Understanding the Evolving Care of Rehabilitation and Stroke Recovery

 In my 15 years of writing, I have seen NOTHING EXACT that helps recovery. It's all still useless guidelines!

Understanding the Evolving Care of Rehabilitation and Stroke Recovery

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June 1, 2025

Author(s):

Francois Bethoux, MD,Andrew Russman, DO

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Key Takeaways

• Neurorehabilitation aims to enhance daily function and quality of life post-stroke through individualized strategies, emphasizing early and intensive rehabilitation.
• Recent advancements include rehabilitation technology, telerehabilitation, community exercise programs, and neuromodulation, offering promising results in motor recovery.

Explore innovative neurorehabilitation strategies for stroke recovery, emphasizing personalized approaches and advanced technologies to enhance patient outcomes.

Francois Bethoux, MD

Neurorehabilitation is a well-established component of post-stroke medical management. Rehabilitation is described by the World Health Organization as “a set of measures that assist individuals who experience (or are likely to experience) disability to achieve and maintain optimal physical, sensory, intellectual, psychological, and social functioning in interaction with their environment.”¹ According to Francois Bethoux, MD, Chair, Department of Physical Medicine and Rehabilitation at Cleveland Clinic, “rehabilitation is a process rather than a discrete event, involves multiple disciplines, and follows the patient’s journey through many transitions and milestones.”

Guidelines recommend starting rehabilitation as early as possible (often within 48 hours after a stroke).² Rehabilitation is often more intensive in the first 6 to 12 months after a stroke, and may start in an inpatient rehabilitation facility, in the home, or in an outpatient setting.

The overall aim of neurorehabilitation is to maximize a person’s ability to perform daily activities and to optimize their quality of life(NOTICE NOT RECOVERY!) through an individualized approach. Mechanisms by which this goal(The only goal in stroke is 100% recovery! Why is no one working towards that?) is achieved include promoting brain plasticity, teaching compensatory strategies (for example, training a non-dominant limb or using an assistive device), managing symptoms that can hinder recovery such as post-stroke pain and spasticity, and empowering the person to maintain a healthy lifestyle.

Andrew Russman, DO

"Multimodal approaches tailored to the individual patient’s disability are necessary to optimize stroke recovery," according to Andrew Russman, DO, a vascular neurologist and Head, Cleveland Clinic Enterprise Stroke Program. Recent advances and new approaches to stroke rehabilitation include:

• Rapidly growing use of rehabilitation technology, such as robotic devices, virtual reality, and instrumented treadmills
• Easier access to rehabilitation in the home environment, for example with telerehabilitation and home monitoring
• Development of community exercise programs that are accessible to individuals with disabilities.
• Use of neuromodulation (transcranial magnetic stimulation or direct current stimulation, deep brain stimulation, vagal nerve stimulation) in combination with rehabilitation therapies focused on movement or task repetitions, with promising results in terms of motor recovery even years after a stroke in some individuals.

Mark Bain, MD

Mark Bain, MD, Head, Cerebrovascular Neurosurgery at Cleveland Clinic, recently began implanting an FDA-approved vagal nerve stimulation device³ in patients with moderate to severe upper limb weakness, to help improve their rehabilitation after stroke. Building upon their positive 2023 phase I trial,⁴ Andre Machado, MD, (Chief, Neurological Institute at Cleveland Clinic) and colleagues are leading the RESTORE study, a pivotal multi-center clinical study of deep brain stimulation combined with rehabilitation to augment post-stroke motor recovery.

Overall, stroke recovery is a long-term dynamic process that requires a holistic and personalized approach, adjusted over time depending on the person’s evolving needs.“We need to be a beacon for our patients striving for something more in their stroke recovery.Embracing these innovative approaches to stroke recovery is critical to expand the treatment options that our patients demand,” concluded Dr. Russman.

REFERENCES
1. World Health Organization (WHO). World Report on Disability. www.who.int/disabilities/world_report/2011/report/en/. Accessed April 27, 2025.
2. Sall J, Eapen BC, Tran JE, Bowles AO, Bursaw A, Rodgers ME. The Management of Stroke Rehabilitation: A Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2019 Dec 17;171(12):916-924.
3. Francisco GE, Engineer ND, Dawson J, Kimberley TJ, et al. Vagal nerve stimulation paired with upper-limb rehabilitation after stroke: 2 and 3-year follow-up from the pilot study. Archives Phys. Med. Rehab. 2023;108(8):1180-1187.
4. Baker KB, Plow EB, Nagel, S, Rosenfledt AB, et al. Cerebellum deep brain stimulation for chronic post-stroke motor rehabilitation: a phase I trial. Nature Medicine 2023;29:2366-2374.

An evidence map of clinical practice guideline recommendations and quality of non-pharmaceutical interventions for post-stroke emotional disorders

Big fucking whoopee.

Guidelines; NOT PROTOCOLS!  Guidelines don't guarantee recovery; properly constructed protocols do!

