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Review article
Clinical practice guidelines in intracerebral haemorrhage
Guías de actuación clínica en la hemorragia intracerebral
M. Rodríguez-Yáñez, M. Castellanos, M.M. Freijo, J.C. López Fernández, J. Martí-Fàbregas, F. Nombela, P. Simal, J. Castillo
Corresponding author
jose.castillo@usc.es

Corresponding author.
, representing the ad hoc committee of the SEN Study Group for Cerebrovascular Diseases: , E. Díez-Tejedor, B. Fuentes, M. Alonso de Leciñana, J. Álvarez-Sabin, J. Arenillas, S. Calleja, I. Casado, A. Dávalos, F. Díaz-Otero, J.A. Egido, J. Gállego..., A. García Pastor, A. Gil-Núñez, F. Gilo, P. Irimia, A. Lago, J. Maestre, J. Masjuan, P. Martínez-Sánchez, E. Martínez-Vila, C. Molina, A. Morales, F. Purroy, M. Ribó, J. Roquer, F. Rubio, T. Segura, J. Serena, J. Tejada, J. Vivancos◊Ver más
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    "titulosAlternativos" => array:1 [
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        "titulo" => "Gu&#237;as de actuaci&#243;n cl&#237;nica en la hemorragia intracerebral"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Intracerebral haemorrhage &#40;ICH&#41; refers to the collection of blood within the cerebral parenchyma as the result of vascular rupture unrelated to trauma&#46; Although the bleed may leak into the ventricular system or the subarachnoid space&#44; it always begins in brain tissue&#46; This trait distinguishes ICH from subarachnoid haemorrhage and primary intraventricular haemorrhage&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Haemorrhages are categorised as primary or secondary depending on the cause of the bleed&#46; Primary ICHs are the most common and they are caused by the rupture of any blood vessel within the brain&#39;s normal vascular system after the vascular wall is weakened by degenerative processes secondary to arterial hypertension &#40;AHT&#41; or amyloid angiopathy&#46; Secondary ICHs are caused by the rupture of blood vessels that are congenitally abnormal or newly formed&#44; or of vessels that contain vascular wall abnormalities or weaknesses caused by coagulation disorders&#46; They are associated with such entities as tumours&#44; arteriovenous malformations &#40;AVM&#41;&#44; coagulation disorders&#44; substance abuse&#44; or haemorrhages inside areas of ischaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">ICH incidence varies by country&#44; race&#44; age&#44; and sex&#44; and it is closely related to AHT prevalence&#46; In Europe&#44; its incidence rate is approximately 15 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> While ICH is only present in 10&#37; to 15&#37; of all strokes&#44; it is associated with a poorer prognosis and higher morbidity and mortality rates&#46; The mortality rate during the first month after ICH is 40&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Most deaths occur in the first 2 days&#44; and only 20&#37; of the total patients are independent 6 months after having had an ICH&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Mortality at 30 days is related to the size and location of the ICH&#46; In patients with an initial haemorrhage volume greater than 60<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#44; mortality for deep haemorrhages is 93&#37;&#44; and for lobar haemorrhages&#44; 72&#37;&#46; If initial volume is less than 30<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#44; mortality rates are 39&#37; for deep haemorrhages&#44; 7&#37; for lobar haemorrhages&#44; and 57&#37; for cerebellar haemorrhages&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The incidence of ICH is on the rise despite improved control over certain risk factors&#46; This is related to the ageing of the population&#46; However&#44; the higher incidence rate among the elderly may also contribute to the decrease in mortality recorded in recent years&#44; because of more pronounced cerebral atrophy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The most important risk factor for developing ICH in all age groups and both sexes is AHT&#44; whether systolic or diastolic&#46; AHT is present in 60&#37; of all cases&#46; Chronic AHT provokes degenerative changes in arteriole walls that favour vascular obstructions&#46; This in turn causes the lacunar infarcts&#44; leukoaraiosis&#44; and vascular rupture that are responsible for the appearance of ICH&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> AHT may also be an acute cause of ICH by affecting small arterioles that are at risk due to hypertrophy of their walls&#46; This leads to haemorrhages such as those caused by certain drugs or haemorrhages occurring after endarterectomy or angioplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Another important cause of ICH is cerebral amyloid angiopathy&#44; which is the leading cause of lobar haemorrhage in elderly subjects&#46; This degenerative process affects small arteries and arterioles located in the leptomeninges and cerebral cortex&#46; Haemorrhages of this type are superficial&#44; often recurring and multiple&#44; and tend to be located in posterior areas of the brain&#46; They appear in elderly subjects&#44; and up to half of all patients present cognitive decline&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Lastly&#44; there are other less common causes of ICH which are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Care strategy and systematic diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">ICH is a neurological emergency&#44; and therefore rapid diagnosis and management are fundamental&#59; as mentioned before&#44; clinical exacerbation is common in the first few hours following ICH&#46; This factor is directly associated with a poorer functional prognosis&#46; A number of observational studies show that 1 in 3 patients with supratentorial haemorrhage and most patients with a posterior fossa haemorrhage present an altered level of consciousness&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Owing to the high risk of early neurological impairment&#44; which is associated with poor long-term prognosis&#44; care must be provided to ICH patients as quickly as possible&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pre-hospital care</span><p id="par0035" class="elsevierStylePara elsevierViewall">The main objective of pre-hospital care is maintaining correct cardiovascular and respiratory function and transporting the patient to the nearest hospital with facilities for acute-phase stroke patients&#46; Additional objectives include taking the patient&#39;s medical history&#44; especially events occurring at symptom onset and information about prior medical conditions&#46; It is important to alert the receiving hospital prior to the arrival of a patient with a possible stroke so that staff can prepare the equipment needed to assess the stroke&#46; This cuts down on delays in completing neuroimaging tests in the emergency department&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Care in the emergency department</span><p id="par0040" class="elsevierStylePara elsevierViewall">Once the haemodynamic and cardiorespiratory functions have been stabilised&#44; further objectives include confirming the type of stroke to differentiate a haemorrhage from ischaemia or other brain lesions&#59; gathering information about ICH aetiology&#59; preventing potential complications&#59; and starting appropriate treatment&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The clinical course of ICH may not offer data distinguishing that entity from other types of stroke unless there are pathognomonic clinical features pointing to a cerebral haemorrhage&#46; However&#44; certain signs and symptoms are more suggestive of ICH than of ischaemia&#46; One symptom that appears frequently is headache&#44; which is present in 40&#37; of ICH cases and only 17&#37; of ischaemic stroke cases&#46; Other common symptoms&#44; present in 50&#37; of ICH cases&#44; include nausea&#44; vomiting&#44; and decreased level of consciousness&#59; these signs are exceptional in ischaemic stroke&#46; We also find increased arterial blood pressure in almost 90&#37; of ICH cases&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">When taking medical histories&#44; doctors must emphasise data such as time of symptom onset&#44; vascular risk factors &#40;AHT&#44; diabetes&#44; hypercholesterolaemia&#41;&#44; substance abuse &#40;tobacco&#44; alcohol&#44; cocaine&#44; amphetamines&#41;&#44; drugs &#40;anticoagulants&#44; antiplatelet drugs&#44; nasal decongestants&#44; diet pills&#44; stimulants&#44; sympathomimetic drugs&#41;&#44; prior traumatic event or recent surgery &#40;especially endarterectomy or carotid angioplasty&#44; which may be associated with reperfusion syndrome&#41;&#44; pre-existing cognitive decline &#40;related to amyloid angiopathy&#41;&#44; seizures&#44; systemic illnesses related to coagulation disorders &#40;liver disease&#44; vasculitis&#44; cancer&#44; blood dyscrasia&#41;&#44; and any family history of neurological diseases associated with increased risk of cerebral bleeding &#40;including arteriovenous malformations and intracranial aneurysms&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In addition to assessing neurological deficit in the initial examination&#44; doctors must evaluate respiration and the haemodynamic state&#46; To this end&#44; an electrocardiogram and chest radiography are needed&#46; A detailed physical examination that includes a cardiovascular study and ophthalmoscopy is often helpful for establishing an aetiological diagnosis&#46; In cases in which the patient has remained bedridden during long periods of time&#44; doctors should check for potential associated complications&#44; including pressure ulcers&#44; compartment syndromes&#44; rhabdomyolysis&#44; and traumatic lesions&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Laboratory tests</span><p id="par0060" class="elsevierStylePara elsevierViewall">It is important to perform blood tests to gather results for complete blood count&#44; electrolytes&#44; urea&#44; creatinine&#44; liver function parameters&#44; and glucose&#46; High creatinine and glucose levels are associated with haemorrhage growth and a poor functional prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Doctors should also complete a coagulation study including activated partial thromboplastin time &#40;APTT&#41; and INR&#46; This is done because haemorrhages associated with anticoagulant treatment are accompanied by increased risk of morbidity and mortality<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> and require urgent treatment to reverse the coagulation