Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update. A Guideline From the American Heart Association, American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group

Joseph Broderick MD, FAHA, Chair; Sander Connolly MD, FAHA, Vice-Chair; Edward Feldmann MD, FAHA; Daniel Hanley MD, FAHA; Carlos Kase MD, FAHA; Derk Krieger MD; Marc Mayberg MD, FAHA; Lewis Morgenstern MD, FAHA; Christopher S. Ogilvy MD; Paul Vespa MD; and Mario Zuccarello MD

Purpose--The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

Methods--A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time.

Results--Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.

The guidelines, published in the June issue of Stroke, Journal of the American Heart Association


COMMENTARIES:

Intracerebral hemorrhage, which causes 10% to 15% of first-ever strokes, has a 30-day mortality rate of 35% to 52%

The guidelines suggest that the hemorrhage should be removed as soon as possible if:

It's greater than 3 cm.
The patient is deteriorating neurologically.
The patient has brain stem compression, hydrocephalus from ventricular obstruction, or both.

There is some evidence that using recombinant activated factor VII within four hours of the stroke limits bleeding and may reduce the risk of death.

The guidelines also recommend that:

Appropriate antiepileptic therapy should always be used for treatment of seizures.
Sources of fever should be treated and antipyretic medications should be given as needed.
Early mobilization and rehabilitation are recommended in patients who are clinically stable.

A new aspect of the guidelines is discussion of withdrawal of care and end-of-life issues. The guidelines recommend that do-not-resuscitate orders not be initiated during the first 24 hours after the onset of stroke because they are associated with "an overall lack of aggressiveness of care."