DNAR status should not limit appropriate medical and surgical interventions unless otherwise explicitly indicated (Class III; Level of Evidence C). (Revised from the previous guideline) Prevention of Recurrent ICH Patients with ICH are at high risk of a recurrent event and of other major vascular disease.267 The cumulative risk of Hemphill et al Management of Spontaneous ICH 2047 ICH recurrence is 1% to 5% per year.267 269 In the Perindopril Protection Against Recurrent Stroke Study (PROGRESS), the hazard ratio (HR) for ICH recurrence among subjects with prior ICH relative to a first ICH in subjects with prior isch- Although the risk of ICH recurrence is highest in the first year after the ini- tial event, the ongoing risk extends for years, particularly in patients with lobar ICH.269,270 Risk Factors Hypertension, older age, and location of the initial hemor- rhage (deep versus lobar) are important risk factors for ICH High BP is associated with an increase in the recurrence of both deep and lobar hemorrhages.271 Increased risk in the elderly is attributed to a higher prevalence of cere- bral amyloid angiopathy (CAA) and increased use of anti- thrombotic medications with accumulating comorbidities.272 CAA is a recognized risk factor for recurrent ICH, particularly in lobar locations.271 Carriers of the apolipoprotein E 2 or patients with previous ICH before the present- and patients with a greater number of microbleeds (particularly microbleeds in lobar brain locations) on gradient echo MRI appear to be at higher risk for ICH recurrence.272,275 In whites, most of the initial and recurrent hemorrhages tend to be lobar, whereas deep hemorrhages (both initial and recur- rent) are more common in Asians.269,276 A history of ischemic stroke, particularly of the small-vessel lacunar type, which shares a common pathogenesis with ICH, might also be a pre- dictor of ICH recurrence.277,278 BP Management Among the preceding risk factors, only BP and the use of anti- thrombotic agents are modifiable. 