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UPDATED GUIDELINE: ACC/AHA 2015: MANAGEMENT OF SPONTANEOUS INTRACEREBRAL HEMORRHAGE

"There is only one corner of universe, you can be certain of improving,
and that is your own self"
                                             - Aldous Huxley

Guideline for Management of Spontaneous Intracerebral Hemorrhage: ACC/AHA 2015-

Salient points:
  • In patient on oral anticoagulation, coagulopathy should be rapidly corrected. 
  • Patients on vitamin K antagonist (warfarin), should be given vitamin K (5-10 mg intravenous) and fresh frozen plasma or prothrombin complex concentrate (PCC). PCC corrects INR more rapidly, requires less volume and associated with fewer complication compared to fresh frozen plasma. Therefore PCC may be preferred. 
  • Although rFVIIa may correct INR, clotting may not be restored in vivo, as it does replace all clotting factors. Therefore it is not recommended for vitamin K antagonist reversal in ICH.
  • For newer oral anticoagulant (NOAC) like debigatron, rivaroxaban and apixaban, activated charcoal can be useful if given within 2 hours of last dose. rFVIIa may be considered for direct thrombin inhibitor (debigatron), whereas PCC may better in factor X antagonist (rivaroxaban and apixaban). Hemodialysis might be effective for debigatran as it is less protein bound in plasma. 
  • In patient presenting with elevated blood pressure, SBP may be lowered safely and acutely to 140 mmHg. This translated to improved functional outcome. 
  • Prophylactic anticonvulsant is not recommended in spontaneous ICH. In patient with level of consciousness not explained by degree ICH, continuous EEG monitoring should be done, and any subclinical seizure should be treated with anticonvulsants.
  • These patient are at risk of aspiration due to dysphagia, therefore formal swallowing screening should be done before starting liquid, solid or medication by mouth. 
  • Intraventricular drainage should be considered in patients with decreased level of consciousness and hydrocephalus. 
  • ICP should be monitored in patient with GCS less than 8, significant IVH or hydrocephalus or clinical evidence of transtentorial herniation. CPP of 50-70 mmHg should be targeted.
  • In cerebellar hemorrhage, surgical evacuation of hematoma should be done, if patient is deteriorating or developing brainstem compression or hydrocephalus.
  • In supratentorial hemorrhage, surgical treatment is not shown to be beneficial in trials. but surgical evacuation of hematoma may be considered as life saving measure in deteriorating patients. Early hematoma evacuation in these patients is not beneficial, compared to when done in deterioration. 
  • Decompression craniotomy might be considered in supratentorial hemorrhage with significant mass effect or raised ICP refractory to optimal medical therapy..
  • Risk factors for recurrent ICH include older age, location of the index ICH (deep versus lobar), antithrombotic drug use, and hypertension. BP control reduces the risk of future ICH, and it is reasonable to target a systolic BP of <130 mm Hg and a diastolic BP of <80 mm Hg.
  • When the indication for antithrombotic therapy is strong, anticoagulation can likely be restarted after nonlobar ICH, and antiplatelet monotherapy can likely be restarted after any ICH. 
  • While there may be an association between statin use and ICH, the data are insufficient to recommend withholding statins after ICH.

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