disorder&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Younger patients should undergo urine screening to detect toxic substances such as cocaine and other sympathomimetic drugs and women of childbearing age will require a pregnancy test&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Neuroimaging</span><p id="par0070" class="elsevierStylePara elsevierViewall">The presence of sudden-onset focal neurological deficit suggests a vascular origin unless there is another proven cause&#46; Although some of the symptoms described above&#44; such as headache&#44; vomiting&#44; and decreased level of consciousness&#44; are suggestive of ICH&#44; these findings are not specific and they do not enable us to differentiate between neurological deficit caused by cerebral ischaemia and that caused by a haemorrhage&#46; For this reason&#44; neuroimaging studies are fundamental&#46; Both computed tomography &#40;CT&#41; and magnetic resonance imaging &#40;MRI&#41; may be used for the initial diagnosis&#46; CT is highly sensitive for identifying haemorrhage during the acute phase&#44; and it is regarded as the technique of choice&#46; Gradient echo MRI sequences are as sensitive as CT for detecting blood during the acute phase of stroke&#44; and they are even more sensitive than CT for detecting old haemorrhages&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However&#44; the availability&#44; lower costs&#44; and shorter times associated with CT mean that this technique is more commonly used than MRI&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">CT allows us to pinpoint the location of the haemorrhage and identify its effects &#40;mass effect&#44; oedema&#44; ventricular extension&#44; and subarachnoid extension&#41;&#46; Furthermore&#44; administering contrast intravenously lets us diagnose certain secondary causes of ICH&#44; such as AVMs or tumours&#46; In the first hours of the process&#44; ICH presents as increased density in the cerebral parenchyma&#44; which is explained by the haemoglobin in the escaped blood&#46; As the days pass&#44; the haemorrhage can be found in the centre of a hypodense ring&#46; At first&#44; this appearance is caused by retraction of the clot&#59; at a later point&#44; it is caused by vasogenic oedema&#46; At the end of several weeks&#44; the high initial density of the haemorrhage begins to decrease from the perimeter toward the centre&#46; The final stage of an ICH as viewed by CT is total reabsorption of haemorrhagic tissue&#46; This produces a residual cavity that is indistinguishable from that left by an old cerebral infarct&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Some data on the location and morphology of ICHs detected using CT may be important to establish an aetiological diagnosis&#46; The most common location of hypertensive ICH is the putamen &#40;30&#37;&#8211;50&#37;&#41;&#44; followed by subcortical white matter &#40;30&#37;&#41; and the cerebellum &#40;16&#37;&#41;&#46; If the location is lobar&#44; the role played by AHT is less significant and amyloid angiopathy is more likely to be the cause&#46; This is especially true in patients older than 60 years with a certain level of cognitive decline&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Other common causes of lobar haemorrhages are arteriovenous malformations &#40;7&#37;&#8211;14&#37;&#41;&#44; tumours &#40;7&#37;&#8211;9&#37;&#41;&#44; and blood dyscrasias&#44; including anticoagulant treatment &#40;5&#37;&#8211;20&#37;&#41;&#46; In 3&#37; of all patients&#44; the haemorrhage remains limited to the intraventricular system&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Since the haemorrhage often grows during the acute phase&#44; and this phenomenon is associated with neurological deterioration and increased morbidity and mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> research is being done on techniques that may help us predict haemorrhage growth&#46; The use of CT angiography with contrast may help identify patients at risk for haemorrhage expansion based on the presence of isolated contrast in the haemorrhage &#40;spot sign&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> This technique is also useful for detecting secondary causes of ICH&#44; such as arteriovenous malformations&#44; tumours&#44; or venous thrombosis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">MRI scans contribute further information about the stage of development of the ICH&#46; Differences in these scans have to do with the way that images of haemoglobin change throughout the catabolism process&#46; In the early stages of acute-phase ICH &#40;initial hours&#41;&#44; oxyhaemoglobin levels in the haemorrhage are high and the MRI shows hypointensities in T1 and hyperintensities in T2&#46; In later stages of acute-phase ICH &#40;first few days&#41;&#44; oxyhaemoglobin converts to deoxyhaemoglobin from the centre of the bleed to its perimeter&#46; In the MR image&#44; this appears as a hypointense area in T2&#44; surrounded by a hyperintense ring corresponding to the oedema&#46; In late stages of ICH &#40;after several weeks&#41;&#44; deoxyhaemoglobin is transformed into methaemoglobin from the perimeter to the centre&#46; The change appears as a peripheral hyperintense signal in T1 which progressively extends to the entire area of the haemorrhage&#46; In the recovery phase &#40;months after onset&#41;&#44; all of the haemoglobin has been transformed into haemosiderin&#44; which creates a pronounced hypointense signal in T2-weighted sequences&#46; MRI gradient-echo sequences are highly sensitive for detecting small chronic haemorrhages&#44; called microbleeds&#44; which measure less than 5<span class="elsevierStyleHsp" style=""></span>mm&#46; Microbleeds appear as hypointense pinpoint lesions and indicate the presence of chronic haemosiderin deposition&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Magnetic resonance angiography &#40;MRA&#41; is a useful technique for detecting vascular lesions associated with ICH&#46; It has a high sensitivity for detecting aneurysms and AVMs&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> MRA is also useful during the venous phase when there is a suspicion of sinus thrombosis as the cause of the haemorrhage&#46; The technique is as reliable as CT angiography with contrast during the venous phase&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Conventional arteriography may be useful when there is a strong suspicion of a secondary cause and results from non-invasive studies are negative&#46; Radiological signs that suggest a secondary cause are presence of subarachnoid haemorrhage&#44; unusual haemorrhage shape &#40;non-circular&#41;&#44; oedema size not proportional to haemorrhage evolution time&#44; uncommon location&#44; or presence of abnormal structures&#46; The probability of detecting a secondary cause by using angiography is higher in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> For suspected vasculitis&#44; conventional angiography is the technique of choice&#46; In some cases&#44; as with cavernous angiomas&#44; conventional angiography may yield negative results&#46; Arteriography is not useful&#44; however&#44; in hypertensive patients older than 45 with haemorrhages in the putamen&#44; thalamus&#44; or posterior fossa&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical treatment</span><p id="par0125" class="elsevierStylePara elsevierViewall">Treatment for patients with ICH is fundamentally medical&#46; It is based on maintaining vital functions&#44; neurological monitoring&#44; maintaining homeostasis&#44; and preventing complications&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The key objective of all of these activities is to prevent increases in haemorrhage size&#44; which would provoke a mass effect&#44; increase intracranial pressure&#44; and cause secondary neurological impairment&#46; All ICH patients must be cared for in hospitals that include a neurologist&#44; neurosurgeon&#44; CT&#44; stroke unit&#44; and intensive care units that are available 24<span class="elsevierStyleHsp" style=""></span>hours a day&#46; If the patient does not require mechanical ventilation&#44; care measures should be carried out in the stroke unit&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;30</span></a> provided that the patient can be examined by a neurosurgeon and has the option of being transferred to the intensive care unit at any time of day should it become necessary&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General care</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resuscitation</span><p id="par0130" class="elsevierStylePara elsevierViewall">All patients with ICH must be cared for in hospitals with stroke units and ICUs available 24<span class="elsevierStyleHsp" style=""></span>hours a day&#46; If the patient does not require mechanical ventilation&#44; life support measures should be applied in the stroke unit&#44; provided that the patient can be examined by a neurosurgeon and has the option of being transferred to the intensive care unit at any time of day if necessary&#46; Admission to a general ICU rather than a specialised neurological ICU increases risk of death by a factor of 3&#46;4&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Likewise&#44; admission to a stroke unit increases probability of survival and a good functional prognosis by 64&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Recent population-based studies suggest that good medical care has a significant impact on mortality and morbidity in ICH&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">An initial assessment of the patient will allow us to evaluate the patient&#39;s level of consciousness and ability to maintain spontaneous breathing&#46; However&#44; even in patients with a high level of consciousness&#44; it is recommended that doctors know the oxygen saturation level&#46; The simplest means of measuring oxygen saturation is by using a pulse oximeter&#46; If arterial oxygen saturation is less than 92&#37;&#44; the patient will require an oxygen mask with a flow that will raise oxygen saturation to above that threshold&#46; Performing an arterial blood gasometry study is optional and depends on the patient&#39;s condition&#46; Up to a third of the patients with supratentorial haemorrhage and almost all patients with a posterior fossa haemorrhage present decreased level of consciousness or bulbar muscle dysfunction that results in the need for intubation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Early intubation in patients who have suffered from very large haemorrhages accompanied by decreased level of consciousness may help prevent aspiration pneumonia&#46; In general&#44; endotracheal