DALLAS, May 17, 2022 — Certain preventive treatments or therapies used to manage intracerebral hemorrhage (ICH) or bleeding caress, are not as effective as previously believed, according to new American Heart Association/American Stroke Association guidelines for the management of people with spontaneous ICH, published today in the journal Stroke of the ‘Association. 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 constant information gains made in the intracerebral hemorrhage field since the publication of the last guideline on the management of ICH in May 2015.
“Progress has been made in a range of areas related to ICH, including the organization of regional health care systems, the reversal of the negative effects of anticoagulants, minimally invasive surgical procedures, and undercurrent 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 president of neurology at Massachusetts General Hospital, both in Boston.
ICH accounts for about 10% of the nearly 800,000 strokes that occur each year in the United States. ships. ICH is also one of the deadliest types of stroke, with a mortality rate of 30-40%. ICH affects blacks and Hispanics at a rate 1.6 times higher than whites according to US studies. Worldwide, strokes (of any kind) are the second leading cause of death and the leading cause of long-term disability.
The likelihood of ICH increases sharply with age, so as the population ages these types of strokes are expected to remain a significant health concern. Additionally, the widespread use of blood thinners is a growing cause of ICH. Therefore, new treatments for ICH and better use of evidence-based approaches are needed for the prevention, care, and recovery of ICH.
Updates to Standard Care Practices
The new guideline suggests that many techniques widely considered ‘standard of care’ are unnecessary. For example, research confirms that wearing compression socks or stockings of any length to prevent deep vein blood clots, 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 an ICH diagnosis. However, more information is needed on whether using compression stockings in combination with medication can prevent blood clots from forming.
“This is an area where we still have a lot of exploration to do. It is unclear whether even specialized compression devices reduce the risk of deep vein thrombosis or improve the overall health of people with cerebral hemorrhage. Even more research is needed on how new blood clot prevention drugs can help, especially in the first 24 to 48 hours after the first symptoms appear,” says Greenberg.
Recommendations for the use of antiepileptic drugs or antidepressants after hemorrhagic stroke are also updated. The guideline states that none of these drug classes help a person’s overall health unless a seizure or depression is already present, therefore they are not advised for most people. Antiepileptic drugs did not help improve functionality or long-term seizure control, and the use of antidepressants increased the risk of bone fractures.
The guideline writing group also addresses previously standard hospital therapies. They suggest that administering steroids to prevent complications from hemorrhagic stroke is ineffective and point out that platelet transfusions, unless used in emergency surgery, can worsen the survivor’s condition. of stroke.
People with a hemorrhagic stroke may have increased pressure in the brain after the bleed, which can damage brain tissue. These people should be considered candidates for immediate pressure-relieving surgery, 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 latest evidence on minimally invasive surgical techniques, requiring 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 likelihood of survival after moderate or significant ICH,” says Greenberg. “It is less clear, however, whether this surgery or any other type of intervention 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 the individual’s quality of life, and the guideline reinforces the importance of having a multidisciplinary team to develop a recovery plan. Research suggests that a person with mild to moderate ICH can start activities like stretching, dressing, bathing, and other normal daily tasks 24-48 hours after the stroke to improve survival rate. and recovery time; however, moving too much or too vigorously within 24 hours is linked to an increased risk of death within 14 days of ICH.
The guideline outlines several areas for future study, including when individuals can return to work, drive and participate in other social engagements. Healthcare professionals also need more information about recommendations for safe sexual activity and levels of exercise after stroke.
The guideline recommends education, practical support and training for family members so that they can be involved and informed about what to expect during rehabilitation.
“People need extra help with these lifestyle changes, whether it’s moving more, cutting down on alcohol, or eating healthier foods. All of this happens after they are discharged from hospital, and we need to make sure that we give families the information they may need to be properly supported,” adds Greenberg.
Education of family or other caregivers benefits the individual’s activity levels and quality of life. Practical support (eg, how to walk safely with the patient) and training (eg, how to perform certain exercises) are reasonable and may make it possible to perform some rehabilitation exercises at home and lead to improved standing balance of patients.
The writing group recommends the development of regional health care systems capable of providing immediate care for hemorrhagic strokes and the ability to quickly transfer people to neurocritical care facilities and neurosurgical units, if necessary. The guideline emphasizes the importance of methods for educating the public, building and maintaining organized systems of care, and ensuring proper training of first responders.
The guideline suggests that there may be a possibility of preventing ICH in some people. Damage to small blood vessels associated with ICH can be seen on magnetic resonance imaging (MRI). MRI is not always done but can be helpful for some people. In addition, the main risk factors for small vessel damage are high blood pressure, type 2 diabetes, and advanced age. Anticoagulants remain an important topic since the use of these drugs can increase complications and death from hemorrhagic stroke. The writing group provides up-to-date advice for the immediate reversal of newer blood thinners like apixaban, rivaroxaban, edoxaban, and dabigatran, as well as older medications like warfarin or heparin.
A renewed focus is placed on the complexities of a do not attempt resuscitation (DNAR) status versus the decision to limit other medical and surgical interventions. The writing group emphasizes the need to educate healthcare professionals, stroke survivors and/or the individual’s caregiver about the differences. The guideline recommends that the severity of a hemorrhage, as measured by standard scales, should not be used as the sole basis for determining life-saving treatments.
“There is no easy way to prevent or cure hemorrhagic stroke, but encouraging progress has been made in all aspects of this disease, from prevention to hospital treatment and post-hospital recovery. We believe the broad body of knowledge set forth in the new guideline will result in significant improvements in ICH care,” said Greenberg.
This guideline 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.
Co-authors are Vice President Wendy C. Ziai, MD, MPH, FAHA; Charlotte Cordonnier, MD, Ph.D.; Dar Dowlatshahi, MD, Ph.D., FAHA; Brandon Francis, MD, MPH; Joshua N. Goldstein, MD, Ph.D., FAHA; J. Claude Hemphill III, MD, MAS, FAHA; Ronda Johnson, MBA; Kiffon M. Keigher, DNP, ACNP-BC, RN; William J. Mack, MD, MS, FAHA; J. Mocco, MD, MS, FAHA; Eileena J. Newton, MD; Ilana M. Ruff, MD; Lauren H. Sansing, MD, MS, FAHA; Sam Schulman, MD, Ph.D.; Magdy H. Selim, MD, Ph.D, FAHA; Kevin N. Sheth, MD, FAHA; Nikola Sprigg, MD; and Katharina Sunnerhagen, MD, Ph.D. The authors’ disclosures are listed in the manuscript.