 An evidence map of clinical practice guideline recommendations and quality of non-pharmaceutical interventions for post-stroke emotional disorders

Ye Li1, Jing Zhang2, Jia-ji Li1, Dan Zhao1, Ling Tang1* and Ying-Hui Jin3*

1Nursing Department of Dong fang Hospital, Beijing University of Chinese Medicine, Beijing, China

2Department of Neurosurgery, Handan Central Hospital, Handan, China

3Center for Evidence-Based and Translational Medicine, Zhong nan Hospital of Wuhan University, Wuhan, Hubei, China

Edited by

Nicola Smania, University of Verona, Italy

Reviewed by

Valentina Varalta, University of Verona, Italy

Daniela Burguêz, Hospital São Lucas da PUCRS, Brazil

*Correspondence

Ling Tang, tangling@zxyjhhl.org.cn; Ying-Hui Jin, jinyinghuiebm@163.com

Received 28 February 2025

Accepted 26 May 2025

Published 09 June 2025

Citation

Li Y, Zhang J, Li J-j, Zhao D, Tang L and Jin Y-H (2025) An evidence map of clinical practice guideline recommendations and quality of non-pharmaceutical interventions for post-stroke emotional disorders. Front. Neurol. 16:1580799. doi: 10.3389/fneur.2025.1580799

Background: Clinical practice guidelines (CPGs) have an indispensable role in guiding the selection of various non-pharmaceutical interventions (NPIs) for post-stroke emotional disorders (PSED). However, little is known about their quality and recommendations. This study aims to critically appraise the quality of existing NPIs for PSED CPGs and extract relevant recommendations, present the research distribution of various NPIs in an evidence map, and assist clinicians in making decisions.

Methods: A systematic search was undertaken in PubMed, Embase, CINAHL, Web of Science, China National Knowledge Infrastructure, Wanfang, VIP, SinoMed, and international guideline developing institutions from origin to November 20, 2024, to identify the CPGs on NPIs for PSED. The CPGs finally selected were blindly evaluated by two reviewers using the Appraisal of Guidelines Research & Evaluation (AGREE) II instrument and the reporting quality was evaluated using the RIGHT statement. The overall agreement among reviewers was analyzed using intraclass correlation coefficient (ICC).

Results: Nine guidelines were included and evaluated. Two CPGs were grade A (recommended) and seven CPGs were grade B (recommended with modification). The reporting rate of RIGHT ranged from 40.00 to 80.00%. Nine NPIs were extracted, and there were similarities and differences between the recommendations.

Conclusion: This study provides specific direction for improving the quality of CPGs for NPIs for PSED, and provides useful information for clinicians and stakeholders, and provides a basis for clinical decision-making.

Keywords

cerebral stroke; emotional disorder; non-pharmacological intervention; clinical practice guidelines; evidence-based medicine

1 Introduction

Cerebral stroke is the second largest cause of death worldwide, accounting for 11.6% of the total number of deaths (1). It is characterized by a high incidence, high recurrence rate, high disability rate and high mortality rate, leading to an increased burden of disease around the world (1). Post-stroke emotional disorder (PSED) is one of the most common and serious complications, commonly occurring at all stages of the disease and its pathogenesis is still unclear (2). It includes post stroke depression (PSD), post-stroke anxiety (PSA), post-stroke comorbid anxiety and depression (PSCAD), post-stroke emotional imbalance (PSEI) and post-stroke anger proneness (PSAP) (3). Approximately one-third of stroke survivors develop some form of emotional disorder (2–4). Studies have shown (5, 6) that emotional disorders are closely related to patients’ prognosis. If patients are not treated in time, it will affect the recovery of neurological function and the ability to return to society, and even lead to increased mortality. There is no universally effective method for the treatment of PSED, and although drug therapy has a certain effect, there are many side effects (7). Some systematic reviews and meta-analyses have shown that non-pharmaceutical interventions (NPIs) can effectively reduce emotional symptoms and improve patient’s quality of life (7–9). Many authoritative organizations have issued a number of CPGs related to the treatment and rehabilitation of Stroke, which contain NPIs to help health care workers and patients to make local health care decisions (10).

The purpose of this study is to evaluate the quality of guidelines related to NPIs for PSED, to make relevant recommendations for NPIs use in PSED, to provide information for standardized practice and management, to identify potential directions that CPGs should focus on in the future, and to provide a reference for relevant policy development and clinical practice.

2 Materials and methods

2.1 Search strategy

We systematically searched the following databases: PubMed, Web of Science, Embase, CINAHL, China National Knowledge Infrastructure (CNKI), Wanfang, VIP, SinoMed, YiMaiTong. We also hand-searched 6 databases of international guideline developing institutions: Guideline International Network (GIN), Registered Nurses’ Association of Ontario (RNAO), Scottish Intercollegate Guidelines Network (SIGN), National Institute for Health and Care Excellence (NICE), National Guideline Clearinghouse (NGC), and New Zealand Guidelines Group (NZGG). Articles were retrieved by combining subject terms and free terms, from origin to November 20, 2024. The full search strategies are shown in Supplementary material 1.

2.2 Study selection

In our study, the inclusion criteria were: guidelines which provided recommendations regarding NPIs for PSED and included access to the full text. Both evidence-based clinical practice guidelines and consensus-based clinical practice guidelines (EB-CPGs and CB-CPGs) were included, and the guidelines had to at least contain details of evidence retrieval and literature evaluation. We have described both consensus statements and expert opinions as CB-CPGs (11). The CPGs had to include NPIs for PSED. The most commonly included NPIs were: psychotherapy, social support therapy, traditional Chinese medicine non-pharmacological therapies, and physical therapy (12). If guidelines were available in multiple languages (such as English and Chinese), only the version in the original language was eligible for inclusion. In cases of updated guidelines, only the most recent version was considered. Exclusion criteria were editorial or correspondence articles that summarized organizational clinical practice guidelines.

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The MIND diet may help reduce Alzheimer's risk, a large study shows

 For me, guidelines like this are not specific enough to follow. I would have to spend vast amounts of time that are better spent having fun.

The MIND diet may help reduce Alzheimer's risk, a large study shows

Following the diet, which is heavy on leafy green vegetables and berries, is associated with a strong and consistent reduction in cognitive decline.

