急性脑血管疾病的诊断

广东省中医院脑血管病中心,急性缺血性脑血管疾病诊断与治疗,脑血管疾病(cerebrovascular disease, CVD)：由于脑血管异常导致的脑部病变。急性脑血管疾病：脑卒中（stroke) 由于各种血管性原因引起的一种非外伤性脑局部血液循环障碍，出现急性局灶性神经功能损伤的一组疾病。,概 念,世界范围的顽症,440万,致死第二位,第一位死亡原因,脑卒中是导致人类死亡的第三位疾病 致残的第一位疾病 MONICA研究表明：脑卒中为中国城市人群死亡第二位原因，农村人群女性第二位、男性第三位死亡原因。 脑卒中死亡率高达30%，约1/3丧失生 活自理能力，存活者3/4不同 程度丧失劳动能力 脑卒中中国每年数百亿人民币损失,脑卒中的危害,脑与脑血管,脑,脑组织生理纨绔子弟,脑组织重约1500g占体重2-3%脑血流占每分心搏出量的20%耗氧量占全身20-30几乎无能量储备,cerebral circulation,cerebral circulation,脑卒中,超过24小时,24小时内恢复,出血性,缺血性,脑梗塞,TIA,脑表面,破入脑实质,脑出血,蛛网膜下腔出血,卒中的分类,TIA定义,短暂性脑缺血发作（transient ischemic attack， TIA）：是指时间短暂并经常反复发作的脑局部供血不足引起的供血区局限性脑功能障碍。每次发作数分钟至1小时，不超过24小时即完全恢复,TIA定义,TIA是指局灶性脑缺血导致突发短暂性、可逆性神经功能障碍。发作持续数分钟，通常在30分钟内完全恢复，超过1小时常遗留轻微神经功能缺损或CT及MRI显示脑组织缺血征象。,TIA新定义,2004年6月第5届世界脑卒中会议TIA工作组提出，TIA是短暂发作的神经功能障碍，由局灶性脑和视网膜缺血引起，典型的TIA临床症状持续不超过小时，并且没有脑梗死依据。,TIA临床表现颈内动脉系统,常见症状为对侧单肢无力、轻偏瘫、麻木感觉 和或对侧面部轻瘫。特征性体征有眼动脉交叉瘫（病侧一过性黑朦或失明、视野模糊、对侧偏瘫及感觉障碍）和Horner征交叉瘫（病侧Horner征、对侧偏瘫）；优势半球受累出现暂时性失语。,TIA临床表现椎基底动脉系统,常见症状有一过性眩晕、共济失调、耳鸣。特征性症状有转头或仰头时下肢突然失去张力而跌 倒，称跌倒发作。 短暂性全面性遗忘症，发作时出现短时间记忆丧 失。 双眼视力障碍发作，出现暂时性皮质盲。可有复 视、吞咽困难、构音不清，脑干的交叉瘫、一侧视力障碍伴对侧局限性肢体无力等。,脑梗死定义,指由于脑血管阻塞或血流动力学障碍等引起的脑组织缺血、坏死的病理状况。,缺血性卒中的分类,卒中,缺血性卒中,原发性出血脑出血蛛网膜下腔出血,穿支动脉病（腔隙性）,心源性栓塞心房纤颤瓣膜病心室血栓其他,隐匿性卒中,其他不常见原因血栓前状态夹层动脉炎偏头痛/血管痉挛药物滥用其他,动脉粥样硬化性脑血管病,低灌注,动脉源性栓塞,15%,85%,20%,25%,20%,30%,5%,动脉粥样硬化性脑梗死,卒中,缺血性卒中,原发性出血脑出血蛛网膜下腔出血,穿支动脉病（腔隙性）,心源性栓塞心房纤颤瓣膜病心室血栓其他,隐匿性卒中,其他不常见原因血栓前状态夹层动脉炎偏头痛/血管痉挛药物滥用其他,动脉粥样硬化性脑血管病,低灌注,动脉源性栓塞,15%,85%,20%,25%,20%,30%,5%,分水岭脑梗死,分水岭脑梗死,又称边缘带梗死，是两条脑动脉供血区边缘带发生的脑梗死。常由于脑动脉狭窄基础上的血液动力学改变所引起。,分水岭脑梗死,卒中,缺血性卒中,原发性出血脑出血蛛网膜下腔出血,穿支动脉病（腔隙性）,心源性栓塞心房纤颤瓣膜病心室血栓其他,隐匿性卒中,其他不常见原因血栓前状态夹层动脉炎偏头痛/血管痉挛药物滥用其他,样硬化动脉粥性脑血管病,低灌注,动脉源性栓塞,15%,85%,20%,25%,20%,30%,5%,动脉源性栓塞,卒中,缺血性卒中,原发性出血脑出血蛛网膜下腔出血,穿支动脉病（腔隙性）,心源性栓塞心房纤颤瓣膜病心室血栓其他,隐匿性卒中,其他不常见原因血栓前状态夹层动脉炎偏头痛/血管痉挛药物滥用其他,动脉粥样硬化性脑血管病,低灌注,动脉源性栓塞,15%,85%,20%,25%,20%,30%,5%,腔隙性脑梗死,腔隙性脑梗死,指脑深部穿通动脉阻塞引起的脑梗死，好发于基底节、内囊、丘脑和脑干。,腔隙性脑梗死,腔隙性脑梗死,卒中,缺血性卒中,原发性出血脑出血蛛网膜下腔出血,穿支动脉病（腔隙性）,心源性栓塞心房纤颤瓣膜病心室血栓其他,隐匿性卒中,其他不常见原因血栓前状态夹层动脉炎偏头痛/血管痉挛药物滥用其他,动脉粥样硬化性脑血管病,低灌注,动脉源性栓塞,15%,85%,20%,25%,20%,30%,5%,心源性脑栓塞,卒中,缺血性卒中,原发性出血脑出血蛛网膜下腔出血,穿支动脉病（腔隙性）,心源性栓塞心房纤颤瓣膜病心室血栓其他,隐匿性卒中,其他不常见原因血栓前状态夹层动脉炎偏头痛/血管痉挛药物滥用其他,动脉粥样硬化性脑血管病,低灌注,动脉源性栓塞,15%,85%,20%,25%,20%,30%,5%,其他原因,出血性脑梗死,指在脑梗死的基础上发生出血，占脑梗死35，出血可以发生在脑梗死后或同时发生。,出血性脑梗死,脑硬死病灶（不可逆的障碍）,梗死病灶周围部（半暗带，可逆的障碍）,脑梗死病理生理,临床表现ACA梗死,大脑前动脉,大脑前动脉,大脑半球内侧面前部3/4皮质,深穿支,内囊前肢和尾状核,皮质支,产生对侧下肢运动及感觉障碍，可伴小便失禁。