• Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed in an accompanying table and may be considered
• In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mm Hg is probably safe

Inpatient Management and Prevention of Secondary Brain Injury

• Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise
• Glucose should be monitored and normoglycemia is recommended

Seizures and Antiepileptic Drugs

• Clinical seizures should be treated with antiepileptic drugs
• Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury
• Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs
• Prophylactic anticonvulsant medication should not be used

Procedures/Surgery

• Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A cerebral perfusion pressure of 50 to 70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation
• Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness

Intraventricular Hemorrhage Recommendation

• Although intraventricular administration of recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational

Clot Removal

• For most patients with ICH, the usefulness of surgery is uncertain. Specific exceptions to this recommendation follow
• Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended
• For patients presenting with lobar clots ≥30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered
• The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational
• Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding

Outcome Prediction and Withdrawal of Technological Support

• Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.

Prevention of Recurrent ICH

• In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein ε2 or ε4 alleles, and greater number of microbleeds on MRI
• After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy
• After the acute ICH period, a goal target of a normal BP of <140/90 (<130/80 if diabetes or chronic kidney disease) is reasonable
• Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence. Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents. Avoidance of heavy alcohol use can be beneficial. There is insufficient data to recommend restrictions on use of statin agents or physical or sexual activity

Rehabilitation and Recovery

• Given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation. Where possible, rehabilitation can be beneficial when begun as early as possible and continued in the community as part of a well-coordinated (seamless) program of accelerated hospital discharge and home-based resettlement to promote ongoing recovery

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Stroke published online Jul 22, 2010