Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association.

Intracerebral hemorrhage (ICH) is more than twice as common as subarachnoid hemorrhage (SAH) and is much more likely to result in death or major disability than cerebral infarction or SAH.1 Although .315 randomized clinical therapeutic trials for acute ischemic stroke and 78 trials for SAH were complete or ongoing (oral communication, Cochrane Collaboration, May 16, 1995) as of 1995, only the results of 4 small randomized surgical trials (353 total patients)2–5 and 4 small medical trials (513 total patients)6–9 of ICH had been published. In these small randomized studies, neither surgical nor medical treatment has been shown conclusively to benefit patients with ICH. Advancing age and hypertension are the most important risk factors for ICH.10–15 ICH occurs slightly more frequently among men than women and is significantly more common among young and middle-aged blacks than whites of similar ages.10,16 Reported incidence rates of ICH among Asian populations are also higher than those reported for whites in the United States and Europe. Pathophysiological change in small arteries and arterioles due to sustained hypertension is generally regarded as the most important cause of ICH.11,12,14,17,18 Cerebral amyloid angiopathy is increasingly recognized as a cause of lobar ICH in the elderly.19–23 Other causes of ICH include vascular malformations, ruptured aneurysms, coagulation disorders, use of anticoagulants and thrombolytic agents, hemorrhage into a cerebral infarct, bleeding into brain tumors, and drug abuse.10 Of the estimated 37 000 Americans who experienced an ICH in 1997, 35% to 52% were dead at 1 month; half of the deaths occurred within the first 2 days.1,17,24 Only 10% of patients were living independently at 1 month; 20% were independent at 6 months.10,24 Although guidelines for medical treatment and surgical removal of ICH are available, management of ICH by neurologists and neurosurgeons varies greatly throughout the world.25,26 Despite a lack of proven benefit for surgery to remove an ICH, it is estimated that 7000 such operations are performed annually in the United States.10 To address this understudied but common and devastating stroke subtype, the American Heart Association Stroke Council formed a task force to develop practice guidelines for the management of ICH and to suggest areas for future research. Task force members used the rules of evidence for specific treatments used by other panels (Table 1). These rules give greater credence to the results of well-designed clinical trials than anecdotal case reports or case series. The limited number of randomized controlled studies of treatment of ICH severely limit strong, positive recommendations for any intervention. Thus, these guidelines should be viewed as a basis for the development of future clinical trials, which are desperately needed.