Interpretation of the American Stroke Association Code ICH Expert Consensus Statement

doi:10.3969/j.issn.1673-5765.2024.06.012

Abstract

Abstract: The acute treatment of intracerebral hemorrhage (ICH) has long been a focus of attention. In 2024, ICH experts from multiple countries have proposed the early comprehensive management plan for acute spontaneous ICH, termed Code ICH, which was published in Stroke. The expert consensus provided detailed recommendations on the brain injury mechanism of acute phase, early integrated diagnosis and treatment strategies, and future research directions for ICH. This paper will interpret and analyze the expert consensus.

Key words: Intracerebral hemorrhage; Expert consensus; Hematoma expansion; Treatment; Management

摘要： 脑出血（intracerebral hemorrhage，ICH）的急性期治疗一直是备受关注的话题。2024年来自多个国家的ICH专家在Stroke杂志上发布了急性自发性ICH的早期综合管理方案——Code ICH。该专家共识围绕ICH的急性期脑损伤机制、早期一体化诊治方案及未来研究方向提出了详细的推荐意见。本文将对该专家共识进行解读。

关键词: 脑出血; 专家共识; 血肿扩大; 治疗; 管理

CLC Number:

LI Zhiming, WANG Zijie, LI Qi. Interpretation of the American Stroke Association Code ICH Expert Consensus Statement[J]. Chinese Journal of Stroke, 2024, 19(6): 714-724.

李之明, 王孜杰, 李琦. 2024美国卒中学会Code ICH脑出血早期一体化诊治方案专家共识解读[J]. 中国卒中杂志, 2024, 19(6): 714-724.

