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Management of Spontaneous Intracerebral Hemorrhage

2. Inpatient Care Following Intracerebral Hemorrhage

7th Edition – 2020 UPDATE


These recommendations are specific to patients with intracerebral hemorrhage and should be considered in addition to inpatient acute stroke management as defined in the most current CSBPR Acute Stroke Management module.

2.0 Inpatient Care following an Intracerebral Hemorrhage

  1. Medically stable patients with an acute intracerebral hemorrhage should be admitted to an acute stroke unit or neuro-intensive care unit [Evidence Level B], and undergo interprofessional stroke team assessment to determine their rehabilitation and other care needs [Evidence Level B].  Refer to CSBPR Acute Stroke Management Section 8 for more information on stroke unit care. Refer to the CSBPR Rehabilitation and Recovery following Stroke module for additional information regarding rehabilitation assessment.
  2. The goals of care and recovery should be established with patient and/or designated substitute decision-maker [Evidence Level B].
    1. Prognostication for the purpose of modifications to goals of care should generally be deferred for 48 to 72 hours after time of presentation, to determine the extent of deficits, response to medical therapy, and potential for worsening of condition [Evidence Level B].  Refer to the CSBPR Acute Stroke Management Section 10 on Palliative Care for additional information.
    2. Exceptions to deferring prognostication and conservative goals of care may include patients with pre-existing wishes to avoid invasive life-sustaining therapies because of co-morbidities (e.g. dementia) or based on their own previously expressed values [Evidence Level C].
2.1 Venous Thromboembolism Prophylaxis
  1. In the acute phase of ICH, patients should be started on intermittent pneumatic compression devices, beginning the day of admission [Evidence Level A].
  2. Graduated compression stockings are not recommended for DVT prevention [Evidence Level A].
  3. Chemoprophylaxis (low molecular weight heparin) can be initiated after 48 hours and documentation of hematoma stabilization on neuroimaging [Evidence Level B].
    1. Documenting hematoma stabilization requires an additional scan that is separated by at least 24 hours from the baseline scan.
2.2 Seizure Management
  1. People with ICH are at a greater risk of seizures at presentation [Evidence Level B] and should be monitored clinically. 
  2. Consider continuous EEG for the diagnosis of nonconvulsive status epilepticus in patients with depressed level of consciousness that is out of proportion to the size and location of ICH. [Evidence Level B].
  3. New-onset seizures in patients admitted to hospital with ICH should be treated with antiepileptic medications if they are not self-limiting [Evidence Level C].
  4. A single, self-limiting seizure occurring at the onset, or within 24 hours after an ICH (considered an “immediate” post-stroke seizure) should not be treated with long-term anticonvulsant medications [Evidence Level C].  Short-term anticonvulsant therapy can be considered in such cases on an individual basis [Evidence Level C].
  5. Patients who have an immediate post-ICH seizure should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status. Recurrent seizures in patients with ICH should be treated as per treatment recommendations for seizures in other neurological conditions [Evidence Level C].
  6. Prophylactic use of anticonvulsants in patients with ICH is not recommended [Evidence Level B].
2.3 Increased Intracranial Pressure (ICP)
  1. In cases of suspected elevated ICP, conservative methods to decrease ICP (such as elevation of head of bed 30 degrees, methods of neuroprotection (e.g., euthermia, euglycemia), analgesia, and mild sedation) are reasonable [Evidence Level C].
  2. In the absence of concerns regarding ICP, head of bed positioning does not seem to influence neurological outcomes or serious adverse events in stroke patients, including ICH [Evidence Level B].
  3. There is insufficient evidence to recommend the routine or prophylactic use of hyperosmotic agents in ICH [Evidence Level C].
  4. a.
    Hyperosmotic agents (mannitol and/or 3% normal saline) can be considered as a temporizing measure to decrease ICP in ICH patients with clinical signs of herniation prior to surgical intervention [Evidence Level C].
  5. Use of corticosteroids to treat ICP in ICH may cause harm, has no proven benefits, and therefore is not recommended [Evidence Level B].

Clinical Considerations for Section 2.3

  1. Hyperthermia and hyperglycemia have been associated with poor outcomes in ICH patients. In the absence of randomized controlled trial research evidence, it is advisable to target normothermia and normoglycemia in hospitalized ICH patients.
  2. In patients with elevated ICP ensure to avoid compression of neck vessels, particularly when securing endotracheal tubes.
2.4 Rehabilitation following intracerebral hemorrhage

Note: Rehabilitation assessment and management for people who have experienced an ICH generally follow the same approaches as for people with other causes of stroke. Therefore, the CSBPR Recommendations for Rehabilitation and Recovery Following Stroke module apply to this patient population. This includes early assessment during acute inpatient care.

