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*Only for medical professionals to read and refer to the release of the "Chinese Multidisciplinary Guidelines for Diagnosis and Treatment of Cerebral Hemorrhage Related to Blood Coagulation Dysfunction", which will better promote the diagnosis and treatment of HDICH! Blood coagulation dysfunction-related intracerebral hemorrhage (HDICH) refers to intraparenchymal hemorrhage that occurs during the use of anticoagulant or antiplatelet drugs, or on the basis of coagulopathy
.
Compared with pure spontaneous intracerebral hemorrhage (ICH), HDICH has a higher incidence of hematoma enlargement, a worse functional prognosis, and a higher mortality rate
.
Its treatment involves the reversal and replacement of coagulation dysfunction, and the restart of antiplatelet or anticoagulant drugs.
Surgical strategies and techniques also have their own particularities and require multidisciplinary cooperation in diagnosis and treatment
.
In order to unify the definition, diagnosis and treatment standards of coagulation dysfunction cerebral hemorrhage, standardize clinical diagnosis and treatment, reduce mortality, and improve patient prognosis and quality of life
.
The Neurosurgery Branch of the Chinese Medical Association, the Emergency Physician Branch of the Chinese Medical Doctor Association, and the Stroke Screening and Prevention Engineering Committee of the National Health and Medical Commission have combined the latest research progress and issued the "HDICH China Multidisciplinary Diagnosis and Treatment Guide" (hereinafter referred to as the "Guide").
Below we will interpret the first aid, treatment and blood pressure management of HDICH in the "Guide"
.
Emergency treatment, coagulation function evaluation and diagnosis The "Guide" recommends that in pre-hospital first aid, the patient should be transferred to the nearest hospital as soon as possible after emergency treatment based on local conditions is carried out on the spot
.
For patients using antiplatelet or anticoagulant drugs, the drug should be stopped immediately (level I recommendation, level C evidence)
.
In the emergency treatment specifications, the "Guide" recommends that patients with suspected hemorrhagic stroke should be quickly diagnosed and evaluated in the emergency department, vital signs should be stabilized, brain CT and other imaging examinations should be performed to confirm the diagnosis, and the necessary laboratory examinations in the emergency department should be completed (Ⅰ Grade recommendation, Grade A evidence)
.
In terms of coagulation function evaluation, the "Guide" points out that comprehensive coagulation function evaluation involves items such as platelets, coagulation function, and fibrinolysis
.
If HDICH is suspected or diagnosed, relevant physicians should be invited to coordinate diagnosis and treatment, confirm the diagnosis and initiate reversal or alternative treatment as soon as possible (level I recommendation, level C evidence).
For patients with clear coagulation dysfunction, it is recommended to use thrombus elasticity as much as possible Figure (TEG) for further evaluation (IIb recommendation, B evidence)
.
The "Guide" also further developed the diagnostic criteria for HDICH, pointing out that on the basis of the imaging examination to confirm ICH, HDICH is defined as one of the following: (1) Antiplatelet, anticoagulant or thrombolytic drugs have been used within the past 1 week of onset
.
(2) Combined with coagulation dysfunction, where platelet count<100×109/L, or international normalized ratio (INR)>1.
2, or activated partial thromboplastin time (APTT) ratio>1.
2, or FIB<2g/L , Or other coagulation indicators suggest weakening of coagulation function
.
Recommendations believe that the diagnosis of HDICH should be combined with medical history, laboratory indicators and imaging comprehensive judgment (level I recommendation, level C evidence)
.
The HDICH non-surgical treatment recommendation guidelines provide recommended treatment opinions for antiplatelet drugs or anticoagulant-related ICH patients
.
Table 1 Antiplatelet drugs or anticoagulant drugs-related ICH treatment opinions Note: ADP=adenosine diphosphate; PCC=prothrombin complex; aPCC=activated prothrombin complex; DOAC=oral anticoagulant while coagulation In the treatment of disease-related ICH, the "Guide" gives advice on the treatment of platelet count reduction and dysfunction, coagulation dysfunction, vascular disease, and hyperfibrinolysis.
.
