Intracerebral hemorrhage
Also known as: brain bleed · hemorrhagic stroke · ICH
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2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage
American Heart Association / American Stroke Association (AHA/ASA) · 2022
The AHA/ASA guideline on diagnosis and treatment of spontaneous (non-traumatic) intracerebral hemorrhage in adults. It spans acute inpatient care, surgical and minimally invasive evacuation options, prevention of recurrence, and post-stroke rehabilitation, and it withdraws support for several practices previously treated as routine. Published in the journal Stroke in May 2022.
- Scope spans primary and secondary prevention, acute inpatient care, and post-stroke rehabilitation. source
- Addresses minimally invasive evacuation of supratentorial and intraventricular hemorrhage and indications for cerebellar hemorrhage surgery. source
- Indexed in PubMed as an AHA/ASA guideline published in Stroke in 2022. source
European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage
European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) · 2025
A joint ESO/EANS guideline covering the diagnosis and management of stroke caused by spontaneous intracerebral haemorrhage. The panel framed 37 PICO questions and applied GRADE to the trial and observational evidence accumulated since ESO's previous ICH guideline. Published in the European Stroke Journal in 2025.
US vs EU key differences
- Blood-pressure guardrails are framed differently: the 2022 AHA/ASA guideline targets systolic BP around 140 mm Hg (kept in a 130-150 range) for patients presenting at 150-220 mm Hg and labels lowering below 130 mm Hg as potentially harmful, whereas the 2025 ESO/EANS guideline targets sustained systolic BP below 140 mm Hg and instead warns against reducing systolic BP by more than about 70 mm Hg in the first hour. source
- Anticoagulation reversal converges across the Atlantic: both guidelines prefer four-factor prothrombin complex concentrate over fresh frozen plasma for vitamin K antagonist-associated bleeding, endorse andexanet alfa for factor Xa inhibitor-associated haemorrhage, and endorse idarucizumab for dabigatran. source
- Surgical guidance differs in framing: the US 2022 guideline confines minimally invasive evacuation to a defined subgroup (supratentorial haematoma above roughly 20-30 mL with Glasgow Coma Scale 5-12, Class 2b), while the 2025 ESO/EANS guideline issues broader weak-for recommendations covering minimally invasive evacuation, open craniotomy and decompressive craniectomy for deep supratentorial bleeds. source
- Version currency differs: the US guideline dates to 2022, while the joint ESO/EANS European guidance is a 2025 document built on a systematic review that screened over 115,000 records and included 208 studies. source
What changed recently
- EU2014 → 20252025-05-22
This GRADE-based joint ESO/EANS document replaces the 2014 ESO ICH guideline, answering 37 PICO questions with evidence accumulated from a decade of randomised trials. It supports early intensive blood-pressure lowering mainly for reducing haematoma expansion rather than for proven functional benefit, weighs anticoagulation reversal explicitly against thromboembolic harm, treats minimally invasive evacuation alongside open craniotomy as options for supratentorial haemorrhage, and advises against anti-inflammatory drugs outside trials.
source ↗curation confidence 90% - US2015 → 20222022-05-17
The 2022 revision of the 2015 ICH guideline downgraded several long-standing practices, stating that graduated compression stockings, prophylactic antiseizure drugs and steroids are of uncertain or no benefit, while adding new recommendations on regional systems of care with rapid transfer to neurocritical/neurosurgical centres, on anticoagulation reversal, on minimally invasive haematoma evacuation, and on using imaging and clinical markers to anticipate haematoma expansion.
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