NeuroVoices: Stephan A. Mayer, MD, FCCM, FNCS, on the Urgent Need to Improve Intracerebral Hemorrhage Care

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The director of neurocritical care and emergency neurology services at Westchester Medical Center Health System discussed the call for a paradigm shift in stroke care with a focus on intracerebral hemorrhage.

Stephan A. Mayer, MD, FCCM, FNCS, irector of neurocritical care and emergency neurology services at Westchester Medical Center Health System

Stephan A. Mayer, MD, FCCM, FNCS

Credit: Westchester Medical Center Health System

Intracerebral hemorrhage (ICH), a condition resulting from the rupture of a cerebral vessel and the subsequent entry of blood into the brain parenchyma, significantly contributes to both mortality and dependency in stroke. Recent findings, outlined in a Nature Reviews Disease Primers review, revealed that only half of patients who experienced ICH survive beyond 1 year, and those survived had lingering effects that adversely impacted their overall quality of life.1 Despite advancements in identifying the causes of ICH over the past decade, a significant gap persists, with no specific treatment currently available for affected patients.

Recently published in Stroke, a reportfrom an international panel of experts in Stroke care stated that quality improvement efforts in the emergency management of ICH should be a priority for patients. Conducted by cosenior author Stephan A. Mayer, MD, FCCM, FNCS, and colleagues, the consensus statement suggested a protocol for Code ICH is needed to potentially provide a framework for future research and innovation in ICH.2 In the report, the experts reviewed the latest literature for ICH treatment supporting the effectiveness of various strategies to improve care.

In a new iteration of NeuroVoices, Mayer, director of neurocritical care and emergency neurology services at Westchester Medical Center Health System, discussed how stroke programs can address the current disparity in quality metrics for ICH. Mayer, who also serves as a professor of neurology and neurosurgery at New York Medical College, talked about the key components of the proposed care bundle for ICH, and how they could improve patient outcomes. In addition, he spoke about how establishing a standardized approach, like the 60-minute door-to-needle target, can potentially enhance stroke care overall.

NeurologyLive: What was your objective going into this research paper?

In short, the paper's objective is to level the playing field between acute ischemic stroke, the most common form of stroke. There are many quality metrics that stroke teams, hospitals, and health systems are held accountable for with this. For example, how many patients who are eligible for tissue plasminogen activator (tPA) get it? How many minutes does it take you to give the TPA? If some, how many are you diagnosing large vessel occlusives (LVOs)? How many LVOs are undergoing thrombectomy? How quickly can you get patients to the angiography suite? What's your success rate of recanalization? There's been a huge disconnect since ICH is 15% of strokes reported but easily the most deadly form of stroke. There's up till now only 3 quality metrics. Do you do an illness scoring system or severity system? If the patient had a blood thinner, did you give anything at all, whenever you wanted to try to reverse the anticoagulation? We wanted to point out this disparity and make a call to action, that it's time for stroke programs and the accrediting organizations to pay more attention to the deadliest form of stroke.

While you were going through the literature, what trends did you observe, and based on that, what were your recommendations?

The trend that's happening right now is what we call care bundles. Care bundles are when you do a couple of crucial things in parallel at the same time, especially for medical emergencies like ICH. While we were working on the project, an important paper came out called INTERACT 3. In the trial, researchers randomized hospitals who were doing it the old way and then implemented the care bundle with aggressive time-based goals for reversing anticoagulation and lowering blood pressure, treating high blood sugar and fever. At the end of the day, you've got about 5000 people in each group, and you compare the outcomes. Overall, better outcomes for patient with ICH that were treated, admitted to and treated by hospital that implemented the care bundle. I think we're going to be hearing more about that. Care bundles are used throughout medicine, we just hadn't really gotten to that point with ICH yet but now it's time.

Is there anything else you wanted to mention about the importance of this research for stroke?

We want Code ICH to become the common nomenclature or terminology that every stroke center uses for their ICH protocol. Specifically in this paper after reviewing the current evidence very closely, we're calling for a 60-minute door to needle target time for lowering extremely high blood pressure and initiating emergency reversal blood thinners. We feel that hospitals and medical centers are not accountable for this right now. But these interventions are used universally, and they're only going to work better and more effective when given as fast as possible. We want to turn up the heat a little bit. Finally, we're excited about what the future will bring. There will be more medical advances, scientific advances. There's a lot of exciting advancements happening with minimally invasive surgery. We want to build on this initial step, and every year add more components to the care bundle as evidence comes out to justify its widespread application.

Transcript edited for clarity. Click here to view more NeuroVoices.

REFERENCES
1. Puy L, Parry-Jones AR, Sandset EC, Dowlatshahi D, Ziai W, Cordonnier C. Intracerebral haemorrhage. Nat Rev Dis Primers. 2023;9(1):14. Published 2023 Mar 16. doi:10.1038/s41572-023-00424-7
2. Li Q, Yakhkind A, Alexandrov AW, et al. Code ICH: A Call to Action. Stroke. Published online December 15, 2023. doi:10.1161/STROKEAHA.123.043033
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