# Surgical Intervention and ICU Management of Spontaneous ICH — AHA/ASA 2022

## Cerebellar Hemorrhage

### Indications for Immediate Surgical Evacuation

In patients with **cerebellar hemorrhage**, immediate surgical evacuation with or without an external ventricular drain (EVD) is recommended to reduce mortality for patients with any of the following (Class I, LOE B-NR):

- **Hematoma volume > 15 mL**
- **Neurological deterioration**
- **Brainstem compression**
- **Hydrocephalus**

- The volume threshold of > 15 mL is a new addition in the 2022 guideline compared with prior guidelines.
- Posterior fossa decompression should not be delayed when indicated, as rapid deterioration can occur from brainstem compression.

## Supratentorial ICH -- Minimally Invasive Surgery

### Endoscopic or Stereotactic Aspiration

- For patients with **supratentorial ICH of > 20-30 mL volume** with **GCS scores of 5-12** (moderate range), **minimally invasive hematoma evacuation** with endoscopic or stereotactic aspiration with or without thrombolytic use **can be useful to reduce mortality** compared with medical management alone (Class IIa, LOE B-R).
  - Evidence from the MISTIE III and ENRICH trials supports reduced mortality with minimally invasive approaches, although improvement in functional outcome remains neutral in most trials.

> **OpenMedicine Calculator:** `calculate_gcs` -- available via MCP for automated GCS scoring to identify candidates for minimally invasive surgery (GCS 5-12).

### Standard Craniotomy

- In patients with **supratentorial ICH**, the usefulness of craniotomy for hematoma evacuation to improve functional outcomes is uncertain (Class IIb, LOE A).
- The **STICH and STICH II** trials did not demonstrate clear benefit of early craniotomy over initial conservative management for most supratentorial ICH patients.
- Craniotomy may be considered in patients with lobar clots within 1 cm of the cortical surface who are deteriorating neurologically.

## Intraventricular Hemorrhage (IVH)

### External Ventricular Drain (EVD)

- In patients with ICH and **IVH with decreasing level of consciousness**, placement of an **EVD** is recommended to treat hydrocephalus (Class I, LOE B-NR).
- EVD allows CSF drainage, ICP monitoring, and potential intraventricular thrombolytic administration.

### Intraventricular Thrombolysis

- In patients with ICH and IVH, **low-dose intraventricular alteplase (1 mg every 8 hours via EVD)** may be considered to facilitate clot resolution and reduce mortality (Class IIb, LOE B-R).
  - Evidence from the **CLEAR III trial** showed that intraventricular alteplase reduced mortality but did not significantly improve the rate of good functional outcome (mRS 0-3).
  - Maximum total dose: 12 doses (12 mg total) or until IVH resolution on CT.

## Intracranial Pressure (ICP) Monitoring and Treatment

- In patients with moderate to severe spontaneous ICH or IVH with a reduced level of consciousness, **ICP monitoring and treatment might be considered** to reduce mortality and improve outcomes (Class IIb, LOE C-LD).
- ICP management may include:
  - Head-of-bed elevation to 30 degrees
  - CSF drainage via EVD
  - Osmotic therapy:
    - **Mannitol 20%: 0.25-1 g/kg IV bolus** every 4-6 hours (serum osmolality target < 320 mOsm/L)
    - **Hypertonic saline (23.4%): 30 mL IV bolus** via central venous catheter for acute herniation
  - Sedation and analgesia
  - Brief hyperventilation (target PaCO2 30-35 mmHg) for acute herniation as a bridge to definitive therapy

## Seizure Management

### Prophylactic Antiseizure Medication

- In patients with spontaneous ICH **without clinical or electrographic seizures**, prophylactic antiseizure medication **is not beneficial** for improving functional outcomes, long-term seizure control, or mortality (Class III: No Benefit, LOE B-R).

### Clinical Seizures

- Clinical seizures in patients with spontaneous ICH should be treated with antiseizure medications (Class I, LOE A).
- If seizures occur, preferred agents include levetiracetam or other non-enzyme-inducing antiseizure medications.
- **Phenytoin should be avoided** due to association with worse outcomes in hemorrhagic stroke.

### EEG Monitoring

- In patients with spontaneous ICH who have **unexplained abnormal or fluctuating mental status** or suspected subclinical seizures, **continuous EEG monitoring (>= 24 hours)** is reasonable to diagnose electrographic seizures (Class IIa, LOE B-NR).

