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In the event of hypertensive cerebral hemorrhage, the multidisciplinary "guidelines and consensus" must be kept in mind!

 Last Update: 2022-04-21
 Source: Internet
 Author: User

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Emergency management and neuroimaging

First Aid Management and Neuroimaging First Aid Management and Neuroimaging

pre-hospital first aid

For the sudden appearance of suspected HICH patients, emergency personnel should quickly assess, and after on-site emergency treatment according to local conditions, the patient should be transferred to a nearby hospital with treatment conditions as soon as possible ( level I recommendation, level C evidence)
.

emergency treatment

For patients with suspected hemorrhagic stroke in the emergency department , initial diagnosis and evaluation should be performed quickly, vital signs should be stabilized, imaging examinations such as head CT should be performed to confirm the diagnosis of HICH , and necessary laboratory tests should be completed in the emergency department ( Class I recommendation, Level A evidence) .

For patients with suspected hemorrhagic stroke in the emergency department , initial diagnosis and evaluation should be performed quickly, vital signs should be stabilized, imaging examinations such as CT for head stroke should be performed to confirm the diagnosis of HICH , and necessary laboratory tests should be completed in the emergency department ( diagnosis level I recommendation, level A evidence) .

neuroimaging neuroimaging

Head CT or MRI examination should be performed as soon as possible after admission to confirm the diagnosis of HICH (Class I recommendation, Level A evidence) .

CTA , MRI , MRA , MRV and DSA can be used to diagnose or exclude secondary cerebral hemorrhage caused by aneurysm, arteriovenous malformation, tumor, moyamoya disease and intracranial venous thrombosis ( thrombus class I recommendation, level B evidence)

Conditional units should routinely perform CTA examination.

The " black hole sign ", " miscellaneous sign " and " island sign " displayed on non- enhanced CT may help predict the risk of hematoma expansion ( Class IIb , Level of Evidence B ).

To assess the risk of hematoma expansion, factors such as baseline hematoma volume, history of oral anticoagulants, and time from onset to the first cranial CT examination should be comprehensively considered ( Class I recommendation, Level A evidence)

Diagnosis and Differential Diagnosis of HIGH Diagnosis and Differential Diagnosis of HIGH

There is no gold standard for the diagnosis of HICH , and it mainly relies on the diagnosis of exclusion
.

The diagnosis of HICH requires comprehensive related examinations to exclude other secondary cerebral hemorrhage diseases ( Class I recommendation, Level C evidence)

There is no gold standard for the diagnosis of HICH , and it mainly relies on the diagnosis of exclusion

Specialist non-surgical treatment of HIGH Specialist non-surgical treatment of HIGH

Decreased intracranial pressure ( ICP ) detection and treatment

All HICH patients should be evaluated and judged by ICP , and intracranial hypertension should be treated in time to prevent severe intracranial hypertension or even brain herniation ( Class I recommendation, Level B evidence)
.

When conditions permit, invasive ICP monitoring can be considered for HICH patients with GCS 3-8 points (Class IIb recommendation, Level C evidence) .

Drugs such as mannitol and hypertonic saline can reduce cerebral edema, reduce ICP , and reduce the risk of brain herniation; the type of drug, therapeutic dose, and frequency of administration can be selected according to specific circumstances ( Class I recommendation, Level C evidence)
.

Sedative and analgesic treatment

sedative and analgesic treatment sedative and analgesic treatment

Sedation and analgesia are recommended for severe HICH patients, especially those with agitation ( Class I , Level of Evidence C ) .

Blood pressure management after HIGH

Blood pressure management after HIGH Blood pressure management after HIGH

In HICH patients with systolic blood pressure between 150 and 220 mmHg and no contraindications to acute antihypertensive therapy , it is safe to reduce systolic blood pressure to 140 mmHg in the acute phase (class I recommendation, level of evidence A ).
ischemic risk ( Class III recommendation, Level A evidence) .

In HICH patients with systolic blood pressure >220 mmHg , continuous intravenous medication to intensify blood pressure lowering and continuous blood pressure monitoring is reasonable, but in clinical practice, it should be individualized according to the length of the patient's history of hypertension , basal blood pressure, ICP status, and blood pressure on admission Determine the blood pressure target ( Class IIa recommendation, Level C evidence) .

In HICH patients with systolic blood pressure >220 mmHg , continuous intravenous medication to intensify blood pressure lowering and continuous blood pressure monitoring is reasonable, but in clinical practice, it should be based on the length of the patient's history of hypertension , basal blood pressure, hypertension ICP , and blood pressure on admission.
Determining blood pressure targets individually ( Class IIa recommendation, Level C evidence) .

In HICH patients with systolic blood pressure of 150-220 mmHg and no contraindications to acute antihypertensive therapy , it may be safe to reduce perioperative systolic blood pressure to 120-140 mmHg (Class IIb , Level of Evidence B ) .

Drug therapy to prevent hematoma expansion

Drug therapy to prevent and treat hematoma expansion

Elevated blood pressure ( >160 mmHg ) after HICH has the risk of promoting hematoma expansion (class IIa recommendation, level of evidence B ) ; intensive blood pressure lowering ( <140 mmHg ) may reduce the incidence of hematoma expansion ( class IIb recommendation, level of evidence A ) ) .

Tranexamic acid can reduce the incidence of hematoma expansion in HICH patients (class IIa recommendation, level of evidence A ) , but cannot improve the survival rate and neurological prognosis ( class III recommendation, level of evidence A ) .

