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DOI: 10.1161/STR.0b013e3181ec611b
published online Jul 22, 2010; Stroke
Cardiovascular Nursing
and on behalf of the American Heart Association Stroke Council and Council on
Macdonald, Steven R. Messé, Pamela H. Mitchell, Magdy Selim, Rafael J. Tamargo
LochP. Broderick, E. Sander Connolly, Jr, Steven M. Greenberg, James N. Huang, R.
Lewis B. Morgenstern, J. Claude Hemphill, III, Craig Anderson, Kyra Becker, Joseph
Association/American Stroke Association
Guideline for Healthcare Professionals From the American Heart
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A
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AHA/ASA Guideline
Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage
A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association
The American Academy of Neurology affirms the value of this guideline as an educational
tool for neurologists.
The American Association of Neurological Surgeons and the Congress of Neurological
Surgeons have reviewed this document and affirm its educational content.
Lewis B. Morgenstern, MD, FAHA, FAAN, Chair;
J. Claude Hemphill III, MD, MAS, FAAN, Vice-Chair; Craig Anderson, MBBS, PhD, FRACP;
Kyra Becker, MD; Joseph P. Broderick, MD, FAHA; E. Sander Connolly, Jr, MD, FAHA;
Steven M. Greenberg, MD, PhD, FAHA, FAAN; James N. Huang, MD; R. Loch Macdonald, MD, PhD;
Steven R. Messé, MD, FAHA; Pamela H. Mitchell, RN, PhD, FAHA, FAAN;
Magdy Selim, MD, PhD, FAHA; Rafael J. Tamargo, MD; on behalf of the American Heart Association
Stroke Council and Council on Cardiovascular Nursing
Purpose—The aim of this guideline 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. Data were synthesized with the use of evidence tables.
Writing committee members met by teleconference to discuss data-derived recommendations. 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 6 expert peer reviewers and by the members of the Stroke Council
Scientific Statements Oversight Committee and 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 care of patients presenting with intracerebral hemorrhage. The
focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management,
preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and
future considerations.
Conclusions—Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early,
aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral
hemorrhage. (Stroke. 2010;41:00-00.)
Key Words: AHA Scientific Statements � intracerebral hemorrhage � treatment � diagnosis
� intracranial pressure � hydrocephalus � surgery
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on May 19, 2010. A copy of the
statement is available at http://www.americanheart.org/presenter.jhtml?identifier�3003999 by selecting either the “topic list” link or the “chronological
list” link (No. KB-0044). To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.
The American Heart Association requests that this document be cited as follows: Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick
JP, Connolly ES Jr, Greenberg SM, Huang JN, Macdonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ; on behalf of the American Heart
Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:●●●–●●●.
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,
visit http://www.americanheart.org/presenter.jhtml?identifier�3023366.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
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© 2010 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STR.0b013e3181ec611b
1
by MICHAEL BRUNKE on July 22, 2010 stroke.ahajournals.orgDownloaded from
Spontaneous, nontraumatic intracerebral hemorrhage (ICH)is a significant cause of morbidity and mortality throughout
the world. Although much has been made of the lack of a
specific targeted therapy, much less is written about the success
and goals of aggressive medical and surgical care for this
disease. Recent population-based studies suggest that most
patients present with small ICHs that are readily survivable with
good medical care.1 This suggests that excellent medical care
likely has a potent, direct impact on ICH morbidity and mortality
now, even before a specific therapy is found. Indeed, as
discussed later, the overall aggressiveness of ICH care is directly
related to mortality from this disease.2 One of the purposes of
this guideline, therefore, is to remind clinicians of the impor-
tance of their care in determining ICH outcome and to provide
an evidence-based framework for that care.
In order to make this review brief and readily useful to
practicing clinicians, the reader is referred elsewhere for the
details of ICH epidemiology.1,3,4 Similarly, there are many
ongoing clinical studies throughout the world related to this
disease. The reader is encouraged to consider referring
patients to these important efforts, which can be found at
http://www.strokecenter.org/trials/. We will not discuss on-
going studies because we cannot cover them all; the focus of
this statement is on currently available therapies. Finally, a
recent guideline on pediatric stroke was published5 that
obviates the need to repeat the issues of pediatric ICH here.
