Recommendations
Urgent
"Time is brain" - spontaneous intracerebral haemorrhage (ICH) is an emergency.
Aggressive early management of ICH is crucial. Early deterioration is common in the first few hours after symptom onset.[23]
Manage any airway, breathing, and circulatory insufficiencies requiring urgent intervention. In particular:
Consider endotracheal intubation.[68]
Give supplemental oxygen only if oxygen saturation drops below 93%.[69] Although the National Institute for Health and Care Excellence (NICE) in the UK recommends starting oxygen only if oxygen saturation drops below 95%, latest evidence suggests that in patients with stroke there are no benefits to initiating oxygen therapy when SpO₂ is ≥93%, and it may cause harm.[69]
Monitor controlled oxygen therapy. An upper SpO₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
A lower target of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[70]
Do not routinely give oxygen to people who are not hypoxic.[69]
Admit anyone with suspected stroke directly to a hyperacute or acute (depending on availability) stroke unit as soon as possible; UK guidelines recommend doing this within 4 hours of presentation to hospital.[55]
Arrange an immediate review by a neurosurgeon to assess whether or not the patient will benefit from neurosurgery.[23][30][71]
Offer rapid lowering of blood pressure (BP) to patients with acute ICH who have a systolic BP of 150 to 220 mmHg AND:[55]
Present within 6 hours of symptom onset
Do not have: an underlying structural cause (e.g., tumour, arteriovenous malformation, or aneurysm); a Glasgow Coma Scale score <6; a massive haematoma with poor expected prognosis [ Glasgow Coma Scale Opens in new window ]
Are not going to have early neurosurgery to evacuate the haematoma.
Follow your local protocol for urgent BP lowering in these patients.[30] Aim to achieve a systolic BP of 130-139 mmHg within one hour, to be sustained for at least 7 days.[30]
Consider rapid BP lowering for patients with acute ICH who have a systolic BP of >220 mmHg OR present beyond 6 hours of symptom onset AND:[55]
Do not have: an underlying structural cause (e.g., tumour, arteriovenous malformation, or aneurysm); a Glasgow Coma Scale score <6; a massive haematoma with poor expected prognosis
Are not going to have early neurosurgery to evacuate the haematoma.
Aim for a systolic BP target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this BP for at least 7 days.[55]
Reverse anticoagulation treatment urgently.[30][72] Return clotting levels to normal as soon as possible in people who were on:
Warfarin (and have elevated international normalised ratio [INR]) or another vitamin K antagonist: give a combination of prothrombin complex concentrate (4-factor) and intravenous vitamin K.[30][55]
Dabigatran: reverse with idarucizumab. If idarucizumab is unavailable, prothrombin complex concentrate (4-factor) may be considered.[30]
Factor Xa inhibitor treatment: give prothrombin complex concentrate (4-factor). Recombinant coagulation factor Xa (andexanet alfa) may be considered in the context of a randomised controlled trial.[30]
Key Recommendations
Patients with intracerebral haemorrhage should be admitted directly to a hyperacute stroke unit for urgent specialist assessment and monitoring of conscious level, and referred immediately for repeat brain imaging if deterioration occurs.[30]
Assess the patient’s level of consciousness using the Glasgow Coma Scale. [ Glasgow Coma Scale Opens in new window ]
Continue to closely monitor consciousness once the patient is on the hyperacute or acute stroke unit.[30]
Monitor blood glucose regularly. Maintain a blood glucose concentration between 4 and 11 mmol/L in people with acute stroke.[55] Give optimal insulin therapy with intravenous insulin and glucose to all adults with type 1 diabetes with threatened or actual stroke. Follow local protocols.[55]
Consider monitoring the patient for signs of elevated intracranial pressure if any of the following is present:[23]
Glasgow Coma Scale score ≤8 that is presumed related to haematoma mass effect [ Glasgow Coma Scale Opens in new window ]
Clinical evidence of transtentorial herniation
Significant intraventricular haemorrhage or hydrocephalus.