Table 2 In addition to targeted treatments for ICH treatment recommendations related to coagulation diseases, pressure control is also the key.
ICH often complicates with hypertension in the acute phase, which is closely related to hematoma enlargement, cerebral edema aggravation, death and poor prognosis [1,2]
.
At present, many observational studies have confirmed that the higher the blood pressure in the acute phase of ICH, the more likely it is to increase the deterioration of the patient's neurological function, the worse the prognosis, and the higher the mortality rate
.
Therefore, reasonable blood pressure management for patients in the acute phase of ICH is of great significance for preventing the deterioration of early neurological function and improving the clinical prognosis in the later stage
.
The release of the "Guidelines" also focused on recommendations for blood pressure management in HDICH patients
.
However, there is currently a lack of clinical evidence specifically for blood pressure management in HDICH patients, so the relevant content of this recommendation refers to the HICH guide [3], which provides a detailed description of blood pressure management
.
In recent years, a number of large RCTs have conducted in-depth studies on the safety and effectiveness of early antihypertensive or early enhanced antihypertensive, including HDICH patients[1,4-6]
.
After referring to the HICH guidelines, the "Guide" recommends the blood pressure treatment goals for HDICH patients: Table 3 The blood pressure treatment goals for HDICH patients are recommended for blood pressure management and treatment.
The "Guide" emphasizes that the use of intravenous administration in the acute phase of HDICH can achieve rapid and steady drop The goal of blood pressure, and nicardipine as the recommended drug for intravenous antihypertensive drugs
.
Nicardipine is a dihydropyridine calcium channel blocker, which acts to lower blood pressure by inhibiting the influx of calcium ions from the expansion of vascular smooth muscle cells
.
Its outstanding feature is that compared with other antihypertensive drugs, the lowering of blood pressure is the most stable, and it is better than other antihypertensive drugs in reducing blood pressure variability
.
In addition, the "Guide" also recommends the therapeutic dose of nicardipine hydrochloride injection: give the initial dose of 5mg/h intravenous infusion, increase by 2.
5mg/h every 15-30 minutes, and the maximum dose of 15mg/h
.
After reaching the target blood pressure, the drug is maintained and the blood pressure is controlled steadily
.
The summary guidelines pointed out that in addition to the reversal of coagulation dysfunction, effective management of blood pressure can improve the prognosis of HDICH patients
.
And blood pressure management should choose intravenous antihypertensive drugs with fast onset, strong controllability, and high safety.
Nicardipine is an intravenous antihypertensive drug, and its role in acute antihypertensive has been recommended by major domestic and foreign guidelines
.
With the introduction of more clinical evidence in the future, the application recommendation of nicardipine in the blood pressure management of HDICH patients will be more clear
.
References: [1]Sakamoto Y, Koga M, Yamagami H, et al.
SAMURAI Study Investigators.
Systolic blood pressure after intravenous antihypertensive treatment and clinical outcomes in hyperacute intracerebral hemorrhage: the stroke acutemanagement with urgent risk-factor assessment and improvement-intracerebral hemorrhagestudy .
Stroke.
2013 Jul;44(7):1846-51.
[2]Rodriguez-LunaD, Piñeiro S, Rubiera M, et al.
Impact of blood pressure changes and course onhematoma growth in acute intracerebral hemorrhage.
Eur J Neurol.
2013Sep ;20(9):1277-83.
[3] Neurosurgery Branch of Chinese Medical Association, Emergency Physician Branch of Chinese Medical Doctor Association, Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association, etc.
Guidelines for Chinese Multidisciplinary Diagnosis and Treatment of Hypertensive Cerebral Hemorrhage [J].
Chinese Journal of Neurosurgery, 2020, 36(8): 757-770.
[4]AndersonCS, Huang Y, Wang JG, et al.
INTERACT Investigators.
Intensive blood pressurereduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilottrial.
Lancet Neurol.
2008 May;7(5):391-9.
[5 ]AndersonCS, Heeley E,
.
The content of the information published by this site does not mean that it agrees with its description and opinions, but only provides more information
.
If copyright issues are involved, please contact us, and we will deal with it as soon as possible
.
