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CME

Intracerebral Hemorrhage

General Information

Description

  • intracerebral hemorrhage (ICH), a type of stroke, is a medical emergency in which bleeding in the brain, caused by ruptured blood vessels or hemorrhagic lesions, leads to brain tissue damage, clinical symptoms, and, in some patients, death1,4

Also Called

  • ICH
  • cerebral hemorrhage
  • cerebral intraparenchymal hemorrhage
  • intracranial hemorrhage (which includes ICH, subarachnoid hemorrhage, and subdural hematoma)
  • hemorrhagic stroke

Types

  • primary intracerebral hemorrhage (ICH) (reported in 78%-88% of cases) - rupture of damaged small arteries or arterioles usually due to hypertension or cerebral amyloid angiopathy1
  • secondary ICH (less common than primary ICH) can arise from any of several conditions such as rupture of aneurysm or vascular malformation, hemorrhagic tumor, or cerebral venous thrombosis1
  • see Causes for additional potential causes and information

References

General References Used

  1. Gross BA, Jankowitz BT, Friedlander RM. Cerebral Intraparenchymal Hemorrhage: A Review. JAMA. 2019 Apr 2;321(13):1295-1303, commentary can be found in JAMA 2019 Aug 20;322(7):694
  2. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al; Council 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):2032-60, commentary can be found in Stroke 2015 Nov;46(11):e236
  3. 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):924-40
  4. Alerhand S, Lay C. Spontaneous Intracerebral Hemorrhage. Emerg Med Clin North Am. 2017 Nov;35(4):825-845

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
    • Reference - ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline on prevention, detection, evaluation, and management of high blood pressure in adults (29133356Hypertension 2018 Jun;71(6):e13)
  • 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 of Methodology (CSBPR 2019 PDF)
  • 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):840)
  • 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):6)

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team 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 Methodology).
  • 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 users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, 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) 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 synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
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      • 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.
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DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
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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.
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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.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

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