&

Essential Topics About the Imaging

Diagnosis and Treatment of
Hemorrhagic Stroke:
A Comprehensive Review of the 2022
AHA Guidelines
Cesar-Alejandro Gil-Garcia, MS, IV1,
Eduardo Flores-Alvarez, MD, MSc2,
Ricardo Cebrian-Garcia, MD3,
Abril-Carolina Mendoza-Lopez, MS, V4,
Leslie-Marisol Gonzalez-Hermosillo, MD5,
Maria-del-Carmen Garcia-Blanco, MD, MBA6, and
Ernesto Roldan-Valadez, MD, MSc, DSc5,7*
From the 1 Facultad de Medicina, Universidad Aut onoma de Sinaloa, Los Mochis, Sinaloa, M exico,
2
Cirugia Neurologica, Hospital Angeles Mexico, CDMX, Mexico, 3 Unidad de Terapia Intensiva,
Hospital Angeles Acoxpa, CDMX, Mexico, 4 Facultad de Medicina, Benem erita Universidad Auton-
oma de Puebla, Puebla, M exico, 5 Directorado de investigaci
on, Hospital General de Mexico “Dr.
Eduardo Liceaga,” CDMX, Mexico, 6 Departamento de Radiologia, Hospital Angeles Acoxpa,
CDMX, Mexico and 7 I.M. Sechenov First Moscow State Medical University (Sechenov University),
Department of Radiology, Moscow, Russia.

Abstract: Intracerebral hemorrhage (ICH) is a severe

stroke with a high death rate (40% mortality). The prev-
alence of hemorrhagic stroke has increased globally,
with changes in the underlying cause over time as antico-
agulant use and hypertension treatment have improved.
The fundamental etiology of ICH and the mechanisms
of harm from ICH, particularly the complex interaction
between edema, inflammation, and blood product toxic-
ity, have been thoroughly revised by the American Heart
Association (AHA) in 2022. Although numerous trials
have investigated the best medicinal and surgical man-
agement of ICH, there is still no discernible improve-
ment in survival and functional tests.

Curr Probl Cardiol 2022;47:101328

0146-2806/$ see front matter
https://doi.org/10.1016/j.cpcardiol.2022.101328

Curr Probl Cardiol, November 2022 1

 Small vessel diseases, such as cerebral amyloid angiop-
athy (CAA) or deep perforator arteriopathy (hyperten-
sive arteriopathy), are the most common causes of
spontaneous non-traumatic intracerebral hemorrhage
(ICH). Even though ICH only causes 10%-15% of all
strokes, it contributes significantly to morbidity and
mortality, with few acute or preventive treatments
proven effective.
Current AHA guidelines acknowledge up to 89% sensi-
tivity for unenhanced brain CT and 81% for brain
MRI. The imaging findings of both methods are helpful
for initial diagnosis and follow-up, sometimes necessary
a few hours after admission, especially for detecting
hemorrhagic transformation or hematoma expansion.
This review summarized the essential topics on hemor-
rhagic stroke epidemiology, risk factors, physiopathol-
ogy, mechanisms of injury, current management
approaches, findings in neuroimaging, goals and out-
comes, recommendations for lifestyle modifications, and
future research directions ICH. A list of updated refer-
ences is included for each topic. (Curr Probl Cardiol
2022;47:101328.)
Keywords: Intracerebral Hemorrhage; Stroke Classification; Epidemiology;
Physiopathology; Diagnosis and Assessment; Neuroimaging; Evolution; Surgi-
cal Interventions; Outcome and Goals; Lifestyle Modifications

Introduction

&
T
oday, one of the main challenges we face in hospital emergency
rooms is stroke, which must be treated immediately to safeguard
the neurological integrity of the patients. The World Health
Organization (WHO) definition of stroke as “rapidly developing clinical
signs of focal (at times global) disturbance of cerebral function, lasting
more than 24 hours or leading to death with no apparent cause other than
that of vascular origin” is still the accepted standard.1
Evidence of clinical practice guidelines recommendations to improve
clinical practice for stroke applicable to patients with or not at risk of
developing cerebrovascular disease has been published by the American
Heart Association (AHA) and American Stroke Association (ASA) since
1990.2

2 Curr Probl Cardiol, November 2022

 Ischemic stroke (IS) and hemorrhagic stroke (HS) are the 2 main cate-
gories that apply to stroke.3 When talking about hemorrhagic strokes,
including intracerebral hemorrhage (ICH) and subarachnoid hemorrhage
(SAH) brought on by aneurysm rupture at the base of the brain 4.
Although both ICH and SAH may now be diagnosed quickly, death and
morbidity rates for both kinds of hemorrhagic stroke convey high mortal-
ity.5-7 Intracerebral hemorrhage (ICH) is the most common hemorrhagic
stroke subtype, and rates increase with an aging population 8 Figure 1
shows the most common types of hemorrhagic stroke.
Spontaneous, non-traumatic ICH can be due to an underlying lesion
such as a tumor, vascular lesion, or angiopathy. Though most cases in the
adult population are not attributable to an underlying lesion, hypertension
is the most common systemic risk factor in up to 70% of ICH patients. It
is associated with increased morbidity and mortality in all age groups. 9
Considering the information mentioned above in this review is focused
on the practical aspects related to hemorrhagic stroke; the main topics
covered are epidemiology, imaging diagnosis, medical treatment (acute
blood pressure lowering, anticoagulant-related bleeding, hemostasis, and
coagulopathy)

Epidemiology of ICH
Approximately 10 % of the 795, 000 strokes per year in the United States
are intracerebral hemorrhages.10 Defined by brain injury attributable to
acute blood extravasation into the brain parenchyma from a ruptured cere-
bral blood vessel, both domestically and globally, populations with fewer
resources tend to be more susceptible to the clinical effects of ICH.2
According to the research conducted in the US, the incidence of ICH is
1.6 times higher in black people than white people 11 and 1.6 times higher
in Mexican Americans than non-Hispanic white people.12 Internationally,
as a percentage of all strokes and in absolute incidence rates, ICH inci-
dence is significantly most significant in the low- and middle. In income
nations than in high-income ones,13,14 the epidemiological characteristics
of strokes are found in Figure 2.
Several additional features of ICH make it a more significant public
health threat than conveyed by incidence number alone. With an early-term
fatality rate of between 30% and 40 % and little to no improvement during
more recent years, ICH is undoubtedly the worst type of acute stroke.15-18
Even with counterbalancing public health advancements in blood pres-
sure (BP) control, the incidence of ICH rises dramatically with aging and
is therefore anticipated to remain significant as the population ages.17

Curr Probl Cardiol, November 2022 3

4
Curr Probl Cardiol, November 2022

FIG 1. Types and most common causes of hemorrhagic stroke.

