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American Stroke Association Guidelines
Recognizing that the management of ICH by neurologists and neurosurgeons throughout the world varies greatly, the Stroke Council of the American Heart Association formed a task force to develop practice guidelines and to suggest areas where further research was needed. In 1999, the first guidelines were published, although the authors acknowledged that the strength of their recommendations was limited by the quality of the medical literature, which consists more of anecdotal case series than well-designed clinical trials. Since then, the guidelines have undergone updates in 2007 and 2010. Besides the evolution of the position statements, these updates reclassified the level of certainty of the treatment effect and recategorized the class of evidence from which they are derived.
Regarding the indications for vascular imaging to search for an underlying structural cause of the ICH, the 1999 Council wrote, "Angiography should be considered for all patients without a clear cause of hemorrhage who are surgical candidates, particularly young, normotensive patients who are clinically stable (level of evidence V, grade C recommendation)." Additionally, they wrote, "Angiography is not required for older hypertensive patients who have a hemorrhage in the basal ganglia, thalamus, cerebellum, or brain stem and in whom CT findings do not suggest a structural lesion ….(level of evidence V, grade C recommendation)." Under the definitions in effect at that time, these were the weakest possible recommendations and based on the lowest quality data. In 2010, the guidelines state that, "…CT angiography, CT venography, contrast-enhanced CT, contrast-enhanced MRI, magnetic resonance angiography, and magnetic resonance venography can be useful to evaluate for underlying structural lesions, including vascular malformations and tumors when there is clinical or radiological suspicion (Class IIa; Level of Evidence: B)."
Regarding the indications for surgical removal of ICH, the 1999 council wrote:
Patients with cerebellar hemorrhage > 3 cm who are neurologically deteriorating or who have brain stem compression and hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible (levels of evidence III through V, grade C recommendation)… Stereotactic aspiration may be associated with better outcomes than standard craniotomy for moderate-sized cerebellar hemorrhages, but this hypothesis has yet to be tested in a randomized study (no recommendation).
In 2007, there was no change to this recommendation, although the authors revised the categorization of its strength as "Class 1, Level of Evidence B," which is an intermediate grade. In 2010, the qualification of the 3-cm-size threshold was abandoned, and a new recommendation concerning ventricular drainage was offered:
Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible ( Class 1; Level of Evidence: B). (Revised from the previous guideline). Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended ( Class III; Level of Evidence: C). (New recommendation).
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