Only for medical and health professionals to understand the information
.
Such information cannot replace professional medical guidance in any way, nor should it be regarded as diagnosis and treatment advice
.
If such information is used for purposes other than understanding the information, this site and the author shall not bear related responsibilities
.
-End-
.
Compared with pure spontaneous intracerebral hemorrhage (ICH), HDICH has a higher incidence of hematoma enlargement, a worse functional prognosis, and a higher mortality rate
.
Its treatment involves the reversal and replacement of coagulation dysfunction, and the restart of antiplatelet or anticoagulant drugs.
Surgical strategies and techniques also have their own particularities and require multidisciplinary cooperation in diagnosis and treatment
.
In order to unify the definition, diagnosis and treatment standards of coagulation dysfunction cerebral hemorrhage, standardize clinical diagnosis and treatment, reduce mortality, and improve patient prognosis and quality of life
.
The Neurosurgery Branch of the Chinese Medical Association, the Emergency Physician Branch of the Chinese Medical Doctor Association, and the Stroke Screening and Prevention Engineering Committee of the National Health and Medical Commission have combined the latest research progress and issued the "HDICH China Multidisciplinary Diagnosis and Treatment Guide" (hereinafter referred to as the "Guide").
Below we will interpret the first aid, treatment and blood pressure management of HDICH in the "Guide"
.
Emergency treatment, coagulation function evaluation and diagnosis The "Guide" recommends that in pre-hospital first aid, the patient should be transferred to the nearest hospital as soon as possible after emergency treatment based on local conditions is carried out on the spot
.
For patients using antiplatelet or anticoagulant drugs, the drug should be stopped immediately (level I recommendation, level C evidence)
.
In the emergency treatment specifications, the "Guide" recommends that patients with suspected hemorrhagic stroke should be quickly diagnosed and evaluated in the emergency department, vital signs should be stabilized, brain CT and other imaging examinations should be performed to confirm the diagnosis, and the necessary laboratory examinations in the emergency department should be completed (Ⅰ Grade recommendation, Grade A evidence)
.
In terms of coagulation function evaluation, the "Guide" points out that comprehensive coagulation function evaluation involves items such as platelets, coagulation function, and fibrinolysis
.
If HDICH is suspected or diagnosed, relevant physicians should be invited to coordinate diagnosis and treatment, confirm the diagnosis and initiate reversal or alternative treatment as soon as possible (level I recommendation, level C evidence).
For patients with clear coagulation dysfunction, it is recommended to use thrombus elasticity as much as possible Figure (TEG) for further evaluation (IIb recommendation, B evidence)
.
The "Guide" also further developed the diagnostic criteria for HDICH, pointing out that on the basis of the imaging examination to confirm ICH, HDICH is defined as one of the following: (1) Antiplatelet, anticoagulant or thrombolytic drugs have been used within the past 1 week of onset
.
(2) Combined with coagulation dysfunction, where platelet count<100×109/L, or international normalized ratio (INR)>1.
2, or activated partial thromboplastin time (APTT) ratio>1.
2, or FIB<2g/L , Or other coagulation indicators suggest weakening of coagulation function
.
Recommendations believe that the diagnosis of HDICH should be combined with medical history, laboratory indicators and imaging comprehensive judgment (level I recommendation, level C evidence)
.
The HDICH non-surgical treatment recommendation guidelines provide recommended treatment opinions for antiplatelet drugs or anticoagulant-related ICH patients
.
Table 1 Antiplatelet drugs or anticoagulant drugs-related ICH treatment opinions Note: ADP=adenosine diphosphate; PCC=prothrombin complex; aPCC=activated prothrombin complex; DOAC=oral anticoagulant while coagulation In the treatment of disease-related ICH, the "Guide" gives advice on the treatment of platelet count reduction and dysfunction, coagulation dysfunction, vascular disease, and hyperfibrinolysis.
.
Table 2 In addition to targeted treatments for ICH treatment recommendations related to coagulation diseases, pressure control is also the key.
ICH often complicates with hypertension in the acute phase, which is closely related to hematoma enlargement, cerebral edema aggravation, death and poor prognosis [1,2]
.
