The document provides information on intracerebral hemorrhage (ICH) from the 2022 American Heart Association/American Stroke Association guidelines. Some key points include:
- ICH mortality is 30-40% and incidence is higher among Black and Mexican American people compared to whites. About 79,000 people experience ICH annually in the US.
- Mechanisms of ICH injury include hematoma expansion, increased intracranial pressure, hydrocephalus, herniation in the first 6 hours (primary injury) and cerebral edema, inflammation, toxicity from blood products after 6 hours (secondary injury).
- Etiology of ICH determines location, with arteriolosclerosis potentially causing both
"Empowering Recovery: Hemorrhagic Stroke Management with Dr. Ganesh"
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Intracerebral hemorhage Diagnosis and managementRamesh Babu
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
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5. Enlist some common indications for obtaining an ECG
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3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
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5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. PopulationHealth Implications
Early-term
I
CHMortality
is30-4
0
%
I
ncidence of I
CH by Race
• ≈1.6-fold greater among Black
than White people
• ≈1.6-fold greater among Mexican
American than non-Hispanic
White people
I
schemicStrokes,
690K
Annual I
schemic Stroke&I
CH I
ncidence
SAH,
1
6
K I
CH,79K
Total Strokes:
~795K
Abbreviations:ICH indicates intracerebral hemorrhage; and SAH, subarachnoid hemorrhage.
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
3. Mechanismsof I
CH I
njury
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Hematom
a
Expansion
↑
ICP
Hydrocephalus
Herniation
0- 6hours
Primary I
njury
>
6hours
SecondaryI
njury
Cerebral Edema
Inflammation
T
oxicityfromBloodProducts
GeneralPrinciple:Acute ICH management targets these mechanisms.
Abbreviations:ICHindicates intracerebral hemorrhage; and ICP, intracranial pressure.
4. I
CH Etiology Determines HemorrhageLocation
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Deep/
PosteriorFossa
I
CHEtiologies
Arteriolosclerosis
• Penetratingarteriolelipohyalinosis
dueto HTN,DM, Age
Macrovascular
• AVM
• Aneurysm
• Dural AVF
• CavernousMalformation/Cavernoma
• Cerebral Venous Thrombosis
LobarI
CHEtiologies
Cerebral Amyloid Angiopathy
• Amyloid deposition in vessel
walls
Arteriolosclerosis
Macrovascular
DiagnosticReasoning:CAA typically causesonly lobar (or superficial cerebellar)
hemorrhages. Arteriolosclerosismay cause both deep and lobar hemorrhages.
Coexistentpathology is possible.
Abbreviations:AVF indicates arteriovenous fistula; AVM, arteriovenous malformation; CAA, cerebral amyloid angiopathy; DM, diabetes mellitus; HTN, hypertension; and ICH, intracerebral hemorrhage.
5. Diagnosis &Assessment |Work-Up for Acute ICH Course
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Timeof
symptomonset
• Headache
• Focalneurologic
deficits
• Seizures
• Decreasedlevel
of consciousness
• Ischemic Stroke
• PriorICH
• Hypertension
• Hyperlipidemia
• Diabetesmellitus
• Metabolic
syndrome
• Imagingbiomarkers
o Cerebral
microbleeds
• Antithrombotics:
• Anticoagulants,
thrombolytics,
antiplatelet agents,
NSAIDS
• Vasoconstrictive
Agents:
o Triptans,SSRIs,
decongestants,
stimulants,
phentermine,
sympathomimetic
drugs
• Antihypertensives:
• Estrogen-containing
oral contraceptives
Associatedwith
(but not specific
for)amyloid
angiopathy
• Smoking
• Alcohol use
• Marijuana
• Sympathomimetic
drugs
• Amphetamines,
methamphetamin
es,cocaine
May beassociated
withcoagulopathy
History
Time Symptoms
Vascular
RiskFactors
Medications Cognitive
Impairment
orDem
entia
SubstanceUse Liverdisease,
Uremia,
Malignancy
and
Hematologic
disorders
Abbreviations:ICH indicates intracerebral hemorrhage; NSAIDS, non-steroidal anti-
inflammatory drugs, and SSRI,selective serotonin reuptake inhibitors.