## Venous Thromboembolism (VTE) Prophylaxis

### Mechanical Prophylaxis

- In **nonambulatory** patients with spontaneous ICH, **intermittent pneumatic compression (IPC) devices** starting on the day of diagnosis are recommended for VTE prophylaxis (Class I, LOE B-R).
- **Graduated compression stockings (knee-high or thigh-high) alone** are **not beneficial** for VTE prophylaxis (Class III: No Benefit, LOE B-R).

### Pharmacologic Prophylaxis

- In nonambulatory patients with spontaneous ICH, initiating **low-dose subcutaneous unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH)** at **24 to 48 hours from ICH onset** may be reasonable to optimize the benefits of VTE prevention relative to the risk of hematoma expansion (Class IIb, LOE B-NR).
  - Document hematoma stability on repeat imaging before initiating pharmacologic prophylaxis.

## Glucose Management

- **Monitoring serum glucose** is recommended to reduce the risk of hyperglycemia and hypoglycemia (Class I, LOE B-NR).
- Treating **hypoglycemia (< 60 mg/dL)** is recommended to reduce mortality (Class I, LOE B-NR).
- Treating **moderate to severe hyperglycemia (> 180 mg/dL)** is reasonable to improve outcomes (Class IIa, LOE B-NR).
- Avoid hypoglycemia (< 60 mg/dL) during insulin therapy; tight glycemic control targeting normoglycemia has not demonstrated benefit and increases hypoglycemia risk.

## Temperature Management

- **Pharmacologically treating an elevated temperature** may be reasonable to improve functional outcomes (Class IIb, LOE B-NR).
- Fever (> 38.3 degrees C / 101 degrees F) is associated with worse outcomes in ICH and should be actively managed.
- Treatment options include:
  - Scheduled acetaminophen
  - Surface or intravascular cooling devices for refractory fever
  - Identify and treat infectious sources

## Surgical and ICU Management Decision Algorithm

```
Patient with spontaneous ICH admitted to stroke unit / neurocritical care
  --> Cerebellar hemorrhage?
      --> Volume > 15 mL OR neurological deterioration OR brainstem compression OR hydrocephalus?
          --> Immediate surgical evacuation +/- EVD [Class I]
  --> Supratentorial ICH?
      --> Volume > 20-30 mL AND GCS 5-12?
          --> Consider minimally invasive hematoma evacuation [Class IIa]
      --> Lobar clot within 1 cm of cortex + deterioration?
          --> Consider craniotomy [Class IIb]
  --> IVH with decreasing consciousness?
      --> Place EVD [Class I]
      --> Consider intraventricular alteplase 1 mg q8h via EVD [Class IIb]
  --> ICP elevated?
      --> Head of bed 30 degrees, sedation, osmotic therapy
      --> EVD for CSF drainage
      --> Mannitol 0.25-1 g/kg IV or hypertonic saline for acute herniation
  --> Seizures?
      --> Clinical seizures: treat with levetiracetam (avoid phenytoin) [Class I]
      --> No seizures: do NOT give prophylactic antiseizure medications [Class III]
      --> Fluctuating mental status: continuous EEG >= 24 hours [Class IIa]
  --> VTE prophylaxis:
      --> IPC devices on day of diagnosis [Class I]
      --> Pharmacologic (UFH or LMWH) at 24-48 hours if hematoma stable [Class IIb]
  --> Glucose: monitor; treat hypo < 60 mg/dL [Class I]; treat hyper > 180 mg/dL [Class IIa]
  --> Temperature: treat fever > 38.3 degrees C [Class IIb]
```

## Limitations

- Evidence for minimally invasive surgery is stronger for mortality reduction than for functional outcome improvement. Optimal patient selection criteria are still being refined.
- The threshold of > 15 mL for cerebellar hemorrhage evacuation is based on observational data and expert consensus rather than randomized trials.
- ICP monitoring practices in ICH vary widely; no randomized trial has specifically tested ICP-guided therapy in spontaneous ICH.
- The optimal timing and agent for pharmacologic VTE prophylaxis remain uncertain. The 24-48-hour window is based on limited evidence and requires demonstration of hematoma stability.
- Intraventricular alteplase (CLEAR III) reduced mortality but did not improve the rate of good functional outcome, limiting the strength of this recommendation.
