Author: Dr Tom Moullaali, Centre for Clinical Brain Sciences, University of Edinburgh; George Institute for Global Health, Sydney.
Can we improve outcomes after intracerebral haemorrhage (ICH) by adopting an approach of early active management with a combination of evidence-based treatments?
ICH has the poorest prognosis of the stroke subtypes – ~40% of patients do not survive beyond the first month. Prognosis is associated with the volume of the underlying haematoma, where the majority of expansion occurs within the first few hours. Subsequent mass effect and cerebral oedema causing raised intracranial pressure, and extension of the haemorrhage into the ventricles causing hydrocephalus can lead to rapid neurological deterioration and death. Further morbidity and mortality from medical complications such as sepsis, venous thromboembolism, and metabolic disturbances is also common.
A single ‘silver bullet’ treatment for ICH remains elusive. Randomised controlled trials that enrolled patients with acute ICH have tested various surgical approaches, blood pressure lowering strategies, haemostatic therapies, anti-inflammatories, and medications to reduce intracranial pressure. None of these in isolation are proven to dramatically alter prognosis, although some have shown promise. Stroke unit care is also of proven benefit after ICH, and data are accumulating to suggest that avoiding a nihilistic approach to management (for example, by avoiding early use of do not resuscitate orders1) may improve prognosis too.
A recent study by Parry-Jones et al2 prospectively evaluated the implementation of a care bundle for ICH patients treated at a comprehensive stroke centre and regional neurosurgical centre in Greater Manchester, UK. Named ‘ABC’, the bundle includes early reversal of Anticoagulation, rapid Blood pressure lowering, and a Care pathway prompting immediate neurosurgical referral, where indicated. The authors found that compared with before implementation of the ABC bundle, the implementation and post-implementation periods were associated with reductions in the odds of death at 30 days, after adjustment for known prognostic factors. These findings are certainly promising, but as the authors acknowledge, they should be tested in a cluster randomised trial to reliably determine the causal pathway. This work also has impressive quality improvement aims from which many of us can learn; information about a smartphone application that simultaneously supports clinical staff to deliver care and collect data for audit purposes can be found here: https://vimeo.com/275981724.
Elsewhere, in China, the third, INTEnsive care bundle with blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT3)3, has recruited over 3000 of the 8621 participants required to test the effects of a goal-directed bundle of care on modified Rankin Scale scores at 6 months. There are a number of parallels in the approach, specifically the focus on rapid blood pressure reduction and reversal of anticoagulation, however, the INTERACT3 bundle also includes intensive glucose control and fever management. Furthermore its multicentre, stepped wedge cluster randomised trial design will provide definitive evidence on the effectiveness of this approach.
In summary, the approach to managing acute ICH is evolving, and may in future include a multifaceted approach underpinned by early active management with a combination of evidence-based treatments. Smartphone applications may enhance the delivery and evaluation of care bundles. Evidence from randomised trials is awaited to confirm the efficacy of this approach on outcomes.
- Morgenstern LB, Zahuranec DB, Sánchez BN, et al. Full medical support for intracerebral hemorrhage. Neurology. 2015.
- Parry-Jones AR, Sammut-Powell C, Paroutoglou K, et al. An Intracerebral Hemorrhage Care Bundle Is Associated with Lower Case Fatality. Ann Neurol. July 2019.
- Details can be found at https://clinicaltrials.gov/ct2/show/NCT03209258