Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
KrishnamurthiRVMoranAEForouzanfarMH, et al.The global burden of hemorrhagic stroke: a summary of findings from the GBD 2010 study. Glob Heart2014; 9: 101–106.
2.
FeiginVLNorrvingBMensahGA. Global burden of stroke. Circul Res2017; 120: 439–448.
3.
Canadian Stroke Best Practices Technical Document: Stroke performance indicators 2019. Heart and Stroke Foundation of Canada.
4.
GoereeRBlackhouseGPetrovicRSalamaS. Cost of stroke in Canada: a 1-year prospective study. J Med Econ2008; 8: 147–167.
5.
SpecognaAVPattenSBTurinTCHillMD. Cost of spontaneous intracerebral hemorrhage in Canada during 1 decade. Stroke2014; 45: 284–286.
6.
SpecognaAVTurinTCPattenSBHillMD. Hospital treatment costs and length of stay associated with hypertension and multimorbidity after hemorrhagic stroke. BMC Neurol2017; 17: 158.
7.
Parry-JonesARSammut-PowellCParoutoglouK, et al.An intracerebral hemorrhage care bundle is associated with lower case fatality. Ann Neurol2019; 86: 495–503.
8.
GuyattGHCookDJJaeschkeR, et al.Grades of recommendation for antithrombotic agents: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest2008; 133(6 Suppl): 123s–131s.
9.
ChalelaJAKidwellCSNentwichLM, et al.Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet (London, England)2007; 369: 293–298.
10.
FiebachJBSchellingerPDGassA, et al.Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Stroke2004; 35: 502–506.
11.
van AschCJVelthuisBKRinkelGJ, et al.Diagnostic yield and accuracy of CT angiography, MR angiography, and DSA for detection of macrovascular causes of intracerebral haemorrhage: prospective, multicentre cohort study. BMJ2015; 351: h5762.
12.
Delgado AlmandozJESchaeferPW, Forero NP, Falla JR, Gonzalez RGRomeroJM. Diagnostic accuracy and yield of multidetector CT angiography in the evaluation of spontaneous intraparenchymal cerebral hemorrhage. Am J Neuroradiol2009; 30: 1213–1221.
13.
WilsonDOgungbemiAAmblerG, et al.Developing an algorithm to identify patients with intracerebral haemorrhage secondary to a macrovascular cause. Eur Stroke J2017; 2: 369–376.
14.
DowlatshahiDDemchukAMFlahertyML, et al.Defining hematoma expansion in intracerebral hemorrhage: relationship with patient outcomes. Neurology2011; 76: 1238–1244.
15.
DemchukAMDowlatshahiDRodriguez-LunaD, et al.Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study. Lancet Neurol2012; 11: 307–314.
16.
Al-Shahi SalmanRFrantziasJLeeRJ, et al.Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. Lancet Neurol2018; 17: 885–894.
17.
QureshiAIPaleschYYBarsanWG, et al.Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. New Engl J Med2016; 375: 1033–1043.
18.
LeasureACQureshiAIMurthySB, et al.Association of intensive blood pressure reduction with risk of hematoma expansion in patients with deep intracerebral hemorrhage. JAMA Neurol2019; 76: 949–955.
19.
AndersonCSHeeleyEHuangY, et al.Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. New Engl J Med2013; 368: 2355–2365.
20.
MoullaaliTJWangXMartinRH, et al.Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data. Lancet Neurol2019; 18: 857–864.
21.
GladstoneDJAvivRIDemchukAM, et al.Effect of recombinant activated coagulation factor vii on hemorrhage expansion among patients with spot sign-positive acute intracerebral hemorrhage: the spotlight and stop-it randomized clinical trials. JAMA Neurol2019; 76(12): 1493--1501. doi:10.1001/jamaneurol.2019.2636.
22.
MayerSABrunNCBegtrupK, et al.Recombinant activated factor VII for acute intracerebral hemorrhage. New Engl J Med2005; 352: 777–785.
23.
MayerSABrunNCBegtrupK, et al.Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. New Engl J Med2008; 358: 2127–2137.
SpriggNFlahertyKAppletonJP, et al.Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet (London, England)2018; 391: 2107–2115.
26.
SteinerTPoliSGriebeM, et al.Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol2016; 15: 566–573.
27.
PollackCVJrReillyPAEikelboomJ, et al.Idarucizumab for dabigatran reversal. New Engl J Med2015; 373: 511–520.
28.
ConnollySJCrowtherMEikelboomJW, et al.Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. New Engl J Med2019; 380: 1326–1335.
29.
GrossBAJankowitzBTFriedlanderRM. Cerebral intraparenchymal hemorrhage: a review. JAMA2019; 321: 1295–1303.
