New Guidelines Issued for Intracerebral Hemorrhage

DALLAS, May 8 -- New evidence-based guidelines for treatment of intracerebral hemorrhage suggest reserving surgery for bleeds greater than 3 cm in deteriorating patients or when there is brainstem compression.

The guidelines, published in the June issue of Stroke, Journal of the American Heart Association, also address, for the first time, end-of-life issues and do-not-resuscitate orders in hemorrhagic stroke. The guidelines suggest that DNR orders not be initiated within the first 24 hours after onset of a stroke.

The heart association's guidelines take into account advances in knowledge since 1999, when the first guidelines were issued, and look forward to new approaches in the next few years, according to Joseph Broderick, M.D., of the University of Cincinnati, who chaired the writing committee.

Intracerebral hemorrhage, which causes 10% to 15% of first-ever strokes, has a 30-day mortality rate of 35% to 52%, Dr. Broderick said. "The time is right for updating the guidelines because there have been a number of published studies that may affect how we manage these very sick patients."

Reducing high blood pressure is still the best way to prevent hemorrhagic stroke, the guidelines note. Untreated hypertension increases the risk of stroke 3.5 times.

Since 1999, Dr. Broderick said, the largest-ever trial on surgical management has been completed (the International Surgical Trial in Intracerebral Haemorrhage).

As a result, "we have a better understanding of when and when not to use surgery but we still need more trials," he said.

The guidelines suggest that the hemorrhage should be removed as soon as possible if:

• It's greater than 3 cm.
• The patient is deteriorating neurologically.
• The patient has brain stem compression, hydrocephalus from ventricular obstruction, or both.

Otherwise, surgical treatment isn't recommended, although it might be considered for patients with a lobar clot within 1 cm of the surface, the guidelines recommend.

Medically, patients with intracerebral hemorrhage should be managed in a hospital ICU experienced in treating the condition.

There is some evidence that using recombinant activated factor VII within four hours of the stroke limits bleeding and may reduce the risk of death.

But the use of the drug needs confirmation, Dr. Broderick said, and a large phase III study is expected to report results soon. Until then, he said, the use of recombinant activated factor VII can't be recommended outside of a clinical trial.

The guidelines also recommend that:

• Appropriate antiepileptic therapy should always be used for treatment of seizures.
• Sources of fever should be treated and antipyretic medications should be given as needed.
• Early mobilization and rehabilitation are recommended in patients who are clinically stable.

Research since the first guidelines were released has also shown that magnetic resonance imaging is equivalent to computed tomography in locating the hemorrhage and pinning down its size.

"Before, a CT scan was the primary option for evaluating stroke patients in an emergency," Dr. Broderick said. "Data now show that MRI scans also do the job and both are first-choice options."

CT scanning is likely to remain in more common use, however, because it is faster and because some patients - those with pacemakers, for instance - can't undergo an MRI scan.

A new aspect of the guidelines is discussion of withdrawal of care and end-of-life issues, he said.

The guidelines recommend that do-not-resuscitate orders not be initiated during the first 24 hours after the onset of stroke because they are associated with "an overall lack of aggressiveness of care."

DNR orders are meant to apply only to aggressive treatment in the case of cardiovascular arrest, the guidelines specify, and patients should receive all other forms of care as aggressively as warranted.

"This is the first time the guidelines try to address how and when physicians should discuss 'do-not-resuscitate' orders," Dr. Broderick said.