Refer any patient who develops hydrocephalus to a neurosurgeon. The neurosurgeon will consider surgical intervention (e.g., insertion of an external ventricular drain).[30][55]
Consult immediately with a neurologist if the patient has uncontrolled or recurrent seizures, or status epilepticus. Follow your local protocol. See Status epilepticus.
Do not start statin treatment in patients with primary ICH unless required for other indications.
Ensure urgent specialist input and treatment to reduce bleeding as patients with ICH can deteriorate rapidly.[30]
Anticoagulation reversal, intensive blood pressure lowering, neurosurgery and access to critical care might all be beneficial in acute ICH but high-quality evidence for these interventions is currently lacking.[71]
Stabilisation
Manage any airway, breathing, and circulatory insufficiencies requiring urgent treatment. In particular:
Consider endotracheal intubation for patients who are unable to protect their airway or those presenting with a depressed level of consciousness (Glasgow Coma Scale score ≤8 [ Glasgow Coma Scale Opens in new window ] ).[68] This should be done by an anaesthetist or trained emergency department staff.
Give supplemental oxygen only if oxygen saturation drops below 93%.[69] Although the National Institute for Health and Care Excellence (NICE) in the UK recommends starting oxygen only if oxygen saturation drops below 95%, latest evidence suggests that in patients with stroke there are no benefits to initiating oxygen therapy when SpO2 is ≥93%, and it may cause harm.[69]
Monitor controlled oxygen therapy. An upper SpO2 limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
Evidence suggests that liberal use of supplemental oxygen (target SpO2 >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[73]
A lower target SpO2 of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[70]
Do not routinely give oxygen to people who are not hypoxic.[69]
Evidence: Target oxygen saturation in acutely ill adults
Too much supplemental oxygen increases mortality.
Evidence from a large systematic review and meta-analysis supports conservative/controlled oxygen therapy versus liberal oxygen therapy in acutely ill adults who are not at risk of hypercapnia.
Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen.
The 2017 British Thoracic Society (BTS) guideline recommends a target SpO2 range of 94% to 98% for patients not at risk of hypercapnia, whereas the 2022 Thoracic Society of Australia and New Zealand (TSANZ) guideline recommends 92% to 96%.[70][74]
The Global Initiative For Asthma (GINA) guidelines recommend a target SpO2 range of 93% to 96% in the context of a severe exacerbation of asthma.[75]
A systematic review including a meta-analysis of data from 25 randomised controlled trials (RCTs), published in 2018, found that in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[73]
In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy versus the conservative therapy group (95% CI 2 to 22 per 1,000 more).
Mortality at 30 days was also higher in the group who had received liberal oxygen (RR 1.14, 95% CI 1.01 to 1.29).
The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, and cardiac arrest, and patients who had emergency surgery. Studies that were limited to people with chronic respiratory illness or psychiatric illness, and patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery, were all excluded from the review.
An upper SpO2 limit of 96% is therefore reasonable when administering supplemental oxygen to medical patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, and sickle cell crisis).[69]
In 2019 the BTS reviewed its guidance in response to this systematic review and meta-analysis and decided an interim update was not required.[70]
The committee noted that the systematic review supported the use of controlled oxygen therapy to a target.
While the systematic review showed an association between higher oxygen saturations and higher mortality, the BTS committee felt the review was not definitive on what the optimal target range should be. The suggested range of 94 to 96% in the review was based on the lower 95% confidence interval and the median baseline SpO2 from the liberal oxygen groups, along with the TSANZ guideline recommendation.
Subsequently, experience during the COVID-19 pandemic has also made clinicians more aware of the feasibility of permissive hypoxaemia.[76]
Management of oxygen therapy in patients in intensive care is specialised and informed by further evidence (not covered in this summary) that is more specific to this setting.[77][78][79]
Refer to hyperacute or acute stroke unit
In hospital
Admit anyone with suspected stroke directly to a hyperacute or acute (depending on availability) stroke unit as soon as possible; UK guidelines recommend doing this within 4 hours of presentation to hospital.[55] Patients with intracerebral haemorrhage should be admitted directly to a hyperacute stroke unit for urgent specialist assessment and monitoring of conscious level.[30]
These patients require urgent specialist assessment and monitoring as they can deteriorate quickly.[30][55]
If the patient deteriorates refer immediately for repeat brain imaging.[30][55]
Evidence: Hyperacute stroke units
People who have had a stroke are more likely to be alive, independent, and living at home at 1 year post-stroke if they received care in an acute inpatient stroke unit, compared with less-organised alternative care. Care in a dedicated stroke ward seems to be the most effective approach.
