AHA/ASA: New Guidelines on Spontaneous Intracerebral Hemorrhage Management

The American Heart Association (AHA) and the American Stroke Association (ASA) issued a new guideline for caring for people with spontaneous intracerebral hemorrhage (ICH).1

This guideline updates the last guideline on ICH that was published in 2015. Most notably, the new guideline states that several treatments and therapies, such as compression socks/stockings, antiseizure medication and steroid treatments, may not be as beneficial as previously thought and have uncertain effectiveness.

The new guidelines recommend that regional systems providing initial ICH care be developed along with the capacity for rapid transfer of patients to facilities with neurocritical care and neurosurgical capabilities.

They also recommended monitoring hematoma expansion by using a range of neuroimaging markers, including signs detectable by using noncontrast computed tomography, as well as clinical markers such as time since stroke onset and use of antithrombotic agents. In addition, the guideline emphasized the importance of identifying markers of both microvascular and macrovascular hemorrhage pathogeneses.

To lower blood pressure after mild to moderate ICH, they recommended treatment regimens that limit blood pressure variability and achieve smooth, sustained blood pressure control. These regimens may reduce the expansion of the hematoma and provide a better functional outcome. Anticoagulation should be reversed after ICH.

Moreover, for patients with cerebellar hemorrhage, indications for immediate surgical evacuation to reduce mortality now include a larger-volume (greater than 15 mL) hematoma.

Regarding rehabilitation, the guideline notes that aggressive mobilization within the first day after an ICH appeared to worsen 14-day mortality.

Finally, the guideline focused on the importance of the home caregiver as part of the treatment continuum.

“There is no easy path to preventing or curing bleeding strokes, yet there is encouraging progress across all aspects of this disease, from prevention to in-hospital treatment and post-hospital recovery,” said Steven M Greenberg, MD, PhD, chair of the guideline writing group in a press release.2 “We believe the wide range of knowledge set forth in the new guideline will translate into meaningful improvements in ICH care.”


—Ellen Kurek



  1. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53:e1-e80. doi:10.1161/STR.0000000000000407
  2. New guideline refines care for brain bleeds: compression socks, some meds not effective. News release. American Heart Association; May 17, 2022. https://newsroom.heart.org/news/new-guideline-refines-care-for-brain-bleeds-compression-socks-some-meds-not-effective

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