Intracerebral hemorrhage secondary prevention: Difference between revisions
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==Overview== | ==Overview== | ||
Effective measures for the secondary prevention of intracerebral hemorrhage include life style modification, treatment of modifiable risk factors such as blood pressure control and anticoagulation medication avoidance, and enforcing the measures to prevent the complications.<ref name="ASA/AHA-ICH-Guid2" /><ref name="ASA/AHA-Primary-Prevention-Guid" /><ref name="DOACs" /><ref name="pmid21309657" /><ref name="Eckman" /><ref name="pmid20539816" /><ref name="pmid23983842" /> | |||
==Secondary prevention== | ==Secondary prevention== | ||
===Life style modification=== | ===Prevention of recurrent ICH === | ||
Life style modification measures which may help reduce the risk of intracerebral hemorrhage recurrent | ====Life style modification==== | ||
Life style modification measures which may help reduce the risk of intracerebral hemorrhage recurrent may include:<ref name="ASA/AHA-ICH-Guid2" /><ref name="ASA/AHA-Primary-Prevention-Guid">2014 AHA/ASA Guidelines for the Primary Prevention of Stroke http://stroke.ahajournals.org/content/early/2014/10/28/STR.00000000000000467 Accessed on November 17, 2016</ref> | |||
*Eating healthy balanced diet | *Eating healthy balanced diet | ||
*Smoking cessation | *Smoking cessation | ||
*Decreased | *Decreased alcohol intake | ||
*Improved support from health care providers & care takers | *Improved support from health care providers & care takers | ||
*Patient education (involvement in BP monitoring to improve adherence to therapy) | *Patient education (involvement in BP monitoring to improve adherence to therapy) | ||
==== Blood pressure control ==== | ==== Blood pressure control ==== | ||
Receive early treatment targeted to an [[SBP]] level <140 mmHg to improve the chances of achieving better functional recovery | Receive early treatment targeted to an [[SBP]] level <140 mmHg to improve the chances of achieving better functional recovery.<ref name="ASA/AHA-ICH-Guid2" /> | ||
====Restarting anticoagulation==== | ====Restarting anticoagulation==== | ||
Restarting anticoagulation should be avoided, UNLESS the risk of [[ischemic stroke]] is MUCH HIGHER than that of recurrent ICH. | Restarting anticoagulation should be avoided, UNLESS the risk of [[ischemic stroke]] is MUCH HIGHER than that of recurrent ICH.<ref name=DOACs>Direct Oral Anticoagulants (DOACs) in the Laboratory: 2015 Review http://dx.doi.org/10.1016/j.thromres.2015.05.001 Accessed on December 1, 2016</ref><ref name="pmid21309657">{{cite journal| author=Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S et al.| title=Apixaban in patients with atrial fibrillation. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 9 | pages= 806-17 | pmid=21309657 | doi=10.1056/NEJMoa1007432 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21309657 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21803760 Review in: Evid Based Med. 2011 Dec;16(6):187-8] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21502641 Review in: Ann Intern Med. 2011 Apr 19;154(8):JC4-3]</ref><ref name=Eckman> Eckman, Mark H., et al. "Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis." Stroke 34.7 (2003): 1710-1716.</ref> | ||
* In AF patients with warfarin-associated lobar ICH or suspected [[Cerebral amyloid angiopathy|CAA]], the risk ICH recurrence seems higher than [[Thromboembolic event|thromboembolic events]]. Therefore, the best management is to discontinue [[Warfarin|warfarin therapy.]] | * In AF patients with warfarin-associated lobar ICH or suspected [[Cerebral amyloid angiopathy|CAA]], the risk ICH recurrence seems higher than [[Thromboembolic event|thromboembolic events]]. Therefore, the best management is to discontinue [[Warfarin|warfarin therapy.]] | ||
**In patients with lobar ICH and [[CHA2DS2-VASc Score|CHADS2 VASc score]] > 5 | |||
*In patients with lobar ICH and [[CHADS2 score]] | *** [[Left atrial appendage|LAA closure]] is a viable option | ||
** LAA closure is a viable option | ***If [[Left atrial appendage|LAA]] is not feasible [[Oral anticoagulation therapy|oral anticoagulation (OAC)]] is considered | ||
**If LAA is not feasible [[Oral anticoagulation therapy|oral anticoagulation (OAC)]] is considered | ***The use of DOACS (e.g. [[Apixaban]]) might be an alternative to [[warfarin]] | ||
**The use of DOACS (e.g. [[Apixaban]]) might be an alternative to [[warfarin]] | *In warfarin-related ICH patients with [[prosthetic valves]]<ref name="pmid21327503">{{cite journal| author=Leiria TL, Lopes RD, Williams JB, Katz JN, Kalil RA, Alexander JH| title=Antithrombotic therapies in patients with prosthetic heart valves: guidelines translated for the clinician. | journal=J Thromb Thrombolysis | year= 2011 | volume= 31 | issue= 4 | pages= 514-22 | pmid=21327503 | doi=10.1007/s11239-011-0574-9 | pmc=3699194 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21327503 }}</ref> | ||
*In warfarin-related ICH patients with [[prosthetic valves]] | |||
**The risk of [[Thromboembolic event|thromboembolic events]] is higher than the risk of recurrent ICH (resumption of [[Oral anticoagulation therapy|OAC]] with [[warfarin]] is often required) | **The risk of [[Thromboembolic event|thromboembolic events]] is higher than the risk of recurrent ICH (resumption of [[Oral anticoagulation therapy|OAC]] with [[warfarin]] is often required) | ||
*The optimal time to resumption of anticoagulation after warfarin-related ICH is unclear and may vary from patient to patient | *The optimal time to resumption of anticoagulation after warfarin-related ICH is unclear and may vary from patient to patient.<ref name="pmid21030703">{{cite journal| author=Majeed A, Kim YK, Roberts RS, Holmström M, Schulman S| title=Optimal timing of resumption of warfarin after intracranial hemorrhage. | journal=Stroke | year= 2010 | volume= 41 | issue= 12 | pages= 2860-6 | pmid=21030703 | doi=10.1161/STROKEAHA.110.593087 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21030703 }}</ref> | ||