The last ICH Guidelines were published in 2007,6 and this
current article serves to update those guidelines. As such,
differences from former recommendations are specified in the
current work. The writing group met by phone to determine
subcategories to evaluate. These included emergency diagnosis
and assessment of ICH and its causes; hemostasis, blood
pressure (BP); intracranial pressure (ICP)/fever/glucose/
seizures/hydrocephalus; iron; ICP monitors/tissue oxygenation;
clot removal; intraventricular hemorrhage (IVH); withdrawal of
technological support; prevention of recurrent ICH; nursing
care; rehab/recovery; future considerations. Each subcategory
was led by an author with 1 or 2 additional authors making
contributions. Full MEDLINE searches were done of all
English-language articles regarding relevant human disease
treatment. Drafts of summaries and recommendations were
circulated to the whole writing group for feedback. A conference
call was held to discuss controversial issues. Sections were
revised and merged by the Chair. The resulting draft was sent to
the whole writing group for comment. Comments were incor-
porated by the Vice Chair and Chair, and the entire committee
was asked to approve the final draft. Changes to the document
were made by the Chair and Vice Chair in response to peer
review, and the document was again sent to the entire writing
group for suggested changes and approval. Recommendations
follow the American Heart Association Stroke Council’s
methods of classifying the level of certainty of the treatment
effect and the class of evidence (Tables 1 and 2). All Class I
recommendations are listed in Table 3.
Emergency Diagnosis and Assessment of ICH
and Its Causes
ICH is a medical emergency. Rapid diagnosis and attentive
management of patients with ICH is crucial because early
deterioration is common in the first few hours after ICH
onset. More than 20% of patients will experience a decrease
in the Glasgow Coma Scale (GCS) score of �2 points
between the prehospital emergency medical services assess-
ment and the initial evaluation in the emergency department
(ED).7 Among those patients with prehospital neurological
decline, the GCS score decreases by an average of 6 points
and the mortality rate is �75%. Further, within the first hour
of presentation to a hospital, 15% of patients demonstrate a
decrease in the GCS score of �2 points.8 The risk for early
neurological deterioration and the high rate of poor long-term
outcomes underscores the need for aggressive early
management.
Prehospital Management
The primary objective in the prehospital setting is to provide
ventilatory and cardiovascular support and to transport the patient to
the closest facility prepared to care for patients with acute stroke
(see ED Management section that follows). Secondary priorities for
emergency medical services providers include obtaining a focused
history regarding the timing of symptom onset (or the time the
patient was last normal) and information about medical history,
medication, and drug use. Finally, emergency medical services
providers should provide advance notice to the ED of the impending
arrival of a potential stroke patient so that critical pathways can be
initiated and consulting services can be alerted. Advance notice by
emergency medical services has been demonstrated to significantly
shorten time to computed tomography (CT) scanning in the ED.9
ED Management
It is of the utmost importance that every ED be prepared to
treat patients with ICH or have a plan for rapid transfer to a
tertiary care center. The crucial resources necessary to man-
age patients with ICH include neurology, neuroradiology,
neurosurgery, and critical care facilities including adequately
trained nurses and physicians. In the ED, appropriate consul-
tative services should be contacted as quickly as possible and
the clinical evaluation should be performed efficiently, with
physicians and nurses working in parallel. Table 4 describes
the integral components of the history, physical examination,
and diagnostic studies that should be obtained in the ED.
For patients with ICH, emergency management may in-
clude neurosurgical interventions for hematoma evacuation,
external ventricular drainage or invasive monitoring and
treatment of ICP, BP management, intubation, and reversal of
coagulopathy. Although many centers have critical pathways
developed for the treatment of acute ischemic stroke, few
have protocols for the management of ICH.18 Such pathways
may allow for more efficient, standardized, and integrated
management of critically ill patients with ICH.
Neuroimaging
The abrupt onset of focal neurological symptoms is presumed to
be vascular in origin until proven otherwise. However, it is
impossible to know whether symptoms are due to ischemia or
hemorrhage based on clinical characteristics alone. Vomiting,
systolic BP �220 mm Hg, severe headache, coma or decreased
level of consciousness, and progression over minutes or hours all
suggest ICH, although none of these findings are specific;
2 Stroke September 2010
by MICHAEL BRUNKE on July 22, 2010 stroke.ahajournals.orgDownloaded from
neuroimaging is thus mandatory.19 CT and magnetic resonance
imaging (MRI) are both reasonable for initial evaluation. CT is
very sensitive for identifying acute hemorrhage and is consid-
ered the gold standard; gradient echo and T2*susceptibility-
weighted MRI are as sensitive as CT for detection of acute blood
and are more sensitive for identification of prior hemorrhage.20,21
Time, cost, proximity to the ED, patient tolerance, clinical status,
and MRI availability may, however, preclude emergent MRI in
a sizeable proportion of cases.22
The high rate of early neurological deterioration after ICH is
in part related to active bleeding that may proceed for hours after
symptom onset. The earlier time from symptom onset to first
neuroimage, the more likely subsequent neuroimages will
demonstrate hematoma expansion.15,23,24 Among patients
undergoing head CT within 3 hours of ICH onset, 28% to
38% have hematoma expansion of greater than one third on
follow-up CT.8,25 Hematoma expansion is predictive of
clinical deterioration and increased morbidity and mortali-
ty.8,10,15,25 As such, identifying patients at risk for hematoma
expansion is an active area of research. CT angiography and
contrast-enhanced CT may identify patients at high risk of
ICH expansion based on the presence of contrast extravasa-
tion within the hematoma.26–30 MRI/angiogram/venogram
and CT angiogram/venogram are reasonably sensitive at
identifying secondary causes of hemorrhage, including arte-
riovenous malformations, tumors, moyamoya, and cerebral
vein thrombosis.31–33 A catheter angiogram may be consid-
ered if clinical suspicion is high or noninvasive studies are
suggestive of an underlying vascular cause. Clinical suspicion
of a secondary cause of ICH may include a prodrome of
headache, neurological, or constitutional symptoms. Radio-
logical suspicions of secondary causes of ICH should be
Table 1. Applying Classification of Recommendations and Level of Evidence
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior
myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak.
Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may
be a very clear clinical consensus that a particular test or therapy is useful or effective.
†In 2003, the ACCF/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline
recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from
the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will
increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.
Morgenstern et al Intracerebral Hemorrhage Guideline 3
by MICHAEL BRUNKE on July 22, 2010 stroke.ahajournals.orgDownloaded from
invoked by the presence of subarachnoid hemorrhage, un-
usual (noncircular) hematoma shape, the presence of edema
out of proportion to the early time an ICH is first imaged, an
unusual location for hemorrhage, and the presence of other
abnormal structures in the brain like a mass. An MR or CT
venogram should be performed if hemorrhage location, rela-
tive edema volume, or abnormal signal in the cerebral sinuses
on routine neuroimaging suggest cerebral vein thrombosis.
In summary, ICH is a medical emergency, characterized by high
morbidity and mortality, which should be promptly diagnosed and
aggressively managed. Hematoma expansion and early deteriora-
tion are common within the first few hours after onset.
Recommendations
1. Rapid neuroimaging with CT or MRI is recommended
to distinguish ischemic stroke from ICH (Class I; Level
of Evidence: A). (Unchanged from the previous guideline)
2. CT angiography and contrast-enhanced CT may be
considered to help identify patients at risk for hema-
toma expansion (Class IIb; Level of Evidence: B), and
CT angiography, CT venography, contrast-enhanced
CT, contrast-enhanced MRI, magnetic resonance an-
giography, and magnetic resonance venography can be
useful to evaluate for underlying structural lesions,
including vascular malformations and tumors when
there is clinical or radiological suspicion (Class IIa;
Level of Evidence: B). (New recommendation)
Medical Treatment for ICH
Hemostasis/Antiplatelets/Deep Vein
Thrombosis Prophylaxis
Underlying hemostatic abnormalities can contribute to ICH.
Patients at risk include those on oral anticoagulants (OACs),
those with acquired or congenital coagulation factor deficien-
cies, and those with qualitative or quantitative platelet abnormal-
ities. Patients undergoing treatment with OACs constitute 12%
to 14% of patients with ICH,34,35 and with increased use of
warfarin, the proportion appears to be increasing.36 Recognition
of an underlying coagulopathy thus provides an opportunity to
target correction in the treatment strategy. For patients with a
coagulation factor deficiency and thrombocytopenia, replace-
ment of the appropriate factor or platelets is indicated.
For patients being treated with OACs who have life-threatening
bleeding, such as intracranial hemorrhage, the general recommen-
dation is to correct the international normalized ratio (INR) as
rapidly as possible.37,38 Infusions of vitamin K and fresh-frozen
plasma (FFP) have historically been recommended, but more
recently, prothrombin complex concentrates (PCCs) and recom-
binant factor VIIa (rFVIIa) have emerged as potential therapies.
Vitamin K remains an adjunct to more rapidly acting initial
therapy for life-threatening OAC-associated hemorrhage be-
cause even when given intravenously, it requires hours to correct
the INR.39–41 The efficacy of FFP is limited by risk of allergic
and infectious transfusion reactions, processing time, and the
volume required for correction. Likelihood of INR correction at
24 hours was linked to time to FFP administration in 1 study,
although 17% of patients still did not have an INR �1.4 at this
time, suggesting that FFP administered in this manner may be
insufficient for rapid correction of coagulopathy.42
PCCs are plasma-derived factor concentrates primarily
used to treat factor IX deficiency. Because PCCs also contain
factors II, VII, and X in addition to IX, they are increasingly
recommended for warfarin reversal. PCCs have the advan-
tages of rapid reconstitution and administration, having high
concentrations of coagulation factors in small volumes, and
processing to inactivate infectious agents. Though different
PCC preparations differ in relative amounts o