June 2, 2025, 8:30 AM EDT / Updated June 2, 2025, 10:19 AM EDT

By Linda Carroll

New evidence finds that the MIND diet lives up to its name, even when it is started later in life.

Middle-aged and older participants in a large, long-term study were less likely to develop Alzheimer’s disease or other types of dementia if they followed a diet filled with green, leafy vegetables, olive oil, whole grains and lots of berries, according to a report presented Monday at the annual meeting of the American Society for Nutrition.

Researchers from University of Hawaii at Mānoa and the University of Southern California discovered that adhering to the MIND diet, which combines the Mediterranean diet with the blood-pressure-lowering DASH diet, results in a stronger and more consistent reduction in dementia risk than what is seen with other healthy diets.

The new findings suggest it’s never too late to switch to a healthy diet, said the study’s lead author, Song-Yi Park, an associate professor at the University of Hawaii at Mānoa. “It shows that sticking to a healthy diet, as well as improving the health of the person’s diet over time, is very important for older adults who want to prevent dementia.”

While all the Mediterranean-related diets appear to be good for the brain, the MIND dietary pattern was specifically designed for brain health.

“One important difference is that MIND includes berries, which have been linked to brain health,” Park said.

The MIND diet, or Mediterranean-DASH Intervention for Neurodegenerative Delay, scores individual foods based on how protective they are and how much is eaten. Berries — especially strawberries and blueberries — for example, get a score of 1 if two or more servings are consumed per week. The score drops to 0.5 if just one serving per week is consumed and a score of 0 if none are.

A person’s individual diet gets an overall rating by adding up the scores for individual foods. The higher the overall score, the better it is for the person’s brain.

Park and her colleagues turned to data from nearly 93,000 U.S. adults who had provided information about what they ate as part of a research project known as The Multiethnic Cohort to get a closer look at how diet influenced the risk of developing dementia.

The Multiethnic Cohort was started in the early 1990s through a joint effort of the University of Hawaii Cancer Center and the USC Norris Comprehensive Cancer Center. The men and women enrolled in the study came from five ethnic/racial populations: Japanese Americans, Native Hawaiians, Black Americans, Latinos and whites.

At the outset, the 215,000 participants were ages 45 to 75. When data for the new study was analyzed, more than 21,000 participants had developed Alzheimer’s or a related dementia.

At the beginning of the study, people who scored higher for adherence to MIND had a 9% lower risk of developing dementia.

The amount of reduction varied among the racial groups in the new analysis. Greater risk reduction, 13%, was seen in participants who identified as Black, Latino or white.

Participants who improved their adherence to MIND over the 10-year period had a 25% lower risk of dementia compared with those whose adherence declined, and that trend was seen across all age and racial groups.

How to follow the MIND diet

Some suggestions for reaching the optimal score for the MIND diet, according to a 2015 study:

• Leafy green vegetables, such as kale, spinach, broccoli, bok choy and mustard: six or more servings per week
• Other vegetables: one serving per day
• Nuts, such as almonds, walnuts or pistachios: five or more servings per week
• Cheese: less than one per week
• Whole grains: three or more per day
• Fish (not fried): one or more servings per week
• Red meat: less than one serving per week
• Fast fried foods: less than one per week
• Pastries and sweets: less than five servings per week

Park cautioned that like all observational studies, the new research reports an association and doesn’t prove that the diet prevents dementia.

It is a high-quality study, Dr. Walter Willett, a professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health and a professor of medicine at the Harvard Medical School, said in an email.

“It adds to the evidence that a Mediterranean-type diet has important benefits for reducing the risk of dementia,” said Willett, who wasn’t involved in the research. “The differences between groups defined by race/ethnicity may well be due to random variation, so at this time it’s reasonable to assume that this healthy dietary pattern has benefits for all groups."

When it comes to leafy green vegetables, it’s probably best to consume a variety rather than a single type, Willett said.

“In particular, spinach is good in many ways, but has high oxalate content and high intake of spinach can cause kidney stones,” he said.

In general, the MIND diet is in line with the principles of the two diets it’s built from, said Dr. Yian Gu, an associate professor of neurological sciences at the Columbia University Irving Medical Center. “Each of those diets has unique characteristics,” she said.

The Mediterranean diet emphasizes multiple daily servings of fruits and vegetables, along with whole grains, legumes, olive oil, seafood, and nuts and seeds, such as chia, flax, pumpkin and sesame.

DASH, or Dietary Approaches to Stop Hypertension, is meant to prevent hypertension, so it emphasizes low salt, which isn’t a major component in the Mediterranean diet.

The MIND diet is easy to follow, Gu said, encouraging people to pick the green, leafy vegetables they prefer. What’s important is to increase the diversity of vegetables.

Another benefit of Mediterranean-type diets: They are helpful with other types of chronic disease, including heart disease and cancer, she said.

Moving Stroke Rehabilitation Forward and Into the Future

 The first line in here should have been: 'Everything in stroke is a fucking failure, we can change that by following this strategy! But, no, the status quo remains! WHICH IS A COMPLETE FUCKING FAILURE!

Proven by these statistics!

1. tPA full recovery? Better than 12%?
2. 30 day deaths? Better than competitors?
3. rehab full recovery? Better than 10%?

 Steven Cramer should know better since he is one of strokes' rock stars.

