2a)
Nopre-existing
life-sustaining
therapylim
itations
Forpatientsw
ho
haveDNARStatus
Limiting other medical
and surgical interventions
unless explicitly specified
isassociated with
increased patient
mortality
(3: Harm)
Abbreviations:DNAR indicates do not attempt resuscitation; and ICH, intracerebral hemorrhage.
Aggressive care including
postponement of new
DNARorders or
withdrawal of medical
support until at least the
2ndfull dayof
hospitalization is
reasonable(2b)

Rehabilitationand Recovery
I
CH
Multidisciplinary
rehabilitationwithregular
teammeetingsand
dischargeplanning is
recommended(1)
Mild-moderateICH
severity:Early supported
dischargeisbeneficial(1)
ModerateICHseverity:
Early rehabilitation
(24-48hoursafter
onset)maybe
considered(2b)
ICHwithout
depression,fluoxetine
therapy isnot effective
toenhancepoststroke
functional status.
(3:NoBenefit)
Very early and intense
mobilization<24hours:
potentiallyharmful
(3:Harm)
Abbreviations:ICH indicates intracerebral hemorrhage; and SSRIs,selective serotonin reuptake inhibitors.

Neurobehavioral Complications
I
CH
I
nthePost-acute
Period
Administration
ofdepression&
anxiety
screeningtools.
(1)
Administration
ofa cognitive
screeningtool.
(1)
Moderate to
Severe
Depression
Appropriateevidence-
basedtreatm
ents
including
psychotherapy&
pharmacotherapy.
(1)
Cognitive
I
mpairment
Referralfor
cognitive
therapy.
(2a)
Mightconsider
cholinesterase
inhibitorsor
memantine.
(2b)
Pre-existing or
NewMood
Disorders
Continuationor
initiationofSSRI
s
afterI
CH.
(2a)
Abbreviations:ICH, intracerebral hemorrhage; and SSRIs,selective serotonin reuptake inhibitors.

Secondary Prevention
Prognosticationof Future ICHRisk
2
Inpatients withspontaneous ICHin whomthe riskfor
recurrentICHmay facilitate prognostication ormanagement
decisions, it isreasonable to incorporate the following risk
factorsforI
CH recurrenceinto decision-making:
• Lobarlocation of theinitial I
CH;
• olderage;
• presence,number,and lobar location of microbleeds on
MRI;
• presence of disseminated cortical superficial siderosis
on MRI;
• poorly controlled hypertension;
• Asian orBlack race;
• and presenceof apolipoprotein Eε2 orε4 alleles. (2a)
1 3
MRIimaging characteristics:
1) Lobarlocation of initial ICH
2) Number and lobar location of microbleeds
3) Presence of cortical superficial siderosis
Abbreviation:ICHindicates intracerebral hemorrhage; and MRI, magnetic resonance imaging.

Blood Pressure Management
Abbreviations:BPindicates blood pressure; HTN, hypertension; ICH, intracerebral hemorrhage; and mmHg, millimeters of mercury.
UncontrolledHTNaccountsfor
74%
of global population-
attributableriskforI
CH.
InpatientswithspontaneousICH,itisreasonabletolowerBPto130/80mmHgfor
long-termmanagementtopreventhemorrhagerecurrence(2a).
GuidingPrinciple

Management of Antithrombotic Agentsand OtherMedications
H
IGH RI
SKof
thrombotic events
ex.Patient with
mechanical valve, LVAD
Earlyresumptionof
anticoagulationis
reasonable(2a)
NonvalvularAF
WEIGHRISKSvsBENEFIT
S
of restarting
anticoagulation
risk>benefit
Resumptionof
anticoagulation
maybereasonable(2b)
Considerinitiationof
anticoagulation7-8w
eeks
afterI
CH (2b)
Resumptionofantiplatelet
therapymaybe
reasonablebasedon
considerationofbenefit
andrisk(2b)
benefit<risk
LAAclosuremay
beconsidered
(2b)
Statins
RisksandbenefitsofstatinsonICH
outcomesandrecurrenceare
uncertain(2b)
NSAIDs
Regularlong-termuseofNSAI
Dsis
potentiallyharmful becauseofthe
increasedriskofI
CH(3:Harm)
Abbreviations:AFindicates atrial fibrillation; ICH, intracerebral hemorrhage; LAA, left atrial appendage; LVAD, left ventricular assist device; and NSAID, non-steroidal anti-inflammatory drugs.