6. Diagnosis&Assessment |Work-Up in AcuteICH
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
PhysicalExamination
• Airw
ay,Breathing&Circulation
• Vitalsigns
• General:Focusedonthehead,
heart,lungs,abdomen,and
extremities
• FocusedNeurologicalExam
(NIHSS,GCS)
Serum
• CBC
• BUNandCreatinine
• LFTs
• Glucose
• Inflammatory markers
• (ESRand/orCRP)
• PT(withINR)
• aPTT
• SpecifictestsforDOACs
Urine
• Urinetoxicologyscreen
• Pregnancytest
Cardiac-specific
• T
roponin
• ECG
Abbreviations:aPTTindicates activated partial thromboplastin time; BUN, blood urea nitrogen; CRP, C-reactive protein; DOAC, direct oral anticoagulant; ECG, electrocardiogram; ESR,erythrocytesedimentation
rate; GCS, Glasgow coma scale; ICH, intracerebral hemorrhage; INR, international normalized ratio; LFTs, liver function tests; NIHSS, National Institutes of Health Stroke Scale; and PT,prothrombin time.
7. Diagnosis&Assessment |Work-Up in AcuteICH
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
I
ndicatorsof I
ncreasedMorbidity &Mortality:
• Thrombocytopenia
• AcuteKidneyI
njury
• Hyperglycemia
• Elevatedtroponin
I
ndicatorsof I
ncreasedHE:
• Anemia •
• Anticoagulant-related
hemorrhages
Identificationofaspot
signonCTAor
contrast-enhancedOR
certainimaging
featuresonNCCTsuch
asheterogeneous
densitiesw
ithinthe
hematomaor
irregularitiesat its
margins.
Abbreviations: CTA indicates computed tomography angiography; HE, hematoma expansion; ICH, intracerebral hemorrhage; and NCCT, noncontrast computed tomography .
8. Diagnosis&Assessment |Neuroimaging to Diagnose ICH
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Timeofpresentationw
ith
stroke-likesymptoms:
Obtainrapid CTorMRIto
confirmthediagnosisof
spontaneousICH (1
)
SerialheadCTscanscanbeusefulfor:
• Patientswithspontaneousintracerebraland/or
intraventricularhemorrhagewithinthefirst24hours
aftersymptomonsettoevaluateforHE
• PatientswithlowGCS scoreorneurologicaldeterioration
toevaluate forHE,hydrocephalus,perihematomal
edema orherniation
(2a)
CTangiographyw
ithinthefirst
fewhoursofI
CHonset:
May bereasonableto detect
somestructural causesof
secondaryICH (2b)
UtilizingCTmarkersofHEtoidentifypatientsatrisk
forHEmaybereasonable.
Imagingfindings:
• Noncontrast CT
:
o Heterogeneousdensitieswithinthehematoma
o I
rregularitiesat thehematomamargins
• CTangiography/ Contrast enhancedCT
:
o Spotsign
(2b)
Beyondfirst24hours: Serial
imaging is generally guided by
clinical picture of the patient
Abbreviations:CT indicates computed tomography; HE, hematoma expansion; ICH, intracerebral hemorrhage; and MRI,magnetic resonance imaging.
9. Diagnosis &Assessment |Strategyto Determine ICHEtiology
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Abbreviations:CT indicates computed tomography; CTA, computed tomography angiogram; HTN, hypertension; ICH, intracerebral
hemorrhage; IVH, intraventricular hemorrhage; MRA,magnetic resonance angiogram; and MRI,magnetic resonance imaging.