,对侧中枢性面、舌及上肢瘫痪,双侧闭塞,出现淡漠、欣快等精神症状，大小便失禁、强握等原始反射,临床表现 MCA梗死,大脑中动脉,皮质支,供应大脑半球外侧面，包括额叶、顶叶、颞叶、脑岛的皮质及皮质下白质,偏瘫和偏身感觉障碍，以面部及上肢为重,深穿支（豆纹动脉）,供应尾状核、豆状核、内囊上3/5,引起对侧上下肢同等程度偏瘫，一般无感觉障碍及偏盲,大脑中动脉,主干闭塞时，可引起对侧偏瘫，偏身感觉障碍和偏盲三偏综合症，左半球受累时还可有失语，可有意识障碍。,大脑后动脉,深穿支,皮质支,主干闭塞,起始部,临床表现 PCA梗死,主干起始端 对侧偏瘫、共济失调、偏身舞动运动，可伴同侧动眼神经麻痹。两侧闭塞 发生昏迷，双侧椎体束征和去脑强直。丘脑和丘脑膝状体动脉的穿通支阻塞 丘脑综合征，表现为对侧痛温觉和（或）深感觉丧失。,大脑后动脉,在与后交通动脉吻合的远端段 颞叶内侧和枕叶皮质的损害，常见对侧同向偏 盲。两侧大脑后动脉远端 皮质盲，病人失明，瞳孔光反应存在。,大脑后动脉,椎动脉、小脑后下动脉,突然眩晕恶心呕吐眼球震颤病变侧的9和10对颅神经麻痹霍纳征小脑性共济失调同侧面部及对侧半身痛温觉障碍,延髓背外侧综合征,基底动脉,基底动脉闭塞 眩晕、耳鸣、复试、构音障碍、吞咽困难、共济失调等症状。基底动脉主干闭塞 四肢瘫、延髓麻痹及昏迷等，常迅速死亡。脑桥基底部梗死 闭锁综合症，患者神志清楚，但由于四肢瘫痪，双侧面瘫及延髓麻痹，不能讲话，只能以眼球上下活动表达意思。,临床表现腔隙性脑梗死,腔隙综合征,纯运动性轻偏瘫（PMH）：一侧面部、上下肢无力，无感觉障碍、视野缺损及皮层功能障碍；病灶位于内囊后肢、脑桥基底或大脑脚。纯感觉性卒中（PSS）：对侧偏身或局部感觉障碍，如麻木、烧灼感或沉重感、刺痛、僵硬感等；病灶位于丘脑腹后核、内囊后肢、放射冠、脑干。,腔隙综合征,感觉运动性卒中（SMS）：出现偏身感觉障碍合并轻偏瘫；病灶在丘脑腹后核、内囊后肢。共济失调性轻偏瘫（AH）：病变对侧PMH伴小脑性济失调。病灶在放射冠和半卵圆中心、内囊后肢、丘脑伴内囊后肢、脑桥基底部上1/3与下2/3交界处。,腔隙综合征,构音障碍手笨拙综合征（DCHS）：严重构音障碍、吞咽困难、病变对侧中枢性面舌瘫、同侧手轻度无力及精细动作笨拙，书写困难、指鼻不准。病灶在脑桥基底部上1/3与下2/3交界处。腔隙状态：严重精神障碍、痴呆、假性球麻痹、双侧锥体束征、类帕金森综合征和尿失禁等。,选择适当的辅助检查,越来越多的辅助检查,卒中辅助检查,脑结构学检查（CT、MRI）脑血管检查（Dupplex、TCD、CTA、MRA）灌注影像检查（CT-P、MR-PWI）其他脑影像检查卒中病因相关检查危险因素评估,卒中辅助检查,脑结构学检查（CT、MRI）脑血管检查（Dupplex、TCD、CTA、MRA）灌注影像检查（CT-P、MR-PWI）其他脑影像检查卒中病因相关检查危险因素评估,CT,脑梗死的CT影像表现,急性期脑梗死,卒中辅助检查,脑结构学检查（CT、MRI）脑血管检查（Dupplex、TCD、CTA、MRA）灌注影像检查（CT-P、MR-PWI）其他脑影像检查卒中病因相关检查危险因素评估,颈动脉双功能超声（Dupplex）,正常CCA, ICA, ECA 血流图,经颅多普勒超声（TCD）：MCA,CTA,CTA,CTA,CTA,MRA,DSA,DSA,卒中辅助检查,脑结构学检查（CT、MRI）脑血管检查（Dupplex、TCD、CTA、MRA）灌注影像检查（CT-P、MR-PWI）其他脑影像检查卒中病因相关检查危险因素评估,影像表现、CBF和脑组织改变的关系,脑灌注成像,MR”灌注“成像MR动态磁敏感对比成像 MR动脉自旋标记成像CT灌注成像XeCT灌注成像,CT灌注成像图像后处理,CT 灌注成像,BT-PFI,DWI-PWI Mismatch,PET,卒中辅助检查,脑结构学检查（CT、MRI）脑血管检查（Dupplex、TCD、CTA、MRA）灌注影像检查（CT-P、MR-PWI）其他脑影像检查卒中病因相关检查危险因素评估,纤维束成像,纤维束成像,ASL-FAIR,Photic Stimulus,CO2 inhaled,fMRI,卒中辅助检查,脑结构学检查（CT、MRI）脑血管检查（Dupplex、TCD、CTA、MRA）灌注影像检查（CT-P、MR-PWI）其他脑影像检查卒中病因相关检查危险因素评估,卵圆孔未闭,卒中辅助检查,脑结构学检查（CT、MRI）脑血管检查（Dupplex、TCD、CTA、MRA）灌注影像检查（CT-P、MR-PWI）其他脑影像检查卒中病因相关检查危险因素评估,危险因素评估,脑卒中的危险因素（1）, 年龄 吸烟 性别 酗酒 高血压 血脂异常 心脏病 颈动脉狭窄 糖尿病 TIA,脑卒中的危险因素（2）, 肥胖 缺乏合理运动 高半胱氨酸血症 食盐摄入量高 血小板聚集性高 口服避孕药 遗传因素 季节与气候 膳食营养素缺乏 药物滥用 促凝危险因素 其它疾病,缺血性卒中诊断依据,病史临床症状和体征辅检 一般辅检 影像检查 特殊检查 其他,缺血性卒中鉴别诊断,卒中？ 瘤卒中？癫痫？晕厥？ 偏头痛？神经耳鼻喉？ 代谢性脑病？ 缺血性卒中？出血性卒中？TIA？脑梗死？,缺血性卒中的治疗,欧洲卒中组织 - ESO - 执行委员会和写作委员会,缺血性卒中和短暂性脑缺血发作治疗指南2008,广东省中医院神经一科 尤劲松,Guidelines Ischaemic Stroke 2008,ESO 指南 2008,内容:教育, 分派和急诊室卒中单元影像和诊断预防一般治疗急性期处理 并发症的处理康复,Public Awareness and Education对公众的教育,建议开展对人群的卒中意识教育(Class II, Level B)。