Orientación Técnica para la Atención Integral del Ataque Cerebrovascular Hemorrágico

Objectives

The guidance aims to reduce lethality, mortality, complications and disability from non-traumatic intracerebral haemorrhage in Chile through evidence-informed, network-based care from suspected stroke through diagnosis, acute treatment, rehabilitation and secondary prevention. It applies to people aged 15 years and over, including haemorrhage in the brain parenchyma with possible ventricular or spinal-cord involvement, and excludes traumatic haemorrhage, subarachnoid haemorrhage, ischaemic stroke, cases in younger people, and primary prevention.[1][2]

• Recognise intracerebral haemorrhage as a neurological and life-threatening emergency, and promote rapid recognition, physiological stabilisation, urgent imaging and specialist management.[3][2]
• Standardise assessment of severity, prognosis and treatment needs through tools including the Glasgow Coma Scale, National Institutes of Health Stroke Scale, Hemphill intracerebral haemorrhage score, Functional Outcome in Patients With Primary Intracerebral Haemorrhage score and modified Rankin Scale.[3][4][5][6]
• Deliver integrated management covering blood-pressure control, reversal of anticoagulant-associated coagulopathy, management of intracranial pressure, neurosurgical assessment, specialised inpatient care and prevention of complications.[4][7][8][9]
• Provide person-centred rehabilitation to optimise physical, cognitive, emotional, communication, social and functional recovery, with goals agreed alongside the person and their family or carer.[10]
• Reduce recurrence and longer-term disability through blood-pressure management, individualised decisions on antithrombotic therapy, and treatment or surveillance of underlying vascular lesions, tumours or other causes where appropriate.[11][12][5]

Implementation

The delivery model is a coordinated clinical network linking ambulance services, emergency departments, diagnostic imaging, neurology, neurosurgery, critical care, stroke units, medical and surgical wards, rehabilitation, specialist outpatient services and primary care. It draws on clinical practice guidelines, scientific-society recommendations and literature reviewed in English and Spanish, while using Chilean population studies for epidemiological information.[2]

• Stabilise airway, breathing and circulation before hospital arrival, document symptom onset or last-known-well time, previous function and relevant medicine use, notify the receiving hospital, and transfer the person to the nearest facility able to manage acute stroke and provide computed tomography.[3][13]
• Activate a stroke code or emergency alert system, obtain non-contrast brain computed tomography ideally within 25 minutes and no later than one hour, and use magnetic resonance imaging or vascular imaging when needed to distinguish haemorrhage, identify expansion risk or investigate an underlying cause.[13][14][15]
• Obtain neurological, neurosurgical and intensive-care consultation in person or through telemedicine following diagnosis, with referral protocols for centres without specialised stroke, neurocritical-care or neurosurgical services.[3][16][17]
• Maintain written protocols and trained staff for intensive blood-pressure management and coagulation reversal, with accessible intravenous medicines and anticoagulant-specific reversal options.[8][9]
• Organise inpatient management in specialised stroke units, neurological intensive or intermediate-care units, or critical-care units, supported by multidisciplinary medical, nursing and rehabilitation teams.[4][16][17]
• Monitor neurological status, consciousness, ventilation, oxygen saturation, swallowing, blood pressure, temperature, glycaemia and intracranial pressure as clinically indicated; assess swallowing promptly, ideally within 24 hours, before oral intake or oral medicines.[18][17][19][20]
• Assess early for surgical management where reduced consciousness, cerebellar haemorrhage, brainstem compression, obstructive hydrocephalus, intraventricular haemorrhage, raised intracranial pressure or mass effect warrants intervention.[4][21][22][23]
• Prevent and manage inpatient complications through respiratory support, nutrition and aspiration prevention, venous thromboembolism prevention, seizure treatment when seizures occur, infection assessment, temperature control and glycaemic management.[16][20][24][25]
• Deliver timely rehabilitation through regular multidisciplinary review, objective assessment of progress and adjustment of agreed goals; continue rehabilitation in community or home settings where needed.[18][10][26]
• Support secondary prevention through ongoing blood-pressure control, review of anticoagulation according to thromboembolic and haemorrhagic risk, and clinical follow-up or lesion-specific treatment for cavernomas, arteriovenous malformations and other underlying causes.[18][11][12][5]

The guidance provides clinical timing targets, assessment scales and monitoring actions, but the supplied material does not specify a programme-level indicator framework, reporting schedule, audit system, budget, financing source or formal accountability arrangements.[27][13][28][29]