intubation and gastric aspiration are indicated in patients with a score of less than 8 on the Glasgow coma scale &#40;GCS&#41;&#46; Intubation should be performed after administration of drugs that suppress the tracheal reflex&#44; since that reflex may cause increased intracranial pressure and exacerbate the neurological lesion&#46; In any case&#44; the indication for orotracheal intubation is debatable&#46; There may be reason to consider it only if doctors plan to apply other treatment measures in order to improve the patient&#39;s neurological situation&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Neurological monitoring</span><p id="par0140" class="elsevierStylePara elsevierViewall">Since a high number of patients experience a decline in the hours following the stroke&#44; periodic monitoring of the level of consciousness and the neurological deficit should be performed during at least the first 72<span class="elsevierStyleHsp" style=""></span>hours&#46; The most widely recommended scales are the NIH stroke scale &#40;NIHSS&#41; for measuring neurological deficit<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> and the GCS for measuring level of consciousness due to its simplicity and reliability&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control over arterial pressure</span><p id="par0145" class="elsevierStylePara elsevierViewall">In most patients with an intracerebral haemorrhage&#44; arterial pressure readings are elevated during the acute phase&#46; In fact&#44; values are often higher than those observed in cases of ischaemic stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Although blood pressure generally decreases spontaneously in the days following the haemorrhage&#44; high readings persist in many patients&#46; Potential pathophysiological mechanisms that promote increases in arterial pressure include activation of the neuroendocrine system &#40;sympathetic&#44; renin-angiotensin&#44; or glucocorticoid systems&#41; due to stress and the elevation of intracranial pressure &#40;Cushing effect&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">High arterial pressure values in patients with ICH may be associated with increased haemorrhage growth&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> which is another sign of poor patient prognosis&#46; Arterial pressure readings in cases of ischaemic stroke follow a U-shaped curve&#44; and both high and low values increase the risk of neurological damage&#44; mortality&#44; and poor functional prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Animal models of ICH have described secondary damage&#44; possibly caused by mechanical compression of microvessels&#44; which induces an ischaemic area around the haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> This leads us to think that decreased arterial pressure could contribute to reduced blood flow in the peri-haemorrhagic region&#44; thereby producing more pronounced neurological impairment&#46; Based on these data&#44; we recommend maintaining systolic blood pressure below 180<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg during the acute phase of ICH&#46; However&#44; neuroimaging studies have been unable to identify ischaemia around the haemorrhage site in human clinical data&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a> and this aspect remains controversial&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The INTERACT study<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> provides new data regarding blood pressure management during the acute phase of ICH&#46; This study was designed in order to evaluate how stricter control over arterial pressure would affect haemorrhage growth and the development of peri-lesional oedema&#46; To that end&#44; the study included 404 patients with spontaneous ICHs that had appeared in the preceding 6<span class="elsevierStyleHsp" style=""></span>hours&#46; Their systolic blood pressure values were &#8805;150<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg and &#8804;220<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46; Patients were randomly assigned to receive blood pressure treatment either according to recommendations in international guidelines or according to stricter standards&#46; In patients whose blood pressure was controlled according to international guidelines&#44; systolic pressure was kept below 180<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46; The objective in the group of patients under stricter standards was to reach a systolic blood pressure of 140<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg during the first hour and maintain levels below that threshold during the following 7 days&#46; Results from the study show that patients assigned to the group with stricter blood pressure control presented less haemorrhage growth and a tendency for the peri-haemorrhagic oedema to decrease&#46; There were no signs of increased neurological decline or poorer functional prognosis&#44; but the study was not designed to evaluate these parameters&#46; Data from the study seem to indicate that strict control over blood pressure is safe&#46; However&#44; we have yet to determine the most appropriate level of arterial pressure&#44; the correct duration for antihypertensive treatment&#44; and the effect of these parameters on the functional prognosis of ICH patients&#46; The study INTERACT 2 is currently underway<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> and its main objective is to evaluate how maintaining strict control over blood pressure during the acute phase affects functional prognosis in ICH patients&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The drugs recommended for blood pressure control are those that do not induce cerebral vasodilation or sudden hypotension&#44; such as intravenous labetalol &#40;loading doses of 10 to 20<span class="elsevierStyleHsp" style=""></span>mg in 1 to 2<span class="elsevierStyleHsp" style=""></span>minutes&#44; repeated every 1 to 20<span class="elsevierStyleHsp" style=""></span>minutes until the blood pressure reaches the desired level or the maximum dose of 200<span class="elsevierStyleHsp" style=""></span>mg has been given&#41;&#59; intravenous enalapril &#40;1<span class="elsevierStyleHsp" style=""></span>mg bolus&#41;&#59; or intravenous urapidil &#40;25<span class="elsevierStyleHsp" style=""></span>mg bolus in 20<span class="elsevierStyleHsp" style=""></span>s&#44; repeating procedure after 5<span class="elsevierStyleHsp" style=""></span>minutes in absence of a response&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Glycaemic control</span><p id="par0165" class="elsevierStylePara elsevierViewall">High glycaemic levels upon admission are associated with increased risk of mortality and poor prognosis in patients with intracerebral haemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a> One clinical trial in critical care patients with or without acute stroke shows that maintaining glucose levels between 80 and 110<span class="elsevierStyleHsp" style=""></span>mg&#47;dL using intravenous insulin has been associated with higher incidence rates of hypoglycaemia episodes&#44; whether systemic or cerebral&#46; It may also be linked to an even higher risk of mortality among the patients receiving this treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;48</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">There are no intervention studies designed specifically for ICH&#44; and as a result&#44; the target level for glycaemic control in ICH patients is not completely clear&#46; However&#44; glucose levels above 155<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in ischaemic stroke have been associated with poor prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> and it is therefore appropriate to correct levels above this threshold&#46; Hypoglycaemia must be prevented by administering a 10&#37; to 20&#37; dextrose solution&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Temperature control</span><p id="par0175" class="elsevierStylePara elsevierViewall">Fever owing to any cause is associated with neurological impairment and poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Although there is no evidence that treatment decreases this risk&#44; symptomatic treatment with antipyretic drugs such as paracetamol is recommended&#46; For patients with fever&#44; we recommend ordering a chest radiography&#44; cultures of blood&#44; sputum&#44; and urine&#44; and urine sediment analysis in order to identify and treat associated infectious processes&#46; Peripheral blood vessels should be systematically checked to rule out phlebitis&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Some recent studies have demonstrated benefits of moderate hypothermia in certain conditions including head trauma&#46; However&#44; its effects have not been explored in cases of patients with ICH&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Managing haemostasis</span><p id="par0185" class="elsevierStylePara elsevierViewall">Haemostatic alterations&#44; such as treatment with oral anticoagulants&#44; coagulation factor deficiencies&#44; or platelet abnormalities&#44; can contribute to haemorrhage growth&#44; which in turn leads to neurological impairment&#46; It is therefore important to correct these factors as quickly as possible&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In cases in which the patient is being treated with oral anticoagulants&#44; the INR must be corrected to reach normal values as soon as possible&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> This should be done using intravenous vitamin K and&#47;or fresh frozen plasma and&#47;or prothrombin complex concentrate&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;53</span></a> The effectiveness of fresh frozen plasma is limited by the risk of allergic reactions and infections&#44; as well as by the considerations of processing time and hypervolaemia&#46; Prothrombin complex concentrates also contain factors II&#44; VII&#44; IX&#44; and X&#44; and they are able to normalise INR values quickly&#46; On this basis&#44; they constitute the treatment of choice for cases of ICH related to oral anticoagulants&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> However&#44; they must be combined with vitamin K&#44; since the half-life of oral anticoagulants is much longer than those of vitamin K-dependent clotting factors&#46; In cases in which patients have received intravenous heparin and display prolonged APTT&#44; doctors should administer protamine sulphate&#46; If ICH has occurred due to fibrinolytic treatment&#44; it may be necessary to administer fresh frozen plasma&#44; platelets&#44; or