Guidelines and Consensus guidelines for multidisciplinary diagnosis and treatment of hypertensive intracerebral hemorrhage in China

2022-05-12 0 By

Guide read hypertensive intracerebral hemorrhage (HICH) refers to a sudden basal ganglia area with a clear history of high blood pressure patients, cerebellum and brainstem, thalamus, ventricle etc parenchymal hemorrhage, and to exclude traumatic, abnormal vascular structures in sexual disease, blood coagulation dysfunction, blood disease, systemic disease and tumor diseases caused by secondary cerebral hemorrhage.The Guideline for The Multidisciplinary Diagnosis and Treatment of Hypertensive Intracerebral hemorrhage (SICH) in China mainly introduces the most common and controversial HICH, and the main recommendations are as follows.Emergency treatment and Neuroimaging examination Pre-hospital emergency Treatment For the sudden appearance of suspected HICH patients, emergency personnel should quickly evaluate, and perform on-site emergency treatment according to local conditions, as soon as possible to transfer the patient to a nearby hospital with treatment conditions (level ⅰ recommendation, level C evidence).Emergency treatment For patients with suspected hemorrhagic stroke, initial diagnosis and evaluation should be carried out quickly in emergency, vital signs should be stabilized, head CT and other imaging examinations should be performed to confirm HICH diagnosis, and necessary laboratory examinations should be completed in emergency (grade ⅰ recommendation, Grade A evidence).The diagnosis of HICH was confirmed by head CT or MRI as soon as possible after neuroimaging (grade I recommendation, Grade 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 (grade I recommendation, grade B evidence).When available, CTA should be performed routinely, with the “speckle sign” shown to predict the risk of hematoma enlargement while excluding secondary intracerebral hemorrhage (grade ⅱ A recommendation, Grade A evidence).The “black hole signs”, “confounding signs” and “island signs” on plain CT may be helpful in predicting the risk of hematoma enlargement (grade ⅱ B recommendation, Grade B evidence).Factors such as baseline hematoma volume, oral history of anticoagulants, and time from onset to first cranial CT examination should be considered in assessing the risk of hematoma enlargement (grade I recommendation, Grade A evidence).Diagnosis and differential diagnosis of HIGH The diagnosis of HICH lacks the gold standard and relies mainly on the diagnosis of exclusion.The diagnosis of HICH requires a comprehensive examination to exclude all other secondary ich disorders (grade I recommendation, grade C evidence).ICP evaluation and judgment should be performed for all HICH patients, and intracranial hypertension should be treated in time to prevent severe HIGH intracranial pressure and even cerebral hernia (Grade I recommendation, grade B evidence).Invasive ICP monitoring can be considered for HICH patients with GCS3-8 (grade ⅱ B recommendation, grade C evidence) when conditions are available.Mannitol and hypertonic saline can reduce cerebral edema, ICP and the risk of cerebral hernia.The type of drug, therapeutic dose and frequency of administration can be selected according to the specific situation (grade I recommendation, grade C evidence).Sedative and analgesic therapy is recommended for patients with severe HICH, especially those with agitation (grade I recommendation, grade C evidence).In HICH patients with post-high bp management systolic blood pressure between 150 and 220 mmHg and no contraindications for acute antihypertensive therapy, lowering systolic blood pressure to 140 mmHg in the acute phase is safe (grade I recommendation, Level A evidence), while lowering systolic blood pressure below 130 mmHg increases the risk of extracranial ischemia (Grade III recommendation, level A evidence).Systolic blood pressure & gt;In HICH patients of 220 mmHg, continuous intravenous medication and continuous blood pressure monitoring are reasonable, but the objective of blood pressure reduction should be determined individually in clinical practice according to the length of hypertension history, basic blood pressure, ICP status and blood pressure at admission (GRADE ⅱ A recommendation, grade C evidence).In HICH patients with a systolic blood pressure of 150 to 220 mmHg and no conjunctive evidence for acute hypotensive therapy, a perioperative systolic blood pressure drop to 120 to 140 mmHg may be safe (grade ⅱ B recommendation, Grade B evidence).Increased blood pressure after treatment with drugs to prevent hematoma enlargement (& GT;160 mmHg) promoting hematoma enlargement (Grade ⅱ A