Curr Probl Cardiol, November 2022

FIG 2. Epidemiological characteristics of hemorrhagic stroke.

5
 Anticoagulants are being used more frequently, another rising source
of ICH19; direct oral anticoagulants (DOACs) are increasingly prescribed
compared to vitamin K antagonists (VKas), an expected trend to balance
the lower ICH risk associated with VKas.20

Fatality
Around 40% of ICH cases die during the first month, and 54% do so
within the first year. Twelve percent to 39% of patients can maintain their
functional independence over time. A meta-analysis of ICH outcomes
between 1980 and 2008 revealed no meaningful change in case fatality
rate over that time18; however, retrospective investigations of sizable
cohorts in the United Kingdom and the United States announced a
marked decline in case of fatality since 2000.21,22 Early stroke case fatal-
ity (21-day to 1 month) differed significantly between countries and
research periods, according to a global epidemiology study on stroke; the
case fatality rate was 25%-30% in high-income nations, while it was
30%-48% in low to medium-income countries.13 Critical care has
improved, which may cause a decline in ICH fatality rates.13 According
to data from the country’s insurance database, as much as 35% of ICH
cases in Korea were fatal in 2004. But in 2009, the 30-day case fatality
rate for in-hospital patients was substantially lower, at 10.2%.23

Physiopathology of ICH

Hypertensive Vascular Change

ICH is usually caused by ruptured vessels degenerating due to long-
standing hypertension. (Insert reference). Responsible arteries show
prominent degeneration of the media and smooth muscles (2) Fibrinoid
necrosis of the sub.-endothelium with micro-aneurysms and focal dilata-
tions may be seen in some patients. Lipohyalinoses, prominently related
to long-standing hypertension, are most often found in non-lobar ICH
(22), whereas cerebral amyloid angiopathy (CAA) is relatively more
common in lobar ICH (23).

Small Vessel Disease Types

Arteriosclerosis (also referred to as Lipohyalinoses) and cerebral amy-
loid angiopathy (CAA) are the 2 prevalent cerebral small artery diseases
that make up the vast majority of primary ICH. Each is a frequent age-

6 Curr Probl Cardiol, November 2022

related pathology that is found at autopsy in 30%-35% of participants in a
longitudinal study of aging, ranging from mild to severe cases.24

Arteriosclerosis
Arteriosclerosis, also known as Lipohyalinoses, is identified as concen-
tric hyalinized arterial wall thickening that prefers the penetrating arterio-
les of the basal ganglia, thalamus, brainstem, and deep cerebellar nuclei
together referred to as deep regions. Age, diabetes, and, most essential,
hypertension are its main risk factors.

Cerebral Amyloid Angiopathy (CAA)

Cerebral Amyloid Angiopathy is a significant cause of intracerebral
hemorrhage (ICH) in the elderly and an essential contributor to age-
related cognitive decline.25-27 CAA is defined by depositing the b-amy-
loid peptide in the walls of arterioles and capillaries in the leptomeninges,
cerebral cortex, and cerebellar hemispheres (lobar territories). The pri-
mary risk factors for CAA are age and apolipoprotein E genotypes con-
taining the e2 or e4 alleles. ICH develops in a relatively small percentage
of brains with severe arteriolosclerosis or CAA. These brain regions are
preferred by the underlying pathologies: deep territories for arterioloscle-
rosis and lobar territories for CAA.2

ICH- Related Brain Injury Mechanisms

Primary Brain Injury

Intense intracranial pressure (ICP) and mechanical compression of
local structures result in mass effect mechanical disruption from extrava-
sated blood, which produces an instant primary brain injury. This second
condition can be especially fatal when bleeding takes place in the poste-
rior fossa, where local compression of the aqueduct of Sylvius can cause
obstructive hydrocephalus, or local compression of the brainstem can
cause cardiorespiratory failure. Hematoma enlargement is highly com-
mon, and one study found that it happens in more than one-third of
patients in the first 24 hours following a stroke.28 Evidence of a “spot
sign” on CT angiography is highly sensitive and specific for predicting
hematoma expansion when noted within three hours of symptom onset.29
Ischemia and vascular compression brought on by herniation syn-
dromes may occur from global elevations in ICP. However, animal and
human research indicate that in non-herniation syndromes, the decreased

Curr Probl Cardiol, November 2022 7

perihematomal blood flow found with ICH is not low enough to result in a
local ischemic penumbra or core and may instead be caused by a
decreased metabolic demand in the surrounding tissue, as shown by sta-
ble or reduced oxygen extraction fractions.30,31

Secondary Brain Injury

Secondary brain injury is brought on by the hematoma’s physiological
reaction (mainly edema and inflammation) and the toxic biochemical and
metabolic consequences of the clot’s constituent parts. In addition to clot
removal, pharmaceutical methods are also used to avoid subsequent brain
injury.8

Edema
After an ICH, perihematomal edema can develop within hours and last
for days to weeks 32; within the first 24 hours following an ICH, perihe-
matomal edema typically increases by 75%.33
With an initially intact blood-brain barrier, some edema is caused by
clot retraction and serum protein accumulation around the clot.34 A key
player in hemostasis during ICH, thrombin also contributes to the break-
down of endothelial cells and the blood-brain barrier. It is an active com-
ponent of the last common pathway in the coagulation cascade.
Thrombin is implicated in the formation of vasogenic edema in experi-
mental models,35 and its inhibition has been proposed as a way to reduce
perihematomal edema after adequate hemostasis of the clot.36
In addition, it has been demonstrated in experimental models that
erythrocyte components carbonic anhydrase, heme, and iron, as well as
hemoglobin and its breakdown products, contribute to brain edema.37
Although edema may resolve, K+, Cl, and Na+ processing problems may
still exist in the cell wall.38

Inflammation
Previous studies have described the role of inflammation in both injury
and recovery from ICH, inflammatory responses in the local perihemato-
mal area and systemically are noted after experimental ICH, and both can
have harmful effects.39,40
Locally, diapedesis of neutrophils occurs within days, and subse-
quently, microglia are activated. Clinically, systemic infection rates are
high with ICH, with 31% of patients in one study having an infection fol-
lowing hemorrhage.41

8 Curr Probl Cardiol, November 2022

Blood Product Toxicity
Another factor contributing to secondary brain injury is hypothesized
to be the toxic effects of hemoglobin, iron, and other blood components
on the nearby brain. In an experimental ICH model, the injection of lysed
blood cells generated significant edema; this effect was not observed
acutely with the injection of packed erythrocytes, indicating that the lysed
products themselves are the leading causes of brain injury.42

