New Study Urges Changes to Hemorrhagic Stroke Standards to Save Lives
Protocols for Intracerebral Hemorrhage, One of the Deadliest and Most Disabling Diseases in the World, Lags Far Behind Those for More Common Strokes Caused by Arterial Blockages
Intracerebral hemorrhage (ICH) is a serious medical emergency caused by the spontaneous rupture of a small artery in the brain, resulting in bleeding into the brain. Although ICH accounts for only 15 to 20 percent of all strokes, it is by far the deadliest and most disabling form of stroke, with a mortality rate of approximately 30 percent.
While a highly standardized and optimized workflow has been adopted worldwide for treating acute ischemic stroke – which is caused by arterial blockages – no such time-based emergency protocols are in widespread use for ICH. Stephan Mayer, M.D., professor of neurology and neurosurgery, along with an international consortium of doctors, is now urging this to change, in a study published in Stroke.
“Neurologists typically cite the phrase ‘time is brain’ to educate the public about the importance of acting quickly when someone is suspected of having a stroke,” says Dr. Mayer, co-senior author of the paper. “The fact of the matter is that this principle is unevenly applied. Hospitals are required to treat ischemic stroke urgently and report their performance but are under no obligation to do the same for ICH, even though it’s a more deadly disease. This disconnect must change.”
The paper, entitled “Code-ICH: A Call to Action,” reviews the latest scientific evidence supporting the effectiveness of various strategies for treating ICH. These include lowering of elevated blood pressure, reversal of blood thinners, treatment for brain swelling, and surgical hematoma removal. Based on the current evidence, they advocate for the immediate and widespread adoption of a “care bundle” designed to reduce blood pressure and reverse the effects of blood thinners within an hour of arrival to the hospital.
“ICH is an emergency and should be treated as one,” adds Joshua N. Goldstein, M.D., professor of emergency medicine at the Harvard Medical School and the co-senior author of the paper. “We know that during the first hours after a brain hemorrhage there is active bleeding that causes continued damage in up to 40 percent of patients. Stroke centers regularly treat hypertension and reverse anticoagulation, but there are currently no standards or requirements to give these treatments as quickly as possible.”
“Care bundles that emphasize ultra-early intervention for ICH have been studied; they dramatically reduce treatment times and improve outcomes,” adds Qi Li, M.D., Ph.D., chair of neurology at The Second Affiliated Hospital of Anhui Medical University, Hefei, China, and first author of the paper. “Evidence-based guidelines from professional organizations are used to codify best practices, but they can take years to develop. We wrote this consensus statement because our patients can’t wait that long. ICH is a life and death situation, and the time to act is now.”
The author group includes 18 experts in ICH care representing the United States, Canada, China, Australia, Italy, the United Kingdom, and Germany.
In an office.
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My name is Dr. Stefan Mayer. I'm Professor of Neurology and Neurosurgery at New York Medical College. I'm a Neuro Intensivist and we treat a lot of stroke. We see a lot of stroke in the neuro-ICU.
85% of strokes are what we call ischemic strokes. They're caused by a clot that blocks an artery to the brain. 15% of strokes are what we call hemorrhagic, where the problem is bleeding into the brain. So there's been this disconnect where there's so much attention and focus on ischemic stroke, so bleeding strokes have been left as kind of a orphan disease, if you will. And so, I saw an opportunity to improve care with this one patient and I started to talk to my colleagues about this.
We're sharing experiences and talking about it. We realized, you know, someone's got to do something about this. And then we said, well, let's do it. And that's literally what led to the scientific collaboration and the creation of this international consensus statement that we published in Stroke, which is the leading journal for that area of medicine in the world.
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Gives a speech.
(SPEECH)
So, it became really a group effort, and we ended up with an authorship group of 18 researchers and scientists and the like, representing, I think, 8 or 10 different countries around the world, all focusing on this same idea. Like, yeah, we've got to do something about speeding up intervention for intracerebral hemorrhage. The Code ICH paper that we co-authored was a call to action, basically, that the time is now to elevate our game for implementing time-based standards of care for how we treat this illness.
So what we want to do is basically influence the process of how the guidelines are written and enacted and make it faster, because literally, people are dying every day of intracerebral hemorrhage, and we're trying to save lives and we're trying to bring those best practices to the bedside in as fast a way as possible.
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Dr. Mayer demonstrates a technique to another physician, then enters his office. Logo, New York Medical College, Text, A Member of Touro University.