建议开展对专业人士（护理人员/急诊内科医生等）的教育以提高卒中意识(Class II, Level B) 。Educational programmes to increase awareness of stroke at the population level are recommended (Class II, Level B)。Educational programmes to increase stroke awareness among professionals (paramedics/emergency physicians) are recommended (Class II, Level B)。,Referral and Patient Transfer患者转诊,建议EMS迅即启动、优先分派卒中患者(Class II, Level B).建议优先转运并提前通知接受医院(Class III, Level B) 。建议可疑卒中患者应被立即转运至最近的有卒中单元的能提供超早期治疗的医疗中心(Class III, Level B) 。建议急救人员应接受简单的评定方法（面-上肢-语言测试）训练来识别卒中(Class IV, GCP)。Immediate EMS contact and priority EMS dispatch are recommended (Class II, Level B)Priority transport with advance notification to the receiving hospital (outside and inside hospital) is ecommended (Class III, Level B)It is recommended that suspected stroke victims should be transported without delay to the nearest medical centre with a stroke unit that can provide ultra-early treatment (Class III, Level B)It is recommended that dispatchers and ambulance personnel be trained to recognise stroke using simple instruments such as the Face-Arm-Speech Test (Class IV, Good Clinical Practice GCP),建议在接收医院立即进行分诊、临床、实验室、影像评估，正确诊断，治疗决策、治疗安排(Class III, Level B) 。建议在边远和农村地区采用直升机转运以提高治疗的速度(Class III, Level C) 。建议在边远和农村地区采用电视远程医疗以提高治疗的速度(Class II, Level B)。建议对可疑TIA患者立即转运到有卒中单元能提供专家评估和紧急治疗的TIA诊所或医疗中心(Class III, Level B)。Immediate emergency room triage, clinical, laboratory and imaging evaluation, accurate diagnosis, therapeutic decision and administration of appropriate treatments at the receiving hospital are recommended (Class III, Level B)It is recommended that in remote or rural areas helicopter transfer should be considered in order to improve access to treatment (Class III, Level C)It is recommended that in remote or rural areas telemedicine should be considered in order to improve access to treatment (Class II, Level B)It is recommended that patients with suspected TIA be referred without delay to a TIA clinic or to a medical centre with a stroke unit that can provide expert evaluation and immediate treatment (Class III, Level B),Referral and Patient Transfer患者转诊,Emergency Management急诊管理,建议为卒中患者开辟绿色通道(Class III, Level C) 。建议安排表3所列各项辅助检查(Class IV, GCP)。Organisation of pre-hospital and in-hospital pathways and systems for acute stroke patients is recommended (Class III, Level C)Ancillary tests, as outlined in table 3 , are recommended (Class IV, GCP),卒中患者的急诊检查,Stroke Services and Stroke Units 卒中治疗和卒中单元,建议所有卒中患者应在卒中单元内接受治疗(Class I, Level A) 。