antifibrinolytics such as aminocaproic acid or tranexamic acid&#46; Recombinant activated factor VII should be administered to patients with both ICH and haemophilia&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Recombinant activated factor VII has also been investigated in ICH patients without disorders of haemostasis&#46; A phase 2 study has shown that recombinant activated factor VII limits haemorrhage growth and improves patients&#8217; functional prognosis compared to a placebo&#44; despite increasing the frequency of thromboembolic complications&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> A phase 3 study confirmed that delivering recombinant activated factor VII limits haemorrhage growth&#44; but no significant differences in prognosis could be found with respect to a placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> It has not yet been shown whether recombinant activated factor VII can deliver benefits in selected patients&#44; but in any case&#44; administering this treatment to all ICH patients indiscriminately does not improve their prognosis and furthermore&#44; it increases the risk of thromboembolic complications&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Patients with ICH and thrombocytopenia must receive transfusions of platelet concentrate&#46; Data from patients without thrombocytopenia who are being treated with antiplatelet drugs are contradictory&#46; Platelet dysfunction has been linked to increased haemorrhage volume and a poor functional result<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a>&#59; however&#44; one clinical trial investigating neuroprotection in cerebral haemorrhages<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> found no differences between patients receiving a placebo and those previously treated with antiplatelet drugs&#46; Therefore&#44; platelet replacement therapy is not indicated for patients taking antiplatelet drugs and those whose platelet count is normal&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Preventing complications</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Deep vein thrombosis and pulmonary embolism</span><p id="par0205" class="elsevierStylePara elsevierViewall">Patients with ICH are at an increased risk of suffering thromboembolic complications&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Sporadic use of compression stockings has not been shown to be effective for preventing deep vein thrombosis&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> However&#44; the combination of intermittent mechanical compression and compression stockings is much more effective&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> The use of low molecular weight heparin beginning on day 1 after a cerebral haemorrhage decreases the risk of thromboembolic complications in ICH patients and does not increase the risk of bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Seizures</span><p id="par0210" class="elsevierStylePara elsevierViewall">The presence of seizures increases the brain&#39;s metabolic demand and exacerbates neurological damage in patients with ICH&#46; If seizures appear&#44; they should initially be treated with benzodiazepine&#44; followed by antiepileptic drugs&#46; However&#44; administering antiepileptic drugs to ICH patients who have not experienced a seizure is associated with increased morbidity and mortality&#44; especially in the case of phenytoin&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63&#44;64</span></a> Prophylactic treatment for seizures is not recommended&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Managing intracranial pressure</span><p id="par0215" class="elsevierStylePara elsevierViewall">Control over intracranial pressure &#40;ICP&#41; is one of the specific treatment objectives in ICH&#44; and the approach should be directed at the underlying cause&#46; The most common causes of high ICP are hydrocephalus due to intraventricular haemorrhage and the mass effect of the haemorrhage&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Placing devices that measure ICP increases the risk of haemorrhage and infection&#44; and such devices should not be used as routine treatment&#46; However&#44; there are also non-invasive techniques that allow us to estimate intracranial pressure in patients with ICH&#44; such as the transcranial Doppler test&#46; An increase in the pulsatility index in the middle cerebral artery of the unaffected hemisphere indicates intracranial hypertension&#44; and this has been shown to predict mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Data on managing ICP in ICH are limited&#59; recommendations have been extrapolated from those used in the management of patients with head trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> Doctors recommend considering ICP treatment and management in patients with ICH with a Glasgow scale score &#8804;8&#44; clinical evidence of transtentorial herniation&#44; significant intraventricular haemorrhage&#44; or hydrocephalus&#46; Nevertheless&#44; we must be aware that very few studies attempt to show the utility of ICP monitoring in ICH patients&#46; Most such studies were unable to discriminate between patients who might be candidates for surgical evacuation of the haemorrhage and candidates for medical treatment only&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Centring the head and raising the headboard to an angle of 20&#176; to 30&#176; improves venous return and may decrease PIC slightly&#46; Hyperventilation decreases partial pressure of oxygen in arterial blood&#44; which leads to cerebral vasoconstriction and a lowered ICP&#46; The target is to reach partial pressure of CO<span class="elsevierStyleInf">2</span> between 28 and 35<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg and subsequently maintain pressure between 25 and 30<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg if the ICP remains high&#46; This results in rapid decrease of ICP&#44; although the effect is temporary and other measures will have to be taken in order for ICP to remain under control&#46; Conditions that can cause increased ICP must be avoided&#44; including fever&#44; Valsalva-like manoeuvres &#40;coughing or vomiting&#41;&#44; seizures&#44; stress&#44; pain&#44; AHT&#44; and hyponatraemia&#46; Osmotherapy reduces ICP by increasing osmolarity in plasma&#44; which in turn displaces water from healthy brain tissue into the vascular compartment&#46; The most commonly employed drugs of this type are mannitol and loop diuretics such as furosemide&#46; Recommendations for dosing 20&#37; mannitol range from 0&#46;7 to 1<span class="elsevierStyleHsp" style=""></span>g&#47;kg &#40;250<span class="elsevierStyleHsp" style=""></span>mL&#41; followed by 0&#46;3 to 0&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg &#40;125<span class="elsevierStyleHsp" style=""></span>mL&#41; every 3 to 8<span class="elsevierStyleHsp" style=""></span>hours&#46; Treatment should not be extended beyond 5 days so as to avoid the rebound effect&#46; Furosemide &#40;10<span class="elsevierStyleHsp" style=""></span>mg every 2&#8211;8<span class="elsevierStyleHsp" style=""></span>hours&#41; may be used simultaneously to maintain the osmotic gradient&#46; Using corticosteroids for this purpose is not effective and may even increase the number of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> Sedation with intravenous drugs&#44; such as benzodiazepines&#44; barbiturates&#44; narcotics&#44; and butyrophenones&#44; reduces brain metabolism and decreases cerebral blood flow and ICP&#46; In contrast&#44; sedation also gives rise to numerous complications which include arterial hypotension and respiratory infections&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Hydrocephalus caused by the presence of an intraventricular bleed is one of the factors associated with a poor prognosis and increased mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;69</span></a> Ventriculostomy must be considered in cases in which hydrocephalus and a decreased level of consciousness are both present&#46; A randomised study named CLEAR III&#44; currently underway&#44; is evaluating the efficacy and safety of intraventricular infusion of thrombolytic drugs in patients with intraparenchymal haemorrhage and ventricular invasion&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">ICH prognosis</span><p id="par0240" class="elsevierStylePara elsevierViewall">Many different studies have turned up factors that may be related to patient prognosis&#46; These variables include age&#44; scores on the GCS and NIHSS scales&#44; haemorrhage volume and location&#44; and the presence of intraventricular haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> Data which may reflect a poor prognosis may be interpreted as a reason for limiting care&#46; This decision affects mortality&#44; and early mortality in particular&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">71&#8211;73</span></a> Current evidence suggests that establishing a sure prognosis is impossible&#46; We therefore do not recommend deciding to limit care in early stages&#46;<elsevierMultimedia ident="tb0010"></elsevierMultimedia></p></span></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Surgical treatment</span><p id="par0385" class="elsevierStylePara elsevierViewall">The question of whether or not an ICH patient should be treated surgically is controversial&#46; While surgery may reduce the effects stemming from the mechanical compression exerted by the haemorrhage and also decrease the toxic effect of blood on nearby brain tissue&#44; surgical risks may be high&#46; In most patients&#44; the benefits of surgery do not outweigh the procedure&#39;s potential for harm&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">One important factor in the decision of whether to treat ICH surgically is the haemorrhage location&#46; Cerebellar haemorrhages larger than 3<span class="elsevierStyleHsp" style=""></span>cm in diameter&#44; those compressing the brainstem&#44; or those with hydrocephalus respond better to surgical treatment than to medical treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">74&#44;75</span></a> In these cases&#44; placing a ventricular shunt without evacuating the haemorrhage is insufficient&#44; and shunt placement with no additional actions is not recommended&#46; In contrast&#44; surgery is not indicated for cerebellar haemorrhages that measure less than 3<span class="elsevierStyleHsp" style=""></span>cm and do not compress the brainstem or involve hydrocephalus&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">The clinical trial STICH observed that patients with a lobar haemorrhage