30.
de Oliveira ManoelAL. Surgery for spontaneous intracerebral hemorrhage. Crit Care2020; 24: 45.
31.
PrasadKMendelowADGregsonB. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database Syst Rev2008; (4): CD000200. doi: 10.1002/14651858.CD000200.pub2.
32.
MendelowADGregsonBAFernandesHM, et al.Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet (London, England)2005; 365: 387–397.
33.
MendelowADGregsonBA, Rowan EN, Murray GD, Gholkar AMitchellPM. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet (London, England)2013; 382: 397–408.
34.
XiaZWuXLiJ, et al.Minimally invasive surgery is superior to conventional craniotomy in patients with spontaneous supratentorial intracerebral hemorrhage: a systematic review and meta-analysis. World Neurosurg2018; 115: 266–273.
35.
ScaggianteJZhangXMoccoJKellnerCP. Minimally invasive surgery for intracerebral hemorrhage. Stroke2018; 49: 2612–2620.
36.
ZhouXChenJLiQ, et al.Minimally invasive surgery for spontaneous supratentorial intracerebral hemorrhage: a meta-analysis of randomized controlled trials. Stroke2012; 43: 2923–2930.
37.
HanleyDFThompsonRERosenblumM, et al.Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet (London, England)2019; 393: 1021–1032.
38.
SahniRWeinbergerJ. Management of intracerebral hemorrhage. Vasc Health Risk Manag2007; 3: 701–709.
39.
LanghornePFearonPRonningOM, et al.Stroke unit care benefits patients with intracerebral hemorrhage: systematic review and meta-analysis. Stroke2013; 44: 3044–3049.
40.
DiringerMNEdwardsDF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med2001; 29: 635–640.
41.
UngererMNRinglebPReuterB, et al.Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage. Eur J Neurol2020; 27: 825–832. https://doi.org/10.1111/ene.14164.
42.
RonningOMGuldvogBStavemK. The benefit of an acute stroke unit in patients with intracranial haemorrhage: a controlled trial. J Neurol Neurosurg Psychiatry2001; 70: 631–634.
43.
CherianLJSmithEESchwammLH, et al.Current practice trends for use of early venous thromboembolism prophylaxis after intracerebral hemorrhage. Neurosurgery2018; 82: 85–92.
44.
DennisMSandercockPGraham C, Forbes J, CollaborationCTSmithJ. The Clots in Legs Or sTockings after Stroke (CLOTS) 3 trial: a randomised controlled trial to determine whether or not intermittent pneumatic compression reduces the risk of post-stroke deep vein thrombosis and to estimate its cost-effectiveness. Health Technol Assess2015; 19: 1–90.
45.
PaciaroniMAgnelliGVenti M, Alberti A, AcciarresiMCasoV. Efficacy and safety of anticoagulants in the prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled studies. J Thromb Haemost2011; 9: 893–898.
46.
BoeerAVothEHenzeT, et al.Early heparin therapy in patients with spontaneous intracerebral haemorrhage. J Neurol Neurosurg Psychiatr1991; 54: 466–467.
47.
IanosiBGaaschMRassV, et al.Early thrombosis prophylaxis with enoxaparin is not associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage. Eur J Neurol2019; 26: 333–341.
48.
TetriSHakalaJJuvelaS, et al.Safety of low-dose subcutaneous enoxaparin for the prevention of venous thromboembolism after primary intracerebral haemorrhage. Thromb Res2008; 123: 206–212.
49.
QianCLöppönenPTetriS, et al.Immediate, early and late seizures after primary intracerebral hemorrhage. Epilepsy Res2014; 108: 732–739.
50.
GarrettMCKomotarRJStarke RM, Merkow MB, OttenMLConnollyES. Predictors of seizure onset after intracerebral hemorrhage and the role of long-term antiepileptic therapy. J Crit Care2009; 24: 335–339.
51.
AngrimanFTirupakuzhi VijayaraghavanBKDragoi L, Lopez Soto C, ChapmanMScalesDC. Antiepileptic drugs to prevent seizures after spontaneous intracerebral hemorrhage. Stroke2019; 50: 1095–1099.
52.
MesséSRSansingLHCucchiaraBL, et al.Prophylactic antiepileptic drug use is associated with poor outcome following ICH. Neurocrit Care2009; 11: 38–44.
53.
AndersonCSArimaHLavadosP, et al.Cluster-randomized, crossover trial of head positioning in acute stroke. New Engl J Med2017; 376: 2437–2447.
54.
AlexandrovAWTsivgoulisGHillMD, et al.HeadPoST: rightly positioned, or flat out wrong?Neurology2018; 90: 885–889.
55.
O'DonnellMJChinSLRangarajanS, et al.Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet (London, England)2016; 388: 761–775.
56.
O'DonnellMJXavierDLiuL, et al.Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet (London, England)2010; 376: 112–123.