Risk Factors
Hypertension, cigarette smoking, excessive alcohol use, low-density
lipoprotein cholesterol, low triglycerides, and medications like sympatho-
mimetics, anticoagulants, and antithrombotic agents are all modifiable
risk factors.2
The risk factors that cannot be changed are old age, male sex, CAA,
and Asian ethnicity. The INTERSTROKE43 study, a case-control investi-
gation involving 6,000 people from 22 different nations, revealed that
high blood pressure, smoking, a high waist-to-hip ratio, diet, and alcohol
consumption were significant risk factors for ICH. These modifiable risk
factors accounted for 88.1% of the population-attributable risk.44
The most significant risk factor for spontaneous ICH is hypertension,
which contributes more to deep ICH than lobar ICH. Patients with deep
ICH are twice as likely to have hypertension as patients with lobar ICH,
according to studies.45-47
Heavy alcohol consumption48 and current smoking49 are linked to an
increased risk of ICH. A case-control study conducted in Australia
revealed a negative correlation between the cholesterol levels and the
risk of ICH.50 Another study discovered that more sense ICH was linked
to lower levels of total cholesterol and low-density lipoprotein
cholesterol.23
According to meta-analyses, antiplatelet therapy was linked to a slight
but significant increase in the risk of ICH. However, several case-control
studies did not demonstrate an increased ICH risk with antiplatelet use.50,
51
Additionally, a meta-analysis revealed that prior antiplatelet use was
linked to a higher risk of death following an ICH. Additional research
demonstrated a link between previous antiplatelet use and a higher risk of
early hematoma growth.52 Dual antiplatelet therapy is particularly likely
to increase the risk of ICH compared to antiplatelet monotherapy.
Patients with atrial fibrillation who take aspirin plus clopidogrel have
almost twice the risk of developing ICH than those who take aspirin alone
(0.4 vs 0.2 percent).53

Curr Probl Cardiol, November 2022 9

 Associations between ICH and sympathomimetic drugs like cocaine,
heroin, amphetamine, and ephedrine have been reported in young
patients. A relatively high dose of phenylpropanolamine was an indepen-
dent risk factor for hemorrhagic stroke, especially in women. A low dose
of phenylpropanolamine found in cold medications was linked in a
Korean case-control study to a higher risk of hemorrhagic stroke in
females.54
A population-based study discovered that chronic kidney disease
increased the risk for ICH, and the association remained significant even
after controlling for covariates.55 The primary mechanism of hyperten-
sive ICH is cerebrovascular small vessel disease, which may be indicated
by chronic kidney disease. The increased risk of ICH in people with
chronic kidney disease may also be due to platelet dysfunction. People
with chronic kidney disease may also have an increased risk of ICH
because of platelet dysfunction.
Cerebral microbleeds (CMBs) are detected in 5-23 elderly individuals.
According to the Framingham study, men and older people were more
likely than women to have CMBs. In additional studies, CMBs were
linked to smoking, diabetes mellitus, and hypertension CMBs may
increase the risk of warfarin or antiplatelet-associated ICH and are linked
to an increased risk of spontaneous ICH.56 Therefore, when using antith-
rombotics in patients with CMBs, it is essential to weigh the benefits and
risks.57 Another possible risk element is an increased risk of ICH may be
linked to a greater number of births. Multiparous women have a signifi-
cantly higher risk of developing ICH than those who are nulliparous or
uniparous, and this risk tends to rise with increasing parity.58 Longer
working hours, more strenuous workdays, and blue-collar work may all
increase the risk of developing ICH.58 Additionally, it was noted that
sleeping for extended periods (8 hours or more) increased the risk of
developing ICH.59 All risk factors are summarized in Figure 3.

Diagnosis and Assessment

In patients with spontaneous ICH, focused history, physical examina-
tion (Table 1), standard laboratory work and tests (such as complete
blood count, prothrombin time/international normalized ratio [INR]/par-
tial thromboplastin time, glucose, cardiac troponin and ECG, toxicologi-
cal screen, and inflammatory markers) should be completed in patients
with spontaneous ICH to determine the kind of bleeding, active medical
conditions, and inflammation indicators.60,61

10 Curr Probl Cardiol, November 2022

Curr Probl Cardiol, November 2022

FIG 3. Risk factors are classified as a) modifiable risk, b) non-modifiable risk, and c) other factors related to the risk. It is essential to identify an acute treatment
for hemorrhagic strokes.
11
TABLE 1. Physical examination and laboratory assessment in patients with intracerebral hemor-
rhage (ICH)

Assessment type
History
Symptoms Headache
Thunderclap: Aneurysm, RCVS, CVST (some
instances) Slower onset: Mass lesion, CVST
(some cases), ischemic stroke with hemorrhagic
transformation
Focal neurologic deficits
Seizures
Decreased level of consciousness
Vascular risk factors Ischemic stroke
Prior ICH
Hypertension
Hyperlipidemia
Diabetes
Metabolic syndrome
Imaging biomarkers
Medications Antithrombotic: anticoagulants, thrombolytic,
antiplatelet agents, NSAIDs
Vasoconstrictive agents: triptans, decongestants,
stimulants, phentermine, sympathomimetic drugs
Antihypertensives
Estrogen-containing oral contraceptives
Cognitive impairment/ dementia With or without amyloid angiopathy
Substance use Smoking
Alcohol use
Marijuana
Sympathomimetic drugs
Liver disease, uremia, malignancy, It May be associated with coagulopathy
hematological disorders
Physical examination
Vital signs
A general physical examination focusing
on the head, heart, lungs, abdomen,
and extremities
A focused neurological examination A structured examination (NIHSS), GCS (in patients
with impaired level of consciousness)
Complimentary assessment
Complete blood count, BUN, and
creatinine, liver function tests, glucose,
inflammatory markers
Prothrombin time, INR, activated partial
thromboplastin time
Cardiac-specific troponin and ECG
Urine toxicology screen
Pregnancy test (woman of childbearing
age)
Abbreviations: RCVS, reversible cerebral vasoconstriction syndrome; CVST, cerebral venous
sinus thrombosis; NSAID, non-steroidal anti-inflammatory drug; NIHSS, National Institutes of
Health Stroke Scale; GCS, Glasgow Coma Scale; BUN, blood urea nitrogen; INR, international
normalized ratio; ECG, electrocardiogram.