The 2016 UK Royal College of Physicians (RCP) National Clinical Guideline on Stroke (subsequently updated in 2023 to the National Clinical Guideline for Stroke for the UK and Ireland) cited a 2013 Cochrane review by the Stroke Unit Trialists' Collaboration to support its recommendation to admit patients with suspected acute stroke to a hyperacute stroke unit.[30]
This Cochrane review (search date January 2013) assessed the effect of organised inpatient stroke unit care compared with alternative less-organised forms of care for people with acute stroke.[80]
It included 28 RCTs, involving a total of 5855 patients admitted to hospital with stroke (using a clinical definition of stroke: focal neurological deficit due to cerebrovascular disease, excluding subarachnoid haemorrhage and subdural haematoma).
Results for organised stroke unit care versus alternative care (general wards or mixed rehabilitation units) showed that patients in stroke units had a reduced “risk of death”, “death or institutionalised care”, and “death or dependency” at final follow-up (median 1 year), 5 years follow-up, and 10 years follow-up.
These conclusions were confirmed in a more recent version (2020) of this Cochrane review which included 29 RCTs (n=5902), new outcome data from recent trials and further assessment via network meta-analysis.[80]
[ 
]
In the community
Arrange immediate emergency admission to an hyperacute (or acute, depending on availability) stroke unit for anyone with:
Persisting neurological symptoms suspected of having acute stroke[30][55]
Resolved neurological symptoms who has a bleeding disorder or is taking an anticoagulant as haemorrhage must be excluded. This is standard practice.[30]
Immediate neurosurgery assessment
Arrange an immediate review by a neurosurgeon to assess whether the patient will benefit from neurosurgery.[23][71]
This review may happen at the emergency department or in the hyperacute or acute stroke unit (depending on the availability of the neurosurgeon). The neurosurgeon often does this remotely rather than attending in person. If in the stroke unit, it is the stroke team who liaises with the surgical team.
Refer any patient who develops hydrocephalus to a neurosurgeon. The neurosurgeon will consider surgical intervention (e.g., insertion of an external ventricular drain).[30][55]
The role of surgery for most patients with spontaneous ICH remains controversial.[23] Neurosurgery to evacuate the haematoma or treat hydrocephalus might improve outcomes, but there is a lack of clear evidence and who to operate on remains uncertain.[71]
According to the UK National Institute for Health and Care Excellence (NICE), people with any of the following clinical features rarely require surgical intervention and should receive medical treatment initially:[55]
Small deep haemorrhages
Lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
A large haemorrhage and significant comorbidities before the stroke
Glasgow Coma Scale score <8 unless this is because of hydrocephalus [ Glasgow Coma Scale Opens in new window ]
Posterior fossa haemorrhage.
Consider rapid lowering of blood pressure (BP) for patients with ICH who have a systolic BP of 150 to 220 mmHg AND:[55]
Present within 6 hours of symptom onset
Do not have: an underlying structural cause (e.g., tumour, arteriovenous malformation, or aneurysm); a Glasgow Coma Scale score <6; a massive haematoma with poor expected prognosis [ Glasgow Coma Scale Opens in new window ]
Are not going to have early neurosurgery to evacuate the haematoma.
