Top Things to Know: 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage

Published: May 17, 2022

  1. ICHs are the deadliest form of acute stroke with early mortality ranging between 30%-40%.
  2. Approximately 10% of the 795,000 strokes per year in the United States are intracerebral hemorrhages or ICHs. They are defined as a brain injury attributable to acute blood extravasation into the brain parenchyma (brain tissue) from a ruptured cerebral blood vessel.
  3. ICH disproportionately affects lower-resourced populations in the U.S. and internationally.
  4. ICH can occur in adults at any age, but the incidence increases with age. Another growing source of ICH is the more widespread use of anticoagulants.
  5. ICHs, like other forms of stroke, occur as the consequence of a defined set of vascular pathologies. This guideline emphasizes the importance of, and approaches to, identifying markers of both microvascular and macrovascular hemorrhage etiologies.
  6. Small vessel disease with arteriolosclerosis and cerebral amyloid angiopathy are the main causes of ICH. The main risk factor for ICH is uncontrolled hypertension.
  7. The organization of healthcare systems is increasingly recognized as a key component of optimal stroke care. This guideline recommends development of regional systems that provide initial intracerebral hemorrhage (ICH) care and the capacity, when appropriate, for rapid transfer to facilities with neurocritical care and neurosurgical capabilities.
  8. Hematoma expansion (HE) is associated with worse ICH outcome. There are now a range of neuroimaging markers that, along with clinical markers such as time since stroke onset and use of antithrombotic agents, help to predict the risk of HE These neuroimaging markers include signs detectable by non-contrast computed tomography (NCCT) - the most widely used neuroimaging modality for ICH.
  9. When implementing acute blood pressure (BP) lowering following mild-to-moderate ICH, treatment regimens that limit BP variability and achieve smooth, sustained BP control appear to reduce HE and yield better functional outcome.
  10. ICH while anticoagulated has extremely high mortality and morbidity. This guideline provides updated recommendations for acute reversal of anticoagulation following ICH, highlighting use of protein complex concentrate complex for reversal of vitamin K antagonists such as warfarin, idarucizumab for reversal of the thrombin inhibitor dabigatran, and andexenet for reversal of factor Xa inhibitors such as rivaroxaban, apixaban, and edoxaban.
  11. Several in-hospital therapies that have historically been used to treat ICH patients appear to confer either no benefit or harm. For emergency or critical care treatment of ICH, prophylactic corticosteroids or continuous hyperosmolar therapy appear to have no benefit for outcome, while use of platelet transfusions outside the setting of emergency surgery or severe thrombocytopenia appears to worsen outcome. Similar considerations apply to some prophylactic treatments historically used to prevent medical complications following ICH. Use of graduated knee- or thigh-high compression stockings alone are not effective prophylactic therapy for prevention of deep vein thrombosis, and prophylactic antiseizure medications in the absence of evidence for seizures do not improve long-term seizure control or functional outcome.
  12. Minimally invasive approaches for evacuation of supratentorial intracerebral and intraventricular hemorrhages (compared to medical management alone) have demonstrated reductions in mortality. The clinical trial evidence for improvement of functional outcome with these procedures is neutral, however. For patients with cerebellar hemorrhage, indications for immediate surgical evacuation with or without external ventricular drain (EVD) to reduce mortality now include larger volume (>15mL) in addition to previously recommended indications of neurologic deterioration, brainstem compression, and hydrocephalus.
  13. The decision of when and how to limit life-sustaining treatments following ICH remains complex and highly dependent on individual preference. This guideline emphasizes that the decision to assign do-not-attempt-resuscitation status is entirely distinct from the decision to limit other medical and surgical interventions and should not be used to do so. On the other hand, the decision to implement an intervention should be shared between the medical provider and patient or surrogate and should reflect the patient's wishes as best as can be discerned. Baseline severity scales can be useful to provide an overall measure of hemorrhage severity but should not be used as the sole basis for limiting life-sustaining treatments.
  14. Rehabilitation and recovery are important determinants of ICH outcome and quality of life. This guideline recommends use of coordinated multidisciplinary inpatient team care with early assessment of discharge planning and a goal of early supported discharge for mild-to-moderate ICH. Implementation of rehabilitation activities such as stretching and functional task training may be considered 24-48 hours after moderate ICH; however early aggressive mobilization within the first 24 hours following ICH appears to worsen 14-day mortality. Multiple randomized trials did not confirm an earlier suggestion that fluoxetine might improve functional recovery after ICH. Fluoxetine reduced depression in these trials but also increased the incidence of fractures.
  15. A key and sometimes overlooked member of the ICH care team is the patient's home caregiver. This guideline recommends psychosocial education, practical support, and training for the caregiver to improve the patient's balance, activity level, and overall quality of life


Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC 3rd, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS; on behalf of the 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 [published online ahead of print May 17, 2022]. Stroke. doi: 10.1161/STR.0000000000000407