American Stroke Association Publishes Updated Guidance for Intracerebral Hemorrhage

Steven M. Greenberg, MD, PhD

A version of this story originally appeared on our sister site, Practical Cardiology.

This month, the American Heart Association (AHA)/American Stroke Association (ASA) announced the publication of a new set of guidelines for the management of intracerebral hemorrhage (ICH),¹ updating the prior set of recommendations published in 2015.²

The guidelines do include significant changes from their predecessor, such as updated recommendations for the use of antiseizure medications (ASMs), as well as antidepressants, after ICH. Specifically, the updated guidance recommends neither of these classes of medications to be used unless seizure, or depression, has already occurred.

In patients with spontaneous ICH, impaired consciousness, and with confirmed electrographic seizures, the guidance recommends that ASMs should be administered to reduce morbidity; in those with spontaneous ICH and clinical seizures, ASMs were similarly recommended to improve functional outcomes and prevent injury from recurrent seizures. Additionally, the guidelines noted that it is reasonable to diagnose electrographic seizures and epileptiform discharges with at least 24 hours of electroencephalography in individuals with spontaneous ICH and unexplained/fluctuating mental status or suspicion of seizures.

“Advances have been made in an array of fields related to ICH, including the organization of regional health care systems, reversal of the negative effects of blood thinners, minimally invasive surgical procedures and the underlying disease in small blood vessels,” said guideline writing group chair Steven M. Greenberg, MD, PhD, a professor of neurology at Harvard Medical School and vice chair of neurology at Massachusetts General Hospital, in a statement.³ His coauthors included vice-chair Wendy C. Ziai, MD, MPH, FAHA, as well as J. Claude Hemphill III, MD, MAS, FAHA, the first author of the prior guidance, among others.

READ MORE: Changing the Future of Stroke Care: The 2021 ASA/AHA Prevention Guidelines

The updated guidelines also offer clarification around the lack of benefit from compression socks or stockings of any length in the prevention of deep vein thrombosis, recommendations for use of intermittent pneumatic compression.

The guidance ultimately includes 9 sections referencing almost 650 publications or documents. The sections focus on introducing ICH, laying out general concepts, keys to organized prehospital and initial systems of care, the diagnosis and assessment of ICH, medical and neurointensive treatment for ICH, as well as surgical interventions, outcome prediction and goals of care, prevention, and recovery, rehabilitation, and complications of ICH.

Greenberg and coauthors noted that the guideline had received endorsement from the American Association of Neurological Surgeons, Congress of Neurological Surgeons, the Society of Vascular and Interventional Neurology, and the Critical Care Society. Additionally, the American Academy of Neurology affirmed the value of this statement as an educational tool for neurologists.

The authors highlighted 10 take-home messages for these new guidelines:

• The organization of healthcare systems is a key part of providing optimal stroke care. The group noted that developing regional systems of care for ICH is crucial to this process, as is the capacity to offer rapid transfer to neurocritical care and neurosurgical facilities when appropriate.
• Worse ICH outcomes are associated with hematoma expansion. The use of neuroimaging biomarkers and clinical markers (such as stroke onset and antithrombotic use) can help predict such expansions, Greenberg et al wrote, adding that noncontrast computed tomography is useful for detecting these markers.
• ICH is the consequence of defined sets of vascular pathology. Similar to other forms of stroke, it is important to identify markers of both microvascular and macrovascular hemorrhage pathogeneses.
• Treatment regiments to limit blood pressure (BP) variability and attain BP control can reduce hematoma expansion. This approach is important when implementing acute BP lowering after mild to moderate ICH, and can produce a better functional outcome.
• Anticoagulated ICH has extremely high mortality and morbidity. The new guidance offers recommendations for acute reversal post ICH, with warfarin, idarucizumab, and andexanet alfa being highlighted as therapies for vitamin K antagonism, thrombin inhibition, and factor Xa inhibition reversal.
• Some historically used in-hospital therapies to treat ICH appear to confer either no benefit or harm. In the emergency or critical care treatment of ICH, prophylactic corticosteroids and continuous hyperosmolar therapy appear to show no benefit. Similarly, Greenberg et al noted that platelet transfusions, outside of emergency surgery or severe thrombocytopenia settings, appears to worsen outcome. Similar considerations were noted for some prophylactic treatments—compression stockings alone or prophylactic ASMs—to prevent medical complications after ICH.
• Minimally invasive approaches for supratentorial ICH and intraventricular hemorrhage evacuation can reduce mortality. Notably, though, clinical trial evidence for the improvement of functional outcomes with these procedures is neutral. In instances of cerebellar hemorrhage, immediate surgical evacuation (with or without an external ventricular drain) to reduce mortality now include larger volume (>15 mL) indications.
• Deciding when and how to limit life-sustaining treatments post ICH is complex and highly dependent on individual preference. This new guideline highlights that the decision to assign do not attempt resuscitation status is explicitly distinct from the decision to limit other medical and surgical interventions, and thus should not be used to do so. Although, it notes that the decision to use an intervention should be shared between the physician and patient/surrogate, and importantly, should reflect the patient’s wishes. As well, the guidance states that “baseline severity scales can be useful to provide an overall measure of hemorrhage severity but should not be used as the sole basis for limiting life-sustaining treatments.”
• Rehabilitation and recovery are important determinants of ICH outcome and quality of life. Coordinated multidisciplinary inpatient team care, including the early assessment of discharge planning and goals for early supported discharge for mild to moderate ICH are recommended. As well, rehabilitation activities, such as stretching and functional task training, can be contemplated within 24 to 48 hours after moderate ICH, though early aggressive mobilization within the first 24 hours can worsen 14-day mortality. Of note, randomized trials failed to confirm that fluoxetine could improve functional recovery after ICH.
• A key and sometimes overlooked member of the ICH care team is the patient’s home caregiver. This new guideline endorses psychosocial education, practical support, and training for caregivers to improve the patient’s balance, activity level, and overall quality of life.

This guidance follows last year’s update to the AHA/ASA secondary stroke prevention guidelines. In 2021, the organization released its most recently updated edition of the guidelines, making changes to the previous document that was published in 2014.⁴ The prevention guideline was divided into 4 sections: diagnostic evaluation for secondary stroke prevention, vascular risk factor management, management by etiology, and systems of care for secondary ischemic stroke prevention. Among the several take-home points, the recommendations stressed on trying to define the ischemic stroke etiology, and thus identifying targets for treatment to reduce the risk of recurrent stroke.

REFERENCES
1. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. Published online May 17, 2022. doi:10.1161/STR.0000000000000407
2. Hemphill III CJ, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015
3. New guideline refines care for brain bleeds: compression socks, some meds not effective. News release. AHA/ASA. May 17, 2022. Accessed May 23, 2022. https://newsroom.heart.org/news/new-guideline-refines-care-for-brain-bleeds-compression-socks-some-meds-not-effective
4. Kleindorfer DO, Towfighl A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021;52:e364-e467. doi:10.1161/STR.0000000000000375