ForPatientsWith… UtilizeThisDiagnosticStrategy…
Deep/PosteriorFossaI
CH
• Age <
45
• Age 45-70 yrs, NOHTN
LobarI
CH
• Age <70yrs
-OR-
CTAngiogram
/VenogramRecom
m
ended(1
)
MR
I+MRAngiogramReasonable(2a)
Cerebral AngiogramReasonable(2a)
- AND-
- AND-
CTA/MRAsuggestiveofmacrovascular
I
CHetiology (anyage)
SpontaneousI
VHw
ithNOparenchymal
hemorrhage(anyage)
-OR- CerebralAngiogramRecom
m
ended (1
)
10. Medical and NeurointensiveTreatment forI
CH
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Acute Blood PressureLowering in Spontaneous ICH
To improvefunctional outcomes.
Medicationtitrationtoensurecontinuoussmooth&sustainedcontrolofBP
,
avoidingpeaksandlargevariabilityinSBP
,can bebeneficial.(2a)
Initiatingtxwithin2hrsofICHonsetandreachingtargetwithin1-hrcanbe
beneficialtoreducetheriskofHE. (2a)
InICHofmildto moderateseveritypresentingwithSBPbetween150and220
mmHg,acuteloweringofSBPto a targetof140mmHgwiththegoalofmaintaining
in therangeof130to150mmHgissafeandmaybereasonable.(2b)
IfpresentingwithlargeorsevereICHorthoserequiringsurgicaldecompression,the
safetyandefficacyofintensiveBPloweringarenotwellestablished.(2b)
IfICHismild tomoderateseveritypresentingwithSBP>150mmHg,acutelowering
ofSBPto hrs.<130mmHgispotentiallyharmful.(3:Harm)
Abbreviations:HEindicates hematoma expansion; ICH, intracerebral hemorrhage; mmHg, millimeters of mercury; SBP, systolic blood pressure;and tx, treatment.
11. Hemostasis&Coagulopathy
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Management of Anticoagulant-Related Hemorrhage
Patients with I
CH onanticoagulation
Discontinue anticoagulationtherapyimmediately. Rapidreversal shouldbeperformedas soonaspossible (1)
VI
TAMI
NKANTAGONI
STS DABIGATRAN FACTORXa-INHIBIT
ORS HEPARINS
I
NR 1
.3–1
.9 I
NR >
2.0
4-FPCC
1
0
-20IU
/
kg
(2b)
4-FPCC
25-50I
U/
kg
(1)
I
VVitaminK
(1)
History: Whenlast dose taken
Activatedcharcoal ifDOAC<2hrs(potentialefficacyupto8hrs)(2b)
Unfractionated
Heparin
LowMolecular
Weight Heparin
Protamine
(2a)
Protamine
(2b)
Is
I
darucizumab
available?
I
darucizum
ab
(2a)
PCCs oraPCC and/
or
renal replacem
ent therapy
(2b)
YES NO
Is
Andexanetalfa
available?
Andexanet
alfa
(2a)
4FactorPCCs oraPCC
(2b)
YES NO
Abbreviations:4-FPCC indicates four-factor prothrombin complex concentrate; aPCC, activated prothrombin complex concentrate; DOAC, direct oral anticoagulant;
ICH, intracerebral hemorrhage; and INR, international normalized ratio.
12. Hemostasis&Coagulopathy
Antiplatelet-Related Hemorrhagein Spontaneous ICH
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Ifthepatientisbeing
treatedwithaspirin,
platelettransfusionmight
beconsideredtoreduce
postoperativebleedingand
mortality.
(2b)
Ifthepatientisbeing
treatedwithASA,
platelettransfusions
arepotentially
harmful andshould
not beadministered.
(3:Harm)
Doesthe
patientrequire
emergent
neurosurgery?
Patients with SpontaneousI
CH
YES
NO
Abbreviations:ASA indicates aspirin; and ICH, intracerebral hemorrhage.
Ifthepatientisbeing
treatedwith antiplatelet
agents,theeffectivenessof
desmopressinwithor
without platelet
transfusionstoreducethe
expansionofthe
hematoma isuncertain.
(2b)
13. Hemostasis&Coagulopathy
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
General Hemostatic T
reatments
Synopsisof the Evidence
• HE occurs in up to a third of patients after ICH and is associated with poor outcome.
