Q. Which new drug is said to bring a revolution in management of Hemorraghic stroke ?
Recombinant Activated Factor VII (NovoSeven- Novo Nordisk) – this drug reduces the bleeding and hence is likely to reduce the growth of hematoma. Trials are on for this and is increasingly used in advance setups for Hemorraghic stroke. This drug is likely to bring a revolution in management of Hemorraghic stroke.
Q. When is CT Scan Better than MRI and MRI Better than CT in Diagnosis of Hemorraghic Stroke ?
- Show associated extension of stroke into the ventricles
- In patients who are unconscious, vomiting or on ventilator
MRI better than CT - Detecting Underlying Structural lesions
- Small Prior hemorrhages
Important CLASS I and CLASS II Recomedations of the Guidelines
The guidelines' class I recommendations (based on evidence for and/or general agreement that the intervention is useful and effective) specify always treating seizures in patients with hemorrhagic stroke with appropriate antiepileptic therapy and treating fever.
The document's class II recommendations (for which evidence of the intervention's usefulness/efficacy is less well established and is based on conflicting evidence and/or a divergence of opinion) include
¬ using a balanced and graded approach to treating elevated cranial pressure,
¬ starting with head-of-the-bed elevation,
¬ analgesia,
¬ and sedation;
¬ treating hyperglycemia;
¬ treating hypertension to target blood pressure levels using a variety of medications including Nicardipine;
¬ and treatment with recombinant activated factor VII within the first 3 to 4 hours after onset, but only in a clinical trial setting, as efficacy and safety must still be confirmed.
The Role of Surgery in Hemorraghic Stroke is Controversial. The 2007 STICH Guidelines (International Surgical Trial in Intracerebral Hemorrhage ) recommendations are included in the current guidelines which are.
Absolute Indication for Surgery (Class I)
- Hemorrhage > 3cm
- Detoriating Neurologically
- Brain Stem Compression
- Hydrocephalus from Ventricular compression
Relative Indication (Class II) - Surgeons should consider evacuating lobar clots 1 cm from head surface by standard craniotomy
Q. What is Ultra early Craniotomy and what is its role in Management of Hemorraghic stroke ?
¬ Ultra Early craniotomy is performing a surgery within 12 hrs of onset of stroke.
¬ This is found to have no clear evidence of benefit to moratlity in the guideline
¬ Infact on the other hand it may increase the risk of recurrent rebleeding
Q. What is Endocsopic Aspiration and what is its role ?
¬ Another intervention of interest involves endoscopic aspiration. It means placing catheters into the clot and sucking it out more gently and without going through too much brain
¬ There has been some positive glimmering, but nothing definitive according to the guidelines
¬ The new guidelines give endoscopic aspiration a class II recommendation, based on a small, single-center randomized trial of 100 patients.
¬ That study found patients whose clots (at least 10 mL in volume) were removed had better outcomes than those treated with medicine only (Auer LM et al. J Neurosurg. 1989;70:530-535).
¬ Endoscopic aspiration of smaller clots led to significantly better quality of life, but survival was similar to those in the medical group
¬ benefit was mostly limited to patients with lobar hematomas and those younger than 60 years.
Q. What are the Guidelines on End of Life Care in such patients ?
¬ But the guidelines advise treating such patients aggressively in the first 24 hours to see what happens, and then to make end-of-life decisions.
¬ This allows time for the physician, family, and patient to think about what is happening.
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