Dr. Steven Cramer (22 posts to October 2011)

Moving Stroke Rehabilitation Forward and Into the Future

Author: Steven C. Cramer, MD, MScAuthor, Article, & Disclosure Information

Publication: Annals of Internal Medicine

https://doi.org/10.7326/ANNALS-24-03568

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Stroke is relatively common, being the third leading cause of death and disability globally (1). (1 in 4 per WHO will have a stroke!)  Although few internists will direct the care of a patient with a recent stroke, most will treat patients with a history of chronic stroke. Furthermore, internists are often a patient’s lifelong primary contact for stroke-related issues because many rehabilitation physicians and stroke neurologists do not maintain long-term relationships with stroke survivors.

Recent advances in the treatment of an acute stroke have garnered considerable attention, but much of the burden of long-term stroke disability nevertheless remains. Reperfusion therapies, both intravenous and endovascular, can return patients …

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Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

 Notice this is guidelines; NOT PROTOCOLS! so, they really don't know what they are doing to get you recovered. Isn't incompetence wonderful when your stroke medical 'professionals' have NO consequences from it, but it affects you!

Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Authors: Blessen C. Eapen, MD, Johanna Tran, MD, Jennifer Ballard-Hernandez, DNP, NP https://orcid.org/0000-0003-1657-1476, Andrew Buelt, DO, DNP, Carrie W. Hoppes, PT, PhD https://orcid.org/0000-0001-5104-7448, Christine Matthews, CScD, Svetlana Pundik, MD, MSc, James Reston, PhD, MPH, MAJ Zahari Tchopev, MD, MBA https://orcid.org/0000-0003-1829-3190, Lisa M. Wayman, PhD, RN, and MAJ Tyler Koehn, MDAuthor, Article, & Disclosure Information

Publication: Annals of Internal Medicine

https://doi.org/10.7326/ANNALS-24-02205

Eligible for CME Point-of-Care

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• Abstract
• Guideline Development Process
• Highlighted 2024 Guideline Updates
• Comparison With Other Guidelines
• Research Recommendations
• Conclusion
• Supplemental Material
• References
• Comments

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Abstract

Description:

In July 2024, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) released a joint update of their 2019 clinical practice guideline (CPG) for the management(NOT RECOVERY!) of stroke rehabilitation. This synopsis is a condensed version of the 2024 CPG, highlighting the key aspects of the guideline development process and describing the major recommendations.

Methods:

The VA/DOD Evidence-Based Practice Work Group convened a joint VA/DOD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine’s tenets for trustworthy CPGs. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature (English-language publications from 1 July 2018 to 2 May 2023). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to evaluate the evidence. The WG developed 47 recommendations along with algorithms for stroke rehabilitation in the inpatient and outpatient settings. Stakeholders outside the WG reviewed the CPG before approval by the VA/DOD Evidence-Based Practice Work Group.

Recommendations:

This synopsis summarizes where evidence is strongest to support guidelines in crucial areas relevant to primary care physicians: transition to community (case management, psychosocial or behavioral interventions); motor therapy (task-specific practice, mirror therapy, rhythmic auditory stimulation, electrical stimulation, botulinum toxin for spasticity); dysphagia, aphasia, and cognition (chin tuck against resistance, respiratory muscle strength training); and mental health (selective serotonin reuptake inhibitor use, psychotherapy, mindfulness-based therapies for treatment but not prevention of depression).

Stroke is a major cause of morbidity, mortality, and disability worldwide. It is a pervasive medical condition affecting nearly 800 000 persons annually in the United States; approximately 75% of cases are first-time occurrences and the remaining 25% are recurrent strokes (1). Roughly 3% of the U.S. population has experienced a stroke, with a projected increase to 4% by 2030 (1). Stroke is the fifth most prevalent cause of death in the United States, accounting for 1 out of every 21 deaths in the nation; alarmingly, a stroke-related death occurs approximately every 3 minutes 17 seconds (1). Stroke is a leading contributor to long-term disability, with approximately 45% of persons aged 15 to 50 years having at least moderate disability after a stroke (2).

The spectrum of disability resulting from stroke manifests diversely. Typical presentations may include motor weakness and sensory disturbances, impairments in speech and swallowing, vision loss or neglect, cognitive challenges involving inattention or memory loss, and emotional difficulties, such as mood disorders or anxiety. Stroke survivors consequently require tailored and timely rehabilitative interventions aligning with their individualized needs (3, 4). Tailored rehabilitative efforts should start as soon as clinically feasible to maximize functional outcomes. These guidelines are relevant for health care professionals across a stroke patient’s continuum of care, including primary care providers, specialists (physiatry, neurology, and cardiology), nurses, and allied health professionals.

The patient population of interest for the 2024 VA/DOD Clinical Practice Guideline for Management of Stroke Rehabilitation (5) is adult patients with poststroke deficits (motor, cognitive, speech, or sensory) who are candidates for rehabilitation. These guidelines can be found at www.healthquality.va.gov/guidelines/rehab/stroke/index.asp.

The focus and scope of the 2024 clinical practice guideline (CPG) is to provide primary care providers in the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) with recommendations and tools for the rehabilitation management of adult patients (aged ≥18 years) who have had a stroke, with an emphasis on an interdisciplinary care approach. The guideline also provides stroke rehabilitation specialist providers with guidelines for evidence-based practice. It is intended to improve quality of care and clinical outcomes; however, it is not intended to define a standard of care. The 2024 guideline is an update to the 2019 VA/DOD Clinical Practice Guideline for Management of Stroke Rehabilitation (6).

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New stroke guidelines a 'huge step forward,' Northwestern cardiologist says

 And yet the ASA is ignoring the burden of stroke doubling by 2050. You solve that by creating 100% RECOVERY PROTOCOLS! You do have stroke in your name, so solve stroke to 100% recovery! By doing this prevention guideline crapola, you can blame the stroke survivor for not following the guidelines since they are not protocols and don't have EXACT PRESCRIPTIONS!