located less than 1<span class="elsevierStyleHsp" style=""></span>cm from the cerebral cortex tended to benefit from surgical treatment&#44; but the tendency was not statistically significant&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> They also discovered a non-statistically significant tendency toward benefiting from surgery in patients with lobar haemorrhage and GCS scores between 9 and 12&#46; However&#44; further clinical trials will be needed to demonstrate this benefit&#46; In cases of haemorrhages located more than 1<span class="elsevierStyleHsp" style=""></span>cm from the cerebral cortex and a GCS score &#8804;8&#44; prognosis is poorer in patients who undergo surgical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">Related studies on haemorrhages located in basal ganglia do not show better results with surgical treatment&#46; We must also be mindful of the fact that gaining access to the haemorrhage will involve passing through healthy brain tissue&#44; meaning that the procedure will produce more severe sequelae&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#44;78</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">Recommended surgical treatment techniques include performing a craniectomy with decompression and evacuation of the haemorrhage&#44; but attempts have been made at developing less invasive techniques&#46; Certain projects have studied the benefits of stereotactic surgery combined with local thrombolysis<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78&#44;80</span></a> or endoscopic aspiration&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">81&#44;82</span></a> These techniques eliminate the haemorrhage more fully and decrease mortality when they are performed in the first 72<span class="elsevierStyleHsp" style=""></span>hours&#46; Nevertheless&#44; they have not been shown to improve patients&#8217; functional prognosis&#46; One clinical trial compared surgery using minimally invasive craniopuncture with medical treatment in cases of small-volume haemorrhages in the basal ganglia&#46; The report observes that the technique is safe and may improve functional prognosis in patients with this type of haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">The optimal moment in which to surgically evacuate the haemorrhage is also a matter of debate&#46; Studies of surgical procedures performed within 24&#44; 48&#44; 72&#44; or 96<span class="elsevierStyleHsp" style=""></span>hours of the haemorrhage have found no differences in outcome except with regard to patients treated with minimally invasive techniques&#44; as indicated above&#46;<elsevierMultimedia ident="tb0015"></elsevierMultimedia></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Secondary prevention</span><p id="par0435" class="elsevierStylePara elsevierViewall">The risk of recurrence after a first ICH is between 2&#46;1&#37; and 3&#46;7&#37; yearly&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">83&#44;84</span></a> In addition&#44; lobar haemorrhages related to amyloid angiopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> haemorrhages secondary to anticoagulant treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> history of prior cerebral haemorrhage&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> advanced age&#44;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> and microbleeds detected by gradient echo MRI<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> increase the risk of recurrence&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">AHT is the modifiable factor with the most influence on risk of ICH recurrence&#44; which is why proper blood pressure control is so important&#46; Good control over blood pressure lowers risk of ICH recurrence&#44; whether for hypertensive haemorrhages or for bleeds secondary to amyloid angiopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a> Although the optimal blood pressure value for reducing risk of ICH recurrence is unknown&#44; maintaining normal blood pressure values &#40;below 120&#47;80<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#41; seems to be a reasonable choice&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a></p><p id="par0445" class="elsevierStylePara elsevierViewall">Oral anticoagulants increase risk of ICH recurrence&#44;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> and the benefits of anticoagulation to prevent thromboembolic events must therefore be weighed against the risk of future ICHs&#46; Risk of recurrence is higher in lobar haemorrhages&#44; which is why anticoagulant treatment should be suspended definitively in patients with atrial fibrillation&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> In cases of deep haemorrhages&#44; risk of recurrence is lower&#46; Generally speaking&#44; doctors should consider suspending anticoagulants during the acute phase except in patients at high risk for thromboembolic events &#40;for example&#44; those fitted with mechanical valves&#41; and at low risk for a haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> When thromboembolic risk is high &#40;CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score &#8805;2&#41;&#44; doctors recommend recommencing oral anticoagulants 7 to 10 days after the stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a> Antiplatelet drugs have a less pronounced effect on haemorrhage risk and severity than oral anticoagulants do&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> They may therefore constitute a treatment alternative in patients who have a moderate level of risk &#40;CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc &#8804;1&#41; or who are functionally dependent &#40;modified Rankin scale 4&#8211;5&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a></p><p id="par0450" class="elsevierStylePara elsevierViewall">In haemorrhages secondary to an underlying lesion&#44; specific treatment decreases risk of recurrence&#46; For example&#44; surgery may be recommended for cavernous angiomas that are surgically accessible and have a bleed rate of 0&#46;7&#37; per year per lesion&#44;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> depending on the risk of a new haemorrhage&#46; A better approach for deep lesions is close monitoring&#59; surgery should be reserved for cases in which impairment is progressive or bleeding is recurrent&#46; Risk of rebleeding in AVMs is high at 18&#37; the first year<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> and 2&#37; per year in later years&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> Treatment that excludes the AVM from the circulatory system is recommended where possible&#46; In this case&#44; alternatives include surgical treatment&#44; endovascular therapy&#44; and radiosurgery&#46; Surgical treatment of ICH depends on the location&#46; Haemorrhages located in the basal ganglia&#44; diencephalon&#44; or brainstem are typically inoperable&#46; Endovascular treatment was initially developed to facilitate resection of very large AVMs&#44; or as an alternative to high-risk surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">96</span></a> However&#44; when lesions are small&#44; complete occlusion may be achieved with endovascular therapy&#46; Radiosurgery is more effective in small AVMs &#40;&#60;3<span class="elsevierStyleHsp" style=""></span>cm&#41;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a> and may also be used for AVMs that cannot be reached with any other technique&#46; In ICH secondary to neoplasia&#44; surgical treatment is generally used to excise the underlying tumour&#46; Nevertheless&#44; treatment depends on the patient&#39;s functional condition and the tumour type and location&#46;<elsevierMultimedia ident="tb0020"></elsevierMultimedia></p><p id="par0480" class="elsevierStylePara elsevierViewall">These clinical guidelines are rewritten periodically because they must reflect a continuous series of advances in clinical trials&#46; They therefore draw from previous SEN recommendations&#44; as well as from current recommendations by the European Stroke Initiative<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> and the American Heart Association Stroke Council&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> These recommendations were taken into account in the process of elaborating the guidelines we present here&#46; Likewise&#44; in order to prepare guidelines according to the standard set by international publications&#44; we used the levels of evidence and grades of recommendation published by the Centre for Evidence-Based Medicine at the University of Oxford &#40;<a class="elsevierStyleCrossRefs" href="#sec0205">Addenda 2 and 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a></p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0485" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        0 => array:2 [
          "identificador" => "xres240994"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec226827"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres240993"
          "titulo" => "Resumen"
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          "identificador" => "xpalclavsec226826"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Care strategy and systematic diagnosis"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Pre-hospital care"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Care in the emergency department"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Laboratory tests"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Neuroimaging"
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        6 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Medical treatment"
          "secciones" => array:2 [
            0 => array:3 [
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              "titulo" => "General care"
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                0 => array:2 [
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                  "titulo" => "Neurological monitoring"
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                2 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Control over arterial pressure"
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                3 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Glycaemic control"
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                  "identificador" => "sec0070"
                  "titulo" => "Temperature control"
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                5 => array:2 [
                  "identificador" => "sec0075"
                  "titulo" => "Managing haemostasis"
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            1 => array:3 [