• Hemostatic therapy for the prevention of HE remains an attractive therapeutic target after ICH.
• Inpatients withspontaneous ICH(withor without the spot sign), the effectiveness of
recombinantfactor VIIato improvefunctional outcome isunclear. (2b)
• Inpatients with spontaneousICH (with orwithoutthespot sign, black hole sign, orblend sign),
theeffectivenessof TXAto improvefunctional outcomeisnotwell established. (2b)
• ICH expansion most commonly occurs very early after onset, and future studies need to target
earlier treatment
Abbreviations:CTA indicates computed tomography angiography; HE, hematoma expansion; and ICH, intracerebral hemorrhage.
14. General I
npatient Care
Considerations for Inpatient Care Setting
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
I
nitiationof Appropriate
LifeSustainingTherapies
(1)
Provisionof careina
specializedinpatient
unitwitha
m
ultidisciplinary
team (1)
I
f specializedunitisnot
available,thentransferto
centerswithfull rangeof high-
acuitycareandexpertise
(1)
I
npatientswithspontaneous
I
CHandclinical hydrocephalus,
transfertocenterswith
Neurosurgicalcapabilitiesfor
hydrocephalus m
anagem
ent
(e.g.EVDplacem
ent and
monitoring)
(1)
Abbreviations:EVD indicates external ventricular drain; and ICH, intracerebral hemorrhage.
15. I
npatient CareChecklist
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
I
n Non-Ambulatory SpontaneousI
CH…
Prevention&
Management
of Acute
Medical
Complications
• Use of standardizedprotocols/order sets is recommended to reduce disability and mortality. (1)
• Formal dysphagia screening protocol should be implemented prior to initiation of oralintake to reduce
disability and the risk of pneumonia. (1)
• Continuous cardiac monitoring for first 24to 72hrs is reasonable tomonitor for cardiac arrhythmias &
new cardiac ischemia. (2a)
• Laboratoryand radiographic testing for infection on admission and throughout the hospital course is
reasonable to improve outcomes. (2a)
Prioritiesfor
NursingCare
• Frequent neurological assessments (including GCS) should be performed by EDnurses in the early
hyperacute phase of careto assess change in status, neurological examination, or LOC. (1)
• Frequent neuro assessments in ICU/Strokeunit upare reasonable up to 72hrs from admission to detect
early ND.(2a)
• Nursing staff with specialized stroke competency education can be effective in improving outcome &
mortality. (2a)
Abbreviations:DVT indicates deep vein thrombosis; ED, emergency department; HE, hematoma expansion; hrs, hours; GCS, Glasgow Coma Scale; ICH, intracerebral hemorrhage; ICU, intensive care unit; LMWH, low molecular
weight heparin; LOC, level of consciousness; ND, neurological deterioration; PE,pulmonary embolism; Tx, treatment; UFH, unfractionated heparin; and VTE,venous thromboembolism.
16. Prophylaxis
… , intermittent pneumatic compression starting onthe day of diagnosis is recommended for VTE(DVT and PE)
prophylaxis. (1)
… low-dose UFHor LMWH can be useful to reduce risk of PE(2a)
… temporaryuse of retrievable filter asbridge until anticoagulationinitiated. (2a)
… low-dose UFHor LMWH prophylaxis at 24to 48hrs from ICH onset may be reasonable tooptimize the
benefits of preventing thrombosis relative to the risk of HE. 2b)
… graduatedcompression stockings of knee-high or thigh-high length alone arenot beneficial for VTE
prophylaxis. (3:No Benefit)
Treatment
… and proximal DVTwhoarenot yet candidatesfor anticoagulation, temporary useof retrievable filter is
reasonable as a bridge until anticoagulation initiated. (2a)
… and proximal DVTor PE,delaying treatment withUFHor LMWH 1to2 weeks after onset of ICHmight be
considered. (2b)
I
npatient CareChecklist
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
I
n Non-Ambulatory SpontaneousI
CH…
Thromboprophylaxis&TxofThrombosis
Abbreviations:DVT indicates deep vein thrombosis; HE, hematoma expansion; hrs, hours; ICH, intracerebral hemorrhage; LMWH, low molecular weight heparin;
PE, pulmonary embolism; Tx, treatment; UFH, unfractionated heparin; and VTE,venous thromboembolism.