建议医疗系统应保证在患者需要时能得到高水平的内外科治疗(Class III, Level B)。建议发展临床网络，包括远程医疗，使患者能接受高水平专家治疗(Class II, Level B) 。It is recommended that all stroke patients should be treated in a stroke unit (Class I, Level A)It is recommended that healthcare systems ensure that acute stroke patients have access to high-technology medical and surgical stroke care when required (Class III, Level B)The development of clinical networks, including telemedicine, is recommended to expand access to high-technology specialist stroke care (Class II, Level B),Diagnostic Imaging影像诊断,建议对可疑TIA或卒中患者行紧急CT (Class I),或MRI (Class II), (Level A) 。建议如果行MRI检查，应包括DWI和T2梯度回波序列(Class II, Level A)。建议对TIA、小中风、症状自发缓解的患者行诊断性检查，包括紧急血管影像（超声、CTA、MRA） (Class I, Level A) 。In patients with suspected TIA or stroke, urgent cranial CT (Class I), or alternatively MRI (Class II), is recommended (Level A)If MRI is used, the inclusion of diffusion-weighted imaging (DWI) and T 2 * -weighted gradient echo sequences is recommended (Class II, Level A)In patients with TIA, minor stroke or early spontaneous recovery, immediate diagnostic work-up, including urgent vascular imaging (ultrasound, CT angiography, or MR angiography), is recommended (Class I, Level A),Other Diagnostic Tests其他诊断性检查,建议对卒中患者早期临床评估，包括生理参数和常规血液检查(Class I, Level A) 。建议所有患者行12导连心电图，另外，也建议对缺血卒中和TIA患者行持续心电监测(Class I, Level A)。急诊处理后，对可疑节律紊乱且无卒中的其他原因时，应完善24小时Holter监测(Class I, Level A)。部分病人应做超声心电图。In patients with acute stroke and TIA, early clinical evaluation, including physiological parameters and routine blood tests, is recommended (Class I, Level A)For all stroke and TIA patients, a sequence of blood tests is recommended ( tables 3 and 5 )It is recommended that all acute stroke and TIA patients should have a 12-lead electrocardiography (ECG). In addition, continuous ECG recording is recommended for ischaemic stroke and TIA patients (Class I, Level A)It is recommended that for stroke and TIA patients seen after the acute phase, 24-hour Holter ECG monitoring should be performed when arrhythmias are suspected and no other causes of stroke are found (Class I, Level A)Echocardiography is recommended in selected patients (Class III, Level B),General Stroke Treatment卒中的一般治疗,建议对较重的神经功能缺损患者72小时内间断监测神经功能、脉搏、血压、体温、血氧饱和度(Class IV, GCP) 。