              "identificador" => "sec0080"
              "titulo" => "Preventing complications"
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                0 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Deep vein thrombosis and pulmonary embolism"
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                1 => array:2 [
                  "identificador" => "sec0090"
                  "titulo" => "Seizures"
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                2 => array:2 [
                  "identificador" => "sec0095"
                  "titulo" => "Managing intracranial pressure"
                ]
                3 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "ICH prognosis"
                ]
              ]
            ]
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          "identificador" => "sec0165"
          "titulo" => "Surgical treatment"
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          "identificador" => "sec0175"
          "titulo" => "Secondary prevention"
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        9 => array:2 [
          "identificador" => "sec0185"
          "titulo" => "Conflict of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-02-23"
    "fechaAceptado" => "2011-03-06"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec226827"
          "palabras" => array:3 [
            0 => "Intracerebral haemorrhage"
            1 => "Guidelines"
            2 => "Stroke"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec226826"
          "palabras" => array:3 [
            0 => "Hemorragia intracerebral"
            1 => "Gu&#237;as"
            2 => "Ictus"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intracerebral haemorrhage accounts for 10&#37; to 15&#37; of all strokes&#44; however it has a poor prognosis with higher rates of morbidity and mortality&#46; Neurological deterioration is often observed during the first hours from onset&#44; and determines the poor prognosis&#46; Intracerebral haemorrhage&#44; therefore&#44; is a neurological emergency which must be diagnosed and treated properly as soon as possible&#46; In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy&#44; systematic diagnosis&#44; acute treatment and secondary prevention for this condition&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La hemorragia intracerebral s&#243;lo representa entre el 10 y el 15&#37; de todos los ictus&#44; sin embargo condiciona un peor pron&#243;stico&#44; con unas tasas m&#225;s elevadas de morbilidad y mortalidad&#46; Es frecuente que durante las primeras horas tras el inicio de los s&#237;ntomas se produzca un empeoramiento cl&#237;nico&#44; lo cual condiciona un peor pron&#243;stico&#44; por lo que la hemorragia intracerebral constituye una emergencia neurol&#243;gica en la que debe realizarse un diagn&#243;stico y tratamiento adecuado de manera precoz&#46; En esta gu&#237;a realizamos una revisi&#243;n de los procedimientos diagn&#243;sticos y los factores que influyen en el pron&#243;stico de los pacientes con hemorragia intracerebral y establecemos unas recomendaciones para la estrategia asistencial&#44; sistem&#225;tica diagn&#243;stica&#44; tratamiento en fase aguda y prevenci&#243;n secundaria en la hemorragia intracerebral&#46;</p>"
      ]
    ]
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Rodr&#237;guez-Y&#225;&#241;ez M&#44; et al&#46; Gu&#237;as de actuaci&#243;n cl&#237;nica en la hemorragia intracerebral&#46; Neurolog&#237;a&#46; 2013&#59;28&#58;236&#8211;49&#46;</p>"
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        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara">The affiliations of the authors and composition of the committee are listed in Addendum 1&#46;</p>"
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            "apendice" => "<p id="par0490" class="elsevierStylePara elsevierViewall">Coordinator&#58; Exuperio D&#237;ez-Tejedor&#44; Hospital Universitario La Paz&#44; Madrid&#46;</p>"
            "etiqueta" => "Addendum 1"
            "titulo" => "Ad hoc committee of the SEN Study Group for Cerebrovascular Diseases constituted to draw up clinical practice guidelines for stroke&#46;"
            "identificador" => "sec0190"
            "apendiceSeccion" => array:2 [
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                "apendice" => "<p id="par0495" class="elsevierStylePara elsevierViewall">Exuperio D&#237;ez-Tejedor &#40;Coord&#41;&#44; Hospital Universitario La Paz&#44; Madrid&#59; Blanca Fuentes &#40;Secretary&#41;&#44; Hospital Universitario La Paz&#44; Madrid&#59; Mar&#237;a Alonso de Leci&#241;ana&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#59; Jos&#233; &#193;lvarez-Sabin&#44; Hospital Universitari Vall d&#8217;Hebron&#44; Barcelona&#59; Juan Arenillas&#44; Hospital Universitario Cl&#237;nico de Valladolid&#59; Sergio Calleja&#44; Hospital Universitario Central de Asturias&#44; Oviedo&#59; Ignacio Casado&#44; Hospital San Pedro&#44; C&#225;ceres&#59; Mar Castellanos&#44; Hospital Josep Trueta&#44; Girona&#59; Jos&#233; Castillo&#44; Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#59; Antonio D&#225;valos&#44; Hospital Universitari Germans Trias i Pujol&#44; Badalona&#59; Fernando D&#237;az-Otero&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Exuperio D&#237;ez-Tejedor&#44; Hospital Universitario La Paz&#44; Madrid&#59; Jos&#233; Antonio Egido&#44; Hospital Cl&#237;nico Universitario San Carlos&#44; Madrid&#59; Juan Carlos Fern&#225;ndez&#44; Hospital Universitario Dr&#46; Negr&#237;n&#44; Las Palmas&#59; Mar Freijo&#44; Hospital Universitario de Basurto&#44; Bilbao&#59; Blanca Fuentes&#44; Hospital Universitario La Paz&#44; Madrid&#59; Jaime G&#225;llego&#44; Hospital General de Navarra&#44; Pamplona&#59; Andr&#233;s Garc&#237;a Pastor&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Antonio Gil-N&#250;&#241;ez&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Francisco Gilo&#44; Hospital Universitario La Princesa&#44; Madrid&#59; Pablo Irimia&#44; Cl&#237;nica Universitaria de Navarra&#44; Pamplona&#59; Aida Lago&#44; Hospital Universitario La Fe&#44; Valencia&#59; Jos&#233; Maestre&#44; Hospital Universitario Virgen de las Nieves&#44; Granada&#59; Jaime Masjuan&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#59; Joan Mart&#237;-F&#225;bregas&#44; Hospital de la Santa Creu i Sant Pau&#44; Barcelona&#59; Patricia Mart&#237;nez-S&#225;nchez&#44; Hospital Universitario La Paz&#44; Madrid&#59; Eduardo Mart&#237;nez-Vila&#44; Cl&#237;nica Universitaria de Navarra&#44; Pamplona&#59; Carlos Molina&#44; Hospital Universitario Vall d&#8217;Hebron&#44; Barcelona&#59; Ana Morales&#44; Hospital Universitario Virgen de la Arrixaca&#44; Murcia&#59; Florentino Nombela&#44; Hospital Universitario La Princesa&#44; Madrid&#59; Francisco Purroy&#44; Hospital Universitario Arnau de Vilanova&#44; L&#233;rida&#59; Marc Rib&#243;&#44; Hospital Universitari Vall d&#8217;Hebron&#44; Barcelona&#59; Manuel Rodr&#237;guez-Y&#225;&#241;ez&#44; Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#59; Jaime Roquer&#44; Hospital del Mar&#44; Barcelona&#59; Francisco Rubio&#44; Hospital Universitario de Bellvitge&#44; Barcelona&#59; Tom&#225;s Segura&#44; Hospital Universitario de Albacete&#44; Albacete&#59; Joaqu&#237;n Serena&#44; Hospital Josep Trueta&#44; Gerona&#59; Patricia Simal&#44; Hospital Cl&#237;nico Universitario San Carlos&#44; Madrid&#59; Javier Tejada&#44; Hospital Universitario de Le&#243;n&#44; Le&#243;n&#59; Jos&#233; Vivancos&#44; Hospital Universitario La Princesa&#44; Madrid&#46;</p>"
                "etiqueta" => "A&#46;1"
                "titulo" => "Drafting committee"
                "identificador" => "sec0195"
              ]
              1 => array:4 [
                "apendice" => "<p id="par0500" class="elsevierStylePara elsevierViewall">Jos&#233; &#193;lvarez-Sab&#237;n&#44; Hospital Universitari Vall d&#8217;Hebron&#44; Barcelona&#59; Jos&#233; Castillo&#44; Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#59; Exuperio D&#237;ez-Tejedor&#44; Hospital Universitario La Paz&#44; Madrid&#59; Antonio Gil-N&#250;&#241;ez&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Jos&#233; Larracoechea&#44; Hospital de Cruces&#44; Bilbao&#59; Eduardo Mart&#237;nez-Vila&#44; Cl&#237;nica Universitaria de Navarra&#44; Pamplona&#59; Jaime Masjuan&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#59; Jorge Mat&#237;as-Guiu&#44; Hospital Cl&#237;nico Universitario San Carlos&#44; Madrid&#59; Francisco Rubio&#44; Hospital de Bellvitge&#44; Barcelona&#46;</p>"
                "etiqueta" => "A&#46;2"
                "titulo" => "Review or institutional committee"
                "identificador" => "sec0200"
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          1 => array:4 [
            "apendice" => "<p id="par0505" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>"
            "etiqueta" => "Addendum 2"
            "titulo" => "Classification of levels of evidence"
            "identificador" => "sec0205"
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            "etiqueta" => "Addendum 3"
            "titulo" => "Grades of recommendation"
            "identificador" => "sec0210"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">High blood pressure</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Von Willebrand factor deficiencyHaemophiliaAfibrinogenemiaHyperfibrinolysis syndromesIdiopathic thrombotic thrombocytopenic purpuraDisseminated intravascular coagulationCoagulation disorders and thrombocytopenia in liver diseaseThrombocytopeniaThrombocythemiaMultiple myeloma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Vitamin K antagonistsHeparinStreptokinaseUrokinaseTissue plasminogen activator&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Brain tumours&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Vasculitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mycotic aneurysms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CocaineAmphetaminesCrackNasal decongestants&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Causes of non-traumatic intracerebral haemorrhage&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic review of randomised clinical trials &#40;with homogeneity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Randomised clinical trial with narrow confidence interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1c&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical practice &#40;all or none&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic review of cohort studies &#40;with homogeneity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cohort study or low quality randomised clinical trial<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2c&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8220;Outcomes&#8221; research&#44;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> ecological studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic reviews of case&#8211;control studies &#40;with homogeneity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case&#8211;control studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case series and poor-quality cohort and case&#8211;control studies<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Experts&#8217; opinion without explicit critical appraisal or based on physiology&#44; bench research or &#8220;first principles&#8221;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab351291.png"
