hemorrhagic stroke nice guidelines
Share this entry. This is because there is no evidence of whether this would be safe or beneficial. The Stroke Unit Trialists’ Collaboration provide 5 key characteristics of markers of a good specialist acute stroke unit: Adults having stroke rehabilitation in hospital or in the community are offered at least. © NICE 2021. It remains unclear whether statins should be continued or discontinued in ICH patients. After a stroke, adults may have significant disabilities that prevent them from returning to work. use prohibited. Incidence of intracerebral and subarachnoid haemorrhage in southern Sweden. (New recommendation), The frequency of clinical seizures early (within 1 week) after ICH is as high as 16%, with the majority occurring at or near onset.158,159 Cortical involvement of ICH is the most important risk factor for early seizures.158–160 In a large single-center study, prophylactic antiseizure drugs significantly reduced the number of clinical seizures after lobar ICH.161 Prospective and population-based studies, however, have shown no association between clinical seizures and neurological outcome or mortality.159,160,162–164. Therapy-based rehabilitation services for stroke patients at home. People should have access to an interpreter or advocate if needed. ischemic and hemorrhagic stroke clinical pathways. Impact of delayed transfer of critically ill stroke patients from the Emergency Department to the Neuro-ICU. The healthcare professional should follow relevant professional guidance, taking full responsibility for the decision. Closing external doors and windows facing a busy street at times when traffic is heavy or congested to help stop highly polluted air getting in. Regarding the recommendation to mobilise people after having a stroke when their clinical condition permits, there was no clear evidence of benefit or harm for early mobilisation within the first 48 hours after symptom onset compared with standard care. (Revised from the previous guideline). Radiographically, it is indistinguishable from cardiogenic pulmonary edema. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. The committee agreed that. Seizures after spontaneous supratentorial intracerebral hemorrhage. These prediction models include individual patient characteristics such as score on the GCS or NIHSS, age, hematoma volume and location, and the presence and amount of IVH.26,30,249–256 None of these prediction models, however, account for the impact of care limitations such as do-not-attempt-resuscitation (DNAR) orders or the withdrawal of technological support. Risk of thromboembolic complications after intracerebral hemorrhage according to ethnicity. One study reported improved outcome on the Glasgow Outcome Scale at 2 months with endoscopy but did not report the rate of permanent CSF diversion.223 The other suggested lower rates of permanent CSF diversion after endoscopy.221 Other reported management strategies for IVH include early ventriculoperitoneal shunting,224 endoscopic third ventriculostomy,225 or lumbar drainage.189 In a study comparing 16 patients treated with VC and lumbar drainage for ICH with IVH to 39 historical control patients treated with VC alone, patients managed with VC plus lumbar drainage had a longer median duration of external CSF drainage but were significantly less likely to require permanent CSF diversion.189, Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncertain (Class IIb; Level of Evidence B). Camino intracranial pressure monitor: prospective study of accuracy and complications. Patients presenting with acute symptoms should be immediately transferred to hospital for accurate diagnosis of stroke type, and urgent initiation of appropriate treatment; patients should be managed by a specialist multidisciplinary stroke team. Several observational studies of patients with anticoagulant-related ICH found low rates of cardioembolic events while not receiving anticoagulation therapy or recurrent ICH when anticoagulation was resumed,298–300 but the results are limited by relatively small sample sizes and short durations of follow-up. Therefore, some areas will need to set up daily TIA clinics to provide this best practice service. It has been suggested that FEIBA or rFVIIa may be better for the direct thrombin inhibitor dabigatran, whereas other PCCs may be better for the factor Xa inhibitors rivaroxaban and apixaban,96–99 but these data are preliminary. Diagnostic accuracy and yield of multidetector CT angiography in the evaluation of spontaneous intraparenchymal cerebral hemorrhage. Stroke. Management at this time is focused on prevention and targeting these complications as they arise. Hematoma expansion and early deterioration are common within the first few hours after onset. Epilepsy occurs in up to 10% of young patients (18–50 years) with ICH; the risk of poststroke epilepsy may be less in older patients.169,170 Risk factors for epilepsy include stroke severity, cortical location of the hematoma, and delayed initial seizures.169,170 There are no data to suggest that early use of antiseizure drugs will prevent lesion-related epilepsy. The committee agreed that the prevalent current practice is to consider intravenous thrombolysis and mechanical thrombectomy. The guidance will also require healthcare professionals to take into account people's pre-stroke functional status and to have a discussion about the risks and benefits. This is usually done with an operation called a craniotomy. Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review. (New recommendation), Limited data exist regarding the frequency of elevated ICP and its management in patients with ICH.182–185 A recently reported cohort study of 243 consecutive ICH patients described ICP monitoring in 57 (23%), of whom 40 (70%) had at least 1 episode of intracranial hypertension (defined as an ICP >20 mm Hg).185 In a randomized trial of intraventricular thrombolysis in 100 patients with intraventricular hemorrhage (IVH) and ICH smaller than 30 mm3, ICP was >20 mm Hg at the time of ventricular catheter (VC) insertion in 14 patients.184 Overall, however, ICP was not frequently elevated during monitoring and VC drainage in these patients. The resulting draft was sent to the entire writing group for comment. Everything NICE has said on preventing, diagnosing and managing stroke and transient ischaemic attack (TIA) in people over 16 in an interactive flowchart. Although ICH has traditionally lagged behind ischemic stroke and aneurysmal subarachnoid hemorrhage in terms of evidence from clinical trials to guide management, the past decade has seen a dramatic increase in studies of ICH intervention. Numerator – the number in the denominator with conditions or obligations to minimise and mitigate road-traffic-related air pollution. FFP is of unclear utility, and vitamin K is not useful. IVH occurs in ≈45% of patients with spontaneous ICH and is an independent factor associated with poor outcome.190,202,203 Pooled analysis of 13 studies found IVH in association with ICH increased the risk of death from 20% without to 51% with IVH.204 IVH can be primary, confined to the ventricles, or secondary, originating as an extension of an ICH. On the basis of these observations, the STICH II trial was undertaken.226,236. Proportion of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment that were given advice on what to do when outdoor air quality is poor. In current practice, mobilisation strategies differ according to stroke severity and the clinical condition of the person with stroke. A baseline severity score should be performed as part of the initial evaluation of patients with ICH (Class I; Level of Evidence B). Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. ICH is a medical emergency. CTA spot sign predicts hematoma expansion in patients with delayed presentation after intracerebral hemorrhage. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. 1-800-AHA-USA-1 The evidence showed that surgery improved mortality rates and, to a lesser extent, functional outcomes as measured by the, The committee noted that although some of the trials included people who had surgery as long as. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial [published correction appears in. a) Level of awareness among children, young people and adults with chronic respiratory or cardiovascular conditions on what to do when outdoor air quality is poor. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Blood pressure as a prognostic factor after acute stroke. Each subcategory was led by a primary author, with 1 or 2 additional authors making contributions. Aggressive care early after ICH onset and postponement of new DNAR orders until at least the second full day of hospitalization is probably recommended (Class IIa; Level of Evidence B). specifying emission standards for private hire and other licensed vehicles. Multidetector row CT angiography in spontaneous lobar intracerebral hemorrhage: a prospective comparison with conventional angiography. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. CT is very sensitive for identifying acute hemorrhage and is considered the “gold standard”; gradient echo and T2* susceptibility-weighted MRI are as sensitive as CT for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.41,42 Time, cost, proximity to the ED, patient tolerance, clinical status, and MRI availability may, however, preclude emergent MRI in many cases.43, The high rate of early neurological deterioration after ICH is related in part to active bleeding that may proceed for hours after symptom onset. 27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added. The STICH II authors performed an updated meta-analysis of surgical trials reporting on 3366 patients.228 A significant advantage for surgery was shown when all patients were considered, but there was significant heterogeneity in the data. Comparison of magnetic resonance angiography, magnetic resonance imaging and conventional angiography in cerebral arteriovenous malformation. Methodology of the Field Administration of Stroke Therapy–Magnesium (FAST-MAG) phase 3 trial: part 2: prehospital study methods. (New recommendation), The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain (Class IIb; Level of Evidence B). The influence of diabetes and hyperglycemia on clinical course after intracerebral hemorrhage. Patients at risk include those taking oral anticoagulant drugs (OACs), antiplatelet agents, those with acquired or congenital coagulation factor deficiencies, and those with inherited or acquired qualitative or quantitative platelet abnormalities. The treatment and management of patients with acute intracerebral hemorrhage depends on the cause and severity of the bleeding. Not routinely offering CT brain imaging will be a change in practice for some providers (especially in the emergency department), whereas MRI use in the TIA clinic aligns broadly with current practice. Haemorrhagic stroke treatments If you have a haemorrhagic stroke you may need surgery to stop the bleeding, remove