Emergency Medicine EducationIntracerebral Hemorrhage 2022 Guideline Update - emDOCs - Net - Emergency Medicine Education

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Intracerebral Hemorrhage 2022 Guideline Update

 JUN 20TH, 2022  BRIT LONG  CATEGORIES: PRACTICE UPDATES
https://www.emdocs.net/intracerebral-hemorrhage-2022-guideline-update/ 1/12
1/7/23, 11:24 AM emDOCs.net – Emergency Medicine EducationIntracerebral Hemorrhage 2022 Guideline Update - emDOCs.net - Emergenc…
Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK)
The American Heart Association/American Stroke Association (AHA/ASA) 2022 Guideline

for managing spontaneous intracerebral hemorrhage (ICH) was recently released. This post
will focus on the key parts of the guideline that affect ED evaluation and management.
Background
ICH is defined as acute blood extravasation into brain parenchyma. There are approximately
795,000 strokes per year, with 10% of these being an ICH. Unfortunately, ICH
disproportionately affects low resource populations worldwide. In the U.S., there is a 1.6-fold
higher risk of ICH in Black and Mexican Americans compared to non-Hispanic White people.
Early mortality is severe, approximating 30-40%, and the incidence drastically increases with
age. The increasing use of anticoagulants has also resulted in greater numbers of ICH. ICH is
often the consequence of several factors, including trauma, cancer, AVMs, aneurysm, venous
pathology (cerebral venous thrombosis), hemorrhagic conversion of ischemic stroke, and
microvascular disease including arteriolosclerosis and cerebral amyloid angiopathy. Once
blood extravasates, it can cause direct pressure effects as well as physiological and cellular
damage.
The remainder of this post will provide a brief synopsis of the guidelines, with some editorial
thoughts as well.
The Recommendations
All recommendations are designated with a class of recommendation (COR) and level of
evidence (LOE). COR is the strength of the recommendation, while the LOE is the quality of
scientific evidence.
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Physical Examination and Laboratory Assessment

Website
Obtain focused history, exam, and routine laboratory testing to assist with identifying the
type of hemorrhage, active medical issues, and risk of unfavorable outcomes. COR 1, LOE C-
LD
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ALGORITHM OF THE MONTH

Wheezing and Stridor (https://ddxof.com/wheezing-and-stridor/).
Neuroimaging
(https://ddxof.com/app)
In patients presenting with stroke-like symptoms, rapid neuroimaging with CT or MRI is
recommended to confirm the diagnosis of spontaneous ICH. COR 1, LOE B-NR
In patients with spontaneous ICH and/or IVH, serial head CT can be useful within the first 24
hours after symptom onset to evaluate for hemorrhage expansion. COR 2a, LOE B-NR
In patients with spontaneous ICH and/or IVH and with low GCS score or ND, serial head CT
can be useful to evaluate for hemorrhage expansion, development of hydrocephalus, brain
swelling, or herniation. COR 2a, LOE C-LD
(http://www.emdocs.net/wp-content/uploads/2022/05/wheezing_lg.png)
In patients with spontaneous ICH, CT angiography (CTA) within the first few hours of ICH
onset may be reasonable to identify patients at risk for subsequent HE. COR 2b, LOE B-NR
Popular Recent Comments
In patients with spontaneous ICH, using noncontrast computed tomography (NCCT) markers
ofSubtle
HE toECG
identify patients
findings in ACS:at riskII for
Part HE mayT-Waves
Hyperacute be reasonable. COR 2b, LOE B-NR
(https://www.emdocs.net/hyperacute-t-
waves/)
February 17, 2016
Editorial Comment: The guideline incorporates CTA, which may assist with diagnosis and
prognostication. The spot sign may be associated with mortality and poor mRS, score, but the
Interpreting Waveform Capnography: Pearls and Pitfalls (https://www.emdocs.net/interpreting-
data are heterogenous and have significant limitations.
waveform-capnography-pearls-and-pitfalls/)
May 30, 2016
Diagnostic
Strep ThroatAssessment for
Mimics: Pearls & Pathogenesis
Pitfalls (https://www.emdocs.net/strep-throat-mimics-pearls-
Inpitfalls/)
patients with lobar spontaneous ICH and age <70 years, deep/posterior fossa spontaneous
September 7, 2016
ICH and age <45 years, or deep/posterior fossa and age 45 to 70 years without history of
hypertension, acute CTA plus consideration of venography is recommended to exclude
What’s that Rash? An approach to dangerous rashes based on morphology
macrovascular causes or cerebral venous thrombosis. COR 1, LOE B-NR
(https://www.emdocs.net/9009-2/)
July 18, 2016
In patients with spontaneous ICH who undergo CT or MRI at admission, CTA plus
consideration of venography or MRA plus consideration of venography performed acutely
g p y p g p yp y
The
can beThromboelastogram
useful to exclude (TEG®): A Five-Minute
macrovascular causesPrimer for the venous
or cerebral Emergency Physician COR 2a, LOE
thrombosis.
(https://www.emdocs.net/thromboelastogram-teg-five-minute-primer-emergency-physician/)
C-LD
December 21, 2016
Editorial Comment: They incorporate venography in a select subset of patients to evaluate

