Key Patient Messages: 2022 Spontaneous Intracerebral Hemorrhage Guideline

  1. An intracerebral hemorrhage (ICH) is a type of stroke in which a blood vessel breaks and causes bleeding into the brain tissue. An ICH is the deadliest type of stroke ICHs account for every one in ten strokes that occur in the United States. This guideline is focused on spontaneous ICHs which is caused by a sudden blood vessel rupture.

    Whenever possible, clinical trial results (evidence) were used to develop the recommendations in this guideline, with the primary goals of improving the quality of care and meeting the needs of the ICH patient. This guideline is important to help with ICH prevention, ICH management and treatment, and ICH recovery for medical teams, ICH survivors, caregivers, and the general public.
  2. The term spontaneous ICH gives the impression that these types of strokes occur for no reason. The stroke is sudden, but the main cause is blood vessel disease, which develops over time. Uncontrolled blood pressure is one of the main causes of ICH. Hereditary factors can cause an ICH. Some lifestyle factors, like illegal drug use and excessive drinking of alcohol, may be contributing factors as well. Among other things, more ICHs are seen with older people.

    Those who are taking medications to prevent blood clots (such as antiplatelets (like aspirin) and anticoagulants (like warfarin or the newer anticoagulants or direct oral anticoagulants) are at a higher risk for a brain bleed than normal. However, these medications are important to prevent other dangerous medical conditions. Discuss concerns with a healthcare provider to better understand the benefits and risks.
  3. Getting immediate medical help is important when someone shows the signs of a stroke. Wasted time can lead to bad outcomes and even death. Medical tests are needed to know the type of stroke and the best way to treat it. Many communities have networks set up to ensure stroke patients get care that is evidence-based and proven to provide better results. Emergency service teams know which hospitals in the community are best prepared to handle stroke patients. Emergency service teams can take some tests on the way to the hospital and talk with the hospital before the patient arrives. This helps the hospital to be prepared for the patient to arrive and saves time.

    Know the most common signs of a stroke:
    • F - Facial drooping
    • A - Arm or leg weakening (can be one or both sides)
    • S - Speech Problems (i.e., slurred, hard to understand, cannot understand you, etc.)
    • T - Time to call 9-1-1 or the local emergency services line
    Dizziness, loss of balance, a sudden, severe headache, or difficulty swallowing are some other common warning signs of a stroke.
  4. The first 24-hours are critical. The medical team uses blood tests, radiology tests, the patient’s medical/social/family history, and various screening tools to diagnose an ICH, know the size of the ICH, and the best method to treat the ICH. This guideline recommends aggressive treatment in the first days of an ICH. Each patient/situation is unique. Therefore, clinical judgment is warranted. This process is stressful for all parties, including the medical team. Open and honest input from the patient (and/or the patient’s representatives) is important to make the best decisions to help the patient and prevent harm due to unknown factors.
  5. Joint/Shared decision making between the care team and the patient (or patient’s representative) is the best approach. Determining the best plan of care is personal and can be very difficult. It is helpful for the medical team to have written documentation of the patient’s desire and to have a representative who is aware of the patient’s desires to help in the decision-making process. The medical team and the patient (or patient’s representative) should talk about the available options and the risks and benefits of each option. The level and types of care to be provided should reflect the patient’s individual circumstances, wishes, and goals.
  6. Advanced Directives and the ICH Patient. ICH patients may become unconscious or lose the ability to make decision for themselves. Do-Not-Attempt Resuscitation (DNAR) Orders usually apply to situations where the patient’s heart or lungs have stopped. This order does not mean that medical and surgical treatment should not be done for ICH. Life-sustaining treatments such as nutrition or hydration, intubation, mechanical ventilation, antibiotics, or vasopressors should not be withheld due to ICH alone. These guidelines recommend an aggressive approach to ICH treatment, regardless of the existence of a DNAR order.
  7. Rehabilitation and Recovery help improve outcomes and quality of life. This guideline recommends early discharge for patients with mild to moderate ICHs. To accomplish this, early rehabilitation within 24-48 hours may be started. Teams composed of various medical specialties are encouraged to work together to provide rehabilitation activities, such as stretching, functional task training, etc. Walking within the first 24 hours is not recommended and appears to increase the chance of early death in ICH patients.

    The patient’s caregiver is an important part of the care team. This guideline supports education and training for the primary caregiver to best care for the patient and prevent injury after discharge. This training includes hands-on, practical ways to assist the patient with activities of daily living (taking medications, cooking, bathing, etc.) and keep the caregiver safe from injury, including use of assistive devices. Education on the psychological and social changes that often are seen with ICH patients and ways to handle these changes is also recommended.
  8. Family often becomes caregivers when the patient returns home. An ICH causes damage to the brain. Some patients may have physical changes, mental changes, and emotional changes after an ICH. Patients and caregivers need to read material provided by the healthcare team, attend educational/training sessions, and ask questions of the medical team before the patient comes home. It is important for patients and caregivers to know community resources that are available and who to call when questions arise after they return home. Recovery can be quick for some and take longer for others. One of the primary goals is to create good lifestyle habits to prevent another stroke.
  9. Education and action are key to preventing stroke/brain bleed. ICH survivors are encouraged to have regular doctor’s visits and speak with their doctor about individual changes that can be made to prevent stroke. In general, there are some life and self-care habits that can help to lower the chance of having an ICH (and preventing a second ICH), such as:
    • Controlling high blood pressure
    • Controlling blood sugar levels and diabetes
    • Eating healthy foods (Examples: fish, fruits, vegetables, whole grains, and healthy fats
    • Not eating much red meat, salt, and unhealthy fats
    • Exercising regularly
    • Lowering stress and seeing a mental health provider, as needed (Examples: Persistent depression, anxiety, mood disorders)
    • Avoiding illegal drugs
    • Not drinking a lot of alcohol
  10. Key Takeaways for the Future. There is still more to learn about ICH. ICH is the deadliest form of stroke, with early death occurring in 30%-40% of ICH patients. ICH trends have not shown much improvement over the years. There is an aging population and the risk for ICH increases with age but can occur in younger adults as well. In the United States and worldwide, ICH occurs more in poorer populations. Those identified as black or Asian are at a higher risk of having a second ICH. The most vulnerable are at a higher risk of ICH and a secondary ICH/stroke.

    Historically, ICH-specific research has been lower than research on other types of strokes (like ischemic stroke). Additional research targeted towards ICH is needed. Specific research focused on the most at risk populations is needed.

    Data shows that public education on recognizing the signs of a stroke is high. More advanced public education is needed targeting stroke prevention and recurrence, especially for those who are most vulnerable.


Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt L, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G,

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

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