References

[1] GBD 2019 Stroke Collaborators. Global，regional，and national burden of stroke and its risk factors，1990—2019：a systematic analysis for the global burden of disease study 2019[J]. Lancet Neurol，2021，20（10）：795-820.
[2] VAN ASCH C J，LUITSE M J，RINKEL G J，et al. Incidence，case fatality，and functional outcome of intracerebral haemorrhage over time，according to age，sex，and ethnic origin：a systematic review and meta-analysis[J]. Lancet Neurol，2010，9（2）：167-176.
[3] DEMEL S L，STANTON R，AZIZ Y N，et al. Reflection on the past，present，and future of thrombolytic therapy for acute ischemic stroke[J/OL]. Neurology，2021，97（20 Suppl 2）：S170–S177[2024-01-01]. https://doi.org/10.1212/WNL.0000000000012806.
[4] LI Q，YAKHKIND A，ALEXANDROV A W，et al. Code ICH：a call to action[J]. Stroke，2024，55（2）：494-505.
[5] BROUWERS H B，CHANG Y C，FALCONE G J，et al. Predicting hematoma expansion after primary intracerebral hemorrhage[J]. JAMA Neurol，2014，71（2）：158-164.
[6] AL-SHAHI SALMAN R，FRANTZIAS J，LEE R J，et al. Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage：a systematic review and meta-analysis of individual patient data[J]. Lancet Neurol，2018，17（10）：885-894.
[7] WANG X，ARIMA H，AL-SHAHI SALMAN R，et al. Clinical prediction algorithm（BRAIN）to determine risk of hematoma growth in acute intracerebral hemorrhage[J]. Stroke，2015，46（2）：376-381.
[8] YOGENDRAKUMAR V，MOORES M，SIKORA L，et al. Evaluating hematoma expansion scores in acute spontaneous intracerebral hemorrhage：a systematic scoping review[J]. Stroke，2020，51（4）：1305-1308.
[9] BOULOUIS G，MOROTTI A，BROUWERS H B，et al. Association between hypodensities detected by computed tomography and hematoma expansion in patients with intracerebral hemorrhage[J]. JAMA Neurol，2016，73（8）：961-968.
[10] OVESEN C，JAKOBSEN J C，GLUUD C，et al. Tranexamic acid for prevention of hematoma expansion in intracerebral hemorrhage patients with or without spot sign[J]. Stroke，2021，52（8）：2629-2636.
[11] GLADSTONE D J，AVIV R I，DEMCHUK A M，et al. Effect of recombinant activated coagulation factor Ⅶ on hemorrhage expansion among patients with spot sign-positive acute intracerebral hemorrhage：the SPOTLIGHT and STOP-IT randomized clinical trials[J]. JAMA Neurol，2019，76（12）：1493-1501.
[12] MOROTTI A，ARBA F，BOULOUIS G，et al. Noncontrast CT markers of intracerebral hemorrhage expansion and poor outcome：a meta-analysis[J]. Neurology，2020，95（14）：632-643.
[13] SPORNS P B，SCHWAKE M，KEMMLING A，et al. Comparison of spot sign，blend sign and black hole sign for outcome prediction in patients with intracerebral hemorrhage[J]. J Stroke，2017，19（3）：333-339.
[14] KEEP R F，HUA Y，XI G H. Intracerebral haemorrhage：mechanisms of injury and therapeutic targets[J]. Lancet Neurol，2012，11（8）：720-731.
[15] IRONSIDE N，CHEN C J，DING D，et al. Perihematomal edema after spontaneous intracerebral hemorrhage[J]. Stroke，2019，50（6）：1626-1633.
[16] WANG J. Preclinical and clinical research on inflammation after intracerebral hemorrhage[J]. Prog Neurobiol，2010，92（4）：463-477.
[17] CHEN Y H，CHEN S P，CHANG J B，et al. Perihematomal edema after intracerebral hemorrhage：an update on pathogenesis，risk factors，and therapeutic advances[J/OL]. Front Immunol，2021，12：740632[2024-01-01]. https://doi.org/10.3389/fimmu.2021.740632.
[18] HUANG X Y，WANG D，MA Y Q，et al. Perihematomal edema-based CT-radiomics model to predict functional outcome in patients with intracerebral hemorrhage[J]. Diagn Interv Imaging，2023，104（9）：391-400.
[19] SUN W P，PAN W Q，KRANZ P G，et al. Predictors of late neurological deterioration after spontaneous intracerebral hemorrhage[J]. Neurocrit Care，2013，19（3）：299-305.
[20] ANDERSON C S，HEELEY E，HUANG Y N，et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage[J]. N Engl J Med，2013，368（25）：2355-2365.
[21] QURESHI A I，PALESCH Y Y，BARSAN W G，et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage[J]. N Engl J Med，2016，375（11）：1033-1043.
[22] TOYODA K，PALESCH Y Y，KOGA M，et al. Regional differences in the response to acute blood pressure lowering after cerebral hemorrhage[J/OL]. Neurology，2021，96（5）：e740-e751[2024-01-01]. https://doi.org/10.1212/WNL.0000000000011229.
[23] LEASURE A C，QURESHI A I，MURTHY S B，et al. Intensive blood pressure reduction and perihematomal edema expansion in deep intracerebral hemorrhage[J]. Stroke，2019，50（8）：2016-2022.
[24] LI Q，WARREN A D，QURESHI A I，et al. Ultra-early blood pressure reduction attenuates hematoma growth and improves outcome in intracerebral hemorrhage[J]. Ann Neurol，2020，88（2）：388-395.