Next »
for CVT. This is an important consideration, as CVT requires anticoagulation even in the
setting of ICH.
FROM THE ARCHIVES

Treatment:
52 Acute BP after
in 52 – #24: Angiography Lowering
Out-of-Hospital Cardiac Arrest without ST-Segment Elevation
(https://www.emdocs.net/52-in-52-24-angiography-after-out-of-hospital-cardiac-arrest-without-st-
In patients with spontaneous ICH requiring acute BP lowering, careful titration to ensure
segment-elevation/)
continuous smooth and sustained control of BP, avoiding peaks and large variability in SBP,
emDOCs Podcast – Episode 69: Decision Making in EM – Getting closer to better
can be beneficial for improving functional outcomes. COR 2a, LOE B-NR
(https://www.emdocs.net/emdocs-podcast-episode-69-decision-making-in-em-getting-closer-to-better/)
Top 10 emDOCs Posts of 2022 (https://www.emdocs.net/top-10-emdocs-posts-of-2022/)

In patients with spontaneous ICH in whom acute BP lowering is considered, initiating
EM@3AM:
treatmentAcute Hemolytic
within 2 hoursAnemia
of ICH(https://www.emdocs.net/em3am-acute-hemolytic-anemia/)
onset and reaching target within 1 hour can be beneficial to
reduce
52 in 52 –the risk
#23: of HE and
Molecular improve
Adsorbent functionalSystem
Recirculating outcome. COR
in Acute 2a,Failure
Liver LOE C-LD
(https://www.emdocs.net/52-in-52-23-molecular-adsorbent-recirculating-system-in-acute-liver-failure/)
In patients with spontaneous ICH of mild to moderate severity presenting with SBP between
150 and 220 mm Hg, acute lowering of SBP to a target of 140 mm Hg with the goal of
EMDOCS IN YOUR MAILBOX
maintaining in the range of 130 to 150 mm Hg is safe and may be reasonable for improving
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functional outcomes. COR 2b, LOE B-R
Enter your email SUBSCRIBE
HARM: In patients with spontaneous ICH of mild to moderate severity presenting with SBP

>150 mm Hg, acute lowering of SBP to
(https://twitter.com/@emdocsdotnet) (https://www.facebook.com/emdocsdotnet)
<130 mm Hg is potentially harmful. COR 3, LOE B-R
 (https://plus.google.com/+emdocsnet)
Editorial Comment: The guideline recommends a range between 130-150 for a BP target in
those with a presenting BP between 150-220, while avoiding drops less than 130. For those
with higher BPs, decrease that BP by 20% in the first hour. If you drop these patients by too
FEATURED ARTICLES
much and too rapidly, end organ injury can occur (ie, renal injury), and cerebral perfusion
pressure will also decrease. The key is a steady, early decrease in BP. Most of the studies
FOAMTOX
included in the guideline included patients where BP treatment was initiated at least 3 hours
after onset of the ICH (ATACH-2, INTERACT). Decreasing BP within the first hour can
improve patient outcomes. Use a reliable antihypertensive infusion such as nicardipine or
clevidipine. An arterial line can be helpful in these critical patients, but if this is not feasible,
make sure the blood pressure cuff is routinely recycled (less than every 10 minutes).
Treatment: Anticoagulant-related hemorrhage