17. General I
npatient Care
Glucose and TemperatureManagement
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Glucose
Management
Monitor serumglucoseto
reduceboth
hyper/hypoglycem
ia. (1
)
Treatserumglucose
<
40-60m
g/dL
toreducem
ortality. (1
)
NICE-SUGARtrialfindings:
• Incritically ill, targetof<
1
8
0mg/dLassociated with
lower mortality than target of 81-108mg/dL.
• Intensive glucose control (target 81-108mg/dL) more
likely to result insevere hypoglycemic events compared
to control.
Temperature
Management
I
npatientswithspontaneousI
CH,
pharm
acologically treatinganelevated
temperaturemaybereasonable to improve
functional outcom
es. (2b)
Theusefulnessof therapeutichypotherm
ia
(<35°C/95°F)todecreaseperi-I
CHedem
a is
unclear. (2b)
T
emperature abnormalities can occur in over 30%
of acute ICH patients, with fever associated with
higher clinical severity and worse outcomes.
Abbreviations:dL indicates deciliter; ICH, intracerebral hemorrhage; mg/dL, milligram per deciliter; mmol/L, millimoles per liter; and NICE-SUGAR,
Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose AlgorithmRegulation.
InpatientswithspontaneousICH,treating
m
oderatetoseverehyperglycem
ia (>
1
80–
200mg/dL,>
1
0
.
0
–
1
1
.
1mmol/L)isreasonabletoimprove
outcom
es. (2a)
18. Seizuresand AntiseizureDrugs
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
NewonsetseizuresinsICHarerelativelycommon(2.8-28%)andoccurwithinthefirst24hrsofhemorrhage
Confirmed clinical or
electrographicseizures
AdministerASD
(1)
sI
CH patientswithout suspicion of
seizure
Unexplainedabnormalorfluctuating
mental status,orsuspiciousofseizures,
cEEGisreasonableto
diagnoseelectrographicseizuresand
epileptiformdischarges
(24hoursorlonger)
(2a)
AvoidASD
(3:No Benefit)
Abbreviation:ASDindicates antiseizure drugs; cEEG, continuous electroencephalography; hrs, hours; and sICH,spontaneousintracerebral hemorrhage.
19. NeuroinvasiveMonitoring, Intracranial Pressure
&Edema Treatment
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
sICHorIVHand hydrocephaluswhichiscontributing to
decreasedlevelof consciousness:
Ventriculardrainageshould
beperformedtoreduce
mortality(1
)
Corticosteroidsshouldnot
beadministeredfor
treatmentofelevatedI
CP
(3:NoBenefit)
ICPmonitoringandtreatment
toreducemortalityand
improveoutcomes(2b)
Early prophylactic
hyperosmolartherapyfor
improvingoutcomesisnotw
ell
established(2b)
Bolushyperosmolartherapy
maybeconsideredfor
transientlyreducingI
CP(2b)
Abbreviation:ICP indicates intracranial pressure; IVH, intraventricular hemorrhage; and sICH, spontaneousintracerebral hemorrhage.
20. Surgical I
nterventions
Minimally InvasiveSurgical Evacuationof ICH
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation.
Intervention
Patient Selection
MISforICH
Supratentorial ICH,hematoma
volume >20-30mL,GCS5-12
MIS±hematoma
thrombolysistoimprove
mortalitycanbeuseful
(2a)
MIS±hematoma
thrombolysistoimprove
functionaloutcomeisof
uncertaineffectiveness
(2b)
ChoosingMISratherthan
craniotomytoimprove
functionaloutcomesmay
bereasonable
(2b)
I 0-
Abbreviations:GCS indicates Glasgow Coma Scale; ICH, intracerebral hemorrhage; and MIS, minimally invasive surgery.