  1. Patients with ICH should have continued monitoring for rehabilitation readiness beyond conventional time frames used in ischemic stroke patients due to emerging evidence regarding their prolonged recovery trajectories [Evidence Level B].

    Note: Early assessments for rehabilitation readiness may underestimate rehabilitation potential.

Rationale +-

Stroke unit care reduces the likelihood of death and disability by as much as 30 percent for men and women of any age with mild, moderate, or severe stroke. Stroke unit care is characterized by a coordinated interdisciplinary team approach for preventing stroke complications, preventing stroke recurrence, accelerating mobilization, and providing early rehabilitation therapy. Evidence suggests that stroke patients treated on acute stroke units have fewer complications, earlier mobilization, and pneumonia is recognized earlier. Patients should be treated in a geographically defined unit, as care through stroke pathways and by roving stroke teams do not provide the same benefit as stroke units. Access to early rehabilitation is a key aspect of stroke unit care. For patients with stroke, rehabilitation should start as early as possible and rehabilitation should be considered an intervention that can occur in any and all settings across the continuum of stroke care.

System Implications +-
  1. Organized systems of stroke care including stroke units with a critical mass of trained staff (interdisciplinary team). If not feasible, then mechanisms for coordinating the care of stroke patients to ensure use of best practices and optimal outcomes.
  2. Protocols and mechanisms to enable the rapid transfer of ICH stroke patients from the Emergency Department to a specialized stroke unit as soon as possible after arrival in hospital, ideally within the first six hours.
  3. Comprehensive and advanced stroke care centres should have leadership roles within their geographic regions to ensure specialized stroke care access is available to patients who may first appear at general health care facilities (usually remote or rural centres) and facilities with basic stroke services only.
  4. Telestroke service infrastructure and utilization should be optimized to ensure access to specialized stroke care across the continuum to meet individual needs (including access to rehabilitation and stroke specialists) including the needs of northern, rural and remote residents in Canada.
  5. Information on geographic location of stroke units and other specialized stroke care models available to community service providers, to facilitate navigation to appropriate resources and to strengthen relationships between each sector along the stroke continuum of care.
Performance Measures +-

System Level

  1. Proportion of ICH patients treated in a Level 4 or Level 5 stroke centre.

Clinical Measures

  1. Number of ICH patients who are admitted to hospital and treated on a specialized stroke unit at any time during their inpatient hospital stay for an acute stroke event (numerator) as a proportion of total number of stroke patients admitted to hospital (core).
  2. Proportion of ICH patients who die in hospital within 7 days and within 30 days of hospital admission for an index stroke (core).
  3. Proportion of total time in hospital for an acute ICH spent on a stroke unit.
  4. Proportion of patients admitted to a stroke unit, who arrive in the stroke unit within 24 hours of Emergency Department arrival.
  5. Percentage of patients admitted to hospital with a diagnosis of acute stroke who experience one or more complications during hospitalization (deep venous thrombosis, pulmonary embolus, secondary cerebral hemorrhage, gastrointestinal bleeding, pressure ulcers, urinary tract infection, pneumonia, seizures [or convulsions]) during inpatient stay.
  6. Median length of stay during acute phase of care for ICH patients admitted to hospital (core). (Stratify by stroke type).
  7. Percentage of ICH patients who experienced prolonged length of stay beyond expected length of stay as a result of experiencing one or more complications.
  8. Percentage of ICH patients who had a referral to specialist palliative care services during inpatient care.
  9. Percentage of dying ICH patients who were placed on an end-of-life care protocol.
  10. Percentage of ICH patients who die in the location specified in their palliative care plan.

Patient-Oriented Outcomes

  1. Self-reported quality of life following ICH using a validated measurement tool.
  2. Proportion of ICH patients discharged to their home or place of residence following an inpatient admission for stroke (core).
  3. Family and caregiver ratings on the palliative care experience following the death in hospital of a patient with ICH.

