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Intracerebral Hemorrhage

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General Information

Description

  • medical emergency characterized by rupture of blood vessels in the brain, usually with bleeding into parenchymal tissue1,4
    • primary - spontaneous hemorrhage unrelated to congenital or acquired lesions
    • secondary - hemorrhage directly related to antithrombotic agent use or underlying congenital or acquired lesions

Also called

  • spontaneous intracerebral hemorrhage
  • cerebral hemorrhage
  • nontraumatic intracerebral hemorrhage
  • hypertensive parenchymal hemorrhage
  • intracranial hemorrhage
  • hemorrhagic stroke

References

General references used

  1. Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009 May 9;373(9675):1632-44OpenInNewfull-textOpenInNew
  2. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al; Councill on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2032-60OpenInNewfull-textPictureAsPdf, commentary can be found in Stroke 2015 Nov;46(11):e236OpenInNew
  3. Steiner T, Kaste M, Forsting M, et al. Recommendations for the management of intracranial haemorrhage - part I: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc Dis. 2006;22(4):294-316OpenInNew
  4. Steiner T, Al-Shahi Salman R, Beer R, et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014 Oct;9(7):840-55OpenInNew
  5. Casaubon LK, Boulanger JM, Blacquiere D, et al; Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015. Int J Stroke. 2015 Aug;10(6):924-40OpenInNew

Recommendation grading systems used

  • American College of Cardiology/American Heart Association (ACC/AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • American College of Physicians (ACP) guideline grading system
    • strength of recommendation
      • Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits
      • Weak - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burdens
      • Insufficient - balance of benefits and risks cannot be determined
    • quality of evidence
      • High - randomized trials without important limitations, or overwhelming evidence from observational studies
      • Moderate - randomized trials with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
      • Low - observational studies or case series
      • Insufficient - evidence is conflicting, poor quality, or lacking
    • Reference - ACP methods for development of clinical practice guidelines and guidance statements (20679562Ann Intern Med 2010 Aug 3;153(3):194OpenInNew)
  • American Heart Association/American Stroke Association (AHA/ASA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • American Heart Association/American Stroke Society (AHA/ASA) 2018 grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
  • Canadian Stroke Best Practice Recommendations (CSBPR) levels of evidence
    • Evidence Level A
      • meta-analysis of randomized controlled trials or consistent findings from ≥ 2 randomized trials
      • desirable effects clearly outweigh undesirable effects or vice versa
    • Evidence Level B
      • single randomized controlled trial or consistent findings from ≥ 2 well-designed nonrandomized and/or uncontrolled trials, and large observational studies
      • desirable effects outweigh or are closely balanced with undesirable effects or vice versa
    • Evidence Level C
      • writing group consensus and/or supported by limited research evidence
      • desirable effects outweigh or are closely balanced with undesirable effects or vice versa
    • Reference - CSBPR Overview and Methodology (CSBPR 2014 PDFPictureAsPdf)
  • European Stroke Organisation (ESO) grading system for recommendations
    • levels of recommendation
      • Strong - intervention's desirable effects clearly outweigh undesirable effects (or clearly do not)
      • Weak - less certain trade-offs due to either low-quality evidence or evidence suggesting close balance of desirable and undesirable effects
    • quality of evidence
      • High - further research very unlikely to change confidence in estimate of effect
      • Moderate - further research likely to have important impact on confidence in estimate of effect; estimate may change
      • Low - further research very likely to have important impact on confidence in estimate of effect; estimate likely to change
      • Very low - any estimate of effect very uncertain
    • Reference - ESO guidelines on management of spontaneous intracerebral hemorrhage (a9h103411940pmdc25156220pInt J Stroke 2014 Oct;9(7):840OpenInNew)
  • European Stroke Initiative (EUSI) grading system for recommendations
    • classifications of recommendations for therapeutic intervention
      • Class I
        • randomized controlled trial or systematic review consisting of randomized, controlled, prospective trials in a sample population with outcome assessment masked
        • requires
          • a) clearly defined primary outcome(s)
          • b) randomization concealment
          • c) clearly defined criteria for exclusion/inclusion
          • d) adequate accounting for crossovers and dropouts with minimal bias potential
          • e) equal baseline characteristics across treatment groups or appropriate adjustment for differences
      • Class II - prospective cohort study in a sample population with outcome assessment masked; trials cannot be lacking > 1 of the criteria needed for a Class I recommendation
      • Class III - controlled trials in a sample population; outcome assessment not dependent on patient treatment
      • Class IV - uncontrolled studies, case reports, case series, or expert opinion
    • classification of recommendations for diagnostic procedures
      • Class I - prospective study with a gold standard applied to a wide range of persons with suspected condition for definition; blinded evaluation testing environment allowing for assessment of relevant tests for diagnostic accuracy
      • Class II - prospective study of a small range of persons with suspected condition, or a well-designed retrospective study with a gold standard applied to a wide range of persons to determine condition compared with a wide range of controls; blinded evaluation testing environment allowing for assessment of relevant tests for diagnostic accuracy
      • Class III - data from a retrospective study with either a small range of people with condition established or with a small range of controls; blinded evaluation testing environment
      • Class IV - any study without blinded evaluation testing or with data from descriptive case series (no controls) or with only expert opinion
    • levels of evidence
      • Level A - effective, ineffective, or harmful; data derived from ≥ 1 Class I study or ≥ 2 reliable Class II studies
      • Level B - likely to be effective, ineffective, or harmful; data derived from ≥ 1 reliable Class II study or overwhelming evidence from a Class III study
      • Level C - probably effective, ineffective, or harmful; data derived from ≥ 2 reliable Class III studies
  • Neurocritical Care Society/Society of Critical Care Medicine (NCS/SCCM) guideline grading system
    • strength of recommendation
      • Strong - most patients should receive the intervention
      • Conditional
        • Most patients would benefit from the intervention, though some may not
        • Assess pros and cons of the intervention, taking into account available evidence and values and preferences of patient
      • Good practice
        • high confidence in estimates of the effect of the intervention, but only indirect evidence that would be challenging to subject to a formalized Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evaluation
    • levels of evidence
      • High - further research is very unlikely to change our confidence in the estimate of effect
      • Moderate - further research is very unlikely to change our confidence in the estimate of effect
      • Low - further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
      • Very low - any estimate of effect is very uncertain
    • Reference - NCS/SCCM guideline on reversal of antithrombotics in intracranial hemorrhage (26714677Neurocrit Care 2016 Feb;24(1):6OpenInNewPDFPictureAsPdf)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115590, Intracerebral Hemorrhage; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115590. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Risk factors