21. Surgical I
nterventions
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 21
Minimally Invasive Surgical Evacuation of Intraventricular Hemorrhage
IVH
SurgicalManagem
ent
SpontaneousI
VH+
ObstructiveHydrocephalus
SpontaneousI
CH<30mL
GCS>
3
I
VHrequiringEVD
SpontaneousI
CH<
3
0mL
I
VHrequiringEVD
EVD EVD+thrombolytic
Neuroendoscopy
+EVD
+
/
-thrombolytic
Functional
Outcome
Benefit
(2b*)
Mortality
Reduction
(I)
Functional
Outcome
Benefit
(2b†)
Functional
Outcome
Benefit
(2b†)
Reduced
Permanent
Shunt
Dependence
(2b†)
Note:*Not well established. †Uncertain
Abbreviations:EVD indicates external ventricular drain; GCS, Glasgowcoma scale; ICH, Intracerebral hemorrhage, and IVH, intraventricular hemorrhage.
Mortality
Reduction
(2a)
22. Surgical I
nterventions
Craniotomy forSupratentorial Hemorrhage
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 22
Craniotomyforhemorrhage
evacuationtoimprovemortality
or functional outcomesisof
uncertainusefulness
(2b)
Craniotomyforhemorrhage
evacuationmaybeconsideredas
a life-savingmeasureinpatients
whoaredeteriorating
(2b)
SupratentorialICHof moderateorgreaterseverity*
Note: *>10 cc with asignificant neurologic
deficit
Abbreviations:ICH indicates intracerebral hemorrhage.
23. Surgical I
nterventions
Craniotomy for Posterior Fossa Hemorrhage
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 23
I
mmediatesurgicalremovalof
hemorrhage±EVDisrecomm
endedto
reducemortality(1
)
CerebellarI
CH
I
fanyof thefollow
ingpresent
Neurologic
deterioration
Brainstem
compression
Obstructive
hydrocephalus
I
CHvolume≥1
5cc
Abbreviations:EVD indicates external ventricular drain; and ICH, intracerebral hemorrhage.
24. Surgical I
nterventions
Craniectomy for ICH
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 24
Abbreviation:ICH indicates intracerebral hemorrhage; and ICP, intracranial pressure.
Inpatients with supratentorial ICHwhoare ina coma, havelarge
hematomas withsignificant midline shift, or have elevated ICP
refractory to medical management:
….decompressivecraniectomy
withorwithout hematoma
evacuationmaybeconsidered
toreducemortality.(2b)
….effectivenessofdecompressive
craniectomy withorwithout
hematoma evacuationto
improvefunctionaloutcomesis
uncertain.(2b)
25. OutcomePredictionand Goalsof Care
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 25
I
npatientswithspontaneousI
CH
… a baseline
severity score might be
reasonable to provide
a generalfram
eworkfor
com
m
unication with
thepatientandtheir
caregivers.(2b)
… a baseline
severity score should
NOTbeusedasthesole
basisforforecasting
individual prognosis or
limiting life-sustaining
treatment. (3:Harm)
Abbreviations:ICH indicates intracerebral hemorrhage.
… administering a
baseline measure of
overall hem
orrhage
severityis recommended
aspart of theinitial
evaluation to provide an
overall measure of clinical
severity. (1)
Examples:
• ICH-score
• Max-ICH
Clic
ktovie
wMeas
ur
e
sforE
valuating
Ove
r
allH
e
m
or
r
hageS
e
ve
r
ity
26. Decisions to Limit Life-SustainingTreatment
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 26
I
npatientswithspontaneousI
CH
Cannotfully
participateinmedical
decision-making
Shareddecision-making
between surrogates and
physicians is reasonable
(2a)
Nopre-existing
life-sustaining
therapylim
itations
Forpatientsw
ho
haveDNARStatus
Limiting other medical
and surgical interventions
unless explicitly specified
isassociated with
increased patient
mortality
(3: Harm)
Abbreviations:DNAR indicates do not attempt resuscitation; and ICH, intracerebral hemorrhage.