57.
ZhangCQinY-YChenQ, et al.Alcohol intake and risk of stroke: a dose-response meta-analysis of prospective studies. Int J Cardiol2014; 174: 669–677.
58.
BiffiAAndersonCDBatteyTWK, et al.Association between blood pressure control and risk of recurrent intracerebral hemorrhage. JAMA2015; 314: 904–912.
59.
GroupSPSSBenaventeORCoffeyCS, et al.Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet (London, England)2013; 382: 507–515.
60.
ArimaHTzourioCAndersonC, et al.Effects of perindopril-based lowering of blood pressure on intracerebral hemorrhage related to amyloid angiopathy: the PROGRESS trial. Stroke2010; 41: 394–396.
61.
AmarencoPLabreucheJ. Lipid management in the prevention of stroke: review and updated meta-analysis of statins for stroke prevention. Lancet Neurol2009; 8: 453–463.
62.
AmarencoPBogousslavskyJCallahanA III, et al.High-dose atorvastatin after stroke or transient ischemic attack. New Engl J Med2006; 355: 549–559.
63.
McKinneyJSKostisWJ. Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials. Stroke2012; 43: 2149–2156.
64.
ZiffOJBanerjeeGAmblerG, et al.Statins and the risk of intracerebral haemorrhage in patients with stroke: systematic review and meta-analysis. J Neurol Neurosurg Psychiatr2019; 90: 75–83.
65.
RibeARVestergaardCHVestergaardM, et al.Statins and risk of intracerebral haemorrhage in a stroke-free population: a nationwide Danish propensity score matched cohort study. EClin Med2019; 8: 78–84.
66.
GoldsteinLBAmarencoPSzarekM, et al.Hemorrhagic stroke in the stroke prevention by aggressive reduction in cholesterol levels study. Neurology2008; 70(24, Pt 2): 2364–2370.
67.
ProiettiMRomitiGFRomanazziI, et al.Restarting oral anticoagulant therapy after major bleeding in atrial fibrillation: a systematic review and meta-analysis. Int J Cardiol2018; 261: 84–91.
68.
Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial. Lancet (London, England) 2019; 393: 2613–2623.
69.
Al-Shahi SalmanRMinksDPMitraD, et al.Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial. Lancet Neurol2019; 18: 643–652.
70.
OttosenTPGrijotaMHansenML, et al.Use of antithrombotic therapy and long-term clinical outcome among patients surviving intracerebral hemorrhage. Stroke2016; 47: 1837–1843.
71.
KuramatsuJBGernerSTSchellingerPD, et al.Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA2015; 313: 824–836.
72.
NielsenPBLarsenTBSkjøth F Gorst-Rasmussen A, RasmussenLHLipGYH. Restarting anticoagulant treatment after intracranial hemorrhage in patients with atrial fibrillation and the impact on recurrent stroke, mortality, and bleeding: a nationwide cohort study. Circulation2015; 132: 517–525.
73.
MurthySBGuptaAMerklerAE, et al.Restarting anticoagulant therapy after intracranial hemorrhage: a systematic review and meta-analysis. Stroke2017; 48: 1594–1600.
74.
BiffiAKuramatsuJBLeasureA, et al.Oral anticoagulation and functional outcome after intracerebral hemorrhage. Ann Neurol2017; 82: 755–765.
75.
ShoamaneshACharidimouAShethKN. Comorbid atrial fibrillation in cerebral amyloid angiopathyrelated intracerebral hemorrhage: between a rock and a hard place. J Stroke Cerebrovasc Dis2019; 28: 104351.
76.
PennlertJOverholserRAsplundK, et al.Optimal timing of anticoagulant treatment after intracerebral hemorrhage in patients with atrial fibrillation. Stroke2017; 48: 314–320.
77.
WeiJWHeeleyELWangJG, et al.Comparison of recovery patterns and prognostic indicators for ischemic and hemorrhagic stroke in China: the ChinaQUEST (QUality Evaluation of Stroke Care and Treatment) Registry study. Stroke2010; 41: 1877–1883.
78.
BhallaAWangYRuddAWolfeCDA. Differences in outcome and predictors between ischemic and intracerebral hemorrhage: the South London Stroke Register. Stroke2013; 44: 2174–2181.
79.
SreekrishnanALeasureACShiFD, et al.Functional improvement among intracerebral hemorrhage (ICH) survivors up to 12 months post-injury. Neurocritical care2017; 27: 326–333.
80.
SelimMFosterLDMoyCS, et al.Deferoxamine mesylate in patients with intracerebral haemorrhage (i-DEF): a multicentre, randomised, placebo-controlled, double-blind phase 2 trial. The Lancet Neurology2019; 18: 428–438.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