recommendation, Grade B evidence);Enhanced blood pressure reduction (<140 mmHg) may reduce the incidence of hematoma enlargement (Grade ⅱ B recommendation, Grade A evidence).Tranexamic acid reduced the incidence of hematoma enlargement in HICH patients (grade ⅱ A recommendation, level A evidence), but did not improve survival or neurological outcome (grade ⅲ recommendation, level A evidence).Tranexamic acid antifibrinolytic therapy did not improve prognosis in HICH patients with positive signs such as “island” or “mixed” hematoma on plain CT scan (grade ⅲ recommendation, grade B evidence).Other HICH patients should be monitored and treated in a NICU or stroke unit with health care professionals (level I recommendation, level B evidence).Blood glucose in HICH patients should be monitored regardless of prior diabetes and controlled within the normal range to avoid hyperglycemia or hyperglycemia (grade I recommendation, grade C evidence).Fever in HICH patients should be controlled to prevent hyperthermia (& GT;38.5 ℃) (Grade ⅱ B recommendation, Grade C evidence).Seizures should be treated with antiepileptic drugs (grade I recommendation, level B evidence).Prophylactic antiepileptic drugs may be used in patients with hematoma involvement in cortical HICH (grade ⅱ A recommendation, level C evidence).Swallowing function should be assessed and screened before HICH patients begin eating to reduce the risk of aspiration pneumonia (grade I recommendation, grade B evidence).Use of intermittent air compression devices early after admission to HICH to prevent venous thrombosis (grade I recommendation, grade B evidence).Surgical treatment of HIGH For patients with SUpratentorial HICH, if severe intracranial hypertension or even cerebral hernia occurs, the hematoma should be removed by emergency surgery.Removal of hematoma can reduce mortality and improve neurological outcome to some extent (grade I recommendation, grade A evidence).Treatment of large supratentorial hematoma with stereotactic hematoma puncture combined with fibrinolytic drugs (& GT;30 ml) is safe, hematoma residual volume <15 ml may improve prognosis (grade ⅱ A recommendation, Grade A evidence).Neuroendoscopy may improve outcomes in patients with supratentorial HICH compared with traditional craniotomy for hematoma removal (grade ⅱ A recommendation, grade B evidence).Decompression with or without hematoma removal reduces mortality in patients with supratentorial HICH with severe intracranial hypertension (grade I2A recommendation, Level B evidence).External ventricular drainage can reduce mortality in most patients with ventricular hemorrhage (grade ⅱ A recommendation, grade B evidence).Stereotactic hematoma puncture combined with fibrinolytic drugs does not improve neurological outcome in patients with ventricular hemorrhage (grade ⅱ B recommendation, Grade A evidence).For the amount of bleeding & GT;In patients with 10 ml cerebellar hemorrhage complicated with brainstem compression or obstructive hydrocephalus, craniotomy is life-saving, but whether it improves neurological outcome has not been determined (grade ⅱ A recommendation, grade B evidence).For severe brain stem hemorrhage (hematoma volume & GT;5 ml, GCS≤8 points), surgical treatment reduced mortality (grade I recommendation, grade B evidence).Early surgery (6-24 h after onset) improves prognosis (grade I recommendation, grade B evidence).Rehabilitation for HIGH All HICH patients should receive rehabilitation (grade I recommendation, grade B evidence).Rehabilitation should be started as soon as possible, and rehabilitation training to leave the bed should be carried out as far as possible (level ⅱ A recommendation, level B evidence).Risk factors for HIGH relapse and prevention include initial blood site, advanced age, microbleeding, being on anticoagulant therapy, and carrying apolipoprotein Eε2 or ε4 allele, which need to be evaluated by stratification (grade ⅱ A recommendation, grade B evidence).To prevent recurrence of HICH, hypertension should be controlled in all HICH patients (grade I recommendation, Grade A evidence).Statin use should be cautious in patients with HICH (grade ⅱ B recommendation, grade C evidence).The diagnosis and treatment of HICH involves multiple disciplines, and the specific process is shown in the attached figure.Sources: Neurosurgery Society of Chinese Medical Association, Emergency Physicians Branch of Chinese Medical Association, Cerebrovascular Group of Neurology Society of Chinese Medical Association, Stroke Screening and Prevention Project Committee of National Health Commission.Chinese journal of emergency medicine,2020,40(8):689-702. 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