New stroke guidelines a 'huge step forward,' Northwestern cardiologist says

The American Heart Association and American Stroke Association recently published updated guidelines for the prevention of stroke. Some of the key updates include the utilization of GLP-1 medications and an emphasis on prevention of stroke in women. 

Sadiya Khan, MD, a cardiologist at Chicago-based Northwestern Medicine's Bluhm Cardiovascular Institute, shared her reaction to the updated guidelines with Becker's.

Editor's note: Response has been lightly edited for clarity and length.

Dr. Sadiya Khan: The premise of the update is that stroke is preventable. That there are key approaches to prevent stroke from ever occurring is a huge step forward for patients and public health. 

In the past decade, we have seen a plateau in death rates due to stroke, similar to coronary heart disease. Even more concerning, we are seeing projections that estimate the burden of stroke nearly doubling by 2050, from 3.9% to 6.4%.

Primary prevention could not be a more important issue and the updated guideline is timely.

Other key points that are worth highlighting: 

• Amplifying the focus on women's health. Specifically highlighting the risk of stroke around pregnancy and the role of endometriosis, premature ovarian failure and early onset menopause as unique risk markers for stroke.
  
  
• A focus on heart-healthy behaviors as the first-line strategy for prevention, specifically promotion of physical activity and mediterranean diet.
  
  
• A need to prioritize implementation gaps as the most important and modifiable risk factor  in control of hypertension as implementation is currently dismal making control inequitable.

Unpacking the 2023 American Heart Association Guidelines: The Ascendancy of Neuroendovascular and Neurocritical Care in Aneurysmal Subarachnoid Hemorrhage Management

 When the hell will we get EXACT PROTOCOLS that follow from an EXACT DAMAGE DIAGNOSIS? Until then you better hope your doctor guesses correctly.

Unpacking the 2023 American Heart Association Guidelines: The Ascendancy of Neuroendovascular and Neurocritical Care in Aneurysmal Subarachnoid Hemorrhage Management

Fawaz Al‐Mufti, MD https://orcid.org/0000-0003-4461-7005 fawaz.al-mufti@wmchealth.org, and Stephan Mayer, MDAuthor Info & Affiliations

Stroke: Vascular and Interventional Neurology

Volume 4, Number 4

https://doi.org/10.1161/SVIN.123.001264

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• Nonstandard Abbreviation and Acronym
• Guiding Precision Care and Tailoring Treatment: Neuroendovascular Techniques at the Forefront
• The Rise of Neurocritical Care
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Nonstandard Abbreviation and Acronym

B‐NR evidence

moderate‐quality evidence

The publication of the 2023 American Heart Association (AHA) Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage represents a milestone in the evolving landscape of cerebrovascular medicine.¹ In this commentary, we aim to examine the fundamental shifts brought into focus by these updated guidelines, highlighting the pivotal roles of neuroendovascular management and the neurocritical intensive care unit (neuro‐ICU). While neurointerventionalists have traditionally played a pivotal role in the management of this condition, these guidelines now expand their responsibilities beyond the confines of the operating room.

Traditionally, aneurysmal subarachnoid hemorrhage (aSAH) management has been centered around the timely repair of ruptured cerebral aneurysms. Indeed, the urgency of preventing rebleeding and securing the aneurysm cannot be overstated, as it most significantly impacts patient outcomes. However, the 2023 AHA Guidelines introduce a paradigm shift by recognizing that the battle against aSAH is 2‐fold. While aneurysm repair remains a critical front, there is a more equitable consideration of securement modality. Furthermore, the neuro‐ICU emerges as an equally vital theater where the clinical outcome is determined.

Guiding Precision Care and Tailoring Treatment: Neuroendovascular Techniques at the Forefront

The updated guidelines for managing aSAH emphasize the importance of personalized treatment strategies that consider the unique characteristics of each aneurysm.¹ Extensive research, exemplified by landmark studies such as the ISAT (International Subarachnoid Aneurysm Trial) and the BRAT (Barrow Ruptured Aneurysm Trial), has provided compelling evidence in favor of coiling as the preferred method, particularly for improving patient outcomes in the critical first year following treatment. However, the landscape of aneurysm management is far from 1‐size‐fits‐all, and these guidelines acknowledge the need for a tailored approach(So guessing).

Timing of Treatment

These guidelines stress the significance of prompt intervention for aSAH.¹ Whether through open surgery or endovascular procedures, treating the ruptured aneurysm as early as possible after presentation, preferably within 24 hours, is strongly recommended. This emphasis on timely care reflects the evolving landscape of aneurysm treatment, where precision and expeditiousness are central to achieving the best results for patients. This recommendation is classified as class I, supported by level B‐NR (nonrandomized) evidence. Delaying treatment, particularly beyond a 3‐day window, is discouraged.

Treatment Goal

The primary objective in treating patients with aSAH is the complete obliteration of the ruptured aneurysm whenever feasible(Why not 100% recovery? That's what all survivors want?).¹ This strategy is advocated to reduce the risk of rebleeding and the need for retreatment. In cases for which immediate complete obliteration is not achievable, partial obliteration to secure the rupture site is an acceptable strategy(So failure is acceptable? Good to know!), with retreatment considered for those displaying functional recovery. This recommendation is also classified as class I, with level B‐NR evidence.