In HICH patients with positive signs such as “ island sign ” and “ mixed sign ” of hematoma on plain CT scan , tranexamic acid antifibrinolytic therapy cannot improve the prognosis ( level III recommendation, level B evidence) .

other

other _

Patients with HICH should be monitored and treated in a NICU or stroke unit staffed by medical professionals (Class I , Level of Evidence B ) .

Regardless of whether they have diabetes in the past, blood glucose should be monitored in patients with HICH , and the blood glucose should be controlled within the normal range to avoid high or low levels ( Class I , Level of Evidence C ) .

Regardless of whether they have diabetes in the past, blood glucose should be monitored in patients with diabetic HICH , and the blood glucose should be controlled within the normal range to avoid high or low levels ( Class I , Level of Evidence C ) .

Fever should be controlled in HICH patients to prevent hyperthermia ( >38.
5 ℃ ) ( Class IIb recommendation, Level of evidence C ) .

Seizures should be treated with antiepileptic drugs ( Class I , Level of Evidence B ) .

For patients with HICH involving hematoma in the cortex , antiepileptic drugs can be used prophylactically Class IIa recommendation, Level of Evidence C ) .

For patients with HICH involving hematoma in the cortex , antiepileptic drugs can be used prophylactically prevention class IIa recommendation, level of evidence C ) .

Swallowing function assessment and screening should be performed before HICH patients start eating to reduce the risk of aspiration pneumonia ( Class I , Level of Evidence B ) .

Swallowing function assessment and screening should be performed before HICH patients start eating to reduce the risk of aspiration pneumonia ( screening level I recommendation, level of evidence B ) .

Use intermittent air compression devices as soon as possible after admission in HICH patients to prevent venous thrombosis ( Class I , Level of Evidence B ) .

Surgical treatment of HIGH

Surgical treatment of HIGH Surgical treatment of HIGH

For patients with supratentorial HICH , if severe intracranial hypertension or even brain herniation occurs, emergency surgery should be performed to remove the hematoma; hematoma removal can reduce the mortality rate and improve neurological prognosis to a certain extent ( Class I recommendation, Level A evidence)
.

The use of stereotaxic hematoma puncture combined with fibrinolytic drugs to treat large supratentorial hematomas ( >30 ml ) is safe, and residual hematoma <15 ml may improve prognosis ( Class IIa , Level of Evidence A ) .

Compared with traditional craniotomy hematoma evacuation, neuroendoscopy may improve the prognosis of patients with supratentorial HICH better (Class IIa , Level of Evidence B ) .

For patients with supratentorial HICH with severe intracranial hypertension , decompressive craniectomy with or without hematoma evacuation can reduce mortality ( Class IIa , Level of Evidence B ) .

Ventricular drainage can reduce the mortality of most patients with intraventricular hemorrhage (Class IIa recommendation, Level of Evidence B ) ; Stereotactic hematoma puncture combined with fibrinolytic drugs cannot improve neurological prognosis in patients with Intracerebral hemorrhage ( Class IIb recommendation, Level of Evidence A ) .

For patients with cerebellar hemorrhage >10 ml combined with brainstem compression or obstructive hydrocephalus, craniotomy can save lives, but whether it can improve neurological outcome is inconclusive ( Class IIa recommendation, Level B evidence)
.

For patients with severe brainstem hemorrhage (hematoma volume > 5 ml , GCS ≤ 8 points), surgical treatment can reduce the mortality ( Class I recommendation, Level B evidence)
.

Early surgery (6-24 hours after onset ) can improve prognosis ( Class I recommendation, Level B evidence)
.

Rehabilitation for HIGH

Rehabilitation for HIGH Rehabilitation for HIGH

All HICH patients should receive rehabilitation therapy ( Class I , Level of Evidence B ) .

Rehabilitation treatment should be started as soon as possible, and rehabilitation training should be carried out as soon as possible ( Class IIa recommendation, Level B evidence)
.

Recurrence and prevention of HIGH

Recurrence and prevention of HIGHRecurrence and prevention of HIGH

Risk factors for HICH recurrence include site of primary bleeding, advanced age, microbleeds, ongoing anticoagulation therapy, and carrying apolipoprotein Eε2 or ε4 alleles, which need to be stratified for evaluation ( Class IIa , Level of Evidence B ) .

To prevent HICH recurrence, hypertension should be controlled in all HICH patients (Class I , Level of Evidence A ) .

Statins should be used with caution in patients with HICH (Class IIb , Level of Evidence C ) .

The diagnosis and treatment of HICH involves multiple disciplines, and the specific process is shown in the attached figure
.

Source of this article:

Neurosurgery Branch of Chinese Medical Association, Emergency Physician Branch of Chinese Medical Doctor Association, Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association , Stroke Screening and Prevention Engineering Committee of National Health Commission .
Multidisciplinary Guidelines for Diagnosis and Treatment of Hypertensive Intracerebral Hemorrhage in China [J].
China Emergency Medicine , 2020, 40(8): 689-702.

Chinese Medical Association Neurosurgery Branch , Chinese Medical Doctor Association Emergency Physician Branch , Chinese Medical Association Neurology Branch Cerebrovascular Disease Group Vascular , National Health Commission Stroke Screening and Prevention Engineering Committee .
Multidisciplinary diagnosis and treatment of hypertensive cerebral hemorrhage in China Guidelines [J].
China Emergency Medicine , 2020, 40(8): 689-702.
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