急性脑卒中救治规范与流程英文课件

1、急性脑卒中救治规范与流程(英文）wengui yu, md, phddivision of neurological critical caredepartments of neurological surgery and neurology neurocritical care of acute stroke急性脑卒中救治规范与流程(英文）the primary diagnoses in neuro-icu intracerebral hemorrhage (ich) subarachnoid hemorrhage (sah) ischemic stroke/tias status post

2、 craniotomy for tumor resection traumatic brain injury (sdh, edh) status post coil embolization, angioplasty, or stenting. 急性脑卒中救治规范与流程(英文）thrombolysis for ischemic stroke intravenous t-pa intraarterial t-paendovascular therapy angioplasty/stenting merci retrieval penumbra clot retrieval coil emboli

3、zation of aneurysmsurgical treatment hemicraniectomy for mca strokeadvances in stroke managements/p ia tpa急性脑卒中救治规范与流程(英文）1. neuro-monitoring1). neuro exam simple and effectiveneurologic changes that need immediate attention mental status change decreased levels of consciousness: lethargy, stupor, c

4、oma. disorientation: name, place, time, and event. speech difficulty: expressive or receptive aphasia cranial nerve palsy: dilated and fixed pupil(s) new weakness/numbness急性脑卒中救治规范与流程(英文）2). neuroimagingsa). ct to follow hematoma expansion, cerebral edema, mass effect, herniation, or hydrocephalus.

5、indicated in first few days after stroke, deterioration on neuro exam, sedated and paralyzed patient.急性脑卒中救治规范与流程(英文）b). cta contrast extravasation predicts hematoma expansionct demonstrates a left putaminal hematoma (a). a small focus of enhancement isseen on cta (b), consistent with extravasation

6、on postcontrast ct (c). unenhancedct image 1 day after presentation reveals hematoma enlargement and ivh (d). - wada et al. stroke. 2007;38:1257 - golstein et al. neurology. 2007;20;68(12):889-94.急性脑卒中救治规范与流程(英文）contrast extravasation predicts mortality in ich a 69-yo man underwent imaging 2 hrs fol

7、lowing onset of right-sided paralysis.admission ncct demonstrates a left thalamic hematoma with extension into the thirdventricle (a). cta (b) and cect (c), respectively, show 2 foci of active extravasation(arrows). follow-up ncct 12 hrs later shows marked hematoma growth with hemorrhagein both late

8、ral ventricles and severe hydrocephalus (d). the patient had a fatal outcome.becker et al. stroke 1999;30:2025-2032 kim et al. american journal of neuroradiology 2008; 29:520-525.急性脑卒中救治规范与流程(英文）the dwi map demonstrates a small area of diffusion restriction in the right mca territory consistent with

9、 acute infarction. the mtt map demonstrates the infarct penumbra which is larger than the infarct, indicating the presence of salvageable tissue.c). mri: vasospasm/delayed ischemic deficit急性脑卒中救治规范与流程(英文）intraventricular catheterintraparenchymal catheterepidural devicesubdural catheter3). icp monito

10、ring急性脑卒中救治规范与流程(英文）4). transcranial doppler (tcd)non-invasive.measure the velocity of flow in the intracranial circulation.the doppler shift measured is inversely proportional to the diameter of the vessel.figs show the position of tcd probes and a sample tracing of normal mca waveform.急性脑卒中救治规范与流程

11、(英文）tcd criteria of vasospasmvasospasmmean blood flow velocity mild120 cm/s severe180 cm/s急性脑卒中救治规范与流程(英文）5). electroencephalograph (eeg) monitoringeeg of a comatose patient showed generalized sharp theta rhythm consistent with non-convulsive seizure activity. 急性脑卒中救治规范与流程(英文）continuous veeg monitor

12、ing: status epilepticus急性脑卒中救治规范与流程(英文）2. cardiac-respiratory monitoring cardiac arrhythmia, stunned myocardium, and acs are common complications of stroke.right hemisphere infarct (insula) increases the risk of cardiac complications (autonomic dysfunction). ecg changes include st-segment depression

13、, qt dispersion, inverted t waves, and prominent u waves.elevated levels of cardiac enzymes are common in patients with sah. stroke may also cause respiratory distress, impaired oropharyngeal mobility, airway obstruction, and aspiration pneumonia.急性脑卒中救治规范与流程(英文）3. critical care of patient with acut

14、e stroke initiate neuro-cardiac-respiratory monitoring, intubate for airway protection if comatose or gcs 8, manage hypertensive crisis or hypotension, treat headache, agitation, hyperglycemia, and aspiration, evaluate electrolyte imbalance, seizure, fever, and infection, gi and dvt prophylaxis.急性脑卒