建议对血氧饱和度220/120 mm Hg或严重心衰、主动脉夹层、高血压脑病患者谨慎降压(Class IV, GCP) 。建议避免突然快速的降压(Class II, Level C)。建议对由于低血容量或神经源性的低血压患者给予扩容治疗(Class IV, GCP) 。建议监测血糖水平(Class IV, GCP) 。建议静脉胰岛素治疗血糖水平10mM患者(Class IV, GCP) 。Routine BP lowering is not recommended following acute stroke (Class IV, GCP)Cautious BP lowering is recommended in patients with extremely high BPs ( 220/120 mm Hg) on repeated measurements, or with severe cardiac failure, aortic dissection, or hypertensive encephalopathy (Class IV, GCP)It is recommended that abrupt BP lowering be avoided (Class II, Level C)It is recommended that low BP secondary to hypovolaemia or associated with neurological deterioration in acute stroke should be treated with volume expanders (Class IV, GCP)Monitoring serum glucose levels is recommended (Class IV, GCP)Treatment of serum glucose levels 180 mg/dl ( 10 m M ) with insulin titration is recommended (Class IV, GCP),卒中的一般治疗,建议严重低血糖（37.5发热患者应筛查是否感染(Class IV, GCP)。建议对体温37.5发热患者给予扑热息痛或物理降温(Class III, Level C)。不建议对免疫正常患者预防使用抗生素(Class II, Level B)。It is recommended that severe hypoglycaemia 37.5 ) should prompt a search for concurrent infection (Class IV, GCP)Treatment of pyrexia (temperature 37.5 ) with paracetamol and fanning is recommended (Class III, Level C)Antibiotic prophylaxis is not recommended in immunocompetent patients (Class II, Level B),Specific Treatment卒中的特殊治疗,推荐对3h内的缺血卒中患者静脉给予rtPA（0.9mg/kg，最大量90mg，10%静推，其余90%1h滴完） (Class I, Level A) 。静脉给予rtPA也许对3h以上的缺血卒中患者有益，但不推荐作为临床常规(Class I, Level B) 。对于选择性溶栓病人，多模式影像评估也许有用，但不推荐作为临床常规(Class III, Level C)。建议溶栓前血压高于185/110mmHg患者应给予降压(Class IV, GCP)。Intravenous rtPA (0.9 mg/kg body weight, maximum 90 mg), with 10% of the dose given as a bolus followed by a 60-min infusion, is recommended within 3 h of onset of ischaemic stroke (Class I, Level A)Intravenous rtPA may be of benefit also for acute ischaemic stroke beyond 3 h after onset (Class I, Level B) but is not recommended for routine clinical practiceThe use of multimodal imaging criteria may be useful for patient selection for thrombolysis but is not recommended for routine clinical practice (Class III, Level C)It is recommended that BP of 185/110 mm Hg or higher is lowered before thrombolysis (Class IV, GCP),卒中的特殊治疗,如果神经功能缺损由于急性缺血卒中所致，建议以癫痫起病的患者也可使用静脉rtPA (Class IV, GCP) 。建议对于年龄80岁的患者可选择性使用静脉rtPA (Class IV, GCP) 。