12 Curr Probl Cardiol, November 2022

 Routine laboratory work provides essential information about coagula-
tion status and organ function that must be addressed rapidly in the set-
ting of a spontaneous ICH. A rapid assessment of laboratory data such as
complete blood count and coagulation profile can help to diagnose coa-
gulopathy attributable to medications or underlying medical conditions
such as hematologic malignancies.62
Targeted therapy that can improve results may result from this. The
coagulation status of surgical patients is crucial in determining whether
craniotomy or external ventricular drainage (EVD) can be done safely.
The clinical picture can be complicated by electrolyte imbalances, renal
failure, and acute cardiac syndromes, all of which call for immediate care
after being admitted to the hospital.63

Neuroimaging for ICH Diagnosis

Neuroimaging modalities, such as CT and MRI, are the critical starting
point in evaluating patients with hemorrhagic stroke 64. To determine
ICH volume (often estimated using the ABC/2 formula (Figure 4) and
distinguish ICH from ischemic stroke, brain imaging is crucial. Due to its
widespread availability, speed, high diagnostic accuracy, and simplicity,
CT is the imaging modality most frequently used to confirm (or rule out)
the presence of ICH. However, MRI using susceptibility-weighted or
echo-planar gradient echo sequences can also accurately detect hyper-
acute ICH.65,66
When coupled with the physical examination to calculate the ICH
score using the variables in Table 2, calculating the hematoma volume
enables better prognostication and communication between medical pro-
fessionals. Brain imaging can help predict outcomes and track the pro-
gression of ICH while the condition is acute. Hematoma expansion
frequently happens quickly after ICH (typically within 24 hours of ICH
onset), and it is linked to mortality and poor outcomes. Figure 5 shows
the evolution of hemorrhagic strokes)28,67,68; Figure 6 shows the sensitiv-
ity and specificity of CT and MRI for hemorrhagic strokes.
Identifying a spot on a CTA or contrast-enhanced CT or specific imag-
ing features on NCCT, such as heterogeneous densities within the hema-
toma or irregularities in it, may impact the triage, monitoring intensity,
and outcome prognostication for such patients. In patients whose neuro-
logical condition worsens, in those whose level of consciousness is
impaired, or in those whose examination is constrained, repeating the CT
after the initial scan to look for the development of hydrocephalus, peri-
hematomal edema, or hematoma expansion can be beneficial.69,70

Curr Probl Cardiol, November 2022 13

FIG 4. The estimated blood volume is the product of these three dimensions divided by 2, but
the average slice thickness for standard head CT protocols is 0.5 cm. As a result, to make calcu-
lations more straightforward, one can multiply A and B by the number of slices on which contigu-
ous blood is visible, then divide by 2.

Identification of Hemorrhage
Any patient exhibiting symptoms of acute neurologic dysfunction
should have their likelihood of suffering a hemorrhagic stroke evaluated.
A non-contrast head CT is typically the first diagnostic method used in

TABLE 2. Determination of ICH score (modified from Hakimi et al. 64)

Component Original score point ICH score points

Glasgow Coma Scale 3-4 2
5-12 1
13-15 0
ICH volume ml 30 1
<30 0
Intraventricular hemorrhage Yes 1
No 0
Infratentorial origin Yes 1
No 0
Age (y) 80 1
<80 0
Total ICH score 0-6

14 Curr Probl Cardiol, November 2022

Curr Probl Cardiol, November 2022

FIG 5. Evolution of hemorrhagic stroke; the upper row of images (A-D) describes the first CT, and the lower row (E-H) represents the second CT after 18 hours
of the hemorrhagic stroke.
15
16
Curr Probl Cardiol, November 2022

FIG 6. Sensitivity and specificity of both studies MRI and CT for hemorrhagic stroke (modified from Hakimi et al. 64).
such situations due to its distinct advantages over other neuroimaging
tools, such as MRI, in emergencies. Due to its high sensitivity and speci-
ficity for identifying acute blood, lower cost, feasibility in unstable
patients, and widespread availability, CT is the first neuroimaging modal-
ity of choice in most acute situations.64
Rapid neuroimaging with CT or MRI is recommended to distinguish
between an intracerebral hemorrhage (ICH) and an ischemic stroke.71 A
hyperdense lesion can be seen on a head CT when someone has acute
ICH. Because the lesion will eventually become isodense with the brain
parenchyma, usually after 1 week, the sensitivity of CT is lower than that
of MRI at this point. The use of CT imaging not only helps to locate the
hemorrhage but also to determine intraventricular extension, gauge the
severity of cerebral edema and mase effects, and calculate the size of the
hemorrhage. The ABC/2 method converts a hematoma’s centimeter-scale
size into a milliliter volume and is the most straightforward way to calcu-
late the amount of blood present on a head CT scan.72 Within the first 3
hours of symptom onset, one-third of patients will have hematoma expan-
sion on a subsequent head CT.71 The spot sign, where contrast is seen
within the hemorrhage and suggests active bleeding, can be used to iden-
tify such patients earlier using a head CTA or a contrast-enhanced head
CT.

Disease-specific States and Neuroimaging

Arterial Hypertensive Vasculopathy

Non-traumatic ICH is most frequently caused by arterial hypertensive
vasculopathy, most commonly linked to chronic arterial hypertension.73
It primarily affects the perforating arteries of the basilar artery, the tha-
lamic perforators arising from the posterior communicating and posterior
cerebral arteries, and the lenticulostriate branches of the middle cerebral
arteries. As a result, specific anatomical locations tend to bleed; (Figure 7
shows the common sites of hemorrhagic stroke). An increased relative
risk of ICH of 3.68-5.55 is brought on by chronic hypertension.74
Depending on the location and size of the ICH, patients typically pres-
ent with neurologic dysfunction ranging from focal neurologic deficits to
altered levels of consciousness. It has been demonstrated that the initial
neuroimaging results (volume and location of the ICH) in conjunction
with the neurologic exam can predict the patient’s prognosis and direct
further medical and surgical management.64 Even if chronic hypertension
is thought to be the primary cause of the ICH, it is still important to rule

Curr Probl Cardiol, November 2022 17

18
Curr Probl Cardiol, November 2022

FIG 7. The most common sites of hemorrhagic stroke are associated with chronic hypertension.
out any secondary causes through vascular neuroimaging. Patients who
present with ICH in coagulopathy or sympathomimetic drug use are sub-
ject to the same principles.

