Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document
Abstract Background Spontaneous intracerebral hemorrhage (ICH) accounts for 9–27% of all strokes worldwide and is associated with high mortality and disability. The main causes include vascular malformations, small- and large-vessel angiopathies, and coagulation disorders. Mortality rates reach appr...
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2025-05-01
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| author | Gianluigi Morello Daniela Alampi Raffaele Aspide Alessandra Beretta Rita Bertuetti Federico Bilotta Etrusca Brogi Giovanni Buscema Anselmo Caricato Davide Caruzzo Carlo Alberto Castioni Arturo Chieregato Andrea Cortegiani Alessandro De Cassai Andrea Fabbri Domenico Gelormini Paolo Gritti Lucrezia Guadrini Alberto Librizzi Nicola Latronico Nicola Limbucci Marina Munari Edoardo Picetti Giuseppina Pipitone Gianluca Pucciarelli Chiara Robba Danilo Toni Salvatore Sardo Simone Maria Zerbi Nicola Zugni Frank Rasulo |
| author_facet | Gianluigi Morello Daniela Alampi Raffaele Aspide Alessandra Beretta Rita Bertuetti Federico Bilotta Etrusca Brogi Giovanni Buscema Anselmo Caricato Davide Caruzzo Carlo Alberto Castioni Arturo Chieregato Andrea Cortegiani Alessandro De Cassai Andrea Fabbri Domenico Gelormini Paolo Gritti Lucrezia Guadrini Alberto Librizzi Nicola Latronico Nicola Limbucci Marina Munari Edoardo Picetti Giuseppina Pipitone Gianluca Pucciarelli Chiara Robba Danilo Toni Salvatore Sardo Simone Maria Zerbi Nicola Zugni Frank Rasulo |
| author_sort | Gianluigi Morello |
| collection | DOAJ |
| description | Abstract Background Spontaneous intracerebral hemorrhage (ICH) accounts for 9–27% of all strokes worldwide and is associated with high mortality and disability. The main causes include vascular malformations, small- and large-vessel angiopathies, and coagulation disorders. Mortality rates reach approximately 40% at 1 month and 54% at 1 year, largely influenced by early management decisions. Rapid intervention, particularly within the first hour, is crucial, especially for patients initially treated in peripheral hospitals. This consensus document, developed by SIAARTI with the endorsement of multiple medical societies, aims to standardize ICH management based on hospital capabilities, aligning with the “time is brain” principle and the 2022 AHA guidelines. Methods A multidisciplinary panel of experts—including neurointensivists, neuroanesthesiologists, neurologists, neuroradiologists, emergency physicians, and neuroscience nurses—developed this consensus document. The process combined a systematic literature review with a modified Delphi method, prioritizing clinical questions using the UCLA-RAND appropriateness methodology. Literature searches were conducted on PubMed following PRISMA 2020 guidelines. Statements were formulated based on both evidence and expert consensus, and the final document underwent external peer review. Results Computer tomography (CT) angiography, with over 90% sensitivity and specificity, is a key tool for identifying macrovascular abnormalities and detecting active bleeding, a critical factor in poor outcomes. Prognostic models, such as the ICH score, assist in clinical decision-making. Strict blood pressure control (target 130–140 mmHg) and early intubation in appropriate cases help mitigate hematoma expansion. Anticonvulsants are recommended only for patients with documented seizures. In cases of anticoagulant-related hemorrhage, prothrombin complex concentrates are effective for rapid reversal, though their long-term impact remains uncertain. Intensive care unit (ICU) admission is determined by ICH severity, with severe cases benefiting from specialized neurocritical care. Conclusion A multidisciplinary and inter-societal discussion provided key recommendations for the immediate management of ICH, based on the available literature. While only a few topics are supported by robust evidence, experts strongly recommend early brain angio CT, risk stratification using scoring systems, clear communication of patient data, and intubation for impaired consciousness. Blood pressure should be controlled with alpha- and beta-blockers, avoiding hypotension. Anticoagulant reversal should be appropriately managed, and eligible patients should be centralized in ICU and neurosurgical centers using dedicated scoring systems. |
