Clinical Literature

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2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

1. Ventricular Drainage and Intracranial Pressure Monitoring:
   • COR 1, LOE B-NR: Ventricular drainage is recommended for patients with spontaneous ICH or intraventricular hemorrhage (IVH) and hydrocephalus to reduce mortality.
   • COR 2b, LOE B-NR: Intracranial pressure (ICP) monitoring may be considered to reduce mortality and improve outcomes in patients with moderate to severe ICH.
2. Seizure Management:
   • COR 1, LOE C-LD: Antiseizure drugs are advised for patients with confirmed electrographic seizures to reduce morbidity.
   • COR 2a, LOE C-LD: Continuous EEG monitoring is reasonable to diagnose electrographic seizures in patients with unexplained mental status changes.
3. Coagulation Factor Replacement and Hemostatic Therapy:
   • COR 2b, LOE B-R: The effectiveness of recombinant factor VIIa and tranexamic acid (TXA) to improve functional outcome in spontaneous ICH is unclear.
4. Platelet Transfusions and Antiplatelet Reversal:
   • COR 2b, LOE C-LD: Platelet transfusion might be considered in aspirin-treated patients requiring emergency surgery.
   • COR 3, LOE B-R: Platelet transfusions are potentially harmful in aspirin-treated patients not scheduled for emergency surgery.
5. Anticoagulant Reversal:
   • COR 2a, LOE B-NR/C-LD: Vitamin K antagonists (VKAs) should be reversed with vitamin K and PCCs (prothrombin complex concentrates) or FFP (fresh frozen plasma).
   • COR 2b, LOE C-LD: In patients with NOAC (non-VKA oral anticoagulant)-associated ICH, specific reversal agents like idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors are recommended.
6. Blood Pressure Management:
   • COR 2a, LOE B-NR: Careful titration of BP is beneficial in improving functional outcomes.
   • COR 2b, LOE C-LD: Acute lowering of SBP to a target of 140 mmHg is safe for most patients, but intensive BP lowering in severe ICH or those requiring surgery is of uncertain safety.
7. Miscellaneous Interventions:
   • COR 3, LOE B-R: Corticosteroids are not recommended for treating elevated ICP in ICH.
   • COR 3, LOE C-LD: Prophylactic antiseizure medication is not beneficial for patients without evidence of seizures.

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Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. Published online May 24, 2023:S0140-6736(23)00806-1.
 
PMID: 37245517

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Background

• Intracerebral hemorrhage is the most serious and least treatable form of stroke
• The current focus on treatment involves normalization of physiologic abnormalities, particularly intensive blood pressure lowering and reversal of coagulopathies

STUDY OBJECTIVE

• Establish whether implementing a goal-directed care bundle incorporating protocols for early intensive blood pressure lowering and management algorithms for hyperglycemia, pyrexia, and abnormal anticoagulation could improve outcomes for acute, spontaneous, intracerebral hemorrhage

STUDY DESIGN

• International, multicenter, prospective, stepped wedge, cluster randomized, blinded, outcome assessed, controlled trial undertaken in primarily low- and middle-income countries

Study Intervention & Comparison

• Care bundle targeting normalization of blood pressure (SBP £140), blood glucose (110-140 or 140-180 if diabetic), body temperature (<37.5°C), and reversal of anticoagulation (INR <1.5) vs usual care

Results

• Primary Safety Outcome
  • Poor functional outcome less likely in care bundle group (OR 0.86, CI 0.76-0.87, p=0.015
• Secondary Safety Outcome
  • Fewer serious adverse events in care bundle group (16% v 20.1%, p=0.0098)

Summary

• The implementation of a care bundle protocol incorporating the early control of elevated blood pressure, blood glucose, and body temperature and correction of abnormal coagulation resulted in an improved functional outcome at 6 months.

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Additional Readings

• Middleton S, McElduff P, Ward J, et al. Implementation of evidence­based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378: 1699–706.
• Parry­Jones AR, Sammut­Powell C, Paroutoglou K, et al. Intracerebral hemorrhage care bundle is associated with lower case fatality. Ann Neurol 2019; 86: 495–503.
• Song L, Wang X, Ouyang M, et al. Associations of an abnormal physiological score with outcomes in acute intracerebral hemorrhage: INTERACT2 study. Stroke 2021; 52: 722–25.

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