How to manage blood pressure for patients with cerebral hemorrhage?

*Only for medical professionals to read for reference.
October 29, 2021 is the 16th World Stroke Day.
The medical profession and the "Huashan Hospital Neurology" will take you to understand these things
.

 According to the "China Stroke Report 2019" data, in 2018, the death rate of Chinese residents from cerebrovascular disease was 149.
49 per 100,000 (the death toll is about 1.
57 million), ranking third, and it is increasing year by year
.

The global burden of disease in 2017 shows that stroke is still the leading cause of death and disability-adjusted life years for Chinese residents, and it is also one of the five major causes of life lost years
.

October 29, 2021 is the 16th "World Stroke Day".
This year's theme is "Be alert to stroke symptoms, identify and treat as soon as possible!"
.

Taking this opportunity, the "medical community" and the "Huashan Hospital Affiliated to Fudan University" specially launched an expert interview activity of "Huashan Shennei will show you about strokes", and specially invited Professor Tang Yuping from the Department of Neurology of Huashan Hospital to treat cerebral hemorrhage prevention and treatment.
Share his insights on related issues
.

A key indicator for predicting poor prognosis of cerebral hemorrhage and hematoma enlargement.
Cerebral hemorrhage is the most serious type of stroke
.

In clinical medicine, early hematoma enlargement is the most important determinant of increasing disability and mortality.
If the hematoma enlargement can be predicted early, it can provide reference and help for the treatment and prognosis evaluation of patients with cerebral hemorrhage
.

At present, the clinical prediction of early hematoma enlargement and poor prognosis of cerebral hemorrhage is mainly based on CT, CTA, MRI and other imaging examinations, but these imaging examinations often have practical problems such as relatively complicated operation and tedious and time-consuming detection
.

Therefore, the relationship between many biochemical markers and the prognosis of cerebral hemorrhage has been studied in recent years, such as low-density lipoprotein, C-reactive protein, serum growth factor, metal matrix protease and so on
.

A previous study by Professor Tang Yuping’s team found that LDH-A is the best molecular marker for predicting poor prognosis of cerebral hemorrhage and hematoma enlargement.
The content of the study is briefly introduced as follows (Figure 1)
.

Figure 1: Research flow chart of Tang Yuping’s team Professor Tang Yuping’s team first used proteomics technology to detect a significant increase in LDH-A levels in blood samples from cerebral hemorrhage patients with early hematoma enlargement and poor prognosis (multiple difference = 3.
85 times, p =0.
005)
.

In order to determine the critical value of LDH-A, Professor Tang Yuping’s team tested the expression level of LDH-A in the follow-up retrospective cohort and performed ROC curve analysis.
The results showed that LDH-A=220U/L is the best critical point
.

Finally, in a prospective cerebral hemorrhage cohort, Professor Tang Yuping’s team divided the patients into LDH≥220U/L group and LDH＜220U/L group.
The follow-up results showed that the neurological function of the LDH≥220U/L group had a poor prognosis (90 days).
The proportion of patients with mRS 4-6 points) was significantly higher than that in the LDH<220U/L group (63% vs 29.
3%) (Figure 2)
.

LDH≥220U/L has certain predictive value for early hematoma expansion of cerebral hemorrhage (sensitivity is 79.
1%, specificity is 80.
0%), and can be used as a predictor of poor prognosis of cerebral hemorrhage (sensitivity is 53.
3%, specificity is 78.
2%)
.

Figure 2: Compared with previous studies on molecular markers of cerebral hemorrhage, the mRS scores of the LDH≥220U/L group and LDH<220U/L group for 90 days have certain advantages
.

First, previous studies mainly focused on the correlation between molecular markers and the 30-day mortality rate of patients, but did not discuss in detail the relationship with the patient’s functional prognosis; second, LDH is a commonly used biochemical test indicator, even in primary hospitals.
It can be tested and has the advantage of being easy to promote
.

In terms of mechanism, Tang Yuping believes that possible mechanisms for LDH as a predictive marker include: increased expression of LDH in central nervous system diseases such as cerebral infarction, LDH is closely related to inflammation, and LDH genes, subtypes and isoforms The influence of enzymes
.