Aggressive care including
postponement of new
DNARorders or
withdrawal of medical
support until at least the
2ndfull dayof
hospitalization is
reasonable(2b)
27. Rehabilitationand Recovery
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 27
I
npatientswithspontaneousI
CH
Multidisciplinary
rehabilitationwithregular
teammeetingsand
dischargeplanning is
recommended(1)
Mild-moderateICH
severity:Early supported
dischargeisbeneficial(1)
ModerateICHseverity:
Early rehabilitation
(24-48hoursafter
onset)maybe
considered(2b)
ICHwithout
depression,fluoxetine
therapy isnot effective
toenhancepoststroke
functional status.
(3:NoBenefit)
Very early and intense
mobilization<24hours:
potentiallyharmful
(3:Harm)
Abbreviations:ICH indicates intracerebral hemorrhage; and SSRIs,selective serotonin reuptake inhibitors.
28. Neurobehavioral Complications
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 28
I
npatientswithspontaneousI
CH
I
nthePost-acute
Period
Administration
ofdepression&
anxiety
screeningtools.
(1)
Administration
ofa cognitive
screeningtool.
(1)
Moderate to
Severe
Depression
Appropriateevidence-
basedtreatm
ents
including
psychotherapy&
pharmacotherapy.
(1)
Cognitive
I
mpairment
Referralfor
cognitive
therapy.
(2a)
Mightconsider
cholinesterase
inhibitorsor
memantine.
(2b)
Pre-existing or
NewMood
Disorders
Continuationor
initiationofSSRI
s
afterI
CH.
(2a)
Abbreviations:ICH, intracerebral hemorrhage; and SSRIs,selective serotonin reuptake inhibitors.
29. Secondary Prevention
Prognosticationof Future ICHRisk
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 29
2
Inpatients withspontaneous ICHin whomthe riskfor
recurrentICHmay facilitate prognostication ormanagement
decisions, it isreasonable to incorporate the following risk
factorsforI
CH recurrenceinto decision-making:
• Lobarlocation of theinitial I
CH;
• olderage;
• presence,number,and lobar location of microbleeds on
MRI;
• presence of disseminated cortical superficial siderosis
on MRI;
• poorly controlled hypertension;
• Asian orBlack race;
• and presenceof apolipoprotein Eε2 orε4 alleles. (2a)
1 3
MRIimaging characteristics:
1) Lobarlocation of initial ICH
2) Number and lobar location of microbleeds
3) Presence of cortical superficial siderosis
Abbreviation:ICHindicates intracerebral hemorrhage; and MRI, magnetic resonance imaging.
30. Secondary Prevention
Blood Pressure Management
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 30
Abbreviations:BPindicates blood pressure; HTN, hypertension; ICH, intracerebral hemorrhage; and mmHg, millimeters of mercury.
UncontrolledHTNaccountsfor
74%
of global population-
attributableriskforI
CH.
InpatientswithspontaneousICH,itisreasonabletolowerBPto130/80mmHgfor
long-termmanagementtopreventhemorrhagerecurrence(2a).
GuidingPrinciple
31. Secondary Prevention
Management of Antithrombotic Agentsand OtherMedications
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 31
H
IGH RI
SKof
thrombotic events
ex.Patient with
mechanical valve, LVAD
Earlyresumptionof
anticoagulationis
reasonable(2a)
NonvalvularAF
WEIGHRISKSvsBENEFIT
S
of restarting
anticoagulation
risk>benefit
Resumptionof
anticoagulation
maybereasonable(2b)
Considerinitiationof
anticoagulation7-8w
eeks
afterI
CH (2b)
Resumptionofantiplatelet
therapymaybe
reasonablebasedon
considerationofbenefit
andrisk(2b)
benefit<risk
LAAclosuremay
beconsidered
(2b)
Statins
RisksandbenefitsofstatinsonICH
outcomesandrecurrenceare
uncertain(2b)
NSAIDs
Regularlong-termuseofNSAI
Dsis
potentiallyharmful becauseofthe
increasedriskofI
CH(3:Harm)
Abbreviations:AFindicates atrial fibrillation; ICH, intracerebral hemorrhage; LAA, left atrial appendage; LVAD, left ventricular assist device; and NSAID, non-steroidal anti-inflammatory drugs.