6h时间窗内的急性MCA阻塞的患者可选择动脉溶栓(Class II, Level B)。建议对急性基底动脉阻塞患者选择性的行动脉溶栓，3h后的基底动脉阻塞患者也可行静脉rtPA溶栓(Class III, Level B)。It is recommended that intravenous rtPA may be used in patients with seizures at stroke onset, if the neurological deficit is related to acute cerebral ischaemia (Class IV, GCP)It is recommended that intravenous rtPA may also be administered in selected patients under 18 years and over 80 years of age, although this is outside the current European labelling (Class III, Level C)Intra-arterial treatment of acute MCA occlusion within a 6-hour time window is recommended as an option (Class II, Level B)Intra-arterial thrombolysis is recommended for acute basilar occlusion in selected patients (Class III, Level B). Intravenous thrombolysis for basilar occlusion is an acceptable alternative even after 3 h (Class III, Level B),卒中的特殊治疗,建议缺血卒中后48h内给予阿司匹林（160325 mg 负荷量）(Class I, Level A)。建议如果计划抗血栓治疗，阿司匹林或其它抗血小板治疗应在24h内给予(Class IV, GCP) 。不建议急性缺血卒中患者常规使用其他抗血小板制剂（单用或联用）(Class III, Level C)。不建议使用血小板糖蛋白IIb-IIIa抑制剂(Class I, Level A)。不建议急性缺血卒中患者早期给予大分子肝素、低分子肝素或肝素类似物治疗(Class I, Level A) 。目前，不建议使用神经保护药物治疗缺血卒中(Class I, Level A)。It is recommended that aspirin (160325 mg loading dose) be given within 48 h after ischaemic stroke (Class I, Level A)It is recommended that if thrombolytic therapy is planned or given, aspirin or other antithrombotic therapy should not be initiated within 24 h (Class IV, GCP)The use of other antiplatelet agents (single or combined) is not recommended in the setting of acute ischaemic stroke (Class III, Level C)The administration of glycoprotein- inhibitors is not recommended (Class I, Level A)Early administration of unfractionated heparin (UFH), low molecular weight heparin or heparinoids is not recommended for the treatment of patients with acute ischaemic stroke (Class I, Level A)Currently, there is no recommendation to treat ischaemic stroke patients with neuroprotective substances (Class I, Level A),Brain edema and Elevated Intracranial Pressure脑水肿和颅内压升高,建议60岁以下的恶性MCA梗死患者发病48h内行手术减压治疗(Class I, Level A) 。建议颅内压升高的患者于手术前予渗透性脱水(Class III, Level C) 。关于低体温治疗梗死占位无推荐意见(Class IV, GCP)。建议大面积梗死压迫脑干的患者行脑室引流或外科减压(Class III, Level C)。