*Avoidance of oral anticoagulation (OAC) for 4-8 weeks, in patients without mechanical heart valves, might decrease the risk of ICH recurrence | *Avoidance of oral anticoagulation (OAC) for 4-8 weeks, in patients without mechanical heart valves, might decrease the risk of ICH recurrence | ||
==== Resumption of statins ==== | |||
There is '''insufficient''' data to recommend restrictions on use of statin agents.<ref name="pmid16899775">{{cite journal| author=Amarenco P, Bogousslavsky J, Callahan A, Goldstein LB, Hennerici M, Rudolph AE et al.| title=High-dose atorvastatin after stroke or transient ischemic attack. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 6 | pages= 549-59 | pmid=16899775 | doi=10.1056/NEJMoa061894 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16899775 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17203927 Review in: ACP J Club. 2007 Jan-Feb;146(1):7]</ref> | |||
===Prevention of complications=== | ===Prevention of complications=== | ||
The preventive measures which may help prevent complications of intracerebral hemorrhage include:<ref name="pmid20539816" /> | The preventive measures which may help prevent complications of intracerebral hemorrhage include:<ref name="ASA/AHA-ICH-Guid2">2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage http://stroke.ahajournals.org/content/early/2015/05/28/STR.0000000000000069 Accessed on November 10, 2016</ref><ref name="pmid20539816" /><ref name="pmid23983842">{{cite journal| author=Armstrong JR, Mosher BD| title=Aspiration pneumonia after stroke: intervention and prevention. | journal=Neurohospitalist | year= 2011 | volume= 1 | issue= 2 | pages= 85-93 | pmid=23983842 | doi=10.1177/1941875210395775 | pmc=3726080 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23983842 }}</ref> | ||
*Use of intermittent pneumatic compression begun as early as the day of hospital admission | *Use of intermittent pneumatic compression begun as early as the day of hospital admission | ||
*[[Prophylactic]] anticonvulsant medication has not been demonstrated to be | *[[Prophylactic]] anticonvulsant medication has not been demonstrated to be beneficial. However, in a case of clinical seizures or electrographic seizures in patients with a change in mental status should be treated with antisezure drugs to prevent recurrence | ||
*Proper positioning of patient, and the use of thick feed with the help of nasogastric tube for feeding to prevent aspiration pneumonia in patients with cranial nerve palsies affecting pharyngeal motility and gag reflex | *Proper positioning of patient, and the use of thick feed with the help of nasogastric tube for feeding to prevent aspiration pneumonia in patients with cranial nerve palsies affecting pharyngeal motility and gag reflex | ||
*Pressure ulcers may be prevented by use of air mattress and regular change in position of patient | *Pressure ulcers may be prevented by use of air mattress and regular change in position of patient | ||
Latest revision as of 17:06, 13 December 2016
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Intracerebral hemorrhage Microchapters |
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Diagnosis |
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Treatment |
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AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015) |
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AHA/ASA Guideline Recommendation for the Primary Prevention of Stroke (2014) |
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Case Studies |
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Intracerebral hemorrhage secondary prevention On the Web |
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American Roentgen Ray Society Images of Intracerebral hemorrhage secondary prevention |
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Risk calculators and risk factors for Intracerebral hemorrhage secondary prevention |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]
Overview
Effective measures for the secondary prevention of intracerebral hemorrhage include life style modification, treatment of modifiable risk factors such as blood pressure control and anticoagulation medication avoidance, and enforcing the measures to prevent the complications.[1][2][3][4][5][6][7]
Secondary prevention
Prevention of recurrent ICH
Life style modification
Life style modification measures which may help reduce the risk of intracerebral hemorrhage recurrent may include:[1][2]
- Eating healthy balanced diet
- Smoking cessation
- Decreased alcohol intake
- Improved support from health care providers & care takers
- Patient education (involvement in BP monitoring to improve adherence to therapy)
Blood pressure control
Receive early treatment targeted to an SBP level <140 mmHg to improve the chances of achieving better functional recovery.[1]
Restarting anticoagulation
Restarting anticoagulation should be avoided, UNLESS the risk of ischemic stroke is MUCH HIGHER than that of recurrent ICH.[3][4][5]
- In AF patients with warfarin-associated lobar ICH or suspected CAA, the risk ICH recurrence seems higher than thromboembolic events. Therefore, the best management is to discontinue warfarin therapy.