32. Secondary Prevention
Lifestyle Modifications / Patient and CaregiverEducation
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 32
LIFESTYLEMODIFICATIO
NS
• Blood pressure control
• Avoiding heavy alcohol use
• Supervised training and counseling
PATI
ENT&CAREGI
VEREDUCATI
ON
• Psychosocial education
• Caregiversupport &training
33. IncorporateavailableMRIinformationon
cerebralmicrobleedburdenorcortical
superficial siderosis to inform decision-
makingforprimaryprevention(2b)
Primary I
CH Prevention inI
ndividualswith
High-RiskI
maging Findings
Cerebral microbleed Corticalsuperficial siderosis
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 33
Abbreviation:ICHindicates intracerebral hemorrhage.
34. Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 34
35. Acknowledgments
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 35
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman
in developing this translational learning product in support of the 2022 Guideline for
the Management of Patients With Spontaneous Intracerebral Hemorrhage: A
Guideline From the American Heart Association/ American Stroke Association
MatthewGusler,DO
NycoleJoseph,MD
ShuoQian,MD
KaranRavishankar,MD
MeghanaSrinivas,MD
MichaelTeitcher,MD
RobinUlep,MD
TheAmericanHeartAssociationrequeststhiselectronicslidedeckbecitedasfollows:
Gusler,M.,Joseph,N.,Quin,S.,Ravishankar,K.,Srinivas,M.,Teitcher,M.,Ulep,R.,Bezanson,J.L.,&Antman,E.M.
(2022). ClinicalUpdate;Adaptedfrom:2022GuidelinefortheManagementofPatients
WithSpontaneousIntracerebralHemorrhage:AGuidelineFromtheAmericanHeartAssociation/
AmericanStrokeAssociation[PowerPointslides].Retrievedfromhttps://professional.heart.org/en/science-news.
36. Appendix
Greenberg, S. M. 2022 AHA/ASA . Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage. Circulation. 36
Measures for evaluating overall hemorrhageseverity
Gregório T
,Pipa S, Cavaleiro P
, Atanásio G, Albuquerque I,Castro Chaves P
, Azevedo L. Original intracerebral hemorrhage
score for the prediction of short-term mortality incerebral hemorrhage: systematic review and meta-analysis. Crit Care Med.
2019;47:857–864.doi:10.1097/CCM.0000000000003744
Gregório T
,Pipa S, Cavaleiro P
, Atanásio G, Albuquerque I,Chaves PC, Azevedo L. Assessmentand comparison of the four
most extensively validatedprognostic scales for intracerebral hemorrhage: systematic review with meta-analysis. Neurocrit
Care. 2019;30:449–466.doi:10.1007/s12028-018-0633-6
Gregório T
,Pipa S, Cavaleiro P
, Atanásio G, Albuquerque I,Chaves PC, Azevedo L. Prognostic models for intracerebral
hemorrhage: systematic review and meta-analysis. BMC Med Res Methodol. 2018;18:145.doi: 10.1186/s12874-018-0613-8
Sembill JA, Gerner ST
,Volbers B,Bobinger T
,Lücking H,Kloska SP
,SchwabS, Huttner HB, Kuramatsu JB.Severity assessment
in maximally treated ICHpatients: the max-ICHscore. Neurology. 2017;89:423–431.doi: 10.1212/WNL.0000000000004174
Sembill JA, Castello JP
,Sprügel MI,Gerner ST
,Hoelter P
, Lücking H,Doerfler A, Schwab S,Huttner HB,Biffi A, et al. Multicenter
validationof the max-ICHscore in intracerebral hemorrhage. Ann Neurol. 2021;89:474–484.doi: 10.1002/ana.25969
Abbreviation:ICHindicates intracerebral hemorrhage.
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