[25] MOULLAALI T J，WANG X，MARTIN R H，et al. Blood pressure control and clinical outcomes in acute intracerebral haemorrhage：a preplanned pooled analysis of individual participant data[J]. Lancet Neurol，2019，18（9）：857-864.
[26] MA L，HU X，SONG L L，et al. The third intensive care bundle with blood pressure reduction in acute cerebral haemorrhage trial（INTERACT 3）：an international，stepped wedge cluster randomised controlled trial[J]. Lancet，2023，402（10395）：27-40.
[27] RODRIGUEZ-LUNA D，PANCORBO O，LLULL L，et al. Effects of achieving rapid，intensive，and sustained blood pressure reduction in intracerebral hemorrhage expansion and functional outcome[J/OL]. Neurology，2024，102（9）：e209244[2024-01-01]. https://doi.org/10.1212/WNL.0000000000209244.
[28] LI G，LIN Y P，YANG J，et al. Intensive ambulance-delivered blood-pressure reduction in hyperacute stroke[J]. N Engl J Med，2024，390（20）：1862-1872.
[29] MAYER S A. Recombinant activated factor Ⅶ for acute intracerebral hemorrhage[J]. Stroke，2007，38（2 Suppl）：763-767.
[30] MAYER S A，DAVIS S M，SKOLNICK B E，et al. Can a subset of intracerebral hemorrhage patients benefit from hemostatic therapy with recombinant activated factor Ⅶ?[J]. Stroke，2009，40（3）：833-840.
[31] WILLIAMS-JOHNSON J A，MCDONALD A H，STRACHAN G G，et al. Effects of tranexamic acid on death，vascular occlusive events，and blood transfusion in trauma patients with significant haemorrhage（CRASH-2）：a randomised，placebo-controlled trial[J]. West Indian Med J，2010，59（6）：612-624.
[32] CRASH-3 trial collaborators. Effects of tranexamic acid on death，disability，vascular occlusive events and other morbidities in patients with acute traumatic brain injury（CRASH-3）：a randomised，placebo-controlled trial[J]. Lancet，2019，394（10210）：1713-1723.
[33] SPRIGG N，FLAHERTY K，APPLETON J P，et al. Tranexamic acid for hyperacute primary intracerebral haemorrhage（TICH-2）：an international randomised，placebo-controlled，phase 3 superiority trial[J]. Lancet，2018，391（10135）：2107-2115.
[34] LIU J Y，NIE X M，GU H Q，et al. Tranexamic acid for acute intracerebral haemorrhage growth based on imaging assessment（TRAIGE）：a multicentre，randomised，placebo-controlled trial[J]. Stroke Vasc Neurol，2021，6（2）：160-169.
[35] MERETOJA A，YASSI N，WU T Y，et al. Tranexamic acid in patients with intracerebral haemorrhage（STOP-AUST）：a multicentre，randomised，placebo-controlled，phase 2 trial[J]. Lancet Neurol，2020，19（12）：980-987.
[36] NIE X M，LIU J Y，LIU D C，et al. Haemostatic therapy in spontaneous intracerebral haemorrhage patients with high-risk of haematoma expansion by CT marker：a systematic review and meta-analysis of randomised trials[J]. Stroke Vasc Neurol，2021，6（2）：170-179.
[37] STEINER T，WEITZ J I，VELTKAMP R. Anticoagulant-associated intracranial hemorrhage in the era of reversal agents[J]. Stroke，2017，48（5）：1432-1437.
[38] STEINER T，POLI S，GRIEBE M，et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists（INCH）：a randomised trial[J]. Lancet Neurol，2016，15（6）：566-573.
[39] KURAMATSU J B，GERNER S T，SCHELLINGER P D，et al. Anticoagulant reversal，blood pressure levels，and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage[J]. JAMA，2015，313（8）：824-836.
[40] GOLDSTEIN J N，THOMAS S H，FRONTIERO V，et al. Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related intracerebral hemorrhage[J]. Stroke，2006，37（1）：151-155.
[41] HUTTNER H B，SCHELLINGER P D，HARTMANN M，et al. Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy：comparison of acute treatment strategies using vitamin K，fresh frozen plasma，and prothrombin complex concentrates[J]. Stroke，2006，37（6）：1465-1470.
[42] BISWAS S，BAHAR Y，BAHAR A R，et al. Present knowledge on direct oral anticoagulant and novel oral anti coagulants and their specific antidotes：a comprehensive review article[J/OL]. Curr Probl Cardiol，2023，48（2）：101483[2024-01-01]. https://doi.org/10.1016/j.cpcardiol.2022.101483.
[43] POLLACK C V，Jr，REILLY P A，VAN RYN J，et al. Idarucizumab for dabigatran reversal—full cohort analysis[J]. N Engl J Med，2017，377（5）：431-441.
[44] DEMCHUK A M，YUE P，ZOTOVA E，et al. Hemostatic efficacy and anti-FⅩa（factor Ⅹa）reversal with andexanet alfa in intracranial hemorrhage：ANNEXA-4 substudy[J]. Stroke，2021，52（6）：2096-2105.
[45] GHADIMI K，DOMBROWSKI K E，LEVY J H，et al. Andexanet alfa for the reversal of factor Ⅹa inhibitor related anticoagulation[J]. Expert Rev Hematol，2016，9（2）：115-122.