Follow your local protocol for urgent BP lowering in these patients.[30] The National Clinical Guideline for Stroke for the UK and Ireland recommend to aim to achieve a systolic BP of 130-139 mmHg within one hour, to be sustained for at least 7 days.[30]
The European Stroke Organisation recommends to lower blood pressure to 140 mmHg (and to keep it above 110 mmHg) to reduce haematoma expansions in patients with hyperacute (<6 hours) ICH. Their expert consensus concludes that the decrease of systolic blood pressure should not exceed 90 mmHg from baseline values.[72]
The National Clinical Guideline for Stroke for the UK and Ireland notes there is limited RCT evidence regarding intensive blood pressure lowering in patients after ICH with baseline systolic blood pressure greater than 220 mmHg or beyond 6 hours from onset, and therefore do not make specific recommendations relating to this group of patients.[30]
However, the National Institute for Health and Care Excellence (NICE) in the UK recommends considering rapid BP lowering on a case-by-case basis for patients, taking into account the risk of harm, with acute ICH who have a systolic BP of 220 mmHg OR present beyond 6 hours of symptom onset AND:[55]
Do not have: an underlying structural cause (e.g., tumour, arteriovenous malformation, or aneurysm); a Glasgow Coma Scale score <6; a massive haematoma with poor expected prognosis
Are not going to have early neurosurgery to evacuate the haematoma.
Aim to reach a systolic BP target of 140 mmHg or lower while ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment.[55]
Evidence: Rapid BP lowering
Rapid BP lowering in patients with acute intracerebral haemorrhage and high systolic blood pressure is associated with a reduced risk of haematoma expansion at 24 hours and a possible improved quality of life at 90 days. There are no clear increased harms in most patients, although aggressive protocols should be avoided due to the risk of renal failure.
In 2022, based on new evidence from a pooled individual patient data (IPD) analysis of the multicentre ATACH-2 and INTERACT2 trials, the UK National Institute of Health and Care Excellence (NICE) updated their guidance on the efficacy and safety of lowering BP in people with acute haemorrhagic stroke.[81]
NICE included seven randomised controlled trials (RCTs) (n=5119) in the previous 2019 review with most of the evidence from ATACH-2 (n=1000) and INTERACT2 (n=2829). At the 2022 update they also included three post hoc analyses of the ATACH-2 study and separately considered the combined IPD analysis.[81]
All trials compared intensive BP therapy with standard BP therapy, although target BP varied between studies and length of treatment ranged from 24 hours to 7 days.
Haematoma expansion was reduced with intensive therapy (6 trials; n=3417; RR 0.82 [95% CI 0.73 to 0.93]; GRADE moderate).
Quality of life at 90 days was better with intensive treatment in the INTERACT2 trial; however, there was no difference in quality of life in the pooled result (2 trials, n=3030, GRADE moderate).
Intensive BP lowering did not affect functional outcomes (modified Rankin Scale 0-2) at 90 days (3 trials; n=3832; RR 1.06 [95% CI 0.99 to 1.13]; absolute risk in control group 44 more per 100, absolute risk in intervention group 47 more per 100 [95% CI 43 fewer to 50 more]; moderate-quality evidence as assessed by GRADE).
There was no clinical difference at 90 days for mortality (7 trials; n=5099; GRADE high), recurrent stroke (3 trials; n=3832; GRADE moderate), or myocardial infarction (1 trial; n=629; GRADE low).
There was no difference at 24 hours in neurological deterioration (5 trials; n=5065, GRADE low) or symptomatic cerebral ischaemia (1 trial; n=201; GRADE low).
There was a possible clinical harm for renal failure at 90 days (4 trials; n=1647; RR 2.07 [95% CI 1.08 to 3.99]; GRADE moderate).
In three of the studies there was no significant difference in renal failure (although all three had low event rates and wide confidence intervals).
The ATACH-2 trial, however, used a more aggressive protocol for lowering BP and this was found to increase the risk of renal failure (21/500 with intensive treatment vs. 9/500 with standard treatment; RR 2.33 [95% CI 1.08 to 5.04]).
The IPD analysis showed that the BP target thresholds in the 2019 NICE recommendation may be harmful, as may a very large reduction (>60 mmHg) in blood pressure within the first hour.[81][82] Therefore, in 2022, the guideline committee decided to remove the aim of reaching the target within 1 hour. The committee also noted that:
Only a third of participants in the INTERACT2 trial achieved the target of 140 mmHg within 1 hour.