Cerebral Amyloid Angiopathy

When a patient with ICH first presents, the cortical regions and superfi-
cial siderosis are neuroimaging findings that are best seen on SWI and
GRE (T2) MR sequences that contribute to the diagnosis of cerebral amy-
loid angiopathy as the underlying cause of ICH. Deeper and more cere-
bral brainstem lesions are less likely to occur in cerebral amyloid
angiopathy.75

Advice for Additional Neuroimaging

The type and the location of blood on the initial head CT can be used
as a guide after neuroimaging. CTA or DSA may be required in subarach-
noid hemorrhage (SAH) or ICH caused by a suspected arteriovenous mal-
formation or arteriovenous fistula. A second head CT may be required a
few hours later to check for midline shift or worsening hemorrhage
edema. The need for magnetic resonance imaging (MRI) or a computed
tomography (CT) venogram when cerebral venous thrombosis is sus-
pected; the need for brain MRI without contrast when the hemorrhagic
transformation of ischemic stroke or ICH from cerebral amyloid angiop-
athy is supposed; and the need for brain MRI with contrast when ICH
from a tumor or infectious process is suspected.64

Additional Test Guidance

The preliminary head CT results may suggest additional testing to help
direct further neuroimaging, such as a lumbar puncture for SAH or infec-
tion, an echocardiogram to check for hypertensive heart disease or endo-
carditis, or body imaging to check for a primary malignancy.64

Recommendations for Urgent, Acute Care

When evaluating a patient with a low level of consciousness, an urgent
head CT is crucial. When an ICH with intraventricular extension and
obstructive hydrocephalus is discovered in a comatose or severely
encephalopathic patient, the patient’s clinical examination may occasion-
ally improve after an external ventricular drain is implanted. Similar

Curr Probl Cardiol, November 2022 19

findings may point to the need for hyperventilation and hyperosmolar
therapy in cases of elevated intracranial pressure.64

Guidance for Prognostication

In addition to the ICH Score described above, the Fisher scale
(Table 2),76 based on the initial non-contrast head CT, is used when com-
municating about SAH.76

Neuroimaging with MRI

Because most centers cannot accommodate numerous urgent MRI
studies, which are frequently ordered through the emergency department,
priority levels for brain MRI studies have been established (Table 3).
The most sensitive MRI sequence for detecting minute amounts of
hemorrhage is susceptibility-weighted imaging (SWI), a high-resolution
three-dimensional gradient recalled echo (GRE) sequence. The most cru-
cial MRI distinguishes between the two most frequent etiologies of ICH:
cerebral amyloid angiopathy and arterial hypertensive vasculopathy.
Magnetic fields and radio waves are used in MRI to create images.
Modern I.5 T MRI scanners are as sensitive as CT scanners at detecting
acute symptoms of ICH.77 Furthermore, MRI has a higher sensitivity
than CT for detecting subacute ICH. Like CT imaging, ICH appears to
change over time on MRI, as shown in Table 4.
In addition to price, MRI has limitations related to logistics and
patient-specific factors. The ability to obtain the study quickly is the most
frequent logistical limitation associated with MRI, and the presence of a
pacemaker or other ferromagnetic foreign object, claustrophobia, and
large body habitus are the most frequent patient-specific limitations.76,77

TABLE 3. Priority levels for brain MRI studies on strokes in emergency rooms (modified from
Hakimi et al. 64)

Priority levels for brain MRI studies on strokes.

Indicated only when the study’s results determine whether the patient needs a Level 1
surgical or endovascular intervention.
They are only indicated when the study’s conclusions affect the patient’s course Level 2
of treatment, such as a discharge home, admission to a floor, or an intensive
care unit.
It will be indicated when the study’s results enhance the treatment strategy, Level 3
such as in a patient suffering from an acute ischemic stroke.

20 Curr Probl Cardiol, November 2022

Curr Probl Cardiol, November 2022

TABLE 4. The appearance of ICH on Noncontrast CT and MRI by stages (modified from Hakimi et al. 64)

Stage Time Phase of blood CT T1- weighted MRI T2- weighted MRI T2*- weighted MRI
Hyperacute Oxyhemoglobin Hyperdense Hypointense Hyperintensity Marked hypointensity
Acute 12-48 hours Deoxyhemoglobin Hyperdense with Isointensity Hypointense with Marked hypointensity
fluid levels hyperintense
perilesional rim
Early subacute 72 hours Methemoglobin Hypodense region of Hyperintensity Hypointensity Hypointensity
intracellular edema with mass
effect
Late subacute 3-20 days Methemoglobin Less intese with
extracellular ringlike profeile
Chronic 9 weeks Hemosiderin and Isodense/ modest Hyperintensity or
ferritin confined isointense core
hypodensity surrounded by a
hypointense rim
21
Hemorrhagic Transformation of Ischemic Stroke
Hemorrhagic transformation is possible in ischemic stroke patients,
particularly those who receive IV thrombolysis or endovascular therapy.
When hemorrhagic transformation of an ischemic stroke is accompanied
by clinical deterioration, as measured by an increase in the National Insti-
tutes of Health Stroke Scale score of 4 or higher, this condition is referred
to as symptomatic.78 Four different subtypes of hemorrhagic transforma-
tion have been identified radiographically: parenchymal hematoma types
1 and 2 and hemorrhagic infarction types 1 and 2.79 Small petechiae
along the infarct’s margins are considered hemorrhagic infarction type 1;
in contrast, hemorrhagic infarction type 2 is defined as more confluent
petechiae within the infarcted area but without a space-occupying effect.
Blood clots with less than 30% of the infarcted area with a minor space-
occupying effect are known as parenchymal hematoma type 1, and dense
blood clots with more than 30% of the infarct volume have a significant
space-occupying impact known as parenchymal hematoma type 2. Clini-
cal relevance for classifying the hemorrhagic transformation into these
neuroimaging subcategories comes from two crucial factors. In the begin-
ning, only parenchymal hematoma type 2 has been discovered to worsen
clinical conditions and harm prognosis independently.80 The decision to
continue antithrombotic therapy can also be made on an individual basis
based on this classification, as opposed to the widespread clinical practice
of only continuing antithrombotic treatment in the presence of parenchy-
mal hematoma types 1 and 2. Table 5 lists some recommendations for
neuroimaging for ICH.

Diagnostic Assessment for ICH Pathogenesis

Acute brain parenchymal bleeding can be caused by heterogeneous dis-
ease entities such as arteriolosclerosis or Lipohyalinoses, CAA, or vascular
abnormalities. Clinicians should investigate the cause of ICH because it may
impact prognosis and acute and preventive therapy plans (80). According to
age group, 1 in 4-1 in 7 patients (arteriovenous malformations, aneurysm,
dural arteriovenous fistula, cavernoma, and cerebral venous thrombosis)
among those under 70 who did not have the typical hypertension-related
deep area ICH have an underlying macrovascular etiology.81

Medical and Neurointensive Treatment for ICH

Treatment of ICH in a dedicated neurointensive care unit is associated
with reduced mortality and improved outcome compared to management

22 Curr Probl Cardiol, November 2022

TABLE 5. Neuroimaging recommendations for ICH according to AHA and ASA Guideline for
the Management of Patients with Spontaneous Intracerebral Hemorrhage in 2022