[46] SIEGAL D M，CURNUTTE J T，CONNOLLY S J，et al. Andexanet alfa for the reversal of factor Ⅹa inhibitor activity[J]. N Engl J Med，2015，373（25）：2413-2424.
[47] CONNOLLY S J，CROWTHER M，EIKELBOOM J W，et al. Full study report of andexanet alfa for bleeding associated with factor Ⅹa inhibitors[J]. N Engl J Med，2019，380（14）：1326-1335.
[48] GERNER S T，KURAMATSU J B，SEMBILL J A，et al. Association of prothrombin complex concentrate administration and hematoma enlargement in non-vitamin K antagonist oral anticoagulant-related intracerebral hemorrhage[J]. Ann Neurol，2018，83（1）：186-196.
[49] GÓMEZ-OUTES A，ALCUBILLA P，CALVO-ROJAS G，et al. Meta-analysis of reversal agents for severe bleeding associated with direct oral anticoagulants[J]. J Am Coll Cardiol，2021，77（24）：2987-3001.
[50] COSTA O S，CONNOLLY S J，SHARMA M，et al. Andexanet alfa versus four-factor prothrombin complex concentrate for the reversal of apixaban-or rivaroxaban-associated intracranial hemorrhage：a propensity score-overlap weighted analysis[J/OL]. Critical Care，2022，26（1）：180[2024-01-01]. https://doi.org/10.1186/s13054-022-04043-8.
[51] HUTTNER H B，GERNER S T，KURAMATSU J B，et al. Hematoma expansion and clinical outcomes in patients with factor-Ⅹa inhibitor-related atraumatic intracerebral hemorrhage treated within the ANNEXA-4 trial versus real-world usual care[J]. Stroke，2022，53（2）：532-543.
[52] CONNOLLY S J，SHARMA M，COHEN A T，et al. Andexanet for factor Ⅹa inhibitor-associated acute intracerebral hemorrhage[J]. N Engl J Med，2024，390（19）：1745-1755.
[53] SHETH K N，SOLOMON N，ALHANTI B，et al. Time to anticoagulation reversal and outcomes after intracerebral hemorrhage[J]. JAMA Neurol，2024，81（4）：363-372.
[54] GROSS B A，JANKOWITZ B T，FRIEDLANDER R M. Cerebral intraparenchymal hemorrhage：a review[J]. JAMA，2019，321（13）：1295-1303.
[55] MENDELOW A D，GREGSON B A，FERNANDES H M，et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the international surgical trial in intracerebral haemorrhage（STICH）：a randomised trial[J]. Lancet，2005，365（9457）：387-397.
[56] MENDELOW A D，GREGSON B A，ROWAN E N，et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas（STICH Ⅱ）：a randomised trial[J]. Lancet，2013，382（9890）：397-408.
[57] ZHOU X Y，CHEN J J，LI Q，et al. Minimally invasive surgery for spontaneous supratentorial intracerebral hemorrhage：a meta-analysis of randomized controlled trials[J]. Stroke，2012，43（11）：2923-2930.
[58] SONDAG L，SCHREUDER F H B M，BOOGAARTS H D，et al. Neurosurgical intervention for supratentorial intracerebral hemorrhage[J]. Ann Neurol，2020，88（2）：239-250.
[59] MORGENSTERN L B，FRANKOWSKI R F，SHEDDEN P，et al. Surgical treatment for intracerebral hemorrhage（STICH）：a single-center，randomized clinical trial[J]. Neurology，1998，51（5）：1359-1363.
[60] HANLEY D F，THOMPSON R E，ROSENBLUM M，et al. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation（MISTIE Ⅲ）：a randomised，controlled，open-label，blinded endpoint phase 3 trial[J]. Lancet，2019，393（10175）：1021-1032.
[61] PRADILLA G，RATCLIFF J J，HALL A J，et al. Trial of early minimally invasive removal of intracerebral hemorrhage[J]. N Engl J Med，2024，390（14）：1277-1289.
[62] GREGSON B A，BRODERICK J P，AUER L M，et al. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage[J]. Stroke，2012，43（6）：1496-1504.
[63] KELLNER C P，SONG R，ALI M，et al. Time to evacuation and functional outcome after minimally invasive endoscopic intracerebral hemorrhage evacuation[J/OL]. Stroke，2021，52（9）：e536-e539[2024-01-01]. https://doi.org/10.1161/STROKEAHA.121.034392.
[64] LJUNGQVIST O，SCOTT M，FEARON K C. Enhanced recovery after surgery：a review[J]. JAMA Surg，2017，152（3）：292-298.
[65] EVANS L，RHODES A，ALHAZZANI W，et al. Surviving sepsis campaign：international guidelines for management of sepsis and septic shock 2021[J/OL]. Crit Care Med，2021，49（11）：e1063-e1143[2024-01-01]. https://doi.org/10.1097/CCM.0000000000005337.
[66] CARDO D，DENNEHY P H，HALVERSON P，et al. Moving toward elimination of healthcare-associated infections：a call to action[J]. Infect Control Hosp Epidemiol，2010，31（11）：1101-1105.
[67] MIDDLETON S，COUGHLAN K，MNATZAGANIAN G，et al. Mortality reduction for fever，hyperglycemia，and swallowing nurse-initiated stroke intervention：QASC trial（quality in acute stroke care）follow-up[J]. Stroke，2017，48（5）：1331-1336.
[68] PARRY-JONES A R，SAMMUT-POWELL C，PAROUTOGLOU K，et al. An intracerebral hemorrhage care bundle is associated with lower case fatality[J]. Ann Neurol，2019，86（4）：495-503.