In patients with anticoagulant-associated spontaneous ICH, anticoagulation should be
(https://www.emdocs.net/toxcard-methylene-blue/)
discontinued immediately and rapid reversal of anticoagulation should be performed as soon
ToxCard: Methylene Blue

as possible after diagnosis of spontaneous ICH to improve survival. COR 1, LOE C-LD
VKAs
VKAs
(https://www.emdocs.net/toxcard-methylene-blue/)
In FOAMTOX
patients with VKA-associated spontaneous ICH and INR ≥2.0, 4-factor (4-F) prothrombin
, TOXCards
complex concentrate (PCC) is recommended in preference to fresh-frozen plasma (FFP) to
achieve rapid correction of INR and limit HE. COR 1, LOE B-R
In patients with VKA-associated spontaneous ICH, intravenous vitamin K should be

administered directly after coagulation factor replacement (PCC or other) to prevent later
increase in INR and subsequent HE. COR 1, LOE C-LD
This blog aims to disrupt how medical providers and trainees can gain public access to high-quality, educational
content while also engaging in a dialogue about best-practices in EM and medical education. We strive to reshape
In patients
medical educationwith
andVKA-associated spontaneous
academia in their evolution ICH
beyond thewith INR ofclassroom.
traditional 1.3 to 1.9, it may be
reasonable to use PCC to achieve rapid correction of INR and limit HE. COR 2b, LOE C-LD
RECENT
Editorial
All Content Comment: Fixed dose 4-F PCC with vitamin
(http://www.emdocs.net/collected- K is the optimal reversal in this setting.
Ask Me Anything
However, the third recommendation of reversing
knowledge/) an INR of 1.3-1.9 is questionable.
(https://www.emdocs.net/category/ama/)
EM Mindset (https://www.emdocs.net/category/em- For Junior Residents
mindset/)
DOACs (https://www.emdocs.net/category/intern-report/)
MORE Write For emDocs
(http://www.emdocs.net/about/#questions)
In patients with direct factor Xa inhibitor–associated spontaneous ICH, andexanet alfa is
About (https://www.emdocs.net/about/) Contact (https://www.emdocs.net/contact/)
reasonable to reverse the anticoagulant effect of factor Xa inhibitors. COR 2a, LOE B-NR
Search Would you like to contribute? Have feedback or
In patients with dabigatran-associated spontaneous ICH, idarucizumab is reasonable to

GET IN TOUCH
reverse the anticoagulant effect of dabigatran. COR 2a, LOE B-NR
suggestions on how we can improve the site? Click below to contact us or find us on Twitter, Facebook or Google+
In patients
Contact with direct factor Xa inhibitor–associated spontaneous ICH, a 4-F PCC or
Us (http://www.emdocs.net/contact/)
activated PCC (aPCC) may be considered to improve hemostasis. COR 2b, LOE B-NR
 (https://twitter.com/@emdocsdotnet)  (https://www.facebook.com/emdocsdotnet)
In(https://plus.google.com/+emdocsnet)
patients with dabigatran- or factor Xa inhibitor–associated spontaneous ICH, when the
DOAC agent was taken within the previous few hours, activated charcoal may be reasonable
to prevent absorption of the DOAC. COR 2b, LOE C-LD
emDocs is licensed under a Creative Commons Attribution 4.0 International License. Powered by Gomalthemes.
In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available,

