Intracerebral hemorrhage (ICH) has long been recognized as one of the most severe forms of stroke. According to the American Heart Association (AHA), ICH accounts for less than 10% of first-ever strokes, but is more likely to result in death or major disability. Studies have estimated that 35% to 52% of patients with ICH die within a month. More than 60,000 patients in the United States have an ICH in a year, but only about 20% of these individuals are expected to be functionally independent 6 months after their event.
The AHA and American Stroke Association (ASA) published an updated evidenced-based guideline in the September 2010 issue of Stroke to inform physicians on the most current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous ICH. The guideline covers diagnosis, hemostasis, blood pressure management, inpatient and nursing management, prevention of medical comorbidities, surgical treatment, prognosis, rehabilitation, prevention of recurrence, and other considerations. The authors incorporated new clinical trial results and multiple updates since the last guidelines were published in 2007 (Table).
“Aggressive, critical care by physicians to treat patients presenting with ICH is likely to improve outcomes.”
“The underlying message of the AHA/ASA guideline update is that ICH is a very treatable disorder, and the overall aggressiveness of ICH care is directly related to mortality from this disease,” says Lewis B. Morgenstern, MD, FAHA, FAAN, who chaired the committee that created the guideline update. “As a medical community, we tend to be too nihilistic in our treatment of ICH. Even though there is currently no ‘magic bullet’ to treat the disease, the nihilism has led to poor outcomes. Aggressive, critical care by physicians to treat patients presenting with ICH is likely to improve outcomes.”
Reviewing the Recommendations
The AHA/ASA guideline committee established both new and revised recommendations for ICH. The committee recommended that initial assessment of ICH include prompt neuroimaging with CT or MRI. CT angiography and contrast-enhanced CT may help identify patients at particularly high risk of hematoma expansion. “Advanced imaging may also help detect underlying causes of ICH, such as vascular malformations,” adds Dr. Morgenstern. Within the first few days after ICH onset, patients are typically medically and neurologically unstable. The AHA/ASA writing committee recommends frequent vital sign checks, neurological assessments, and continuous cardiopulmonary monitoring for the inpatient management and prevention of secondary brain injury. Additionally, patients receiving IV vasoactive medications should receive continuous intra-arterial blood pressure monitoring. New and revised recommendations also state that glucose be monitored and normoglycemia maintained. Clinical seizures and patients with depressed mental status who are also found to have seizures on electroencephalograms should be treated with antiepileptic drugs. Prophylactic anticonvulsants are not recommended.
For most patients with ICH, the usefulness of surgery is uncertain, and further research is required. However, there is a new statement in the guideline addressing patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction. “Previously, some believed such patients were best treated with intraventricular drainage rather than surgery,” says Dr. Morgenstern. “However, a higher level recommendation now proposes that those patients be treated with surgery as soon as possible. Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended.”
When Not to Make DNR Orders
Another important modification has been the upgrading of a recommendation on withdrawal of care. According to the guideline, most patients that die from ICH do so during the initial acute hospitalization—usually in the setting of withdrawal of support due to a presumed poor prognosis. Several studies have identified withdrawal of medical support and other early care limitations, such as do not resuscitate (DNR) orders within the first day of hospitalization, as independent outcome predictors.
The guideline now conclusively states that a trial of aggressive therapy should be considered before a DNR decision is made. “There is concern that decisions by physicians to limit care early after ICH and give a DNR order are resulting in self-fulfilling prophecies of poor outcomes because they are inaccurately presuming poor results,” Dr. Morgenstern says. “These decisions often lead to clinicians failing to provide initial aggressive therapy in patients with ICH who still may have favorable outcomes.”
Dr. Morgenstern notes that physicians should be cautious when trying to establish a prognosis early after ICH, especially when withdrawal of support and DNR orders are under consideration. Aggressive guideline-concordant therapy is recommended for all ICH patients who do not have pre-existing DNR orders. Additionally, care limitations should not be recommended by physicians during the first few days after ICH. “Our ability to prognosticate about ICH is very limited,” says Dr. Morgenstern. “Physicians need to take the lead and use evidence-based strategies to improve outcomes with aggressive care in patients with ICH. That’s the key to improving outcomes in this potentially deadly disease.”
Morgenstern LB, Hemphill JC 3rd, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108-2129.
Zahuranec DB, Morgenstern LB, Sánchez BN, et al. Do-not-resuscitate orders and predictive models after intracerebral hemorrhage. Neurology. 2010;75:626-633.
Moon JS, Janjua N, Ahmed S, et al. Prehospital neurologic deterioration in patients with intracerebral hemorrhage. Crit Care Med. 2008;36:172-175.
Cooper D, Jauch E, Flaherty ML. Critical pathways for the management of stroke and intracerebral hemorrhage: a survey of US hospitals. Crit Pathw Cardiol. 2007;6:18-23.
Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369:293-298.