national-clinical-guidelines-for-stroke-fourth-edition

National clinical guideline for stroke
incident stroke (equivalent to about 1/100,000 population/year), the number may impose
some stress on neurosurgical services.
4.7 Immediate management of intracerebral haemorrhage
About 10% of all patients presenting with acute stroke have primary intracerebral
haemorrhage (PIH) as the cause. There is no antidote to the direct thrombin or factor Xa
inhibitors currently available so patients admitted with PIH when taking these drugs
need to be managed with supportive care.
4.7.1 Recommendations
A Clotting levels in people with a primary intracerebral haemorrhage who were
receiving anticoagulation with a vitamin K antagonist (eg warfarin) before their
stroke, should be returned to a normal international normalised ratio (INR) as soon
as possible, by reversing the effects of the warfarin/vitamin K antagonist treatment
using a combination of prothrombin complex concentrate and intravenous vitamin
K.
B People with an intracerebral haemorrhage should be monitored by specialists in
neurosurgical or stroke care for deterioration in consciousness level and referred
immediately for brain imaging when necessary.
C People should be considered for surgical intervention following primary intracranial
haemorrhage if they have hydrocephalus.
D People with any of the following rarely require surgical intervention and should
receive medical treatment initially:
● small deep haemorrhages
● lobar haemorrhage without either hydrocephalus or rapid neurological
deterioration
4.7.2 Sources
● a large haemorrhage and significant prior comorbidities before the stroke
● supratentorial haemorrhage with a Glasgow Coma Score of less than 8 unless this is
because of hydrocephalus.
A–D National Institute for Health and Clinical Excellence 2008b
4.8 Immediate diagnosis and management of subarachnoid haemorrhage
Subarachnoid haemorrhage accounts for approximately 5% of all acute strokes. 10–15%
of those affected die before reaching hospital and about 25% die within 24 hours of the
bleed (ictus). Overall survival is about 50%, half of whom will have residual disability
and most of whom will experience long-term symptoms, especially fatigue and cognitive
symptoms. However, amongst patients admitted to a neurosurgical unit with a confirmed
aneurysm, 85% will survive (Society of British Neurosurgeons 2006). Case fatality and
unfavourable outcome rates rise with age and are higher in the over 65 age group
(Society of British Neurosurgeons 2006). Rebleeding is the most frequent cause of death
after the initial presentation. Thus diagnosis, referral to a tertiary centre and treatment to
48 © Royal College of Physicians 2012