aPCC or PCCs may be considered to improve hemostasis. COR 2b, LOE C-LD
In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available,

renal replacement therapy (RRT) may be considered to reduce dabigatran concentration.
COR 2b, LOE C-LD
Editorial Comment: There is limited evidence supporting improved patient-centered

outcomes with andexanet alfa. 4-F PCC and aPCC are effective reversal agents, with more
literature support compared to anexanet alfa for DOAC reversal. An institutional protocol
utilizing aPCC is recommended.
Heparins
In patients with unfractionated heparin (UFH)–associated spontaneous ICH, intravenous

protamine is reasonable to reverse the anticoagulant effect of heparin. COR 2a, LOE C-LD
In patients with low-molecular-weight heparin (LMWH)–associated spontaneous ICH,

intravenous protamine may be considered to partially reverse the anticoagulant effect of
heparin. COR 2b, LOE C-LD
Treatment: Antiplatelet-related hemorrhage

For patients with spontaneous ICH being treated with aspirin and who require emergency
neurosurgery, platelet transfusion might be considered to reduce postoperative bleeding and
mortality. COR 2b, LOE C-LD
For patients with spontaneous ICH being treated with antiplatelet agents, the effectiveness
of desmopressin with or without platelet transfusions to reduce the expansion of the
hematoma is uncertain. COR 2b, LOE C-LD
HARM: For patients with spontaneous ICH being treated with aspirin and not scheduled for
emergency surgery, platelet transfusions are potentially harmful and should not be
administered. LOE B-R
Editorial Comment: Desmopressin 0.3 mcg/kg IV is promising, especially in patients with
renal disease or those on aspirin. Many centers use platelet response testing. This may assist
in determining the need for platelet transfusion in those on ASA or clopidogrel. Make sure to
speak with neurosurgery as well.
From EMCrit.org (https://emcrit.org/emcrit/reversal-safe-smart/)
Treatment: General Hemostatic Measures

In patients with spontaneous ICH (with or without the spot sign), the effectiveness of
recombinant factor VIIa to improve functional outcome is unclear. COR 2b, LOE B-R.
In patients with spontaneous ICH (with or without the spot sign, black hole sign, or blend
sign), the effectiveness of TXA to improve functional outcomes is not well established. COR
2b, LOE B-R
Editorial Comment: TXA is likely not beneficial in patients with ICH.
General Inpatient Care

In patients with spontaneous ICH, provision of care in a specialized inpatient (eg, stroke) unit
with a multidisciplinary team is recommended to improve outcomes and reduce mortality
with a multidisciplinary team is recommended to improve outcomes and reduce mortality.
COR 1, LOE A
In patients with spontaneous ICH and clinical hydrocephalus, transfer to centers with
neurosurgical capabilities for definitive hydrocephalus management (eg, EVD placement and
monitoring) is recommended to reduce mortality. COR 1, LOE B-NR
In patients with moderate to severe spontaneous ICH, IVH, hydrocephalus, or infratentorial

location, provision of care in a neuro-specific ICU compared with a general ICU is reasonable
to improve outcomes and reduce mortality. COR 2a, LOE B-NR
In patients with IVH or infratentorial ICH location, transfer to centers with neurosurgical
capabilities might be reasonable to improve outcomes. COR 2b, LOE B-NR
Editorial Comment: A dedicated care team and ICU can improve outcomes. Have a low
threshold to transfer these patients to centers with a multidisciplinary care team, including
neurosurgery and neurocritical care teams.
Thromboprophylaxis
In nonambulatory patients with spontaneous ICH, intermittent pneumatic compression (IPC)
starting on the day of diagnosis is recommended for VTE (DVT and pulmonary embolism [PE])
prophylaxis. COR 1, LOE B-R
In nonambulatory patients with spontaneous ICH, low-dose UFH or LMWH can be useful to
reduce the risk for PE. COR 2a, LOE C-LD
In nonambulatory patients with spontaneous ICH, initiating low-dose UFH or LMWH