For patients with cerebral hemorrhage, how should blood pressure be managed? Professor Tang Yuping believes that with the increasing evidence of evidence-based medicine, the relevant guidelines for blood pressure management requirements in the acute phase of cerebral hemorrhage have also been changing
.

Based on the INTERACT research evidence, the 2010 American Heart Association/American Stroke Association (American Heart Association/American Stroke Association, AHA/ASA) guidelines for the diagnosis and treatment of spontaneous cerebral hemorrhage concluded that patients with acute cerebral hemorrhage whose systolic blood pressure is between 150 and 220 mmHg quickly drop to 140 mmHg may be safe (Class IIa recommendation, level B evidence)
.

According to the results of the INTERACT-2 study, compared with standard blood pressure (target systolic blood pressure is 140～180mmHg), intensive blood pressure (target systolic blood pressure <140mmHg) cannot improve the death or severe disability of patients, but intensive blood pressure can make mRS score The distribution has undergone a significant favorable transition, and the functional recovery of patients with enhanced blood pressure is significantly better than that of the standard blood pressure group
.

AHA/ASA updated the guidelines again in 2015, improved the level of evidence, and revised the impact on functional prognosis: It is recommended that for hospitalized patients with systolic blood pressure between 150 and 220 mmHg, rapid blood pressure reduction to 140mmHg is safe (type I recommendation, level A evidence), and may improve the functional prognosis of patients (type IIa recommendation, level B evidence)
.

In addition, this guideline states that patients with systolic blood pressure> 220 mmHg should be actively administered intravenous blood pressure under continuous blood pressure monitoring (Class IIb recommendation, level C evidence) as a newly added recommendation, but for cerebral hemorrhage with systolic blood pressure> 220 mmHg, blood pressure reduction goals No clear requirements have been made
.

However, in 2016, after the ATACH-2 clinical trial included subjects similar to INTERACT-2, the results of the study showed that patients did not benefit from intensive blood pressure reduction, and the results showed that with intensive blood pressure treatment, patients 7 The incidence of impaired renal function increased significantly within a day
.

Therefore, different guidelines are also controversial about the goal of blood pressure reduction after intracerebral hemorrhage and the timing of initiation of blood pressure treatment
.

The 2019 Chinese Guidelines for Diagnosis and Treatment of Cerebral Hemorrhage has synthesized several clinical research evidences in recent years, and adjusted blood pressure management after cerebral hemorrhage: (1) For patients with systolic blood pressure of 150~220mmHg and no acute blood pressure contraindications, acute phase It is safe to reduce systolic blood pressure to 130~140mmHg (level I recommendation, level A evidence), but combined with the research results of ATACH-2 and INTERACT-2, the guidelines no longer believe that the above-mentioned blood pressure reduction measures can improve the prognosis of neurological function.
Reducing the systolic blood pressure below 130mmHg increases the risk of extracranial ischemia
.

(2) The guidelines for patients with systolic blood pressure> 220mmHg still believe that intensive intravenous blood pressure reduction and continuous blood pressure monitoring are reasonable, and continue to emphasize that individualized anti-hypertensive treatment plans should be developed.
For patients with systolic blood pressure> 220mmHg, the systolic blood pressure can be reduced.
The target value is set to 160mmHg
.

(3) During the antihypertensive treatment, the changes in blood pressure levels should be closely observed to avoid blood pressure fluctuations, and blood pressure monitoring should be performed every 5 to 15 minutes (level I recommendation, level C evidence)
.

In addition, Professor Tang Yuping also proposed that in view of the fact that intensive antihypertensive treatment benefited less after 4.
8 hours of onset in the INTERACT-2 study, intensive antihypertensive treatment should be as early as possible
.

What should be done in the early recognition and management of cerebral hemorrhage? For the early recognition of cerebral hemorrhage, Tang Yuping believes that, just like ischemic stroke, we can also use "BE FAST" to identify patients with cerebral hemorrhage early
.

