"Chinese Multidisciplinary Diagnosis and Treatment Guidelines for Cerebral Hemorrhage Related to Blood Coagulation Dysfunction" is released!

Blood coagulation dysfunction-related intracerebral hemorrhage (HDICH) refers to intraparenchymal hemorrhage that occurs during the use of anticoagulant or antiplatelet drugs, or on the basis of coagulopathy
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The Chinese Multidisciplinary Guidelines for the Diagnosis and Treatment of Cerebral Hemorrhage Related to Coagulation Dysfunction, jointly formulated by the Neurosurgery Branch of the Chinese Medical Association, the Emergency Physician Branch of the Chinese Medical Doctor Association, and the National Health Commission's Stroke Screening and Prevention Engineering Committee, mainly target 8 Make recommendations
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01 Emergency treatment and evaluation of coagulation function (1) If the patient is found to be HDICH in the pre-hospital emergency, the specific name of the medication should be clarified, and the antiplatelet or anticoagulant drugs should be stopped immediately (level I recommendation, level C evidence)
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(2) In the emergency department, patients with suspected hemorrhagic stroke should be quickly diagnosed and evaluated, vital signs should be stabilized, head CT and other imaging examinations should be performed to confirm the diagnosis, and necessary laboratory examinations in the emergency department should be completed (level I recommendation, level A evidence)
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(3) If HDICH is suspected or diagnosed, relevant physicians should be invited to coordinate diagnosis and treatment, confirm the diagnosis and initiate reversal or alternative treatment as soon as possible (level I recommendation, level C evidence)
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(4) For patients with clear coagulation dysfunction, it is recommended to use TEG as far as possible for further evaluation (level IIb recommendation, level B evidence)
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02 Diagnosis and differential diagnosis of HDICH The diagnosis of HDICH requires a comprehensive judgment based on medical history, laboratory indicators and imaging (level I recommendation, level C evidence)
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03 ICH related to antiplatelet drugs and anticoagulant drugs ➤ ICH related to antiplatelet drugs (1) For patients with ICH related to antiplatelet drugs, stop antiplatelet drugs immediately (level I recommendation, level C evidence)
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(2) Platelet transfusion is not recommended for patients with antiplatelet-related ICH treated in internal medicine (level III recommendation, level B evidence)
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(3) For patients with antiplatelet-related ICH who need emergency surgery, platelet function can be combined with platelet transfusion before and after surgery, and platelet function can be monitored at the same time (level IIa recommendation, level B evidence)
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(4) Surgery can reduce the mortality of patients with severe antiplatelet drugs-related ICH (level IIb recommendation, level B evidence)
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(5) For patients with ICH related to ADP receptor inhibitors, aspirin, and cyclooxygenase 1 inhibitors, a single dose of desmopressin (0.
4μg/kg) can be considered (level IIb recommendation, level B evidence)
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➤Anticoagulant-related ICH (1) For anticoagulant-related ICH, it is recommended to stop the anticoagulant immediately (level I recommendation, level C evidence)
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(2) For warfarin-related ICH, it is recommended to immediately give vitamin K (level I recommendation, level C evidence) and PCC (level IIb recommendation, level B evidence), and rFⅦa (level III recommendation, level C evidence) is not recommended
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(3) For DOAC-related ICH, specific reversal drugs (such as idacelizumab and Andexanet alpha) are recommended (level IIb recommendation, level B evidence)
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(4) For patients using unfractionated heparin or low molecular weight heparin, immediately stop the drug and use protamine to reverse (level I recommendation, level B evidence).
If possible, Andexanet alfa is the first choice to reverse the activity of low molecular weight heparin (level IIb recommendation, C Level of evidence)
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For patients taking fondaparinux, stop the drug immediately and use aPCC to reverse it (level IIb recommendation, level C evidence)
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04 ICH related to coagulation disease (1) Whether it is caused by blood system disease or platelet abnormality secondary to other causes, the primary disease should be actively treated and the cause of platelet abnormality should be removed (level IIa recommendation, level C evidence)
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(2) Patients with ICH should maintain a platelet count ≥100×109/L (level IIa recommendation, level C evidence); for those preparing for neurosurgery, it is recommended that the platelet count reach 100×109/L as far as possible (level I recommendation, level C) Evidence)
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(3) The main treatment for patients with hereditary coagulation factor deficiency is factor replacement therapy (level I recommendation, level A evidence).
Those with acquired coagulation dysfunction should eliminate or control the cause of coagulation dysfunction as soon as possible (level I recommendation, C Level of evidence)
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05 Other non-surgical treatments for HDICH (1) Tranexamic acid can reduce hematoma enlargement in HDICH patients (level IIa recommendation, level A evidence), but it cannot improve the survival rate and neurological prognosis of patients (level IIb recommendation, level A evidence) )
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(2) rFⅦa can reduce hematoma enlargement in patients (Class IIa recommendation, Level A evidence), but it is controversial in improving survival and neurological prognosis (Class IIb recommendation, Level A evidence)
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(3) For HDICH patients whose systolic blood pressure is 150～220mmHg and there is no contraindication to acute antihypertensive therapy, it may be safe to reduce the systolic blood pressure to 140mmHg in the acute phase (level IIa recommendation, level A evidence), and it may be lower than 130mmHg.
Increase the risk of extracranial ischemia (level III recommendation, level A evidence)
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(4) For HDICH patients with epileptic seizures, anti-epileptic therapy can be taken preventively (level IIb recommendation, level C evidence)
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(5) It is recommended that patients with severe HDICH, especially those with agitation, be treated with sedation and analgesia (level I recommendation, level C evidence)
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06 Surgical treatment of HDICH (1) For HDICH patients who meet the indications for surgery, the timing and strategy of surgery should be determined according to the condition and HXHD classification (level IIb recommendation, level C evidence)
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(2) According to different types of bleeding during the operation, use corresponding hemostatic techniques and hemostatic materials to properly stop the bleeding (level IIb recommendation, level C evidence)
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(3) Monitor the body temperature of adult patients and all pediatric patients who have a long anesthesia time (>30min) during the operation to maintain normal body temperature (level IIb recommendation, level C evidence)
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(4) When closing the skull, try to watertightly close the dura mater and exhaust air to avoid postoperative low ICP (level IIb recommendation, level C evidence)
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07 Rehabilitation and restart of antiplatelet or anticoagulation therapy (1) For patients with antiplatelet or anticoagulant drug-related ICH who are at high risk of embolization (mechanical mitral valve, etc.
), low molecular heparin can be given on the 6th day of bleeding after a comprehensive assessment Bridging therapy (level IIb recommendation, level C evidence)
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(2) For patients with ICH related to other antiplatelet or anticoagulant drugs, bridging therapy is not recommended before restarting anticoagulation or antiplatelet therapy (level III recommendation, level C evidence)
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08 HDICH recurrence and prevention (1) Please refer to the HICH guidelines for conventional advice on HDICH recurrence and prevention
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(2) It is necessary to pay attention to drugs and foods that interact with warfarin to reduce the risk of re-bleeding (level IIa recommendation, level C evidence)
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The above content is extracted from: Chinese Medical Association Neurosurgery Branch, Chinese Medical Doctors Association Emergency Physician Branch, National Health Commission Stroke Screening and Prevention Engineering Committee.
Chinese Multidisciplinary Diagnosis and Treatment Guidelines for Cerebral Hemorrhage Related to Blood Coagulation Dysfunction[J].
China Journal of Neurosurgery, 2021, 37(7): 649-662.