              ]
            ]
          ]
          "notaPie" => array:5 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">When all patients died before a certain treatment became available&#44; and some who received the treatment survived&#59; or if some patients died before the treatment existed&#44; and none of those receiving the treatment died&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara">For example&#44; follow-up rates below 80&#37;&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara">The term &#8216;outcomes research&#8217; refers to cohort studies in patients with the same diagnosis in which the events that occur are related to treatments delivered to the patients&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara">Cohort study&#58; no clear definition of the groups being compared and&#47;or no objective measurement of treatments and events &#40;preferably blinded&#41; and&#47;or without properly identifying or controlling for known confounders and&#47;or complete and sufficient follow-up period&#46; Case&#8211;control study&#58; no clear definition of the groups being compared and&#47;or no objective measurement of treatments and events &#40;preferably blinded&#41; and&#47;or without properly identifying or controlling for known confounders&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara">The term &#8216;first principles&#8217; refers to the adoption of a specific clinical practice based on pathophysiological evidence&#46;</p>"
            ]
          ]
        ]
      ]
      2 => array:5 [
        "identificador" => "tbl0010"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Grade of recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level 1 studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level 2 or 3 studies&#44; or extrapolations from level 1 studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level 4 studies&#44; or extrapolations from level 2 or 3 studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level 5 studies&#44; or inconclusive studies of any level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab351289.png"
              ]
            ]
          ]
        ]
      ]
      3 => array:5 [
        "identificador" => "tb0005"
        "tipo" => "MULTIMEDIATEXTO"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "texto" => array:1 [
          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recommendations for the care strategy and systematic diagnosis</span><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">An emergency brain CT or MRI scan is recommended on an emergency basis in order to distinguish between ICH and other ischaemic or structural lesions &#40;level of evidence 1&#44; grade A recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">CT angiography with contrast may be useful for identifying patients who are at risk for haemorrhage growth &#40;level of evidence 2b&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">CT angiography and&#47;or MRI angiography may be useful for identifying structural lesions that are aetiologically related to ICH when there is a suspicion based on radiological findings &#40;level of evidence 2a&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Conventional angiography must be considered in patients when the ICH aetiology has not been determined by non-invasive methods and radiological signs are suggestive of a structural lesion &#40;level of evidence 4&#44; grade C recommendation&#41;&#46;</p></li></ul></p></span></span>"
        ]
      ]
      4 => array:5 [
        "identificador" => "tb0010"
        "tipo" => "MULTIMEDIATEXTO"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "texto" => array:1 [
          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recommendations in medical treatment</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General care</span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Life support and oxygen saturation</span><p id="par0245" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">If arterial oxygen saturation is less than 92&#37;&#44; the patient will require an oxygen mask with a flow sufficient to maintain oxygen saturation above that threshold&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Early intubation is recommended in patients with a massive ICH and low level of consciousness &#40;GCS<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>8&#41; if the patient&#39;s prior functional state is good&#44; but not if all brainstem signs have disappeared &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li></ul></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Neurological monitoring</span><p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Level of consciousness and neurological deficit must be evaluated periodically during at least the first 72<span class="elsevierStyleHsp" style=""></span>hours after the stroke&#46; Neurological impairment should be measured using the NIHSS scale&#59; level of consciousness is monitored using the Glasgow coma scale &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li></ul></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Arterial pressure</span><p id="par0270" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">The current recommendation&#44; as we await results from new clinical trials&#44; is to treat patients whose systolic blood pressure exceeds 180<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg &#40;level of evidence 2b&#44; grade C recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Rapid reduction of systolic blood pressure to the limit of 140<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg is safe in patients whose systolic blood pressure readings fall between 150 and 220<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg &#40;level of evidence 2a&#44; grade B recommendation&#41;&#46;</p></li></ul></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Glycaemia</span><p id="par0285" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">1&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Blood glucose levels must be checked regularly and hyperglycaemia above 155<span class="elsevierStyleHsp" style=""></span>mg&#47;dL is to be avoided &#40;level of evidence 2c&#44; grade C recommendation&#41;&#46; If the glucose level exceeds that threshold&#44; it should be corrected with insulin&#46; Glucose levels below 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL must be corrected with 10&#37; to 20&#37; dextrose &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li></ul></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Temperature</span><p id="par0295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Doctors recommend treating hyperthermia above 37&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C with intravenous paracetamol &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li></ul></p></span></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Managing haemostasis</span><p id="par0305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">1&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Patients with coagulation factor deficiency or severe thrombocytopenia should be treated with the lacking coagulation factors or platelets&#44; respectively &#40;level of evidence 1&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Patients on anticoagulant treatment with ICH and elevated INR should receive intravenous prothrombin complex concentrate and vitamin K&#44; plus fresh plasma if necessary&#44; to replace vitamin K-dependent factors until INR level is normalised &#40;level of evidence 1&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">3&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Patients who have undergone intravenous heparin treatment and have a prolonged APTT should receive treatment with protamine sulphate &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">4&#46;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Patients with ICH who have undergone thrombolytic treatment should receive a transfusion of fresh plasma and platelets or antifibrinolytic drugs such as aminocaproic acid or tranexamic acid &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li></ul></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Preventing complications</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Deep vein thrombosis and pulmonary embolism</span><p id="par0330" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">1&#46;</span><p id="par0335" class="elsevierStylePara elsevierViewall">A combination of intermittent mechanical compression and compression stockings should be used to prevent deep vein thrombosis &#40;level of evidence 1&#44; recommendation level B&#41;&#46; Beginning on day 1&#44; it is possible to administer prophylactic treatment with low molecular weight heparin &#40;level of evidence 2b&#44; grade B recommendation&#41;&#46;</p></li></ul></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Seizures</span><p id="par0340" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">1&#46;</span><p id="par0345" class="elsevierStylePara elsevierViewall">If seizures appear&#44; the patient will require antiepileptic drugs &#40;level of evidence 1&#44; grade A recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">2&#46;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Prophylactic treatment with antiepileptic drugs is not indicated &#40;level of evidence 3&#44; grade B recommendation&#41;&#46;</p></li></ul></p></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Managing intracranial pressure</span><p id="par0355" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">1&#46;</span><p id="par0360" class="elsevierStylePara elsevierViewall">ICP must be monitored in patients with a GCS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8 and signs of transtentorial herniation or hydrocephalus &#40;level of evidence 2b&#44; grade C recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">2&#46;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Placing a ventricular shunt should be considered for patients with hydrocephalus &#40;level of evidence 2a&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">3&#46;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Although osmotic diuretics are recommended as the first treatment option&#44; they are not indicated for prophylactic use &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">4&#46;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Doctors recommend hyperventilation in cases that do not respond to treatment with osmotic diuretics&#44; provided that the patient has a good functional prognosis &#40;level of evidence 5&#44; grade C recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">5&#46;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Corticosteroids are not recommended as treatment for primary ICH &#40;level of evidence 2&#44; grade B recommendation&#41;&#46;</p></li></ul></p></span></span>"