| format | Article |
| id | doaj-art-e5e8b4a3a34f43a7a694a732523e4aeb |
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| issn | 2731-3786 |
| language | English |
| publishDate | 2025-05-01 |
| publisher | BMC |
| record_format | Article |
| series | Journal of Anesthesia, Analgesia and Critical Care |
| spelling | doaj-art-e5e8b4a3a34f43a7a694a732523e4aeb2025-08-20T01:49:35ZengBMCJournal of Anesthesia, Analgesia and Critical Care2731-37862025-05-015111210.1186/s44158-025-00244-zGolden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety documentGianluigi Morello0Daniela Alampi1Raffaele Aspide2Alessandra Beretta3Rita Bertuetti4Federico Bilotta5Etrusca Brogi6Giovanni Buscema7Anselmo Caricato8Davide Caruzzo9Carlo Alberto Castioni10Arturo Chieregato11Andrea Cortegiani12Alessandro De Cassai13Andrea Fabbri14Domenico Gelormini15Paolo Gritti16Lucrezia Guadrini17Alberto Librizzi18Nicola Latronico19Nicola Limbucci20Marina Munari21Edoardo Picetti22Giuseppina Pipitone23Gianluca Pucciarelli24Chiara Robba25Danilo Toni26Salvatore Sardo27Simone Maria Zerbi28Nicola Zugni29Frank Rasulo30ASP Catania, Anesthesia and Intensive Care, Militello HospitalUnit of Anesthesia, Department of Clinical and Surgical Translational Medicine, Intensive Care and Pain Medicine, Sant’Andrea Hospital, Sapienza UniversityIRCCS Istituto delle Scienze Neurologiche di Bologna, Anesthesia and Intensive Care UnitNeurocritical and Postoperative Care, Neuroanesthesia, ASST Spedali Civili Di BresciaNeurocritical and Postoperative Care, Neuroanesthesia, ASST Spedali Civili Di BresciaDepartment of Anesthesiology and Intensive Care Medicine, University of Rome “La Sapienza”Neuroscience Intensive Care Unit, ASST Grande Ospedale Metropolitano NiguardaDepartment of Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Policlinico“G. Rodolico — San Marco”diTerapia Intensiva Neurochirurgica, Fondazione Policlinico Universitario A.Gemelli IRCCSAzienda Sanitaria Universitaria Friuli Centrale Di UdineIRCCS Istituto delle Scienze Neurologiche di Bologna, Anesthesia and Intensive Care UnitNeuroscience Intensive Care Unit, ASST Grande Ospedale Metropolitano NiguardaDepartment of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of PalermoUniversity of PaduaEmergency Department, Local Health Agency of RomagnaNeurocritical and Postoperative Care Unit, Department of Emergency, Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Integrata Di VeronaDepartment of Anesthesia and Intensive Care Unit, Papa Giovanni XXIII HospitalNeurocritical and Postoperative Care, Neuroanesthesia, ASST Spedali Civili Di BresciaNeurocritical and Postoperative Care, Neuroanesthesia, ASST Spedali Civili Di BresciaDepartment of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of BresciaInterventional Neurovascular Unit, Careggi University HospitalDepartment of Anesthesia, Intensive Care and Neurointensive Care, University Hospital of PaduaDepartment of Anesthesia and Intensive Care, Parma University HospitalDepartment of Neurosurgery, Parma University HospitalDepartment of Biomedicine and Prevention, University of Rome Tor VergataDepartment of Surgical Science and Integrated Diagnostic, University of GenovaEmergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of RomeDepartment of Medical Sciences and Public Health, University of CagliariDepartment of Emergency, Anesthesia and Intensive Care, Neurointensive Care, ASST Lariana Ospedale Sant’AnnaNeurocritical and Postoperative Care, Neuroanesthesia, ASST Spedali Civili Di BresciaDept. of Neuroanesthesia, Neurocritical and Postoperative Care, ASST Spedali Civili University Affiliated Hospital of BresciaAbstract Background Spontaneous intracerebral hemorrhage (ICH) accounts for 9–27% of all strokes worldwide and is associated with high mortality and disability. The main causes include vascular malformations, small- and large-vessel angiopathies, and coagulation disorders. Mortality rates reach approximately 40% at 1 month and 54% at 