Modality of Treatment for Posterior Circulation Aneurysms

These guidelines provide specific guidance for aSAH resulting from ruptured aneurysms in the posterior circulation.¹ In cases in which coiling these aneurysms is feasible, it is recommended over surgical clipping to enhance patient outcomes. This partiality is supported by class I evidence with level B‐R (randomized).

Emergency Clot Evacuation

For patients with aSAH considered salvageable but presenting with a depressed level of consciousness due to a large intraparenchymal hematoma, emergency clot evacuation is recommended.¹ This intervention is pivotal in reducing death and is classified as a class I recommendation with level B‐R evidence.

Specialist Evaluation

The guidelines underline the importance of involving specialists with expertise in both endovascular and surgical treatments for evaluating ruptured aneurysm.¹ This assessment is essential for determining the most suitable treatment approach tailored to individual patient and aneurysm characteristics. Although categorized as class IIb, this recommendation is supported by level B‐R evidence.

Age‐Specific Considerations

Age plays a crucial role in treatment decisions for patients with aSAH.¹ The efficacy of coiling or clipping in improving outcomes for individuals aged >70 years is uncertain, marked as a class IIb recommendation with level C‐LD (limited data) evidence. Conversely, for patients aged <40 years, surgical clipping of the ruptured aneurysm may be considered preferable to enhance treatment durability and overall outcome.

Modality of Treatment for Equally Suitable Aneurysms

In cases of good‐grade aSAH stemming from ruptured aneurysms in the anterior circulation, where primary coiling and clipping are both viable, the 2023 AHA guidelines endorse primary coiling for superior 1‐year functional outcomes.¹ Supported by level A evidence, this recommendation holds a class I designation. However, both treatment options are considered reasonable to achieve favorable long‐term outcomes, constituting a class IIa recommendation with level B‐R evidence.

Endovascular Advancements

These guidelines underscore the growing acceptance of advanced techniques in aneurysm treatment, particularly for wide‐neck aneurysms resistant to traditional methods.¹ Notably, stent‐assisted coiling and flow diversion have gained favor.

Use of Flow Diverters for Fusiform/Blister Aneurysms

In cases of aSAH from ruptured fusiform or blister aneurysms, the use of flow diverters is considered reasonable to reduce death, as indicated by a class IIa recommendation with level C‐LD evidence.¹

Stents or Flow Diverters for Saccular Aneurysms

It is crucial to note, however, that for patients with aSAH with ruptured saccular aneurysms suitable for either primary coiling or clipping, the guidelines advise against using stents or flow diverters due to a higher risk of complications.¹ This recommendation is classified as class III, indicating harm, with level B‐NR evidence. In such instances, where coiling is not deemed suitable or when there is a state of equipoise, the guidelines emphasize the importance of comprehensive multidisciplinary discussions. These discussions should carefully weigh the merits of both neurosurgical and neuroendovascular alternatives, considering each patient's unique circumstances and clinical presentation.

In summary, these guidelines represent a significant step forward in tailoring aSAH treatment to individual patient needs. By emphasizing precision and timeliness in intervention, they aim to achieve the best possible outcomes for patients facing this critical medical condition. The growing acceptance of advanced techniques reflects the dynamic nature of aneurysm management, highlighting the importance of staying abreast of evolving treatment options and engaging in thoughtful, multidisciplinary discussions to optimize patient care.

The Rise of Neurocritical Care

The neuro‐ICU has, in recent years, transitioned from a supporting role to taking center stage in aSAH management. This change is not arbitrary; it is substantiated by a growing body of evidence that underscores the importance of specialized critical care for patients with aSAH.² Multidisciplinary teams in neuro‐ICUs have been shown to significantly enhance patient survival and improve overall outcomes. These teams bring together neurointensivists, neurosurgeons, interventionists, nurses, and other specialists, working in concert to provide the highest standard of care.

The rationale behind this shift is also founded on comparative effectiveness research that consistently demonstrates the benefits of specialized neurocritical care.³ High‐volume centers equipped with dedicated neuro‐ICUs have consistently reported lower mortality rates and improved patient outcomes. This is not merely a theoretical concept but a practical reality that demands acknowledgment and implementation.

Ultimately, the 2023 AHA guidelines serve as a call to action for the medical community, urging physicians, hospitals, medical societies, and national organizations to recognize and champion the importance of neuro‐ICUs in aSAH management.¹ With these guidelines, it is recognized that comprehensive care for patients with aSAH encompasses not only surgical prowess but also the intricate and specialized care delivered within the neuro‐ICU.

Refresher on Mechanical Ventilation

The 2023 guidelines sought to reduce the duration of mechanical ventilation and the risk of hospital‐acquired pneumonia, recognizing that optimal outcomes for critically ill ventilated patients are more likely when evidence‐based care bundles are applied.¹ For patients experiencing aSAH who require mechanical ventilation for >24 hours, it is strongly recommended to implement a standardized ICU care bundle. This recommendation underscores the importance of drawing from the extensive research conducted in both medical and surgical ICUs and consistently applying these principles to patients with high‐grade aSAH (HG‐aSAH). The core components of the ventilator bundle, often referred to as “ABCDEF,” encompass the following aspects:

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Assess, prevent, and manage pain

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Both spontaneous awakening trials and spontaneous breathing trials

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Choice of analgesia and sedation

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Delirium: assess, prevent, and manage

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Early mobility and exercise

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Family engagement and empowerment

In practical terms, what this means for patients with HG‐aSAH is 2‐fold. First, there is substantial evidence supporting the reduction in the use of opioid narcotics and a preference for nonsteroidal anti‐inflammatory drugs like acetaminophen, ibuprofen, and ketorolac.⁴ Second, it involves the regular interruption of sedation, at least once daily, to assess the patient's neurological status and prevent excessive sedation.

