Guide Highlights:
The 10 central points of the 2022 guide 1. The organization of health care systems is increasingly recognized as a key component of optimal stroke care. This guideline recommends the development of regional systems that provide initial intracerebral hemorrhage (ICH) care and the ability, when appropriate, for rapid transfer to facilities with neurosurgical and neurocritical care capabilities. 2. Hematoma expansion is associated with worse ICH outcome. There are now a range of neuroimaging markers that, together with clinical markers such as time since stroke onset and use of antithrombotic agents, help predict the risk of hematoma expansion. These neuroimaging markers include signs detectable by non-contrast computed tomography, the most commonly used neuroimaging modality for ICH. 3. ICH, like other forms of stroke, occur as a consequence of a defined set of vascular pathologies. This guideline emphasizes the importance and approaches to identify markers of pathogenesis of both microvascular and macrovascular hemorrhage. 4. When acute blood pressure reduction is implemented after mild to moderate ICH, treatment regimens that limit blood pressure variability and achieve gentle, sustained blood pressure control appear to reduce hematoma expansion and produce a better functional result. 5. ICH during anticoagulation has extremely high mortality and morbidity. This guideline provides updated recommendations for acute reversal of anticoagulation after ICH, highlighting the use of protein complex concentrates to reverse vitamin K antagonists such as warfarin, idarucizumab to reverse the thrombin inhibitor dabigatran, and andexanet alfa to reverse factor Xa inhibitors such as rivaroxaban, apixaban and edoxaban. 6. Several in-hospital therapies that have historically been used to treat patients with ICH appear to produce no benefit or harm. For the emergency or intensive care treatment of ICH, prophylactic corticosteroids or continuous hyperosmolar therapy do not appear to have any benefit for outcome, while the use of platelet transfusions outside the context of emergency surgery or severe thrombocytopenia appears worsen the result. Similar considerations apply to some prophylactic treatments historically used to prevent medical complications after ICH. The use of graduated knee- or thigh-high compression stockings alone is not an effective prophylactic therapy for the prevention of deep vein thrombosis, and prophylactic antiseizure medications in the absence of evidence of seizures do not improve seizure control at all. long term or functional outcome. 7. Minimally invasive approaches to evacuation of supratentorial ICH and intraventricular hemorrhages, compared with medical treatment alone, have demonstrated reductions in mortality. However, evidence from clinical trials on improved functional outcome with these procedures is neutral. For patients with cerebellar hemorrhage, indications for immediate surgical evacuation with or without external ventricular drainage to reduce mortality now include a larger volume (>15 mL) in addition to the previously recommended indications of neurologic deterioration, brainstem compression, and hydrocephalus. . 8. The decision of when and how to limit life-sustaining treatments after ICH remains complex and largely depends on individual preferences. This guidance emphasizes that the decision to assign do not attempt resuscitation status is completely different from the decision to limit other medical and surgical interventions and should not be used to do so. On the other hand, the decision to implement an intervention should be shared between the doctor and the patient or his or her surrogate and should reflect the patient’s wishes as best as possible. Baseline severity scales may be useful in providing a general measure of bleeding severity, but should not be used as the sole basis for limiting life-sustaining treatments. 9. Rehabilitation and recovery are important determinants of ICH outcome and quality of life. This guideline recommends the use of a coordinated multidisciplinary inpatient care team with early assessment of discharge planning and a goal of early discharge with support for mild to moderate ICH. Implementation of rehabilitation activities such as stretching and functional task training may be considered 24 to 48 hours after moderate ICH; however, early aggressive mobilization within the first 24 hours after ICH appears to worsen 14-day mortality. Multiple randomized trials did not confirm a previous suggestion that fluoxetine could improve functional recovery after ICH. Fluoxetine reduced depression in these trials but also increased the incidence of fractures. 10. A key and sometimes overlooked member of the ICH care team is the patient’s home caregiver. This guideline recommends psychosocial education, practical support, and caregiver training to improve the patient’s balance, activity level, and overall quality of life. |
Comments
Some preventive treatments or therapies used to control intracerebral hemorrhage (ICH) or hemorrhagic stroke are not as effective as previously believed, according to new American Heart Association/American Stroke Association guidance for the care of people with hemorrhage. spontaneous intracerebral stroke, published in the Stroke Association journal. The guidelines detail the latest evidence-based treatment recommendations and are the official clinical practice recommendations of the Association.
The guideline includes recommendations on surgical techniques, individual activity levels after ICH, and additional education and training for home caregivers. It reflects the continued advances in information made in the field of intracerebral hemorrhage since the last guideline on the management of ICH was published in May 2015.
“Advances have been made in a variety of fields related to ICH, including the organization of regional healthcare systems, reversal of the negative effects of anticoagulants, minimally invasive surgical procedures, and underlying disease in small blood vessels.” says Steven M. Greenberg, MD, Ph.D., FAHA, chair of the guideline writing group, professor of neurology at Harvard Medical School and vice chair of neurology at Massachusetts General Hospital, both in Boston.
ICH accounts for approximately 10% of the nearly 800,000 strokes that occur annually in the US.
Typical causes of primary ICH (that is, ICH that is not due to another condition, such as head trauma) include uncontrolled high blood pressure and age-related degeneration of the brain’s blood vessels. ICH is also one of the deadliest types of strokes, with a mortality rate of 30% to 40%. ICH affects black and Hispanic people at a rate 1.6 times higher than white people according to US studies. Worldwide, stroke (of any type) is the second leading cause of death and a leading cause of long-term disability.
