Prehospital neurologic deterioration in patients with intracerebral hemorrhage

Moon, Jean; Janjua, Nazli; Ahmed, S. Sultan; Kirmani, Jawad F.; Harris‐Lane, Pansy; Jacob, Molly; Ezzeddine, Mustapha A.; Qureshi, Adnan I.

doi:10.1097/01.ccm.0000297876.62464.6b

Cited by 68 publications

(52 citation statements)

References 25 publications

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“…More than 20% of patients will experience a decrease in the Glasgow Coma Scale (GCS) of 2 or more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the emergency department (ED). 6 Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital arrival. 7,8 The risk for early neurological deterioration and the high rate of poor long-term outcomes underscore the need for aggressive early management.…”

Section: Emergency Diagnosis and Assessmentmentioning

confidence: 99%

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Hemphill¹,

Greenberg²,

Anderson³

et al. 2015

Stroke

2,812

1,115

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2032Purpose-The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. Methods-A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. Results-Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. Conclusions-Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted.These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

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Section: Emergency Diagnosis and Assessmentmentioning

confidence: 99%

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Hemphill¹,

Greenberg²,

Anderson³

et al. 2015

Stroke

2,812

1,115

View full text Add to dashboard Cite

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“…The Emergency Medical Services BP management practices vary considerably in the absence of distinction between ischemic stroke and ICH. 43 ␣Based on recommendations of the ASA, Stroke Council, 44,46 and/or European Stroke Initiative. 45 ␤ The recommended BP treatment threshold is similar to the existing ASA and European Stroke Initiative recommendations for patients with ICH.…”

Section: Figurementioning

confidence: 99%

“…7,[42][43][44][45][46][47] BP responses can be categorized as (1) spontaneous decline without medication; (2) no clear decline, or even an elevation, despite administration of antihypertensive medication; (3) modest decline with antihypertensive medication (Ϸ10% to 15% from baseline value); and (4) intense decline with antihypertensive medication (Ն20% from baseline value). The studies presented below are confounded by overlap of the 4 categories of responses in varying proportions and require interpretation with this understanding.…”

Section: Management Of Acute Hypertensive Response In Stroke Subtypesmentioning

confidence: 99%

Acute Hypertensive Response in Patients With Stroke

2008

Self Cite

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A cute hypertensive response is the elevation of blood pressure (BP) above normal and premorbid values that initially occurs within the first 24 hours of symptom onset in patients with stroke. This phenomenon was reported in Ͼ60% of patients presenting with stroke in a nationally representative study from the United States. 1 With Ϸ980 000 patients 2 admitted with stroke each year in the United States, the estimated annual prevalence of acute hypertensive response is more than half a million patients. With Ϸ15 million patients experiencing stroke worldwide each year, 3 the acute hypertensive response may be expected in Ϸ10 million patients per year. The acute hypertensive response in stroke patients is managed by a diverse group of physicians, including emergency physicians, intensivists, internists, primary care physicians, neurologists, neurosurgeons, and cardiologists. Previous audits suggest that antihypertensive agents and management strategies vary considerably and are not always consistent with recommended guidelines. 4 Data from 1181 acute ischemic stroke patients enrolled in the Project for Improvement of Stroke Care Management suggested that administration of antihypertensive medication within 24 hours in 56% of the patients was inconsistent with guidelines provided by the American Stroke Association (ASA). 5 The present review article summarizes the current concepts pertaining to treatment of the acute hypertensive response derived from recent guidelines provided by professional organizations and "best available" evidence derived from experimental and clinical studies and discusses incorporation of these concepts into clinical practice. Randomized trials, nonrandomized controlled studies, and selected observational studies were identified with multiple searches on Medline from 1980 to 2007 by cross-referencing the key words of stroke, acute hypertension, antihypertensive agents, acute stroke, and hypertension. Pertinent articles identified from bibliographies of selected articles were also reviewed. Treatment targets and strategies were identified by review of existing guidelines from professional organizations. Definition of Acute Hypertensive ResponseThe 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement 6 and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 7 define hypertension on the basis of the presence of consistent BP Ն140/90 mm Hg (multiple readings on separate days). This definition of hypertension is a threshold for the use of long-term antihypertensive treatment that is supported by evidence derived from randomized trials and clinicor population-based data that demonstrate reduction in cardiovascular events with this threshold for treatment. The same definition cannot be applied in the case of acute hypertensive response, because the above-mentioned ascertainment criteria and rationale are not valid. The executive summary of the ISH statement 8 on management of BP i...

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“…The very early period after stroke onset is known to be associated with more frequent fluctuations in clinical course than later periods, with frequent worsening occurring in ICrH patients and both improvement and worsening occurring in ACI patients. [20][21][22][23] In the 2 National Institute of Neurological Disorders and Stroke (NINDS)-tissue-type plasminogen activator trials, among placebo patients, later NIHSS assessments correlated with final outcome progressively strongly compared with earlier assessments. 22 Among placebo patients, between 1 to 3 hours and 24 hours, substantial (≥4 point) improvement or worsening occurred in fully 57% of patients.…”

Section: Strokementioning

confidence: 99%

Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity

Kim

Chung

Starkman

et al. 2017

Stroke

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Background and Purpose-The Los Angeles Motor Scale (LAMS) is a 3-item, 0-to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region. Methods-We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals. Results-Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20-50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119-180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120-180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were r=0.49 for the prehospital LAMS and r=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale, r=−0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74-0.78); EPA LAMS, 0.85 (95% confidence interval 0.83-0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85-0.88). Conclusions-In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field.

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Prehospital neurologic deterioration in patients with intracerebral hemorrhage

Cited by 68 publications

References 25 publications

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Acute Hypertensive Response in Patients With Stroke

Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity

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