Recommendations COR LOE

Neuroimaging for ICH
Rapid neuroimaging with CT or MRI is advised in patients 1 B-NR
who exhibit stroke-like symptoms to confirm the
diagnosis of spontaneous ICH.65
Within the first 24 hours of the onset of symptoms, CT can 2a B-NR
be helpful in patients with spontaneous ICH serial head
to assess for hemorrhage expansion.68
Serial head CTs can help assess for hemorrhage 2a C-LD
expansion, the onset of hydrocephalus, brain swelling, or
herniation in patients with spontaneous ICH who have a
low GCS score or ND.100
Abbreviations: COR, Class of Recommendation; LOE, Level of Evidence; B-NR, level B non-ran-
domized; C-LD, level C limited data; GCS, Glasgow Coma Scale; ND, neurological deteriora-
tion; ICH, intracerebral hemorrhage.

in a general ICU.82 The key factors that affect how long an ICU patient
stays are infection, fever, and acute lung injury, highlighting the impor-
tance of policies designed to reduce these risk factors.83 Because early
prognostication is challenging to predict, therapeutic nihilism should be
avoided in the first few days. The overall aggressiveness of ICH therapy
is closely associated with death; the most crucial treatment for ICH is
shown in Table 6.

Surgical Interventions

Minimally Invasive Surgery (MIS) for ICH Techniques

The evacuation procedures used in MIS and ICH are very similar. With
care taken to avoid vital brain areas and blood vessels, surgeons will use
imaging reconstruction to choose the best trajectory and corresponding
access point to approach the hematoma. Instrumentation is inserted after
a small access point is created in the skull (Figure 8). Most protocols also
call for a subsequent computed tomography (CT) scan to evaluate the
success of the evacuation. The size of the access port and the tools used
to remove the blood clot differ significantly between techniques. Another
critical distinction is whether the method involves the infusion of phar-
macologic thrombolytics. The amount of time needed to maintain access
to the clot also varies. While some techniques allow access to the clot to
be given up by the end of the initial surgery, others drain the hematoma
over several days. AHA guidelines emphasize the application of

Curr Probl Cardiol, November 2022 23

TABLE 6. Antiplatelet-related hemorrhage, thromboprophylaxis, temperature management, and
treatment of thrombosis for ICH according to AHA and ASA Guideline for the Management of
Patients with Spontaneous Intracerebral Hemorrhage in 2022

Recommendations COR LOE

Antiplatelet-related hemorrhage
For patients with spontaneous ICH being treated with aspirin 2b C-LD
and require emergency neurosurgery, platelet transfusion
might be considered to reduce postoperative bleeding and
mortality2
Patients with spontaneous ICH being treated with aspirin and 3: Harm B-R
not scheduled for emergency surgery, platelet transfusions
are potentially harmful and should not be administered.
Thromboprophylaxis
In non-ambulatory patients with spontaneous ICH, intermittent 1 B-R
pneumatic compression (IPC) starting on the day of
diagnosis is recommended for VTE prophylaxis
In non-ambulatory patients with spontaneous ICH, low-dose 2a C-LD
UFH or LMWH can help reduce the risk of PE2
Temperature management
For patients with spontaneous ICH, pharmacologically treating 2b C-LD
an elevated temperature may be reasonable to improve
functional outcomes
Treatment of thrombosis
For patients with acute spontaneous ICH and proximal DVT 2a C-LD
who are not candidates for anticoagulation, the temporary
use of a retrievable filter is reasonable
For patients with acute spontaneous ICH and proximal DVT 2a C-LD
who are not candidates for anticoagulation, the temporary
use of a retrievable filter is reasonable mortality2
Abbreviations: COR, Class of Recommendation; LOE, Level of Evidence; B-R, level B random-
ized; C-LD, level C limited data; ICH, intracerebral hemorrhage; VTE, venous thromboembolism;
UFH, unfractionated heparin; LMWH, low-molecular-weight heparin; PE, pulmonary embolism;
DVT, deep vein thrombosis.

thrombolytics, the size of the instrumentation and related burr hole, and
the point at which access to the clot is stopped.

Craniotomy for ICH

In patients with supratentorial ICH who are in a coma, have large
hematomas with significant midline shift, or have elevated ICP refractory
to medical management, decompressive craniectomy with or without
hematoma evacuation may be considered to reduce mortality.84,85 How-
ever, in the group of patients, as mentioned earlier, the effectiveness of
decompressive craniectomy with or without hematoma evacuation to
improve functional outcomes is uncertain.86,87

24 Curr Probl Cardiol, November 2022

Curr Probl Cardiol, November 2022

FIG 8. The relative sizes of the minimally invasive surgery instruments for intracerebral hemorrhage (ICH) evacuation.
25
Thrombolytic Techniques

Craniopuncture
Craniopuncture is the standard of care for treating ICH in China (30). A
YL-1 needle, used for a cranial puncture, has a 3 mm diameter hollow can-
nula that houses the puncture needle. Before attaching the cannula to the skull
and aspirating the hematoma, the puncture needle is drilled through the skull
and into the hematoma. Urokinase or recombinant tissue plasminogen activa-
tor (rtPA)-containing lysis fluid is administered to aid in additional aspiration
after the initial aspiration. Every 6 12 hours, a new dose of the thrombolytic
drug is administered to the hematoma. After the initial drainage, a follow-up
CT scan is done one to three days later to gauge how much blood is still there.
The drainage needle stays in the brain for three to five days.86,87

Stereotactic Aspiration with Thrombolysis

If a patient is accepted, they are given a second CT scan at least six hours
after their initial diagnostic CT to assess the stability of the clot. The surgeon
chooses a trajectory and drills a 1 cm burr hole at the appropriate location if
the clot appears stable.86 Using image guidance, a 4.8 mm (14F) diameter
sheath is stereotactically inserted halfway along the clot’s long axis and in
the middle of the hematoma’s short axis. Once resistance is felt while manu-
ally aspirating the clot with a syringe, a drainage catheter is inserted, and the
sheath is removed. The incision is stitched up after the catheter is subcutane-
ously tunneled away from the burr hole. A three-way stopcock is attached to
the catheter to enable drainage and injection of thrombolytics and saline.
After a postoperative CT scan shows periprocedural clot stability, rtPA injec-
tions begin six hours later. Then, up to nine rtPA injections may be adminis-
tered every eight hours. Once the clot has been reduced to less than 15 mL
or after the ninth administration, injections are stopped. To determine the
amount of clot still present and evaluate clot stability, CT scans are con-
ducted every day. The catheter is left in place for 24 hours after the clot has
been sufficiently reduced or for 25 hours following the last dose of rt-PA
before being removed.86,88

Goals of Care and Outcomes Predictions

Outcome prediction
Baseline measures of ICH severity have been created and tested over
the past 20 years. Measures like the ICH score have been increasingly

26 Curr Probl Cardiol, November 2022

validated across various patients and ICH characteristics in numerous
independent cohorts. It is unclear precisely what they do in clinical prac-
tice, but it is vital to consider some recommendations to achieve the goals
addressed in these events, which are found in Table 7.