blood or relieve any pressure that has built up around your brain. The decision to use a VC or a parenchymal catheter device should be based on whether there is a need to drain CSF to treat hydrocephalus or elevated ICP. The potential of DC to improve outcomes for patients with ICH has not been well studied. Even so, there is growing evidence that patients with ICH make slightly greater and faster gains in recovery than patients with ischemic stroke.31,314–317, In general, recovery is more rapid in the first few weeks but may continue for many months after ICH,28,316 with approximately half of all survivors remaining dependent on others for activities of daily living.30 However, patients vary in their speed and degree of recovery, and there is no hard rule as to when recovery ends. This NICE Pathway covers the diagnosis and initial management of acute stroke and, 2 September 2020 Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke (NICE diagnostics guidance 41) added to preventing further occlusive vascular events for, 28 May 2019 Therapeutic hypothermia for acute ischaemic stroke (NICE interventional procedures guidance 647) added to. For patients with a known coagulation factor deficiency or platelet disorder, replacement of the appropriate factor or platelets, often with the assistance of a consultant hematologist, is indicated. If necessary, actions to mitigate the impact of charges on specific groups should be identified. The risk of haemorrhage in this group, and of other risks associated with administering aspirin (aspirin allergy or gastrointestinal bleed), is low. Thigh-length versus below-knee stockings for deep venous thrombosis prophylaxis after stroke: a randomized trial [published correction appears in. (New recommendation), Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from ICH (Class I; Level of Evidence A). Cognition, mood, motivation, and social support all influence recovery, and it is difficult to separate intrinsic from adaptive recovery. (New recommendation), Protamine sulfate may be considered to reverse heparin in patients with acute ICH (Class IIb; Level of Evidence C). 1. The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. Lifestyle factors on the risks of ischemic and hemorrhagic stroke. Potential reversal strategies using FEIBA, other PCCs, or rFVIIa might be considered. Restarting anticoagulation in prosthetic heart valve patients after intracranial haemorrhage: a 2-year follow-up. Summary of recommendations This is the second in a series of eight guideline chapters that provide evidence-based recommendations for recovery from stroke and TIA. The presence of microbleeds might increase the risk of ICH recurrence in warfarin users, although there are no prospective data. Ongoing and future studies in this area, such as ATACH II,324 will seek to solidify the evidence for efficacy of BP lowering and refine the BP ranges and targets that should be applied in practice. Results of the Secondary Prevention of Small Subcortical Strokes (SPS3) study have shown that the greatest benefit of “more intensive” BP lowering is on the prevention of ICH in patients with established small-vessel stroke disease and that lowering target SBP to <130 mm Hg significantly reduced the risk of ICH (risk reduction, 60%; HR, 0.37; P=0.03),281 which suggests that ICH patients should have their BP lowered to or beyond the targets currently recommended in other high-risk groups (<130 mm Hg systolic and 80 mm Hg diastolic in the presence of diabetes mellitus, heart failure, or chronic kidney disease).282 Other factors, such as BP variability, the presence of obstructive sleep apnea,283,284 obesity, and other lifestyle modifications, should also be considered despite the lack of systematic data regarding their effect on ICH recurrence. The public sector fleet is substantial and includes various vehicle types, some of which are highly polluting. The intensity of care and the expertise of those providing it is maintained. a) Length of hospital stay for adults who have had a stroke. The reduced flow of blood and oxygen can lead to areas of the brain being damaged or dying. Salvage therapies might include barbiturate coma or mild hypothermia. This is not directly applicable to the area of review, which was about TIA at first contact with a healthcare professional. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. (Revised from the previous guideline) Specific exceptions and potential subgroup considerations are outlined below in recommendations 3 through 6. Reinitiation of anticoagulation after warfarin-associated intracranial hemorrhage and mortality risk: the Best Practice for Reinitiating Anticoagulation Therapy After Intracranial Bleeding (BRAIN) study. Spot signs in intracerebral hemorrhage: useful for identifying patients at risk for hematoma enlargement? Stroke 44:3032-3038 The link will take you to an abstract of the article. