Primary prevention

Treatment of hypertension is the most important measure for primary prevention of intracerebral hemorrhage.

Important lifestyle measures that can reduce the risk for intracerebral hemorrhage are good nutrition; exercise; abstinence from smoking, illegal drug use, and heavy drinking; and good blood sugar control in people with diabetes.[9][58][59][60]

Use of antithrombotic medicines may also increase the risk of intracerebral hemorrhage, but in most cases the benefits of antithrombotic medication outweigh the risk of intracerebral hemorrhage. Direct oral anticoagulants are associated with reduced risk of intracerebral hemorrhage compared with warfarin.[41]

Patients with vascular malformations discovered on brain imaging, without a history of hemorrhage, are recommended to consult with relevant specialists including a neurosurgeon. If the bleeding risk is high, preventive surgery, endovascular obliteration, or radiosurgery may be warranted.

Secondary prevention

Treatment to lower blood pressure

Blood pressure (BP) should be well controlled, particularly for patients with hemorrhage location that is typical of hypertensive vasculopathy.

Meta-analyses of randomized controlled trials indicate that intensive lowering of systolic BP to <139 mmHg is safe in patients with acute intracerebral hemorrhage (ICH), but is not associated with improved functional outcome or reduced mortality compared with standard BP-lowering treatment (i.e., systolic BP <180 mmHg).[177][178]

After the acute phase, American College of Cardiology/American Heart Association guidelines suggest that a BP goal of <130 mmHg/80 mmHg may be reasonable for secondary stroke prevention.[179]

One meta-analysis concluded that exercise-based interventions after stroke are effective in reducing systolic blood pressure, as well as reducing fasting glucose and fasting insulin, and increasing high-density lipoprotein cholesterol.[180]

Restarting anticoagulation

In general, anticoagulants are avoided post-ICH unless there is an artificial heart valve or other similarly compelling medical indication.[9][181] The American Stroke Association guidelines recommend avoiding resuming oral anticoagulation following a lobar hemorrhage, although it can still be considered in cases of non-lobar ICH.[9]

Meta-analysis has shown that resuming oral anticoagulation may benefit survivors of anticoagulation-associated ICH with atrial fibrillation, who are at higher risk for ischemic stroke than for ICH recurrence.[182] Resumption of oral anticoagulation in these patients may be considered after weighing benefit and risk.[9]

Data suggest that newer oral anticoagulants are associated with reduced risk of spontaneous ICH compared with warfarin.[165][183][184][185] When secondary ICH occurs after anticoagulant treatment, newer oral anticoagulants are associated with smaller hematomas and with better functional outcome than warfarin.[186][187][188] 

When considering restarting anticoagulation, the risk of ischemic stroke must be weighed against the risk of bleeding. The optimal timing to restart anticoagulation is unclear. The American Heart Association/American Stroke Association state that the decision to restart anticoagulation (e.g., at 14 days after ICH for patients with a left ventricular assist device [LVAD] and potentially earlier for patients with mechanical valves and relatively small ICHs) is reasonable and safe in patients with LVAD or mechanical valves but requires individualized assessment of risk and benefit.[9] The timing of resumption or initiation of anticoagulation in patients with atrial fibrillation and ICH is challenging. Existing studies are limited by confounding by indication and by clinician and patient preferences.[9] Decisions should be considered on a case-by-case basis of individual risk assessments of thromboembolism, recurrent ICH, and late ICH expansion.[9]

Left atrial appendage

In patients with anticoagulation-associated ICH with atrial fibrillation deemed ineligible for anticoagulation, a left atrial appendage (LAA) occlusion device may be an alternative to anticoagulation.[9] The LAA procedure has shown early success as an antiembolic intervention when compared with placebo; however, more data are needed in order to conclude its safety and effectiveness by comparison with anticoagulation.[189]

Antiplatelet therapy

Aspirin appears to have a relatively small effect on increasing the risk of recurrent ICH and can be considered with caution in patients who are at high risk for thrombotic events after secondary ICH.[190][191][192]​​

In one cohort study, older people receiving daily aspirin-based antiplatelet treatment without routine proton-pump inhibitor (PPI) use were at higher and more sustained risk of major bleeding than younger patients. The estimated numbers needed to treat for routine PPI use to prevent major upper gastrointestinal bleed were low, and the authors concluded that co-prescription should be encouraged in this patient population.[193]

Lifestyle

Lifestyle changes should be encouraged.[9][71]​ Patients should be referred to smoking and alcohol cessation programs as necessary.[71] Counseling with or without drug therapy (nicotine replacement, bupropion, or varenicline) is recommended to assist in stopping smoking to reduce risk of recurrent stroke.[71] Avoiding heavy alcohol consumption is reasonable to reduce hypertension and risk of stroke recurrence.[9] Patients with residual disability should be referred to physical therapists or cardiac rehabilitation professionals for supervised and goal-oriented rehabilitation.[71] In patients with stroke or transient ischemic attack who are able and willing to increase physical activity, engaging in an exercise class that includes counseling to change physical activity behavior can be beneficial for reducing cardiometabolic risk factors and increasing leisure time physical activity participation.[71] When this is not possible, the patient’s physical activity goals should be customized to their exercise tolerance, stage of recovery, environment, available social support, physical activity preferences, and specific impairments, activity limitations, and participation restrictions.[71] In patients who sit for long periods of uninterrupted time during the day, it may be reasonable to recommend breaking up sedentary time with intervals as short as 3 minutes of standing or light exercise every 30 minutes for their cardiovascular health.[71]

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