At present, many observational studies have confirmed that the higher the blood pressure in the acute phase of ICH, the more likely it is to increase the deterioration of the patient's neurological function, the worse the prognosis, and the higher the mortality rate
.
Therefore, reasonable blood pressure management for patients in the acute phase of ICH is of great significance for preventing the deterioration of early neurological function and improving the clinical prognosis in the later stage
.
The release of the "Guidelines" also focused on recommendations for blood pressure management in HDICH patients
.
However, there is currently a lack of clinical evidence specifically for blood pressure management in HDICH patients, so the relevant content of this recommendation refers to the HICH guide [3], which provides a detailed description of blood pressure management
.
In recent years, a number of large RCTs have conducted in-depth studies on the safety and effectiveness of early antihypertensive or early enhanced antihypertensive, including HDICH patients[1,4-6]
.
After referring to the HICH guidelines, the "Guide" recommends the blood pressure treatment goals for HDICH patients: Table 3 The blood pressure treatment goals for HDICH patients are recommended for blood pressure management and treatment.
The "Guide" emphasizes that the use of intravenous administration in the acute phase of HDICH can achieve rapid and steady drop The goal of blood pressure, and nicardipine as the recommended drug for intravenous antihypertensive drugs
.
Nicardipine is a dihydropyridine calcium channel blocker, which acts to lower blood pressure by inhibiting the influx of calcium ions from the expansion of vascular smooth muscle cells
.
Its outstanding feature is that compared with other antihypertensive drugs, the lowering of blood pressure is the most stable, and it is better than other antihypertensive drugs in reducing blood pressure variability
.
In addition, the "Guide" also recommends the therapeutic dose of nicardipine hydrochloride injection: give the initial dose of 5mg/h intravenous infusion, increase by 2.
5mg/h every 15-30 minutes, and the maximum dose of 15mg/h
.
After reaching the target blood pressure, the drug is maintained and the blood pressure is controlled steadily
.
The summary guidelines pointed out that in addition to the reversal of coagulation dysfunction, effective management of blood pressure can improve the prognosis of HDICH patients
.
And blood pressure management should choose intravenous antihypertensive drugs with fast onset, strong controllability, and high safety.
Nicardipine is an intravenous antihypertensive drug, and its role in acute antihypertensive has been recommended by major domestic and foreign guidelines
.
With the introduction of more clinical evidence in the future, the application recommendation of nicardipine in the blood pressure management of HDICH patients will be more clear
.
References: [1]Sakamoto Y, Koga M, Yamagami H, et al.
SAMURAI Study Investigators.
Systolic blood pressure after intravenous antihypertensive treatment and clinical outcomes in hyperacute intracerebral hemorrhage: the stroke acutemanagement with urgent risk-factor assessment and improvement-intracerebral hemorrhagestudy .
Stroke.
2013 Jul;44(7):1846-51.
[2]Rodriguez-LunaD, Piñeiro S, Rubiera M, et al.
Impact of blood pressure changes and course onhematoma growth in acute intracerebral hemorrhage.
Eur J Neurol.
2013Sep ;20(9):1277-83.
[3] Neurosurgery Branch of Chinese Medical Association, Emergency Physician Branch of Chinese Medical Doctor Association, Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association, etc.
Guidelines for Chinese Multidisciplinary Diagnosis and Treatment of Hypertensive Cerebral Hemorrhage [J].
Chinese Journal of Neurosurgery, 2020, 36(8): 757-770.
[4]AndersonCS, Huang Y, Wang JG, et al.
INTERACT Investigators.
Intensive blood pressurereduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilottrial.
Lancet Neurol.
2008 May;7(5):391-9.
[5 ]AndersonCS, Heeley E,
.
The content of the information published by this site does not mean that it agrees with its description and opinions, but only provides more information
.
If copyright issues are involved, please contact us, and we will deal with it as soon as possible
.
Only for medical and health professionals to understand the information
.
Such information cannot replace professional medical guidance in any way, nor should it be regarded as diagnosis and treatment advice
.
If such information is used for purposes other than understanding the information, this site and the author shall not bear related responsibilities
.
-End-
