Citicoline for Hemorrhagic Stroke

Guideline Position

The American Heart Association/American Stroke Association guidelines state that citicoline cannot be recommended for acute stroke treatment due to lack of consistent efficacy, with this recommendation carrying Grade A strength of evidence based on multiple randomized controlled trials 1, 2.
The absence of recommendation for citicoline extends to hemorrhagic stroke given the paucity of definitive evidence 3, 4.

No definitive trials have been completed to validate preliminary findings of citicoline's potential benefit in hemorrhagic stroke, despite a pilot study showing a trend toward benefit but being underpowered 3, 4.

The International Citicoline Trial on Acute Stroke (ICTUS) found no difference in 90-day outcomes between citicoline and placebo in patients with moderate to severe ischemic stroke (OR 1.03, 95% CI 0.86-1.25, p=0.364) 1, 2.
The failure of citicoline in ischemic stroke suggests limited therapeutic potential in hemorrhagic stroke 1.

Acute blood pressure management is critical, as hypertension increases the risk of hematoma expansion 5.
Reversal of anticoagulation when applicable, following established protocols 6.
Surgical evaluation for cerebellar hemorrhages causing brainstem compression or hydrocephalus, which can be life-saving 6, 5.
Avoidance of hypotonic fluids that may worsen cerebral edema; use isotonic saline instead 6, 5.
Temperature and glucose management: maintain normothermia and avoid hyperglycemia, as both are associated with worse outcomes 5.