The likelihood of ICH increases significantly with age, so as the population ages, these types of stroke are expected to remain a major health problem. Furthermore, the widespread use of anticoagulants is a growing cause of ICH. Therefore, new treatments for ICH and better use of evidence-based approaches for ICH prevention, care, and recovery are needed.
Updates to standard care practices
The new guidance suggests that many techniques widely considered "standard care" are not necessary.
For example, research confirms that wearing compression socks or stockings of any length to prevent blood clots from forming in the deep veins, known as deep vein thrombosis, after a hemorrhagic stroke is not effective .
Instead, a method known as intermittent pneumatic compression , which involves wrapping the lower legs and feet in inflatable boots, may be helpful if started on the same day as the ICH diagnosis. However, more information is needed on whether using compression stockings in combination with medications can prevent blood clots from forming.
“This is an area where we still have a lot to explore. It is not clear whether even specialized compression devices reduce the risks of deep vein thrombosis or improve the overall health of people with brain hemorrhage. Even more research is needed on how new blood clot prevention medications can help, especially within the first 24 to 48 hours of the first symptoms,” says Greenberg.
Recommendations for the use of antiseizure or antidepressant medications after hemorrhagic stroke were also updated. The guideline states that none of these classes of medications help a person’s overall health unless a seizure or depression is already occurring, so they are not recommended for most people. Antiseizure medication did not contribute to improvements in function or long-term seizure control, and antidepressant use increased the chance of bone fractures.
The guideline writing group also addresses previously standard inpatient therapies. They suggest that giving steroids to prevent complications of hemorrhagic stroke is ineffective and highlight that platelet transfusions , unless used during emergency surgery, may worsen the condition of the stroke survivor.
Surgical intervention
People with a hemorrhagic stroke may have increased pressure in the brain after the hemorrhage, which can damage brain tissue.
These people should be considered candidates for immediate surgical procedures to relieve pressure, according to the guideline. This is usually done through an opening in the skull to relieve pressure, and in some cases, additional techniques may be used to drain excess fluid. The guidelines committee reviewed the most recent data on minimally invasive surgical techniques, which require a smaller opening through the skull. Some research suggests that procedures with a less invasive approach are less likely to damage brain tissue while removing fluid buildup.
“The evidence is now reasonably strong that minimally invasive surgery can improve a patient’s chance of surviving after moderate or large ICH,” Greenberg says. “However, it is less clear whether this or any other type of surgical procedure improves the chances of survival and recovery from ICH, which are our ultimate goals.”
Recovery and Rehabilitation
Stroke rehabilitation includes several strategies to help restore an individual’s quality of life, and the guide reinforces the importance of having a multidisciplinary team develop a recovery plan.
Research suggests that a person with mild or moderate ICH can begin activities such as stretching, dressing, bathing, and other normal daily tasks 24 to 48 hours after the stroke to improve survival rate and recovery time; However, moving too much or too intensely within 24 hours is associated with an increased risk of death within 14 days of ICH.
The guideline outlines several areas for future study, including how quickly people can return to work, driving, and participating in other social engagements. Health professionals also need more information about recommendations for sexual activity and levels of exercise that are safe after a stroke.
Home Caregivers
The guide recommends education, practical support and training for family members so they can participate and know what to expect during rehabilitation.
“People need extra help with these lifestyle changes, whether it’s moving more, reducing alcohol consumption or eating healthier foods. “All of this happens after they leave the hospital, and we need to make sure we are empowering families with the information they may need to provide them with the appropriate support,” adds Greenberg.
Education for family or other caregivers benefits the individual’s activity levels and quality of life. Practical support (such as walking safely with the patient) and training (such as performing certain exercises) are reasonable and may make it feasible to perform some rehabilitation exercises at home and lead to an improvement in the patients’ standing balance. patients.
Other highlights
The writing group recommends the development of regional health care systems capable of providing immediate care for hemorrhagic stroke and the ability to quickly transfer people to neurocritical care facilities and neurosurgical units, if necessary. The guideline emphasizes the importance of methods to educate the public, create and maintain organized systems of care, and ensure adequate training of first responders.
The guideline suggests that there may be an opportunity to prevent ICH in some people. The damage to small blood vessels that is associated with ICH can be seen on magnetic resonance imaging (MRI). MRI is not always done, but it can be helpful for some people.
Additionally, the main risk factors for small blood vessel damage are high blood pressure, type 2 diabetes, and older age. Anticoagulants remain an important issue as the use of these medications can increase complications and death from hemorrhagic stroke.
The writing group provides updated guidance for immediate reversal of newer anticoagulants such as apixaban, rivaroxaban, edoxaban, and dabigatran, as well as older medications such as warfarin or heparin.
Renewed emphasis is placed on the complexities of a do-not-attempt-resuscitate (DNAR) state versus the decision to limit other medical and surgical interventions. The writing group highlights the need to educate medical professionals, stroke survivors, and/or the individual’s caregiver about the differences. The guideline recommends that the severity of bleeding, as measured by standard scales, not be used as the sole basis for determining life-saving treatments.
“There is no easy path to preventing or curing hemorrhagic strokes, but there is encouraging progress in all aspects of this disease, from prevention to in-hospital treatment and post-hospital recovery. “We believe that the broad range of knowledge laid out in the new guidance will translate into significant improvements in ICP care,” says Greenberg.
This guide was prepared by the volunteer writing group on behalf of the American Heart Association/American Stroke Association. The Association’s guidelines detail the latest evidence-based treatment recommendations and are the Association’s official clinical practice recommendations for various cardiovascular diseases and stroke conditions.