- In patients with lobar ICH and CHADS2 VASc score > 5
- LAA closure is a viable option
- If LAA is not feasible oral anticoagulation (OAC) is considered
- The use of DOACS (e.g. Apixaban) might be an alternative to warfarin
- In patients with lobar ICH and CHADS2 VASc score > 5
- In warfarin-related ICH patients with prosthetic valves[8]
- The risk of thromboembolic events is higher than the risk of recurrent ICH (resumption of OAC with warfarin is often required)
- The optimal time to resumption of anticoagulation after warfarin-related ICH is unclear and may vary from patient to patient.[9]
- Avoidance of oral anticoagulation (OAC) for 4-8 weeks, in patients without mechanical heart valves, might decrease the risk of ICH recurrence
Resumption of statins
There is insufficient data to recommend restrictions on use of statin agents.[10]
Prevention of complications
The preventive measures which may help prevent complications of intracerebral hemorrhage include:[1][6][7]
- Use of intermittent pneumatic compression begun as early as the day of hospital admission
- Prophylactic anticonvulsant medication has not been demonstrated to be beneficial. However, in a case of clinical seizures or electrographic seizures in patients with a change in mental status should be treated with antisezure drugs to prevent recurrence
- Proper positioning of patient, and the use of thick feed with the help of nasogastric tube for feeding to prevent aspiration pneumonia in patients with cranial nerve palsies affecting pharyngeal motility and gag reflex
- Pressure ulcers may be prevented by use of air mattress and regular change in position of patient
References
- ↑ 1.0 1.1 1.2 1.3 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage http://stroke.ahajournals.org/content/early/2015/05/28/STR.0000000000000069 Accessed on November 10, 2016
- ↑ 2.0 2.1 2014 AHA/ASA Guidelines for the Primary Prevention of Stroke http://stroke.ahajournals.org/content/early/2014/10/28/STR.00000000000000467 Accessed on November 17, 2016
- ↑ 3.0 3.1 Direct Oral Anticoagulants (DOACs) in the Laboratory: 2015 Review http://dx.doi.org/10.1016/j.thromres.2015.05.001 Accessed on December 1, 2016
- ↑ 4.0 4.1 Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S; et al. (2011). "Apixaban in patients with atrial fibrillation". N Engl J Med. 364 (9): 806–17. doi:10.1056/NEJMoa1007432. PMID 21309657. Review in: Evid Based Med. 2011 Dec;16(6):187-8 Review in: Ann Intern Med. 2011 Apr 19;154(8):JC4-3
- ↑ 5.0 5.1 Eckman, Mark H., et al. "Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis." Stroke 34.7 (2003): 1710-1716.
- ↑ 6.0 6.1
- ↑ 7.0 7.1 Armstrong JR, Mosher BD (2011). "Aspiration pneumonia after stroke: intervention and prevention". Neurohospitalist. 1 (2): 85–93. doi:10.1177/1941875210395775. PMC 3726080. PMID 23983842.
- ↑ Leiria TL, Lopes RD, Williams JB, Katz JN, Kalil RA, Alexander JH (2011). "Antithrombotic therapies in patients with prosthetic heart valves: guidelines translated for the clinician". J Thromb Thrombolysis. 31 (4): 514–22. doi:10.1007/s11239-011-0574-9. PMC 3699194. PMID 21327503.
- ↑ Majeed A, Kim YK, Roberts RS, Holmström M, Schulman S (2010). "Optimal timing of resumption of warfarin after intracranial hemorrhage". Stroke. 41 (12): 2860–6. doi:10.1161/STROKEAHA.110.593087. PMID 21030703.
- ↑ Amarenco P, Bogousslavsky J, Callahan A, Goldstein LB, Hennerici M, Rudolph AE; et al. (2006). "High-dose atorvastatin after stroke or transient ischemic attack". N Engl J Med. 355 (6): 549–59. doi:10.1056/NEJMoa061894. PMID 16899775. Review in: ACP J Club. 2007 Jan-Feb;146(1):7