    • Genetic risk factors

    • Factors not associated with increased risk

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Cardiac

      • Lungs

      • KeyboardArrowRight

        Neuro

        • Severity scales

        • Neurological signs and symptoms

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • KeyboardArrowRight

      Clinical prediction rules

      • Secondary intracerebral hemorrhage (SICH) score

      • Boston criteria

    • Blood tests

    • Urine studies

    • KeyboardArrowRight

      Imaging studies

      • Computed tomography (CT)

      • Magnetic resonance imaging (MRI)

      • Catheter angiography

      • Chest x-ray

    • Electrocardiography (ECG)

    • KeyboardArrowRight

      Other diagnostic testing

      • Swallowing assessment and monitoring

      • Seizure assessment and monitoring

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Treatment setting

      • Prehospital management

      • Stroke/specialized unit

    • Supportive care

    • Elevated intracranial pressure

    • Blood pressure management

    • Seizure management

    • KeyboardArrowRight

      Antithrombotic agent and coagulopathy management

      • Recommendations from professional organizations

      • Efficacy

      • Resumption of anticoagulants

    • Antifibrinolytic agents

    • KeyboardArrowRight

      Venous thromboembolism prophylaxis

      • KeyboardArrowRight

        Recommendations for deep vein thrombosis (DVT) prevention

        • American College of Chest Physicians (ACCP)

        • American Heart Association/American Stroke Association (AHA/ASA)

        • American College of Physicians (ACP)

        • Canadian Stroke Best Practice Recommendations (CSBPR)

        • National Institute for Health and Clinical Excellence (NICE)

      • Efficacy

    • Secondary intraventricular hemorrhage (IVH) management

    • KeyboardArrowRight

      Surgical evacuation

      • Indications

      • Early management and perioperative considerations

      • Timing of surgical evacuation

      • Methods of surgical evacuation

    • Consultation and referral

    • KeyboardArrowRight

      Other management

      • Additional treatment considerations

      • Secondary prevention

      • Palliative care or for patients with do not resuscitate (DNR) order

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • Mortality

      • Recurrence and recovery

      • Scoring systems for outcome prediction

      • Negative prognostic factors

      • Factors not associated with negative outcome

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • Guideline comparison

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Central and South American guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Alexander Rae-Grant MD, FRCPC, FAAN
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Affiliations

Deputy Editor Neurology, DynaMed Plus; Massachusetts, United States; Neurologist, Cleveland Clinic; Ohio, United States

Conflicts of Interest

Dr. Rae-Grant declares no relevant financial conflicts of interest.

Recommendations Editor
Esther Jolanda van Zuuren MD
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Affiliations

Head of Allergy, Dermatology, and Venereology, Leiden University Medical Centre; Netherlands

Conflicts of Interest

Dr. van Zuuren declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD, FAAFP
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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Life-threatening intracerebral hemorrhage following saw-scaled viper (Echis carinatus) envenoming

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