"B" means Balance, which means loss of balance, balance or coordination, and sudden difficulty in walking; "E" means Eyes, which means eyes, sudden changes in vision, and difficulty seeing objects; "F" means Face, which means face , The face is asymmetrical, and the angle of the mouth is skewed; "A" means Arms, which refers to the arm.
Sudden weakness or numbness in the arm usually appears on one side of the body; "S" means Speech, which means language, difficulty in speech, and difficulty in understanding; "T" stands for Time, which refers to time.
If these symptoms appear, it means that there may be signs of stroke
.
Call 120 immediately .

But unlike cerebral infarction, the symptoms of cerebral hemorrhage are relatively heavier, and the incidence of coma is higher (NIHSS score and GCS score can be used for evaluation)
.

The onset of cerebral hemorrhage is more rapid and the disease progresses faster, and it can reach the peak within a few hours
.

Brain tissue edema is more serious in patients with cerebral hemorrhage, so it is often accompanied by symptoms of increased intracranial pressure such as headache, nausea, and vomiting
.

As for the management of cerebral hemorrhage, a brief summary is as follows: (1) Blood pressure management after cerebral hemorrhage is as described above; (2) Blood glucose should be controlled at 7.
8~10.
0mmol/L
.

Blood glucose monitoring should be strengthened and dealt with accordingly: insulin therapy can be given when the blood glucose exceeds 10mmol/L; when the blood glucose is lower than 3.
3mmol/L, 10%-20% glucose can be given orally or injected
.

(3) The clinical efficacy of factor Ⅶ in the treatment of cerebral hemorrhage is still uncertain, and may increase the risk of thromboembolism, so routine use is not recommended
.

Tranexamic acid can help limit the expansion of hematoma and reduce the early mortality rate, but the long-term benefit is uncertain, and it is not recommended to use it without selection
.

(4) For seizures, preventive use of antiepileptic drugs is not recommended.
For seizures within 7 days, antiepileptic drugs are recommended for 3 to 6 months.
For seizures longer than 7 days, epilepsy drugs are required.
It depends on the specific situation
.

(5) For intraventricular hemorrhage, EVD combined with rt-PA is relatively safe to treat intraventricular hemorrhage, which can help reduce the mortality of severely ill patients, but whether it can improve neurological function remains to be further studied
.

(6) If there are obvious indications of antithrombotic drugs, anticoagulant drugs can be used for patients with non-lobe hemorrhage, and antiplatelet monotherapy can be used for all patients with cerebral hemorrhage
.

(7) When there are obvious indications for the use of anticoagulant drugs, the best time to restart anticoagulant therapy for anticoagulant-related cerebral hemorrhage is not clear
.

In patients with non-mechanical valves, oral anticoagulants should be avoided for at least 4 weeks
.

If there are indications for use, aspirin monotherapy can be started a few days after cerebral hemorrhage
.

 Expert profile Tang Yuping, MD, chief physician of the Department of Neurology, Huashan Hospital Affiliated to Fudan University
.

Clinical Visiting Scholar of Massachusetts General Hospital (MGH), Harvard University, USA Member of the Neurotranslational Medicine Group of the Chinese Medical Association Neurology Branch Executive Director of the Youth Council of the Shanghai Stroke Society Deputy Chairman of the Shanghai Stroke Society Integrative Chinese and Western Medicine Branch "Cerebral Hemorrhage" The editorial board is good at the clinical diagnosis and treatment of cerebrovascular diseases and neurological difficult diseases
.

Participated in the compilation of the third edition of "Neurology" textbook of Fudan University (in charge of cerebral hemorrhage) and Shanghai emergency training textbook (in charge of neuromuscular diseases); published more than 40 SCI articles; won the first class of Shanghai Medical Science and Technology Progress Award (2013), China Medical Award (2013), Shanghai Medical Science and Technology Progress Third Prize (2014), National Ministry of Education Science and Technology Progress Second Prize (2015)
.

Due to the interview content, some of the content may not be comprehensive enough, please pay attention to the screening