WSC 2025 | Recommendations in the ESO and EANS guidelines on stroke due to spontaneous ICH

The key recommendations are first that the same is true for ICH as it is true for ischemic stroke and that is that these patients should be treated on a specialized unit or stroke unit. It has clearly been shown that this has an effect not only on mortality, but also on the clinical outcome of patients. So this is why we made this to be a strong recommendation. The second recommendation or the second expert consensus statement, but I think one of the key elements in this guideline is to acutely lower the blood pressure below 140 millimeters of mercury and to then keep the blood pressure between 130 and 150 millimeters of mercury in bleedings that do not exceed 30 milliliters. The next thing that is recommended is to do this as fast as possible, at least within six hours, but best within two hours, and to avoid larger blood pressure fluctuations. The next recommendation is on the use of reversal agents, but that one I answered in the question before. The fourth area the guideline is dealing with is with new surgical interventions. It is recommended to consider new surgical intervention depending on the location of the bleeding, on the age of the patients, on the time window and the technique that is available. So there are a couple of sub-PICOs to this PICO that deal with, for example, minimally invasive surgery, that deal with application of external ventricular drainage, that deal with infratentorial bleedings, where just to give you an example, it is recommended to consider evacuating patients when they have a cerebellar bleeding, which exceeds 15 milliliters. The other important recommendation is the use of care bundles. There is a study that goes back that was published last year and showed that the combination of temperature lowering, normalization of glucose, blood pressure lowering and reversal of vitamin K antagonist bleeding is of benefit, of clinical benefit for the patient. So we recommend considering that as we do recommend considering even other pieces that might be, that should be part of a care bundle. For example, having a new surgical pathway in an algorithm and the use of reversal agents. And the final PICO question deals with secondary prevention of ICH. And there it is things like restarting antiplatelet agents, which is something we recommend considering. We also recommend considering the use of oral anticoagulants in patients who have atrial fibrillation, depending on certain criteria, which are in the guideline, we also recommend continuing statin therapy. And finally, we also recommend considering the use of left atrial appendage occluder.

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