1 year, largely influenced by early management decisions. Rapid intervention, particularly within the first hour, is crucial, especially for patients initially treated in peripheral hospitals. This consensus document, developed by SIAARTI with the endorsement of multiple medical societies, aims to standardize ICH management based on hospital capabilities, aligning with the “time is brain” principle and the 2022 AHA guidelines. Methods A multidisciplinary panel of experts—including neurointensivists, neuroanesthesiologists, neurologists, neuroradiologists, emergency physicians, and neuroscience nurses—developed this consensus document. The process combined a systematic literature review with a modified Delphi method, prioritizing clinical questions using the UCLA-RAND appropriateness methodology. Literature searches were conducted on PubMed following PRISMA 2020 guidelines. Statements were formulated based on both evidence and expert consensus, and the final document underwent external peer review. Results Computer tomography (CT) angiography, with over 90% sensitivity and specificity, is a key tool for identifying macrovascular abnormalities and detecting active bleeding, a critical factor in poor outcomes. Prognostic models, such as the ICH score, assist in clinical decision-making. Strict blood pressure control (target 130–140 mmHg) and early intubation in appropriate cases help mitigate hematoma expansion. Anticonvulsants are recommended only for patients with documented seizures. In cases of anticoagulant-related hemorrhage, prothrombin complex concentrates are effective for rapid reversal, though their long-term impact remains uncertain. Intensive care unit (ICU) admission is determined by ICH severity, with severe cases benefiting from specialized neurocritical care. Conclusion A multidisciplinary and inter-societal discussion provided key recommendations for the immediate management of ICH, based on the available literature. While only a few topics are supported by robust evidence, experts strongly recommend early brain angio CT, risk stratification using scoring systems, clear communication of patient data, and intubation for impaired consciousness. Blood pressure should be controlled with alpha- and beta-blockers, avoiding hypotension. Anticoagulant reversal should be appropriately managed, and eligible patients should be centralized in ICU and neurosurgical centers using dedicated scoring systems.https://doi.org/10.1186/s44158-025-00244-zIntracerebral hemorrhageClinical questionsComputed tomography angiographyGlasgow Coma ScaleSystolic blood pressureTranexamic acid |
| spellingShingle | Gianluigi Morello Daniela Alampi Raffaele Aspide Alessandra Beretta Rita Bertuetti Federico Bilotta Etrusca Brogi Giovanni Buscema Anselmo Caricato Davide Caruzzo Carlo Alberto Castioni Arturo Chieregato Andrea Cortegiani Alessandro De Cassai Andrea Fabbri Domenico Gelormini Paolo Gritti Lucrezia Guadrini Alberto Librizzi Nicola Latronico Nicola Limbucci Marina Munari Edoardo Picetti Giuseppina Pipitone Gianluca Pucciarelli Chiara Robba Danilo Toni Salvatore Sardo Simone Maria Zerbi Nicola Zugni Frank Rasulo Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document Journal of Anesthesia, Analgesia and Critical Care Intracerebral hemorrhage Clinical questions Computed tomography angiography Glasgow Coma Scale Systolic blood pressure Tranexamic acid |
| title | Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document |
| title_full | Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document |
| title_fullStr | Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document |
| title_full_unstemmed | Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document |
| title_short | Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document |
| title_sort | golden hour management in the patient with intraparenchymal cerebral hemorrhage an italian intersociety document |
| topic | Intracerebral hemorrhage Clinical questions Computed tomography angiography Glasgow Coma Scale Systolic blood pressure Tranexamic acid |
| url | https://doi.org/10.1186/s44158-025-00244-z |
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