Monitoring & Evaluation

Monitoring is primarily clinical and episode-based, using standardised severity, functional and physiological assessments throughout emergency, inpatient, surgical, rehabilitation and follow-up care. The extracts do not establish a document-wide programme monitoring framework, routine reporting schedule, surveillance system, audit requirement, indicator set or named accountability body.[27][30][29][31]

• Assess initial neurological severity using the Glasgow Coma Scale, National Institutes of Health Stroke Scale, Hemphill intracerebral haemorrhage scale and Functional Outcome in Patients With Primary Intracerebral Haemorrhage score.[3][4][13]
• Document symptom onset or the last time the person was known to be well, prior functional status, relevant medical history and anticoagulant exposure to inform urgent management.[3][13][32]
• Perform non-contrast computed tomography or magnetic resonance imaging rapidly to distinguish haemorrhage from infarction, with imaging ideally within 25 minutes and no later than one hour after stroke-code activation.[3][13]
• Use CT contrast-extravasation imaging, including the spot sign, and vascular imaging where indicated to assess haematoma-expansion risk and investigate secondary causes.[32][14][15]
• Monitor neurological deterioration closely during acute admission, as substantial deterioration may continue during the first 24 hours after hospitalisation.[2][13]
• Monitor consciousness, spontaneous ventilation, oxygen saturation, swallowing, temperature, blood glucose, blood pressure and, where clinically indicated, intracranial pressure.[18][7][17][20]
• Complete swallowing assessment as early as possible, ideally within 24 hours of admission, with periodic reassessment because swallowing function may change during acute illness.[4][17][19]
• Measure capillary blood glucose at intervals of one to six hours according to clinical circumstances, and monitor temperature periodically while investigating possible infectious causes of fever.[19][20]
• Consider intracranial-pressure monitoring and treatment for severe presentations, including Glasgow Coma Scale scores of 8 or below, clinical herniation, substantial intraventricular haemorrhage or hydrocephalus; routine use of invasive devices is not supported because conclusive benefit is lacking.[18][33]
• Check fibrinogen after reversal of fibrinolytic-associated coagulation disorders and consider further cryoprecipitate when fibrinogen is below 150 mg/dL.[9]
• Maintain written protocols and trained staff for intensive blood-pressure control and management of coagulation disorders, providing a practical mechanism for consistent clinical practice.[8][9]
• Review neurological and cardiopulmonary status frequently in specialised stroke, neurocritical, intermediate-care or critical-care settings, with referral protocols for centres lacking these capabilities.[16][17]
• Use outcome evidence to inform care models: specialised stroke-unit care was associated with reduced death or dependence in a meta-analysis, while the cited intracerebral-haemorrhage subgroup had a relative risk of 0.79, with a 95% confidence interval of 0.61 to 1.00.[16]
• Monitor surgical and ventricular-drainage complications, including intracranial pressure, catheter obstruction, ventriculitis, rebleeding, functional outcome and mortality when treating intraventricular haemorrhage.[22][23]
• Use standardised rehabilitation assessments to measure progress objectively, convene multidisciplinary reviews, and revise goals and therapy intensity as recovery potential changes over subsequent months.[10][26]
• Continue clinical follow-up for deep cavernous lesions and monitor for progressive deficits or recurrent bleeding; no broader follow-up indicator set is specified.[12]

Costing & Financing

No explicit budget, costing methodology, financing source, funding gap, resource-mobilisation plan, allocation, or economic assumption is specified in the extracts.[27][4][2][28][10]

• Provide service capacity for rapid neuroimaging, laboratory testing, stroke-code activation, telemedicine or in-person specialist consultation, neurosurgery, critical care, specialised stroke units, rehabilitation and referral transport, although no unit costs or funding mechanisms are given.[3][13][16][17]
• Maintain accessible intravenous antihypertensive medicines and agent-specific anticoagulant-reversal treatments within written local protocols, supported by staff training; the source does not assign costs to these requirements.[8][9]
• Recognise a potential efficiency concern where ventricular drainage is undertaken without simultaneous consideration of additional haematoma-evacuation techniques, as delay may permit deterioration and duplicate operating-theatre expenditure.[22]
• Record a Ministry of Health procurement reference, tender ID 757-100-L117, connected to technical authorship, but provide no monetary amount or financial terms.[27][34]