        ]
      ]
      5 => array:5 [
        "identificador" => "tb0015"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recommendations for surgical treatment</span><p id="par0415" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">1&#46;</span><p id="par0420" class="elsevierStylePara elsevierViewall">Surgical treatment is recommended as soon as possible for patients with cerebellar haemorrhages who present with neurological impairment&#44; brainstem compression&#44; or hydrocephalus &#40;level of evidence 1&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">2&#46;</span><p id="par0425" class="elsevierStylePara elsevierViewall">In patients with neurological impairment and a lobar haemorrhage exceeding 30<span class="elsevierStyleHsp" style=""></span>mL in volume and located less than 1<span class="elsevierStyleHsp" style=""></span>cm from the cerebral cortex&#44; surgical treatment should also be considered &#40;level of evidence 2b&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">3&#46;</span><p id="par0430" class="elsevierStylePara elsevierViewall">Evacuation procedures are not recommended for deep haemorrhages &#40;level of evidence 2&#44; grade B recommendation&#41;&#46; Although minimally invasive surgery may be an alternative in the future&#44; data are not sufficient to recommend stereotactic surgery to evacuate haemorrhages at the present time &#40;level of evidence 2&#44; grade B recommendation&#41;&#46;</p></li></ul></p></span></span>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recommendations for secondary prevention</span><p id="par0455" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">1&#46;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Maintaining blood pressure values below 120&#47;80<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg is recommended for all patients with ICH &#40;level of evidence 2a&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">2&#46;</span><p id="par0465" class="elsevierStylePara elsevierViewall">Anticoagulants should not be administered following a lobar ICH in cases with non-valvular atrial fibrillation &#40;level of evidence 2a&#44; grade B recommendation&#41;&#46; Antiplatelet drugs may be administered to these patients as an alternative to anticoagulants &#40;level of evidence 2&#44; grade B recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">3&#46;</span><p id="par0470" class="elsevierStylePara elsevierViewall">In cases of accessible cavernous angiomas&#44; doctors should evaluate surgical treatment according to the risk of bleeding &#40;level of evidence 5&#44; grade D recommendation&#41;&#46; Monitoring is recommended for haemorrhages at deep locations&#59; surgery should be considered in cases of rebleeding or increasing neurological deficit &#40;level of evidence 5&#44; grade D recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">4&#46;</span><p id="par0475" class="elsevierStylePara elsevierViewall">Recommended treatments for AVMs may be surgical&#44; endovascular&#44; and&#47;or radiosurgical depending on the surgical risk and the size and location of the lesion &#40;level of evidence 5&#44; grade D recommendation&#41;&#46;</p></li></ul></p></span></span>"
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                        0 => array:2 [ …2]
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                    0 => array:1 [
                      "Libro" => array:3 [
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                        "editorial" => "Butterworth-Heineman"
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              "etiqueta" => "2"
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [ …2]
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                  ]
                  "host" => array:1 [
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                        "fecha" => "1991"
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              "etiqueta" => "3"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                    ]
                  ]
                  "host" => array:1 [
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            ]
            3 => array:3 [
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                  "host" => array:1 [
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                        "paginaInicial" => "141"
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                        "serieFecha" => "1994"
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
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                      "autores" => array:1 [
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                  "host" => array:1 [
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            ]
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              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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            6 => array:3 [
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              "etiqueta" => "7"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cerebral amyloid angiopathy&#58; incidence and complications in the aging brain I&#46; Cerebral hemorrhage"
                      "autores" => array:1 [
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                  ]
                  "host" => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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              "etiqueta" => "12"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Determinants of intracerebral hemorrhage growth&#58; an exploratory analysis"
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            12 => array:3 [
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              "etiqueta" => "13"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Hematoma growth in oral anticoagulant related intracerebral hemorrhage"
                      "autores" => array:1 [
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                    ]
                  ]
                  "host" => array:1 [
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              ]
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            13 => array:3 [
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              "etiqueta" => "14"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                  ]
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              "identificador" => "bib0075"
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                  ]
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            15 => array:3 [
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                        "fecha" => "1982"
                        "volumen" => "228"
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                      "autores" => array:1 [
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                  ]
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                    0 => array:1 [
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                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                    ]
                  ]
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                      "Revista" => array:6 [
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                        "fecha" => "1999"
                        "volumen" => "246"
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              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
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                      "titulo" => "Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage"
                      "autores" => array:1 [
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1212/01.wnl.0000208408.98482.99"
                      "Revista" => array:6 [
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                        "fecha" => "2006"
                        "volumen" => "66"
                        "paginaInicial" => "1175"
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              ]
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            19 => array:3 [
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              "etiqueta" => "20"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/01.STR.0000259633.59404.f3"
                      "Revista" => array:6 [
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                        "fecha" => "2007"
                        "volumen" => "38"
                        "paginaInicial" => "1257"
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                      "autores" => array:1 [
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                  "host" => array:1 [
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                      "Revista" => array:6 [
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                        "fecha" => "2008"
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                        "paginaInicial" => "520"
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            21 => array:3 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "volumen" => "33"
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                ]
              ]
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              "referencia" => array:1 [
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                  ]
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Article information
ISSN: 21735808
Original language: English
DOI:10.1016/j.nrleng.2011.03.011
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