Measurement Notes

  1. Level 4 and 5 centres based on SBP criteria, these facilities include a stroke unit and access to neurosurgical services onsite.
Summary of the Evidence +-

Evidence Table and Reference List

Specialized Units

While it is now well-accepted that patients with ischemic stroke admitted to a stroke unit featuring dedicated beds and staff have better outcomes compared with patients admitted to general or less-specialized units, there is also evidence that the subset of patients who have experienced ICH realize the same benefits. In a systematic review, Langhorne et al (2013) included the results from 8 trials in which patients with ischemic and hemorrhagic stroke were randomized to receive care on a stroke unit or an alternative setting. Stroke unit care was associated with significant reductions in the risk of death or dependency (mRS 3-5) (RR=0.81, 95% CI 0.71-0.92, p<0.0001) and death (RR=0.79, 95% CI 0.64-0.97, p=0.02), with no significant interactions based on stroke type. Diringer & Edwards (2001) reviewed the charts of 1,038 patients who had been admitted to either a neuro-ICU (n=2) or a medical and/or surgical ICU (n=40) following ICH and reported that after adjusting for demographics, severity of ICH, and ICU and institutional characteristics, admission to a general ICU was associated with an increase in hospital mortality (OR=3.4; 95% CI 1.65–7.6). Additional independent predictors of higher mortality were advancing age, lower GCS scores, fewer ICH patients treated and smaller ICU size. In contrast, having a full-time intensivist was associated with lower mortality rate. Ronning et al. (2001) also reported improved survival during the first 30 days and one year following admittance to an acute stroke unit care. At 30 days, fewer patients in the stroke unit group were dead (39% vs. 63%, adjusted OR=0.40, 95% CI 0.17-0.94). There was no difference in one-year mortality between groups (52% vs. 69%, adjusted OR=0.58, 95% CI 0.24-1.38), or the number of patients discharged home between groups (27% vs. 52%, adjusted OR=1.60, 95% 0.62-4.00).

Venous Thromboembolism (VTE) Prophylaxis

The use of external compression stockings/devices was investigated in a series of three large, related RCTs, the Clots in Legs Or sTockings after Stroke (CLOTS) trials. In the third trial, CLOTS 3 (Dennis et al. 2013), patients were randomized to a wear thigh length intermittent pneumatic compression (IPC) device or to no IPC for a minimum of 30 days. Of the 2,876 patients included, 13% had suffered an ICH. The mean duration of IPC use was 12.5 days and 100% adherence to treatment was achieved in only 31% in the IPC group. The incidence of proximal DVT within 30 days was significantly lower for patients in the IPC group (8.5% vs. 12.1%, OR=0.65, 95% CI 0.51-0.84, p=0.001, ARR=3.6%, 95% CI 1.4%-5.8%). There were no significant differences between groups for the outcomes of: death at 30 days (10.8% vs. 13.1%, p=0.057), symptomatic proximal DVT (2.7% vs. 3.4%, p=0.269), or pulmonary embolism (2.0% vs. 2.4%, p=0.453). The incidence of any DVT (symptomatic, asymptomatic, proximal or calf) was significantly lower for IPC group (16.2% vs. 21.1%, OR=0.72, 95% CI 0.60-0.87, p=0.001). At 6 months, the incidence of any DVT remained significantly lower in the IPC group (16.7% vs. 21.7%, OR=0.72, 95% CI 0.60-0.87, p=0.001). The incidence of any DVT, death or PE also remained significantly lower for IPC group (36.6% vs. 43.5%, OR=0.74, 95% CI 0.63-0.86, p<0.0001). In a systematic review and meta-analysis, Paciaroni et al. (2011) reported that early treatment with UFH and LMWH initiated between 1-6 days following ICH led to a significant reduction in the incidence of pulmonary embolus (1.7% vs. 2.9%; P = 0.01), without an increase in hematoma expansion. In a small randomized trial of 68 patients with ICH, participants randomized to LWMH on day 2 following their ICH experienced fewer pulmonary emboli than those randomized to initiate treatment on days 4 and 10, without an apparent increase in rebleeding (Boeer et al. 1991).

Seizure Management

Following ICH, patients are at increased risk of seizures. Early-onset seizure typically occur at or near event onset, and are thought to be less common, while late-onset seizures occur 6-12 months post event. Whether to treat a first occurrence of a post stroke seizure following an ICH, is a topic of debate. Individual patient risk factors should be considered. However, long-term use of antiepileptic drugs (AED) has not been shown to be effective at reducing the odds of recurrent seizure (Angriman et al. 2019), and may be associated with poor outcome (Messe et al. 2009). There are very few studies that have the use of AEDs in stroke, generally and following ICH, specifically.

Increased Intracranial Pressure

While a wide variety of nonsurgical interventions are used commonly to lower intracranial pressure following ICH, including head elevation, hyperosmotic agents, hyperventilation, analgesia, and sedation, RCT evidence of their effectiveness is lacking. Head‑ PoST (Anderson et al. 2017) randomized over 11,000 patients following stroke to receive care in either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees, which was initiated as soon as possible and maintained for 24 hours). There were no significant differences between groups in any of the primary or secondary clinical outcomes (mRS scores, death or major disability at 7 and 90 days). The results were similar in the subgroup of 8% of patients with ICH.

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