Effective prevention of delirium, a common challenge after aSAH, is achieved by avoiding benzodiazepine sedation. Instead, dexmedetomidine is recommended for achieving light sedation while also helping to manage the autonomic dysregulation (ie, storming) often seen in these patients.⁵ Finally, systematic early mobilization necessitates a substantial commitment from both physical therapy and nursing teams. For example, every Hunt–Hess grade III patient capable of following commands with an external ventricular drain should be ambulated daily. These initiatives are best organized and led by a dedicated team of neurointensivists.

Advancements in Neuromonitoring

The updated guidelines emphasize the importance of employing advanced monitoring techniques in the management of patients with HG‐aSAH, particularly when their neurological examination is limited.¹ The direction of neurocritical care, especially for severe brain injuries like HG‐aSAH, is undeniably moving toward sophisticated multimodality brain monitoring. The foundation of this approach involves initiating long‐term continuous video electroencephalogram monitoring, a practice that should be maintained for at least 48 hours in all comatose patients, including those with HG‐aSAH.⁶

Studies have indicated that nonconvulsive seizures are more prevalent in this patient population than previously thought, with a frequency ranging from 10% to 30%.⁷ Importantly, there is substantial evidence to suggest that electrographic seizure activity can significantly impact the patient's level of consciousness and exacerbate secondary brain injury. Furthermore, nonconvulsive seizures have been identified as potential mimics of delayed cerebral ischemia (DCI) after aSAH.^{8, 9}

In recent years, there has been a notable surge in interest and research dedicated to neuromonitoring techniques, encompassing both invasive and noninvasive approaches. One particularly intriguing noninvasive method is transcranial Doppler, often likened to a highly sophisticated ultrasound for the brain. It stands out with an impressive sensitivity exceeding 90%, making it a valuable bedside tool for detecting cerebral abnormalities. However, it is equally important to acknowledge the inherent limitations of this technique. While it excels in sensitivity, it exhibits a specificity of 71% and is also limited by a positive predictive value of 57%. These statistics underscore the need for cautious interpretation and consideration of other clinical factors when using transcranial Doppler data.

Quantitative electroencephalogram patterns have emerged as another noninvasive neuromonitoring approach with great potential.¹ These patterns have shown promise in detecting DCI, with supporting evidence from prospective studies suggesting their clinical relevance. The ability to noninvasively identify DCI is a significant step forward in managing patients with complex neurological conditions.

Invasive neuromonitoring tools, such as brain tissue oxygen monitoring, cerebral microdialysis, and electrocorticography, have also found their place in the realm of DCI detection.¹ This assertion is supported by a comprehensive review encompassing 47 studies. These invasive techniques provide valuable insights into cerebral physiology and can be instrumental in tailoring treatment strategies for individual patients.

In summary, it is important to recognize that the optimal indications and best practices for these neuromonitoring methods are still under investigation. The field continues to evolve as researchers refine their understanding of when and how to deploy these techniques most effectively. Moreover, while these tools hold great promise, their ultimate impact on clinical outcomes in the context of subarachnoid hemorrhage and other neurological conditions remains an area of active exploration.

Antiseizure Medication Controversy

One contentious topic within the management of aSAH that the guidelines grapple with is the use of prophylactic antiseizure medications.¹ While the guidelines do recommend against their routine administration, they do so with an understanding that numerous medical centers continue to adopt a universal approach in administering these medications to patients with aSAH. This disparity in practice highlights the ongoing debate surrounding the benefits and risks associated with prophylactic antiseizure medications in this patient population, particularly in relation to cognitive outcomes.

The rationale for administering prophylactic antiseizure medications stems from concerns about the heightened risk of seizures in patients with aSAH due to the brain's exposure to blood and potential irritants from the hemorrhage. Consequently, some medical institutions have chosen to err on the side of caution by providing antiseizure medications to all patients with aSAH, regardless of their individual risk factors. Although antiseizure medications can effectively reduce the risk of seizures, they are not without their own set of adverse effects. These medications may lead to side effects such as sedation, impaired cognition, and even delirium.

There is a growing body of evidence suggesting that long‐term use of certain antiseizure medications, particularly phenytoin, may be associated with negative cognitive outcomes in patients with aSAH.¹ This raises concerns about whether the potential benefits in terms of seizure prevention outweigh the risks, especially when it comes to the patient's overall cognitive function and quality of life. The cumulative risk of convulsive seizures in hospitalized patients with aSAH has been reported to be 4%. Could the risk of delirium or oversedation from routine antiseizure medication use be higher? It has been reported that continued phenytoin use after discharge in patients with aSAH is associated with worse cognitive outcomes that then improve when the medication is stopped. We do not anticipate any change in practice until clinical trials are conducted to address the issue of antiseizure medication use after aSAH.

The guidelines acknowledge this contentious landscape and the need for further clarity.¹ They highlight the importance of conducting additional clinical trials to better understand the impact of prophylactic antiseizure medications on cognitive outcomes in patients with aSAH. This research would aim to provide concrete evidence regarding the risk–benefit balance, potentially informing more precise recommendations in the future.

Caution Against Hemodynamic Prophylaxis and Hypervolemia

The cautionary approach to hemodynamic augmentation and hypervolemia in the 2023 AHA Guidelines for aSAH management signifies another notable departure from previous strategies.¹ This shift aligns with a broader principle in critical care medicine: the recognition that sometimes less intervention can yield better outcomes. It reflects the acknowledgment that excessive medical interventions, even with the best intentions, can lead to unintended complications that may worsen the patient's condition.

