Updated AHA/ASA guidelines for the management of patients with spontaneous intracerebral hemorrhage are published in the journal Stroke. The previous version of the guide was released in 2015.
Experts recommend the use of neuroimaging techniques along with clinical signs to assess the risk of increased hemorrhage. The most common method is computed tomography without contrast enhancement.
For patients with spontaneous intracerebral hemorrhages of mild to moderate severity, therapy aimed at maintaining systolic blood pressure levels within 130-150 mmHg is recommended. The safety and effectiveness of lowering blood pressure in severe spontaneous hemorrhage has not been fully established.
The changes affected the treatment of spontaneous intracerebral hemorrhages while taking anticoagulants. The medications should be stopped immediately.
For patients who have taken vitamin K antagonists (for example, warfarin), the administration of prothrombin complex concentrate is indicated. Idarucizumab is used to reverse the action of the thrombin inhibitor dabigatran. To correct the effect of factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), andexanet alfa is indicated.
Experts recommend abandoning several traditional treatments that continue to be used for spontaneous intracerebral hemorrhage according to established practice, although their use is, at best, not beneficial. This includes prophylactic corticosteroids or hyperosmolar therapy in intensive care settings, since their use does not improve the prognosis of the disease. Platelet transfusions are contraindicated except in cases of emergency surgery or acute thrombocytopenia.
Intermittent pneumatic compression is recommended to prevent deep vein thrombosis immediately after diagnosis. According to updated recommendations, wearing compression stockings of varying degrees of density is no longer considered an effective preventative measure.
It is not recommended to prescribe antiepileptic drugs or antidepressants to patients in the absence of seizures and depression. Studies have shown that antiepileptic drugs do not promote functional recovery after spontaneous intracerebral hemorrhage, and antidepressants increase the risk of bone fractures.
Experts recommend using a minimally invasive approach aimed at evacuation of hematomas. This therapy improves disease outcomes compared with drug treatment alone. Cerebellar hemorrhages greater than 15 mL provide an additional indication for urgent surgical evacuation with or without external ventricular drainage, in addition to neurological impairment, brainstem compression, and hydrocephalus.