Lifestyle Modifications / Patient and CaregiverEducation
LIFESTYLEMODIFICATIO
NS
• Blood pressure control
• Avoiding heavy alcohol use
• Supervised training and counseling
PATI
ENT&CAREGI
VEREDUCATI
ON
• Psychosocial education
• Caregiversupport &training

IncorporateavailableMRIinformationon
cerebralmicrobleedburdenorcortical
superficial siderosis to inform decision-
makingforprimaryprevention(2b)
Primary I
CH Prevention inI
ndividualswith
High-RiskI
maging Findings
Cerebral microbleed Corticalsuperficial siderosis
Abbreviation:ICHindicates intracerebral hemorrhage.

Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman
in developing this translational learning product in support of the 2022 Guideline for
the Management of Patients With Spontaneous Intracerebral Hemorrhage: A
Guideline From the American Heart Association/ American Stroke Association
MatthewGusler,DO
NycoleJoseph,MD
ShuoQian,MD
KaranRavishankar,MD
MeghanaSrinivas,MD
MichaelTeitcher,MD
RobinUlep,MD
TheAmericanHeartAssociationrequeststhiselectronicslidedeckbecitedasfollows:
Gusler,M.,Joseph,N.,Quin,S.,Ravishankar,K.,Srinivas,M.,Teitcher,M.,Ulep,R.,Bezanson,J.L.,&Antman,E.M.
(2022). ClinicalUpdate;Adaptedfrom:2022GuidelinefortheManagementofPatients
WithSpontaneousIntracerebralHemorrhage:AGuidelineFromtheAmericanHeartAssociation/
AmericanStrokeAssociation[PowerPointslides].Retrievedfromhttps://professional.heart.org/en/science-news.

Appendix
Measures for evaluating overall hemorrhageseverity
Gregório T
,Pipa S, Cavaleiro P
, Atanásio G, Albuquerque I,Castro Chaves P
, Azevedo L. Original intracerebral hemorrhage
score for the prediction of short-term mortality incerebral hemorrhage: systematic review and meta-analysis. Crit Care Med.
2019;47:857–864.doi:10.1097/CCM.0000000000003744
Gregório T
, Atanásio G, Albuquerque I,Chaves PC, Azevedo L. Assessmentand comparison of the four
most extensively validatedprognostic scales for intracerebral hemorrhage: systematic review with meta-analysis. Neurocrit
Care. 2019;30:449–466.doi:10.1007/s12028-018-0633-6
Gregório T
, Atanásio G, Albuquerque I,Chaves PC, Azevedo L. Prognostic models for intracerebral
hemorrhage: systematic review and meta-analysis. BMC Med Res Methodol. 2018;18:145.doi: 10.1186/s12874-018-0613-8
Sembill JA, Gerner ST
,Volbers B,Bobinger T
,Lücking H,Kloska SP
,SchwabS, Huttner HB, Kuramatsu JB.Severity assessment
in maximally treated ICHpatients: the max-ICHscore. Neurology. 2017;89:423–431.doi: 10.1212/WNL.0000000000004174
Sembill JA, Castello JP
,Sprügel MI,Gerner ST
,Hoelter P
, Lücking H,Doerfler A, Schwab S,Huttner HB,Biffi A, et al. Multicenter
validationof the max-ICHscore in intracerebral hemorrhage. Ann Neurol. 2021;89:474–484.doi: 10.1002/ana.25969
Abbreviation:ICHindicates intracerebral hemorrhage.
⭪Returntopreviousslide

2022-Guideline-for-the-Management-of-Patients-With-Spontaneous-ICH-Clinical-Update-Slides.pptx

Recommended

Recommended

More Related Content

Similar to 2022-Guideline-for-the-Management-of-Patients-With-Spontaneous-ICH-Clinical-Update-Slides.pptx

Similar to 2022-Guideline-for-the-Management-of-Patients-With-Spontaneous-ICH-Clinical-Update-Slides.pptx (20)

Recently uploaded

Recently uploaded (20)

2022-Guideline-for-the-Management-of-Patients-With-Spontaneous-ICH-Clinical-Update-Slides.pptx