Decisions to Limit Life-sustaining Treatment

Most ICH patients who pass away while receiving treatment in a hos-
pital do so after doctors, and other decision-makers decide to restrict the
use of life-supporting measures like artificial nutrition or hydration, intu-
bation, mechanical ventilation, antibiotics, or vasopressors. These
choices are presumably made considering the low likelihood of a positive
outcome and by the wishes of the patients and their legally recognized
surrogates, typically their families. However, there is still a lot of doubt
about how accurate prognostication is, particularly in the early stages of
ICH.
When a patient destined to recover from their ICH has limitations of
life-sustaining therapies or withdrawal of life support, this results in a
self-fulfilling prophecy of poor outcome. Numerous studies have found
that care limitations in the form of withdrawal of medical aid or institu-
tion of do not attempt resuscitation orders are independently associated
with increased risk of mortality and may lower the likelihood of favorable
functional outcomes when they are instituted early (usually within the
first day) after ICH onset.89,90 As a result, suggestions are made regarding
the application and purpose of these care limitations and the method of

TABLE 7. Recommendations for Goals and Outcomes Predictions for ICH modified from AHA
and ASA Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage
in 2022

Recommendations COR LOE

Goals and Outcomes
To provide an overall measure of clinical severity in patients with 1 B-NR
spontaneous ICH, it is advised to administer a baseline
assessment of overall hemorrhage severity as part of the initial
evaluation.
In patients with spontaneous ICH, a baseline severity score may 2b B-R
be reasonable to provide a general framework for
communication with the patient and their caregivers.
When determining a patient’s prognosis or limiting life-sustaining 3: No benefit B-NR
care for those with spontaneous ICH, a baseline severity score
shouldn’t be the only factor considered.
Abbreviations: COR, Class of Recommendation; LOE, Level of Evidence; B-NR, level B non-ran-
domized; B-R, level B randomized.

Curr Probl Cardiol, November 2022 27

physician and surrogate decision-making. Every recommendation should
be considered in the context of the applicable cultural, religious, and legal
environments.

Post-ICH recovery, Rehabilitation, and Complications

Rehabilitation and Recovery

Depending on the needs of the individual patient and the length of time
since the stroke, stroke rehabilitation may involve a variety of tailored
measures from various professionals.
The result of rehabilitation is believed to be a mix of recovery attribut-
able to brain reorganization and compensatory techniques. Weekly team
meetings to discuss patient discharge and proper timing are essential to
enhancing multidisciplinary teamwork on the ward and enhancing func-
tional results. Although it is not advised to engage in frequent, vigorous
mobilization within the first 24 hours following the onset of a stroke,
starting rehabilitation after 24-48 hours seems beneficial. The likelihood
of independent living is increased by early supported discharge, which
enables the transfer of care and services from the hospital to the home
(community setting). Fluoxetine has been tested in animals with encour-
aging outcomes. Brain plasticity is the capacity of neural networks in the
brain to change through expansion and reorganization. It does not, how-
ever, speed recovery in stroke patients. Many data on recovery and reha-
bilitation are drawn from studies of all types of strokes, and when
available, data come from ICH subgroups.2

Neurobehavioral Complications
Cognitive dysfunction and mood swings are frequent effects of ICH.
Within the first year following a stroke, 20 to 25 percent of patients with
ICH experience poststroke depression, which lasts over time.91,92
Post-ICH dementia increases over time, with one study showing an
incidence of new-onset dementia of 14.2 percent at one year and rising to
28.3 percent at four years. Thirty-three percent of patients with ICH expe-
rience dementia either before or after their ICH, and the incidence of
post-ICH dementia increase over time, three years after a stroke; there
was a 32 percent prevalence of cognitive impairment, according to
another study. According to analysis, the neuroimaging characteristics of
patients who experience post-ICH dementia suggest that underlying CAA
may be a contributing factor. Clinical professionals frequently fail to

28 Curr Probl Cardiol, November 2022

recognize neurobehavioral side effects following ICH, which worsens
long-term patient-centered outcomes like independence and community
reintegration. Poststroke depression increases physical limitations, which
can hinder rehabilitation efforts. It is linked to higher short- and long-
term mortality, poor functional outcomes, and poststroke depression.2
Suicide rates in the first two years following a stroke are twice as high
as in the general population. Poststroke depression can also result in sui-
cide. Like this, cognitive impairment forecasts post-stroke disability and
mortality. Additionally, there is a relationship between the two: Depres-
sion can cause cognitive symptoms and interfere with cognitive function.
Stroke recovery can be significantly impacted by identifying and treating
these stroke complications.2,93

Prevention

Primary Prevention in Individuals with High-Risk Imaging

Findings
Neuroimaging is not typically performed as part of risk stratification
for primary (first-ever) ICH risk. However, MRI is occasionally available
in some people and may show markers potentially alarming for ICH risk
in the future. Data on neuroimaging markers and the risk of the first-ever
spontaneous ICH are scarce from large populations. There isn’t enough
data to support specific practice, even though clinicians may consider
these data when preparing potential preventive treatments like antithrom-
botic therapy or blood pressure (BP) management. Notably, the risk of
primary ICH is lower than the secondary (recurrent) ICH risk by many
orders of magnitude. It is lower than the risk of prior ischemic stroke
even in people with these markers.94

Secondary Prevention

Blood Pressure Management. All stroke subtypes share hypertension

as a major modifiable risk factor, which has a strong causal relationship
with ICH. the ICH risk that can be attributed to the entire world’s popula-
tion is caused by uncontrolled hypertension in up to 73.6%. Despite this,
some ICH survivors still have poorly controlled blood pressure. Due to
overlapping risk factors, patients with ICH are also at risk of developing
ischemic stroke and cardiovascular disease in the future2; treating hyper-
tension after ICH is a secure and efficient method to lower future ICH

Curr Probl Cardiol, November 2022 29

risk and events related to all types of vascular disease. Therefore, it is
essential to monitor and identify uncontrolled hypertension following
ICH and to manage blood pressure aggressively to prevent recurrence.95
Table 8 is the recommendation for the management of BP.