A reduction of more than 60 mmHg within 1 hour was associated with significantly worse outcomes such as renal failure, early neurological deterioration, and death, compared with standard treatment.
There is sufficient evidence to show that intensive lowering of systolic blood pressure can be safe when using less aggressive protocols, although there is an absence of evidence in clinically frail adults.
The 2019 NICE guideline stated that treatment should start within 6 hours and continue for 7 days. However, this timeframe was removed from the 2022 guideline due to weak evidence and concerns about the potential impact on patient flow, bed management, and resource use.
There was limited evidence in people presenting beyond 6 hours of symptom onset and in people with a systolic BP over 220 mmHg at presentation, therefore NICE made a weaker recommendation for these groups.
Urgently reverse abnormalities of clotting, particularly in patients taking anticoagulants.[30][72]
About 10% to 20% of acute ICHs occur in patients taking oral anticoagulants, and this aetiology is associated with a high risk of early haematoma expansion.[71]
Return clotting levels to normal as soon as possible in people who were on:
Warfarin (and have elevated international normalised ratio [INR]) or another vitamin K antagonist: give a combination of prothrombin complex concentrate (4-factor) and intravenous vitamin K (phytomenadione)[30][55][72]
Dabigatran: reverse with idarucizumab.[30][72] If idarucizumab is unavailable, prothrombin complex concentrate (4-factor) may be considered.[30]
Factor Xa inhibitor: treat with prothrombin complex concentrate (4-factor).[30][72] Andexanet alfa may be considered in the context of a randomised controlled trial.[30]
Monitor the patient’s clinical status closely and provide supportive care as appropriate.[30] In particular, monitor:
Level of consciousness
Blood glucose
Blood pressure
Oxygen saturation
Hydration
Temperature
Cardiac rhythm and rate.
Monitor the patient for complications, particularly signs of elevated intracranial pressure and seizures.
Refer immediately for repeat brain imaging if the patient deteriorates.[30][55]
Level of consciousness
Assess the patient’s level of consciousness using the Glasgow Coma Scale. [ Glasgow Coma Scale Opens in new window ] Monitoring of consciousness should continue once the patient is on the hyperacute or acute stroke unit.[30]
Blood glucose
Monitor blood glucose regularly. Maintain a blood glucose concentration between 4 and 11 mmol/L in people with acute stroke.[55]
Give optimal insulin therapy with intravenous insulin and glucose to all adults with type 1 diabetes with threatened or actual stroke. Follow local protocols.[55]
Evidence: Glyacemic control in acute stroke
Limited available data do not show a significant benefit with tight glycaemic control compared with usual care in patients with haemorrhagic stroke who develop post-stroke hyperglycaemia, and there is an increased risk of hypoglycaemia.[30][55][83]
There is very little evidence from RCTs on glycaemic control in people with haemorrhagic stroke. Guideline groups have therefore considered pragmatic studies (where every patient presenting with acute stroke is included in the study) or large prospective studies when making their recommendations.
Guidelines vary in their recommendations for target range for blood glucose in this situation.
The UK National Institute for Health and Care Excellence (NICE) guideline on stroke from 2008 recommends keeping blood glucose between 4 and 11 mmol/L (this was not changed in the 2022 update of this guideline).[55]
This recommendation is underpinned by:
Evidence from the United Kingdom Glucose Insulin in Stroke Trial (GIST-UK), which found no support for tight blood glucose control in patients with mildly or moderately elevated blood glucose levels following acute stroke (15% of participants had haemorrhagic stroke)[84]
Consensus of the guideline panel on recommended glucose range.
The guideline panel agreed by consensus that patients with pre-existing diabetes should continue to be treated according to current guidelines.