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage [published correction appears in. This guideline covers interventions in the acute stage of a stroke or transient ischaemic attack (TIA). (Revised from previous guideline), Avoidance of long-term anticoagulation with warfarin as a treatment for nonvalvular atrial fibrillation is probably recommended after warfarin-associated spontaneous lobar ICH because of the relatively high risk of recurrence (Class IIa; Level of Evidence B). e) Evidence that local authorities identify key actions to address air pollution and monitor progress against them. Higher intensity stroke rehabilitation therapies can improve the quality of life for adults who have had a stroke. Denominator – the number of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment. Recombinant factor VIIa for warfarin-associated intracranial bleeding. Antiplatelet agents do not appear to dramatically increase the risk of hematoma expansion52,102 and therefore appear to be generally safe for use after ICH, including ICH caused by CAA. How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage? Local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution. However, preventing stroke is likely to result in cost savings later on. (Revised from the previous guideline), Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. Two randomized trials have been reported comparing endoscopic removal of IVH with VC in patients with IVH secondary to primary ICH <30 mm3.221,223 In 1 of the studies, urokinase was also used in both treatment groups.223 Among the 46 patients treated with endoscopy compared with 44 treated with VC, mortality was not significantly different. The European Stroke Organisation (ESO) Guidelines on Intravenous Thrombolysis (IVT) for Acute Ischaemic Stroke. Sections addressing hemorrhagic stroke in previous editions of the Prehospital and Emergency Stroke Care module have been removed and will be included in a dedicated hemorrhagic stroke module, to be released in the fall of 2018. Randomized trials comparing surgery to conservative management have not demonstrated a clear benefit for surgical intervention. On the basis of inconclusive evidence from prior trials, STICH was undertaken to determine whether early surgery reduces mortality and improves neurological outcome compared with conservative management for supratentorial ICH when the treating neurosurgeon determined that uncertainty of preferred treatment was present.235 In this trial, 1033 patients from 83 centers in 27 countries were randomized to early surgery (<24 hours of randomization) or initial conservative treatment. Emergency reversal of anticoagulation after intracerebral hemorrhage. Novel approaches to neuroprotection trials in acute ischemic stroke. Acute nephropathy (defined in a study by Oleinik et al181 as a rise in creatinine of at least 25% or 0.5 mg/dL to a level of at least 1.5 mg/dL) occurred in 41 of 539 ICH patients (8%) admitted to a single institution over a 5-year period and was no more frequent in those who underwent CT angiography,181 which suggests that kidney injury was a result of overall medical status rather than this particular procedure. Drafts of summaries and recommendations were circulated to the entire writing group for feedback. Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials. Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk. This site uses cookies. Administration of intravenous vitamin K alone is insufficient for reversal in the first hours but should be part of all acute VKA reversal strategies in a dose of 5 to 10 mg, usually given slowly via the intravenous route. DNAR status should not limit appropriate medical and surgical interventions unless otherwise explicitly indicated (Class III; Level of Evidence C). Full details of the evidence and the committee's discussion are in, Evidence showed that risk prediction scores (. (Revised from the previous guideline), After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset (Class IIb; Level of Evidence B). Dose effect of intraventricular fibrinolysis in ventricular hemorrhage. PATCH: Platelet Transfusion in Cerebral Haemorrhage: study protocol for a multicentre, randomised, controlled trial. An agreed local structured health and social care review tool can be used, for example the. The recommendation to consider endovascular therapy for posterior circulation stroke reflects current best practice. Earlier blood pressure-lowering and greater attenuation of hematoma growth in acute intracerebral hemorrhage: INTERACT pilot phase. Routine CT imaging is common in current practice and the committee agreed that this could waste resources, extend the length of stay in the emergency department, and expose people to unnecessary radiation. Therefore, it may not be suitable for some people because of their living arrangements, for example, if they are homeless recent refugees, asylum seekers or migrant workers. The strategy may also be impacted by the availability of different types of specialist seating. Surgical Trial in Lobar Intracerebral Haemorrhage (STICH II) protocol. Guidelines for the management of severe traumatic brain injury, VI: indications for intracranial pressure monitoring [published correction appears in, Guidelines for the management of severe traumatic brain injury, IX: cerebral perfusion thresholds [published correction appears in, Guidelines for the management of severe traumatic brain injury, VIII: intracranial pressure thresholds [published correction appears in. Admission to these units should be within, Evidence of local arrangements and written clinical protocols to ensure that adults presenting at an A&E department with suspected stroke are admitted to a specialist acute stroke unit within, Proportion of A&E department presentations of suspected stroke in adults in which the person is admitted to a specialist acute stroke unit within, Numerator – the number in the denominator in which the person is admitted to a specialist acute stroke unit within. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. A decision analysis. Hemorrhagic stroke in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels study.