One of the critical aspects of this cautionary approach is the recognition of potential complications associated with aggressive hemodynamic management.¹⁰ By attempting to artificially increase blood pressure or volume in patients with aSAH, health care providers may inadvertently trigger an adverse event. In certain circumstances, we may develop a strong fixation on pursuing active interventions, making it quite tempting to deviate from established protocols. For instance, one might consider, “I know that per the guidelines we're only supposed to induce hypertension in the face of symptomatic vasospasm, but I'm concerned about this particular patient.” In addition to potentially fatal complications such as myocardial infarction and pulmonary edema, the guidelines highlight the risk of exacerbating intracranial pressure, which can be detrimental in patients with aSAH, who are already at risk of elevated pressure within the skull. Additionally, there is the practice of prophylactically inducing hypertension to arbitrary blood pressure targets in every patient. This is a common occurrence.

Another noteworthy concern is the possibility of inducing posterior reversible encephalopathy syndrome, a neurological condition characterized by symptoms such as headache, altered mental status, seizures, and visual disturbances. Posterior reversible encephalopathy syndrome can occur when there is a sudden increase in blood pressure, which can result from aggressive attempts to elevate it in patients aSAH. Recognizing the potential harm of such interventions is crucial in avoiding these complications.

As a final deterrent from aggressive hemodynamic management, the guidelines draw attention to the concept of pressor dependence.¹ This phenomenon is thought to occur when patients are subjected to aggressive blood pressure management, resulting in their bodies becoming reliant on medications to sustain blood pressure within a reasonable target range. This can make it challenging to wean patients off these medications without their blood pressure dropping below the desired threshold. Even if only occurring in the thoughts and concerns of the neuro‐ICU team, this phenomenon can lead to prolonged hospital stays and increased health care resource usage.

More Oral Nimodipine?

With a continuance of the 2012 recommendations, the updated guidelines stamp the significance of early enteral nimodipine initiation in preventing DCI and enhancing functional outcomes in cases of aSAH.¹

In clinical practice, the administration of oral nimodipine occurs along a schedule of 60 mg every 4 hours, following the precedent set by the British Nimodipine Trial in 1989.¹¹ Unfortunately, this regimen often gets discontinued as soon as patients with aSAH exhibit symptomatic vasospasm due to its tendency to cause systemic hypotension. As a result, health care providers often resort to halving the dosage or, more commonly, suspending nimodipine altogether.

The question that has persisted over time is whether there might be superior agents or administration protocols for arterial vasodilators that could provide more effective alternatives.¹ Examples include continuous intravenous infusion of nimodipine, a practice prevalent in Europe, or the use of fasudil and clazosentan, which are favored in Japan. However, it is crucial to note that the current body of evidence does not support an immediate shift in US clinical practice. This underscores the dynamic nature of medical practice, with a recognition that as science advances, treatment strategies may evolve to provide better outcomes for patients with aSAH.

Taking the Guidelines Into Practice

In managing cases of aSAH, it is crucial to recognize that there is not a definitive volume threshold that guides treatment decisions. Each patient's condition must be carefully evaluated, highlighting the importance of individualized care. Timely transfer of patients presenting with acute severe headaches or new neurological deficits is paramount to ensure they undergo appropriate diagnostic assessments and receive specialized care as needed. Patients presenting >6 hours after the onset of severe headaches or those with new neurological deficits should undergo a noncontrast head computed tomography. If this initial scan is negative for aSAH, lumbar puncture becomes essential to confirm or exclude the presence of subarachnoid blood. Similarly, for individuals with spontaneous aSAH and a strong suspicion of aneurysmal involvement but inconclusive results from computed tomography angiography, digital subtraction angiography is the recommended diagnostic tool to identify or rule out cerebral aneurysms promptly.

Prompt identification of aneurysmal sources remains a paramount concern for clinical management.¹ Comprehensive use of advanced imaging methods, such as CT angiography, can significantly aid in this regard. Furthermore, using established grading scales can aid in outcome prediction and guide discussions with patients, families, and surrogates regarding treatment choices. Decisions regarding the treatment of ruptured aneurysms should be made by specialists well versed in both endovascular and surgical approaches. Ultimately, the determination to use clipping, coil embolization, or even flow diversion should be tailored to the patient's distinctive characteristics and the aneurysm's unique features. As highlighted by the current guidelines, there is a growing preference for coil embolization for good‐grade aSAH cases originating from anterior circulation ruptured aneurysms.¹

Neuro‐ICU management should encompass preventive measures such as deep vein thrombosis prophylaxis, maintaining euvolemia, and thoughtful fluid management.¹ While invasive neuromonitoring techniques are increasingly valuable for detecting DCI in high‐grade aSAH cases, the specific goals for fluid management require further clarification. Although the risk of rerupture in aSAH cases is relatively low, the use of imaging to guide treatment decisions for survivors in the neuro‐ICU is recommended, particularly in individuals with residual aneurysms. Regular monitoring for the development of new aneurysms is also essential, especially in younger patients with multiple aneurysms or a strong family history of aSAH.

Additionally, considerations such as the timing of cerebrospinal fluid diversion, choice of fluids, sodium goals, temperature management, glucose control, and monitoring of intracranial pressure and multimodal monitoring are important aspects of comprehensive aSAH management that deserve further attention and investigation.¹ Finally, early identification of deficits, especially in behavioral and cognitive domains, is crucial. Interventions for mood disorders can significantly improve long‐term outcomes, and providing counseling on the higher risk of long‐term cognitive dysfunction may prove beneficial for patients recovering from aSAH.

References at link.