The 2016 National Clinical Guideline published by the Royal College of Physicians in the UK, updated in 2023 (National Clinical Guideline for Stroke for the UK and Ireland) recommends a broader target range of 5 to 15 mmol/L, with close monitoring to avoid hypoglycaemia.[30]
This guideline also cites the GIST-UK trial to support this recommendation.[84]
The recommendation in the European Stroke Organisation (ESO) guidelines from 2018 is underpinned by evidence from a systematic review.[83]
This guideline makes a weak recommendation against the routine use of intravenous insulin to achieve tight glycaemic control as a means to improve functional outcome, survival, or infarct size (very low-quality evidence as assessed using GRADE).[83]
Blood pressure
Monitor blood pressure intensively and follow recommendations in the Rapid blood pressure lowing section, above.
Oxygen saturation
Give supplemental oxygen only if oxygen saturation drops below 93%.[69] Although the National Institute for Health and Care Excellence (NICE) in the UK recommends starting oxygen only if oxygen saturation drops below 95%, latest evidence suggests that in patients with stroke there are no benefits to initiating oxygen therapy when SpO2 is ≥93%, and it may cause harm.[69]
Monitor controlled oxygen therapy. An upper SpO2 limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
Evidence suggests that liberal use of supplemental oxygen (target SpO2 >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[73]
A lower target SpO2 of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[70]
Do not routinely give oxygen to people who are not hypoxic.[69]
Hydration
Assess the patient’s hydration using multiple methods within 4 hours of their arrival at hospital. Review regularly; manage as needed to maintain normal hydration.[30][55]
Temperature
Monitor temperature.[30] Patients with stroke can lose their thermoregulation acutely and may need interventions in the absence of infection.
Give an antipyretic (e.g., paracetamol) in patients with high temperature.[85]
Cardiac rhythm and rate
Use your clinical judgement to determine the most appropriate method of monitoring cardiac rhythm and rate based on the individual patient and follow your hospital protocol.
Intracranial pressure
Consider monitoring the patient for signs of elevated intracranial pressure (ICP) and treatment if any of the following is present:[23]
Glasgow Coma Scale score ≤8 that is presumed related to haematoma mass effect
Clinical evidence of transtentorial herniation
Significant intraventricular haemorrhage or hydrocephalus.
Refer any patient who develops hydrocephalus to a neurosurgeon. The neurosurgeon will consider surgical intervention (e.g., insertion of an external ventricular drain).[30][55]
Common causes of elevated ICP are hydrocephalus from intraventricular haemorrhage or mass effect from the haematoma.[23]
Haematoma evacuation and decompressive hemicraniectomy are options for treating elevated ICP.[23]
Seizures
Consult immediately with a neurologist if the patient has uncontrolled or recurrent seizures, or status epilepticus. New-onset seizures in the context of spontaneous ICH are relatively common (affecting between 2.8% and 28% of patients); most of these seizures occur within the first 24 hours of the haemorrhage.[23] See Status epilepticus.
Choose an anticonvulsant based on individual patient characteristics.[23] Follow your hospital protocol. In clinical practice, levetiracetam and sodium valproate are commonly used.
Statins
Do not start statin treatment in patients with spontaneous ICH unless required for other indications.[30]
Swallowing assessment and nutrition
On admission, ensure the patient has their swallowing function assessed by appropriately trained staff before being given any oral food, fluid, or medication:[30][55]
If the admission screen indicates problems with swallowing, ensure specialist assessment within 24 hours of admission (preferably) and not more than 72 hours afterwards.