Surgical decompressive therapy within 48 h after symptom onset is recommended in patients up to 60 years of age with evolving malignant MCA infarcts (Class I, Level A)It is recommended that osmotherapy can be used to treat elevated ICP prior to surgery if this is considered (Class III, Level C)No recommendation can be given regarding hypothermic therapy in patients with space-occupying infarctions (Class IV, GCP)It is recommended that ventriculostomy or surgical decompression be considered for treatment of large cerebellar infarctions that compress the brainstem (Class III, Level C),Prevention and Management of Complications并发症的预防和管理,建议卒中后的感染患者给予合适的抗生素(Class IV, GCP)。不建议预防使用抗生素，左氧氟沙星对急性卒中患者可能有害(Class II, Level B)。建议充分补给水分和弹力袜以降低静脉血栓发生率(Class IV, GCP)。建议早期活动以预防并发症，如吸入性肺炎、深静脉血栓和褥疮(Class IV, GCP)。建议对于DVT和PE高风险患者皮下给予低剂量肝素或低分子肝素(Class I, Level A)。 It is recommended that infections after stroke should be treated with appropriate antibiotics (Class IV, GCP) Prophylactic administration of antibiotics is not recommended, and levofloxacin can be detrimental in acute stroke patients (Class II, Level B) Early rehydration and graded compression stockings are recommended to reduce the incidence of venous thromboembolism (Class IV, GCP) Early mobilization is recommended to prevent complications such as aspiration pneumonia, DVT and pressure ulcers (Class IV, GCP) It is recommended that low-dose subcutaneous heparin or low molecular weight heparins should be considered for patients at high risk of DVT or PE (Class I, Level A),并发症的预防和管理,建议给予抗癫痫药物预防卒中后癫痫再发(Class I, Level A)，对于无癫痫发作的近期卒中患者不建议预防使用抗癫痫药物(Class IV, GCP)。建议对每个卒中患者评估跌倒风险(Class IV, GCP) 。建议给有跌倒风险的卒中患者补充钙和维生素D(Class II, Level B)。建议给有骨折史的女性给予二磷酸盐(Class II, Level B)。建议对尿失禁的卒中病人进行专业性的评估和处理(Class III, Level C)。 Administration of anticonvulsants is recommended to prevent recurrent post-stroke seizures (Class I, Level A). Prophylactic administration of anticonvulsants to patients with recent stroke who have not had seizures is not recommended (Class IV, GCP) An assessment of falls risk is recommended for every stroke patient (Class IV, GCP) Calcium/vitamin D supplements are recommended in stroke patients at risk of falls (Class II, Level B) Bisphosphonates (alendronate, etidronate and risedronate) are recommended in women with previous fractures (Class II, Level B) In stroke patients with urinary incontinence, specialist assessment and management is recommended (Class III, Level C)。,并发症的预防和管理,建议对卒中患者进行吞咽评估，但治疗方法尚无特殊(Class III, GCP) 。口服食品添加剂仅建议给予无呕吐的营养不良卒中患者(Class II, Level B)。建议对吞咽障碍的卒中患者早期开始鼻饲（48h内）(Cla