Author: Dr Tom Moullaali
Centre for Clinical Brain Sciences, University of Edinburgh, UK
George Institute for Global Health, Sydney, Australia
Intracerebral haemorrhage assessment, consultation and treatment (ICH-ACT)
I don’t need to re-iterate challenges in the management of ICH here; readers will have experience of this often devastating condition which generally carries a poor prognosis. Worse still, there are very few proven treatments to help our patients. But we know that some things work: rapid recognition and management in an acute stroke unit, identification of underlying causes which may have specific treatments (e.g. cerebral venous sinus thrombosis, aneurysms, arteriovenous malformations), and in selected patients, early blood pressure lowering, anticoagulant reversal and neurosurgical intervention. Symptomatic management of pain, nausea, urinary retention and recognition and management of early medical complications is also very important. For people who survive acute ICH, long-term blood pressure lowering can reduce the risk of recurrent stroke by about 50%.
Here in Edinburgh, Professor Rustam Al-Shahi Salman and the Research to Understand Stroke due to Haemorrhage (RUSH) team developed evidence-based guidance for the management of people with acute ICH. We called it ICH assessment, consultation and treatment (or ICH-ACT for short): https://www.bloodpressureclinic.ed.ac.uk/sites/default/files/atoms/files/intra-cerebral_haemorrhage.pdf. This complemented our population-based audit developed by Professor Salman, Dr Neshika criteria and several other dedicated team members.1 We measure the care of our patients with ICH against a short list of evidence-based criteria, and aim to improve care where opportunities exist in the data we collect.
How do you improve care for your patients with ICH? I’d love to hear your ideas. Here are some of my experiences below to stimulate conversation…
I learned a great deal during my first 5 years in Edinburgh where I studied for my PhD and now work as a neurology registrar (resident).
First, good care for patients with acute ICH requires collaboration. I will be speaking at an emergency department educational meeting next week to revisit diagnosis and management of ICH, and use of ICH ACT in our emergency department. This teaching session fosters collaboration and provides education for the next generation of emergency clinicians who are often the first to see patients with ICH when they arrive in hospital. Their awareness of our evidence-based guidance is key to establishing good care early.
Second, simple quality improvement interventions can improve care for patients with ICH. Our guidance about the reporting of non-contrast CT head scans and acquisition of CT angiography and venography supported our very busy emergency department to focus resources where they are needed most, based on best available evidence. During my PhD fellowship, I led a quality improvement intervention to promote long-term blood pressure lowering after ICH, which led to a significant increase in the uptake of this effective treatment.2
Do you have any ideas for quality improvement in your hospital? I’d love to hear your thoughts: get in touch @tom_moullaali on Twitter for more discussion!
- Samarasekera N, Fonville A, Lerpiniere C, et al. Influence of intracerebral hemorrhage location on incidence, characteristics, and outcome: Population-based study. Stroke 2015;46(2):361–368.
- Bonello K, Nelson A, Moullaali TJ, Al-Shahi Salman R. Prescription of blood pressure lowering treatment after intracerebral haemorrhage: prospective, population-based cohort study. Eur. Stroke J. 2020;6:44–52.
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