To avoid aspiration pneumonia, give food, fluids, and medication to people with dysphagia in a form that can be swallowed without aspiration, after specialist assessment of swallowing.[55]
Start nutrition support for people who are at risk of malnutrition. Routine nutritional supplementation is not recommended for people who are adequately nourished on admission.[55]
Optimal positioning and early mobilisation
Ensure patients have an initial specialist assessment for positioning as soon as possible and within 4 hours of arrival at hospital.[30]
Assess individual clinical needs and personal preferences to determine the patient’s optimal head position. Take into account factors such as comfort, physical and cognitive abilities, and postural control.[55] Stroke units should not have a policy or practice that favours either a sitting up or lying-flat head position.[30] When lying or sitting, patients with acute stroke should be positioned to minimise the risk of aspiration and other respiratory complications, shoulder pain and subluxation, contractures and skin pressure ulceration.[30]
Evidence: Optimal positioning
Evidence shows no difference in outcomes when the patient with acute stroke is positioned lying flat or with their head elevated. Therefore the optimum position should be individually tailored to suit the patient.[86]
There is wide variation in clinical practice, with lying flat thought to help maintain blood flow to 'at-risk' brain regions, but possibly increasing the risk of complications such as pneumonia. In 2019, the UK National Institute for Health and Care Excellence (NICE) performed a systematic review for their 2019 stroke guideline update, comparing positioning patients with acute stroke lying flat versus sitting up. The review included two studies, reported in six papers, both of PROBE (prospective, randomised, open-label, controlled trial with blinded outcome evaluation) design.[86]
In the pilot HeadPoST study (94 people) all participants had acute ischaemic stroke. The intervention group lay flat for 24 hours, then from 24 to 48 hours had their heads raised slowly to a maximum of 15°; after 48 hours, heads were elevated further to the standard 30° or more. The control group sat up with heads elevated to 30° or more as soon as possible after the diagnosis, and were maintained in this position for at least 48 hours.[87]
In the full HeadPoST study (11,093 people), 8.4% of participants had acute haemorrhagic stroke. The intervention group lay flat as soon as possible after presentation and for at least 24 hours. The control group sat up with heads elevated to at least 30° immediately upon presentation to the emergency department and for at least 24 hours.[88]
The NICE guideline review reported that:
Despite the pilot trial finding that there was a possible benefit with lying down in terms of function at 90 days, the larger full study did not find any difference between groups (modified Rankin Scale 0-2 (2 studies; n=9840; RR 1.07; 95% CI 0.9 to 1.26; GRADE very low quality).
There was no clinically important difference in recurrent stroke (2 studies; n=11,185; moderate-quality evidence assessed using GRADE), pneumonia at 90 days (1 study; n=11,093; GRADE low quality), EQ-5D for pain/discomfort at 90 days (1 study; n=8830; GRADE low quality), length of stay (1 study; n=94; GRADE low quality) or mortality at 90 days (2 studies; n=10,945; GRADE moderate quality).
The guideline committee noted that large numbers of patients were excluded from enrolment due to clinician discretion (particularly in relation to their ability to tolerate the lying flat position) and the average stroke severity was lower and not representative of the range of stroke severities managed within UK stroke centres.
The committee therefore concluded that individual factors such as comfort, medical condition, pressure care, pain, physical and cognitive abilities, orientation, alignment, postural control, and compliance should be considered when positioning patients with acute stroke.[86]
Despite the majority of patients in the included studies having acute ischaemic stroke, NICE made a broad recommendation for all people with acute stroke.
NICE’s recommendations on positioning were unchanged in the 2022 update of their stroke guideline.
Arrange assessment of patients with mobilisation difficulties by an appropriately trained healthcare professional as soon as possible. Ensure this assessment is conducted within the first 24 hours of onset to determine the most appropriate and safe methods of transfer and mobilisation.[30] Help the patient to sit out of bed, stand, or walk as soon as their clinical condition permits as part of an active management programme in a specialist stroke unit.[55] Mobilisation typically begins between 24 and 48 hours of stroke onset.[30] If the patient needs help to sit out of bed, stand, or walk, do not provide high-intensity mobilisation in the first 24 hours after symptom onset.[30][55]
High-intensity mobilisation refers to the very early mobilisation intervention from the AVERT trial.[30][89] It includes mobilisation that: begins within the first 24 hours of stroke onset; includes at least three additional out-of-bed sessions compared with usual care; focuses on sitting, standing, and walking (that is, out of bed) activity.
Evidence: Early mobilisation (within 48 hours)
Guidelines suggest that early mobilisation (within 48 hours) may be appropriate in patients who require minimal assistance to mobilise (e.g., those who have had a mild stroke, or are experiencing language and/or upper limb dysfunction alone), although evidence is limited.[90]
When the UK National Institute for Health and Care Excellence (NICE) updated their guideline on stroke in 2019, they found two studies examining early (within 48 hours) mobilisation involving a total of 75 people.[90][91][92]
The review by NICE incorporating these two studies reported that there was no significant difference for the outcomes of mortality, functional outcome (modified Rankin Scale), neurological deterioration, adverse events, or length of hospital stay (all very low-quality evidence assessed using GRADE).
