New evidence improves care for brain hemorrhage: Compression stockings, some drugs ineffective

New evidence improves care for brain hemorrhage: Compression stockings, some drugs ineffective

Stroke 5-17 Central illustration of ICH guidelines. Credit: Copyright American Heart Association / American Stroke Association 2022

Some of the treatments or preventative treatments used to manage intracerebral hemorrhage (ICH), or hemorrhagic stroke, are not as effective as previously thought, according to new American Heart Association/American Stroke Association guidelines for the care of people with spontaneous ICH, published today in the Journal of Stroke. Cerebrospinal Society. The guidelines detail the latest evidence-based treatment recommendations and are the association’s official clinical practice recommendations.

The guide includes recommendations on surgical techniques, individual activity levels after ICH, and additional education and training for caregivers at home. It reflects the consistent informational gains made in the field of intracerebral hemorrhage since the publication of the last ICH management guideline in May 2015.

Stephen M. says Greenberg, MD, Ph.D. D., FAHA, chair of the guideline writing group, professor of neurology at Harvard Medical School and vice chair of the division of neurology at Massachusetts General Hospital, both in Boston.

ICH accounts for about 10% of the approximately 800,000 strokes that occur annually in the United States. Typical causes of primary ICH hemorrhage (that is, ICH not due to another condition such as head trauma) include uncontrolled hypertension and age-related cerebral degeneration of vessels. 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, stroke (of any kind) is the second leading cause of death and the leading cause of long-term disability.

The likelihood of having ICH increases sharply with age, so as the population ages, these types of strokes are expected to remain a major health concern. In addition, the widespread use of blood thinners is a growing cause of ICH. Therefore, new therapies for ICH and better use of evidence-based approaches to the prevention, care and recovery of ICH are needed.

Standard Care Practice Updates

The new guidelines suggest that many of the techniques widely considered “standard care” are not necessary. For example, research confirms that wearing compression stockings or stockings of any length to prevent a blood clot in the deep veins, known as DVT, after a hemorrhagic stroke is not effective. Alternatively, a method known as intermittent airway compression, which involves wrapping the lower legs and feet in inflatable shoes, may be helpful if started on the same day as the ICH diagnosis. However, more information is needed about whether using compression stockings with medications might prevent blood clots.

“This is an area that we still have a lot of exploration to do. It is unclear whether specialized compression devices reduce the risk of DVT or improve the overall health of people with cerebral hemorrhage. More research is needed on how the new drugs might help. To prevent blood clots, especially during the first 24 to 48 hours of the first symptoms,” says Greenberg.

Recommendations for the use of anticonvulsant drugs or antidepressants after hemorrhagic stroke have also been updated. The guideline states that none of these classes of drugs help a person’s overall health unless the seizure or depression is already present, so they are not recommended for most people. Anti-seizure medications did not improve long-term function or control of seizures, and use of antidepressants increased the chance of bone fractures.

The guideline writing group also addresses previous standard therapies within the hospital. They suggest that giving steroids to prevent complications from stroke bleeding is ineffective and highlight that platelet transfusions, unless used during emergency surgery, may worsen the condition of stroke survivors.

Surgical intervention

People who have a hemorrhagic stroke may experience increased pressure in the brain after bleeding, which can damage brain tissue. These people should be considered candidates for immediate surgical procedures to relieve pressure, according to the guidelines. 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 data on minimally invasive surgical techniques, which require 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 may improve a patient’s survival after moderate or significant bleeding from ICH,” Greenberg says. “However, it is unclear whether this or any other type of surgical procedure improves the chances of survival and recovery from ICH, which are our ultimate goals.”

Healing and rehabilitation

Rehabilitation after stroke includes many strategies to help restore an individual’s quality of life, and the guideline reinforces the importance of a multidisciplinary team to develop a recovery plan. Research suggests that a person with mild or moderate ICH deficiency may begin activities such as stretching, dressing, bathing, and other normal daily tasks 24-48 hours after a stroke to improve survival rate and recovery time; However, moving too much or too intensely within 24 hours is associated with an increased risk of death within 14 days after nonphysical haemorrhage.

The guideline outlines several areas for future study, including how quickly individuals can return to work, drive, and participate in other social engagements. Health care professionals also need more information about recommendations regarding sexual activity and safe levels of exercise after a stroke.

home care providers

The guidelines recommend education, practical support and training for family members to be involved and know what to expect during rehabilitation.

“People need extra help with these lifestyle changes, whether that’s getting around more, limiting their alcohol use or eating healthy foods. All of this happens after they leave hospital, and we need to make sure we empower families with the information they may need to be supportive. correctly,” Greenberg adds.

Education of the family or other caregivers benefits the individual’s activity levels and quality of life. Practical support (such as how to walk safely with the patient) and training (such as how to perform certain exercises) is reasonable and may make some rehabilitation exercises at home possible and permanently improve the patient’s balance.

Other highlights

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 facilities with neurological care and neurosurgery units, if needed. The guideline stresses the importance of methods for educating the public, building and maintaining structured systems of care and ensuring appropriate training for first responders.

The guidelines suggest that there may be a chance of preventing ICH in some people. Damage to the small blood vessels associated with ICH can be seen on magnetic resonance imaging (MRI). An MRI is not always done but may be helpful for some individuals. In addition, the main risk factors for damage to small vessels are high blood pressure, type 2 diabetes and old age. Blood thinners remain an important topic because use of these medications may increase complications and death from hemorrhagic stroke. The writing group provides updated guidelines for immediate reversal of newer blood thinners such as apixaban, rivaroxaban, edoxaban, and dabigatran, as well as older medications such as warfarin or heparin.

The focus is again on the intricacies of DNAR versus the decision to restrict other medical and surgical interventions. The writing group highlights the need to educate medical professionals, stroke survivors, and/or the individual’s caregiver about the differences. The guidelines recommend that the severity of bleeding, as measured by standard measures, should not be used as the sole basis for determining life-saving treatments.

“There is no easy path to preventing or treating hemorrhagic strokes, yet there is encouraging progress in all aspects of this disease, from prevention to in-hospital treatment and post-hospital recovery. We believe the wide range of knowledge provided in the new guideline will translate into improvements meaningful in ICH care,” Greenberg says.

This guide was prepared by the Voluntary Writing Group on behalf of the American Heart Association/American Stroke Association. The Society’s guidelines detail the latest evidence-based treatment recommendations and are the Society’s official clinical practice recommendations for various cardiovascular diseases and strokes.

The risk of a second stroke can be reduced with prevention efforts based on the cause of the first stroke

more information:
The 2022 guide to the management of patients with spontaneous cerebral hemorrhage: evidence from the American Heart Association/American Stroke Association, brain attack (2022). doi: 10.1161/str.0000000000000407

Submitted by the American Heart Association

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2022-05-17 09:33:16

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