Management of Other Medications

The clinical challenges of managing medication in patients taking
these drugs who experience an incident ICH are brought up by the poten-
tial increased risk of recurrent ICH associated with several drug classes,
including SSRIs, statins, and NSAIDs. In the SPARCL trial (Stroke Pre-
vention by Aggressive Reduction in Cholesterol Levels), statin therapy
was linked to a higher risk of recurrent ICH in patients with ICH.
Although this association has not been found in other observational, non-
randomized studies in patients with hypercholesterolemia, the risk may
vary depending on the patient’s risk for recurrent ICH and the type of
statin being taken.2 The indications and risk-benefit profiles for a specific
patient must be considered for both classes of medications. Because regu-
lar long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) is
linked to an increased risk of bleeding, it should be avoided in patients
with ICH.

Lifestyle Modifications and Caregiver Education

Lifestyle changes are an essential self-care element of poststroke man-
agement that are included in both primary and secondary prevention, and
the recommendations are in Table 9. They benefit overall health by
increasing physical activity, quitting smoking, drinking less alcohol, and

TABLE 8. Recommendations for blood pressure management for ICH modified from AHA and
ASA Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage in
2022

Recommendations COR LOE

Recommendations for Blood Pressure management.
Blood pressure control is advised to prevent recurrent bleeding in 1 B-R
patients with spontaneous ICH.
In patients with spontaneous ICH, it is reasonable to lower blood 2a B-NR
pressure to an SBP of 130 mmHg and diastolic blood pressure (DBP) of
80 mmHg for long-term management to prevent hemorrhage
recurrence.
Abbreviations: COR, Class of Recommendation; LOE, Level of Evidence; B-R, level B random-
ized; B-NR, level B non-randomized.

30 Curr Probl Cardiol, November 2022

TABLE 9. Recommendations for lifestyle modifications and caregiver education (modified from
AHA and ASA Guideline for the Management of Patients with Spontaneous Intracerebral Hemor-
rhage in 2022)

Recommendations COR LOE

Lifestyle modification
A lifestyle change is reasonable to reduce blood pressure in patients 2a C-LD
with spontaneous ICH.
Avoiding excessive alcohol consumption is reasonable for patients 2a C-LD
with spontaneous ICH to lower hypertension and the chance of ICH
recurrence.
For patients with spontaneous ICH, lifestyle modifications like 2b C-LD
supervised training and counseling may be reasonable to enhance
functional recovery.
Patient and caregiver education
Psychosocial education for the caregiver may be beneficial to 2a C-LD
increase the patient’s level of activity, participation, and the quality
of life in those with spontaneous ICH.
There are practical ways to help patients with spontaneous ICH 2a C-LD
improve their standing balance, including training for the caregiver.
Abbreviations: COR, Class of Recommendation; LOE, Level of Evidence; C-LD, level C limited
data.

eating a healthy diet.96 These suggestions are helpful for a variety of so-
called non-communicable conditions linked to a person’s way of life.
After the patient with ICH is discharged from the acute hospital and
undergoes rehabilitation, the family frequently steps in to provide care
for the patient. The caregiver must be actively involved and knowledge-
able about maximizing rehabilitation. As a result, information about the
diseases, what to do, and what to anticipate is needed for caregivers.
Among the caregiver, interventions are helping with ADLs and mobility
or engaging in exercise with the patient. For this, the caregiver must
receive practical training, information about assistive technology, and
assistance is an important consideration the Figure 9 shows the most fre-
quently lifestyle modifications recommendations Table 10.

Future Directions
Following an intracerebral hemorrhage, the neurologic function must
be preserved; hence new therapies must be created. More research should
be done on the genetic elements that might make someone more suscepti-
ble to intracerebral hemorrhage. A deeper understanding of the injury,
the sequence of pathophysiologic events, and the mediators of these
events that result in subsequent injuries may be necessary to develop
treatments that lessen cerebral edema and neuronal damage. In the last

Curr Probl Cardiol, November 2022 31

 FIG 9. Lifestyle modifications.

years, several quantitative MRI biomarkers have been proven helpful in

understanding the evolution of ischemic stroke (fractional anisotropy,97
apparent diffusion coefficient,98 time to peak99); these markers should be
validated in assessing hemorrhagic stroke.
It is still debatable how to control blood pressure effectively and
whether a patient with an intracerebral hemorrhage must undergo surgery
to remove the affected area. A randomized experiment is necessary to
ascertain the impact of blood pressure control on hematoma growth. It is
essential to design and test in randomized trials surgical approaches that
optimize the quantity of hematoma removed, reduce harm to healthy tis-
sue, and prevent postoperative bleeding. Recognizing that there can be a

TABLE 10. Recommendations for prognostication of future ICH risk for ICH (modified from AHA
and ASA Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage
in 2022)

Recommendations COR LOE

Recommendations for prognostication of future ICH risk
Risk factors for ICH recurrence in patients with spontaneous ICH in 2a B-NR
whom the risk for recurrent ICH may facilitate prognostication or
management decisions:
The following factors increase the risk of developing ICH:
(a) lobar location of the initial ICH
(b) older age
(c) presence, number, and lobar location of microbleeds on MRI
(d) presence of disseminated cortical superficial siderosis on MRI
(e) poorly controlled hypertension
(f) Asian or Black race
(g) presence of apolipoprotein E2 or E4 alleles.
Abbreviations: COR, Class of Recommendation; LOE, Level of Evidence; B-NR, level B non-
randomized.

32 Curr Probl Cardiol, November 2022

window of time when surgical evacuation is most advantageous in terms
of the long-term result is also crucial.

Conclusions
Although intracerebral hemorrhage is a severe neurologic emergency
that needs earlier goal-directed treatment, supportive care, and interven-
tion, key points to identify in the emergency brain imaging are ICH and
intraventricular extension, the presence of hydrocephalus, and the sources
of macrovascular bleeding. Early treatment of hematoma expansion and
modifiable factors (perihematomal edema and inflammation) improve the
survival and outcome. Simultaneous management of treatable factors
(elevated blood pressure and anticoagulation reversal) is imperative. The
need for surgery and the function of minimally invasive techniques are
still unclear. The restarting of antithrombotic medications, blood pressure
control, and statin use are 3 fundamentals of secondary prevention.

Statements and Declarations

All authors have read and agreed to the published version of the
manuscript.

Competing interests
All authors whose names are listed certify that they have NO affilia-
tions with or involvement in any organization or entity with any financial
interest (such as honoraria; educational grants; participation in speakers’
bureaus; membership, employment, consultancies, stock ownership, or
other equity interest; and expert testimony or patent-licensing arrange-
ments), or non-financial interest (such as personal or professional rela-
tionships, affiliations, knowledge or beliefs) in the subject matter or
materials discussed in this manuscript.

Declaration of interests
The authors declare that they have no known competing financial inter-
ests or personal relationships that could have appeared to influence the
work reported in this paper.

Curr Probl Cardiol, November 2022 33

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