The guideline panel made a consensus recommendation that mobilisation should be considered as and when the patient’s clinical condition permits.
Both studies were only in people with acute ischaemic stroke; however NICE made a broad recommendation for all people with acute stroke.
NICE's recommendations on early mobilisation were unchanged in the 2022 update of their stroke guideline.
Evidence: Very early mobilisation (within 24 hours)
Very early mobilisation does not seem to improve outcomes, and high intensity strategies may cause clinical harm in early functional outcomes, possibly due to reduced cerebral perfusion. Therefore very early mobilisation should not be actively pursued. However patients who can mobilise with little or no help in the first 24 hours after stroke should not be discouraged from doing so.[30][90]
[ ]
[Evidence B]
The UK National Institute for Health and Care Excellence (NICE) review for their 2019 guideline found six studies examining very early (within 24 hours) mobilisation involving a total of 2475 people.[90]
Five of the studies included people with ischaemic and haemorrhagic stroke, the remaining one only included people with ischaemic stroke.
The majority of data was from the AVERT III 2016 trial.[93][94][95][96][97] This study used a high-intensity mobilisation strategy beginning within 24 hours of stroke symptom onset and including at least three additional out-of-bed (sitting, standing, or walking) sessions compared with usual care.
For functional outcomes there was a suggestion of clinical harm as a result of very early mobilisation with fewer patients reaching a modified Rankin Score 0-2 at 7 days (2 studies; n=191; 118 fewer per 1000 [from 223 fewer to 20 more], low-quality evidence assessed using GRADE); however there was no significant difference between very early mobilisation and usual care for modified Rankin Score 0-2 at 90 days (5 studies; n=2377; GRADE high) or 12 months (2 studies; n=2152; GRADE moderate).
There was also no significant difference between groups for recurrent stroke (1 study; n=71; GRADE low), neurological deterioration (1 study; n=138; GRADE very low), adverse events (2 studies; n=209; GRADE moderate), length of hospital stay (1 study; n=124; GRADE low) or mortality at 90 days (6 studies; n=2475; GRADE moderate).
One small study found a statistically significant benefit of very early mobilisation for functional outcomes measured by the Barthel index at discharge (n=90; GRADE moderate) and at 90 days (n=80; GRADE moderate), but the guideline committee did not consider this clinically meaningful.[90]
NICE comments that evidence on very early mobilisation is difficult to interpret due to the differences in intensity, timing and type of mobilisation used in the trials, and lack of stratification by initial ability to mobilise independently.
The NICE guideline committee consensus is not to restrict appropriate very early (within 24 hours) mobilisation in people who are independently mobile after having a stroke. NICE advises not to start intense mobilisation (more frequent mobilisations of a longer duration than ‘usual care’) within the first 24 hours among people who need help to sit out of bed, stand, or walk, because this could reduce cerebral perfusion in these patients.
NICE’s recommendations on very early mobilisation were unchanged in the 2022 update of their stroke guideline.
The National Clinical Guideline for Stroke for the UK and Ireland makes a similar recommendations that mobilisation within 24 hours of onset of stroke should only be for patients who require little or no assistance to mobilise, basing their decision on the results of the AVERT trial.[30]
Prevention of deep venous thrombosis and pulmonary embolism
Give intermittent pneumatic compression within 3 days of admission for the prevention of deep venous thrombosis and pulmonary embolism in immobile patients. Give continuous treatment for 30 days or until the patient is mobile or discharged, whichever is sooner.[30]
Do not routinely give low molecular weight heparin (LMWH) or use graduated compression stockings.[30] However, in practice, consider prophylactic LMWH if intermittent pneumatic compression is contraindicated or not possible.
How to take a venous blood sample from the antecubital fossa using a vacuum needle.
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