prophylaxis at 24 to 48 hours from ICH onset may be reasonable to optimize the benefits of
preventing thrombosis relative to the risk of HE. COR 2b, LOE C-LD
Editorial Comment: In most situations, thromboprophylaxis can be left to the intensivist and
neurosurgeon.
Glucose
In patients with spontaneous ICH, monitoring serum glucose is recommended to reduce
the risk of hyperglycemia and hypoglycemia. COR 1, LOE C-LD
In patients with spontaneous ICH, treating hypoglycemia (<40–60 mg/d, <2.2–3.3 mmol/L) is
recommended to reduce mortality. COR 1, LOE C-LD
In patients with spontaneous ICH treating moderate to severe hyperglycemia (>180 200
In patients with spontaneous ICH, treating moderate to severe hyperglycemia (>180– 200
mg/dL, >10.0–11.1 mmol/L) is reasonable to improve outcomes. COR 2a, LOE C-LD
Editorial Comment: Avoid hypo- and hyperglycemia.
Temperature
In patients with spontaneous ICH, pharmacologically treating an elevated temperature may
be reasonable to improve functional outcomes. COR 2b, LOE C-LD
In patients with spontaneous ICH, the usefulness of therapeutic hypothermia (<35C/95F) to

decrease peri-ICH edema is unclear. COR 2b, LOE C-LD
Editorial Comment: Avoid elevated temperatures, but there is no clear evidence supporting
therapeutic hypothermia.
Seizures and Antiseizure Medications

In patients with spontaneous ICH, impaired consciousness, and confirmed electrographic
seizures, antiseizure drugs should be administered to reduce morbidity. COR 1, LOE C-LD
In patients with spontaneous ICH and clinical seizures, antiseizure drugs are recommended
to improve functional outcomes and prevent brain injury from prolonged recurrent seizures.
COR 1, LOE C-EO
In patients with spontaneous ICH and unexplained abnormal or fluctuating mental status or
suspicion of seizures, continuous electroencephalography (≥24 hours) is reasonable to
diagnose electrographic seizures and epileptiform discharges. COR 2a, LOE C-LD
No Benefit: In patients with spontaneous ICH without evidence of seizures, prophylactic

antiseizure medication is not beneficial to improve functional outcomes, long-term seizure
control, or mortality. LOE B-NR
Editorial Comment: Treat seizures if they occur, but otherwise, do not provide prophylactic
antiseizure medications.
ICP and Cerebral Edema

In patients with spontaneous ICH or IVH and hydrocephalus that is contributing to
decreased level of consciousness, ventricular drainage should be performed to reduce
mortality. COR 1, LOE B-NR
In patients with moderate to severe spontaneous ICH or IVH with a reduced level of
consciousness, ICP monitoring and treatment might be considered to reduce mortality and
improve outcomes. COR 2b, LOE B-NR
In patients with spontaneous ICH, the efficacy of early prophylactic hyperosmolar therapy
for improving outcomes is not well established. COR 2b, LOE B-NR
In patients with spontaneous ICH, bolus hyperosmolar therapy may be considered for
transiently reducing ICP. COR 2b, LOE C-LD
No Benefit: In patients with spontaneous ICH, corticosteroids should not be administered

for treatment of elevated ICP. LOE B-R
Editorial Comment: If concerned about elevated ICP and the patient decompensates,
administer a bolus hyperosmolar agent such as hypertonic saline, and a bolus is probably
better than a continuous infusion. Hypertonic saline may be better than mannitol. Steroids
are also not recommended.
Surgical Therapies
There are specific patient populations that may improve with surgical interventions,
especially those with larger bleeds and depressed GCS. The key is to consult neurosurgery
early in the care of these patients.
Outcome Prediction
In patients with spontaneous ICH, administering a baseline measure of overall hemorrhage
severity is recommended as part of the initial evaluation to provide an overall measure of
clinical severity. COR 1, LOE B-NR
In patients with spontaneous ICH, a baseline severity score might be reasonable to provide a
general framework for communication with the patient and their caregivers. COR 2b, LOE B-
NR
No Benefit: In patients with spontaneous ICH, a baseline severity score should not be used
as the sole basis for forecasting individual prognosis or limiting life-sustaining treatment.
LOE B-NR
Editorial Comment: Be careful using the ICH score (https://www.mdcalc.com/intracerebral-

