Lien vers les tableaux de données probantes et la liste des références (en anglais)
While it is now well-accepted that patients with ischemic stroke admitted to a stroke unit featuring dedicated beds and staff have better outcomes compared with patients admitted to general or less-specialized units, there is also evidence that the subset of patients who have experienced ICH realize the same benefits. In a systematic review, Langhorne et al (2013) included the results from 8 trials in which patients with ischemic and hemorrhagic stroke were randomized to receive care on a stroke unit or an alternative setting. Stroke unit care was associated with significant reductions in the risk of death or dependency (mRS 3-5) (RR=0.81, 95% CI 0.71-0.92, p<0.0001) and death (RR=0.79, 95% CI 0.64-0.97, p=0.02), with no significant interactions based on stroke type. Diringer & Edwards (2001) reviewed the charts of 1,038 patients who had been admitted to either a neuro-ICU (n=2) or a medical and/or surgical ICU (n=40) following ICH and reported that after adjusting for demographics, severity of ICH, and ICU and institutional characteristics, admission to a general ICU was associated with an increase in hospital mortality (OR=3.4; 95% CI 1.65–7.6). Additional independent predictors of higher mortality were advancing age, lower GCS scores, fewer ICH patients treated and smaller ICU size. In contrast, having a full-time intensivist was associated with lower mortality rate. Ronning et al. (2001) also reported improved survival during the first 30 days and one year following admittance to an acute stroke unit care. At 30 days, fewer patients in the stroke unit group were dead (39% vs. 63%, adjusted OR=0.40, 95% CI 0.17-0.94). There was no difference in one-year mortality between groups (52% vs. 69%, adjusted OR=0.58, 95% CI 0.24-1.38), or the number of patients discharged home between groups (27% vs. 52%, adjusted OR=1.60, 95% 0.62-4.00).
Venous Thromboembolism (VTE) Prophylaxis
The use of external compression stockings/devices was investigated in a series of three large, related RCTs, the Clots in Legs Or sTockings after Stroke (CLOTS) trials. In the third trial, CLOTS 3 (Dennis et al. 2013), patients were randomized to a wear thigh length intermittent pneumatic compression (IPC) device or to no IPC for a minimum of 30 days. Of the 2,876 patients included, 13% had suffered an ICH. The mean duration of IPC use was 12.5 days and 100% adherence to treatment was achieved in only 31% in the IPC group. The incidence of proximal DVT within 30 days was significantly lower for patients in the IPC group (8.5% vs. 12.1%, OR=0.65, 95% CI 0.51-0.84, p=0.001, ARR=3.6%, 95% CI 1.4%-5.8%). There were no significant differences between groups for the outcomes of: death at 30 days (10.8% vs. 13.1%, p=0.057), symptomatic proximal DVT (2.7% vs. 3.4%, p=0.269), or pulmonary embolism (2.0% vs. 2.4%, p=0.453). The incidence of any DVT (symptomatic, asymptomatic, proximal or calf) was significantly lower for IPC group (16.2% vs. 21.1%, OR=0.72, 95% CI 0.60-0.87, p=0.001). At 6 months, the incidence of any DVT remained significantly lower in the IPC group (16.7% vs. 21.7%, OR=0.72, 95% CI 0.60-0.87, p=0.001). The incidence of any DVT, death or PE also remained significantly lower for IPC group (36.6% vs. 43.5%, OR=0.74, 95% CI 0.63-0.86, p<0.0001). In a systematic review and meta-analysis, Paciaroni et al. (2011) reported that early treatment with UFH and LMWH initiated between 1-6 days following ICH led to a significant reduction in the incidence of pulmonary embolus (1.7% vs. 2.9%; P = 0.01), without an increase in hematoma expansion. In a small randomized trial of 68 patients with ICH, participants randomized to LWMH on day 2 following their ICH experienced fewer pulmonary emboli than those randomized to initiate treatment on days 4 and 10, without an apparent increase in rebleeding (Boeer et al. 1991).
Following ICH, patients are at increased risk of seizures. Early-onset seizure typically occur at or near event onset, and are thought to be less common, while late-onset seizures occur 6-12 months post event. Whether to treat a first occurrence of a post stroke seizure following an ICH, is a topic of debate. Individual patient risk factors should be considered. However, long-term use of antiepileptic drugs (AED) has not been shown to be effective at reducing the odds of recurrent seizure (Angriman et al. 2019), and may be associated with poor outcome (Messe et al. 2009). There are very few studies that have the use of AEDs in stroke, generally and following ICH, specifically.
Increased Intracranial Pressure
While a wide variety of nonsurgical interventions are used commonly to lower intracranial pressure following ICH, including head elevation, hyperosmotic agents, hyperventilation, analgesia, and sedation, RCT evidence of their effectiveness is lacking. Head‑ PoST (Anderson et al. 2017) randomized over 11,000 patients following stroke to receive care in either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees, which was initiated as soon as possible and maintained for 24 hours). There were no significant differences between groups in any of the primary or secondary clinical outcomes (mRS scores, death or major disability at 7 and 90 days). The results were similar in the subgroup of 8% of patients with ICH.