hemorrhage-ich-score) to prognosticate. It may be helpful with assessing disease severity.
Much of the patient’s prognosis depends on their baseline status prior to the ICH.
Summary:
ICH is deadly and accounts for 10% of all strokes.
In the patient with suspected stroke, perform a rapid assessment (such as CPSS, VAN), and obtain a
glucose and noncontrast head CT. CTA may be helpful, as can venography in select patients.
Once ICH is diagnosed on CT, our goals are to stabilize the patient, control blood pressure (rapid
control with an IV infusion), prevent further injury (avoid elevated ICP, hypoxia, hypotension,
hypoglycemia), and admit to an appropriate facility (ie, transfer may be needed).
Consult neurosurgery early in the care of these patients.
Reference:
Greenberg SM, Ziai WC, Cordonnier C, et al; American Heart Association/American Stroke
Association. 2022 Guideline for the Management of Patients With Spontaneous
Intracerebral Hemorrhage: A Guideline From the American Heart Association/American
Stroke Association. Stroke. 2022 May 17:101161STR0000000000000407. doi:
10.1161/STR.0000000000000407. (https://pubmed.ncbi.nlm.nih.gov/35579034/)

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1/7/23, 11:24 AM emDOCs.net – Emergency Medicine EducationIntracerebral Hemorrhage 2022 Guideline Update - emDOCs.

PREVIOUS POST (HTTPS://WWW.EMDOCS.NET/EM3AM-CERUMEN-IMPACTION/)

Intracerebral Hemorrhage 2022 Guideline Update

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK)

The American Heart Association/American Stroke Association (AHA/ASA) 2022 Guideline

Physical Examination and Laboratory Assessment

Notify me of follow-up comments by email.

Notify me of new posts by email.

emDOCs subscribes to the Free Open Access Meducation (FOAMed)

WRITE FOR EMDOCS

ALGORITHM OF THE MONTH

Editorial Comment: They incorporate venography in a select subset of patients to evaluate

FROM THE ARCHIVES

Top 10 emDOCs Posts of 2022 (https://www.emdocs.net/top-10-emdocs-posts-of-2022/)

Treatment: Anticoagulant-related hemorrhage

ToxCard: Methylene Blue

In patients with VKA-associated spontaneous ICH, intravenous vitamin K should be

In patients with dabigatran-associated spontaneous ICH, idarucizumab is reasonable to

In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available,

In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available,

Editorial Comment: There is limited evidence supporting improved patient-centered

In patients with unfractionated heparin (UFH)–associated spontaneous ICH, intravenous

In patients with low-molecular-weight heparin (LMWH)–associated spontaneous ICH,

Treatment: Antiplatelet-related hemorrhage

From EMCrit.org (https://emcrit.org/emcrit/reversal-safe-smart/)

Treatment: General Hemostatic Measures

Editorial Comment: TXA is likely not beneficial in patients with ICH.

General Inpatient Care

In patients with moderate to severe spontaneous ICH, IVH, hydrocephalus, or infratentorial

In nonambulatory patients with spontaneous ICH, initiating low-dose UFH or LMWH

Editorial Comment: Avoid hypo- and hyperglycemia.

In patients with spontaneous ICH, the usefulness of therapeutic hypothermia (<35C/95F) to

Seizures and Antiseizure Medications

No Benefit: In patients with spontaneous ICH without evidence of seizures, prophylactic

ICP and Cerebral Edema

No Benefit: In patients with spontaneous ICH, corticosteroids should not be administered

Editorial Comment: Be careful using the ICH score (https://www.mdcalc.com/intracerebral-

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