15、中救治规范与流程(英文）4. management of blood pressure (bp)both elevated and low bp are associated with poor outcome after stroke. the common causes of elevated bp: stress of the stroke (large infarct, ich, sah). increased intracranial pressure. hypoxia, a full bladder, nausea/vomiting, pain/headache. preexist

16、ing hypertension.blood pressure reduction to prevent hemorrhagic conversion or rehemorrhage. to prevent hyperperfusion syndrome. blood pressure augmentation hypotension. vasospasm.急性脑卒中救治规范与流程(英文）management of hypertensive crisisinitial therapy labetalol 10-20 mg iv q30 min prn hydralazine 10-20 mg

17、iv q30 min prnfor persistent hypertension nicardipine 2-15 mg/hr iv infusion or nipride 0.3-10 mcg/kg/min iv infusionstart and titrate oral medications bb, ccb, acei, hydralazine, or clonidine.in case of hypotension reduce anti-hypertensive and iv fluid bolus. 急性脑卒中救治规范与流程(英文）indications: prevention

18、 of hemorrhage or hematoma expansion urgent neurosurgical interventioncoagulopathy from warfarin or hepatic failure factor viia 40-80 g/kg iv + vitamin k 10 mg iv daily x 3. prothrombin complex concentrate (pcc): 25-50 units/kg iv. fresh frozen plasma (ffp) 10-20 ml/kgheparin-induced coagulopathy pr

19、otamine sulfate 1mg for each 100 u heparin received in the last 3ht-pa induced thrombolysis cryoprecipitates 6-8 unitsthrombocytopenia or platelet dysfunction single donor platelets 2-6 units5. urgent reversal of coagulopathy急性脑卒中救治规范与流程(英文）6. management of elevated icp/hydrocephalusexternal ventric

20、ular drainage (evd): open at 0-20 cm h2o. osmolar therapy: mannitol 0.5-1 gm/kg iv q4hhypertonic saline: 3% or 23.4% naclhyperventilation (short term use prior to emergent surgery):- hypocarbia (pco2 30-35) reduction of cbfsedatives/paralytic agentspentobarbital coma急性脑卒中救治规范与流程(英文）7. decompressive

21、craniectomy large cerebellar infarct or hemorrhage. hemisphere infarct with edema and potential herniation.jauss et al. j neurol 1999; 246:257-64raco et al. neurosurgery. 2003;53(5):1061. robertson et al. neurosurgery. 2004;55(1):55.急性脑卒中救治规范与流程(英文）hemicraniectomy for mca stroke3 clinical trials: de

22、cimal, hamlet, and destiny.93 patients randomized to surgical or medical therapy.patients 60 years of age.the timing of surgery 48 hrs after stroke onset.outcome with mrs at 1 yr. 2007;6(3):215-22 急性脑卒中救治规范与流程(英文）1033 patients with supertentorial ich enrolled in 87 centersrandomized within 72 hr of

23、ich onset early surgery no surgery early (but 20% had later surgery) showed no benefit in mortality good outcomesurgical treatment of ich (stich trial) mendel ad, et al. lancet 2005, 365:387急性脑卒中救治规范与流程(英文）8. intra-ventricular t-pa for ivhintraventricular hemorrhage (ivh) occurs in 15-40% of patient

24、s with ich or sah. severe ivh causes hydrocephalus, increased icp or herniation. death occurs in all patients with gcs less than 8 and severe ivh. intra-ventricular t-pa facilitate the clearance of ivh improve outcome. findlay et al. neurosurgery 74:803807, 1991rohde et al, j neurol neurosurg psychi

25、atry 1995;58: 447451naff et al. neurosurgery 2004;54:57783急性脑卒中救治规范与流程(英文）9. vasospasm and delayed ischemic deficit diagnosis occur at day 3-10, neuorologic deterioration. tcd, cta or cerebral angiography. prevention and treatment nimodipine 60 mg q4h, triple h (hypervolemia, hypertension, and hemod

26、ilution) keep cvp 8-12, raise map by 15-20% to improve cerebral perfusion. endovascular therapy: balloon angioplasty or ia nicardipine.l-vabasilar arteryvasospasm急性脑卒中救治规范与流程(英文）10. cerebral salt wasting syndrome hyponatremia, hypovolemia, and elevated serum bnp. associated with brain edema, vasospa

27、sm and poor outcome. aggressive treatment with 3% nacl infusion salt tablets florinef 0.1-0.2 mg /day急性脑卒中救治规范与流程(英文）11. therapeutic hypothermiahypothermia in global ischemia moderate hypothermia (32-34 oc) for 12-24 hrs increases favorable neurologic outcome at 6 months in comatose survivors of out

28、-of-hospital cardiac arrest.bernard sa, et al. nejm 2002; 346:557-563.michael holzer et al. nejm 2002; 346:549-556. hypothermia in ischemic stroke. safe and feasible. effective in controlling icp due to the mass effect of large infarct. reduce mca stroke mortality. schwab et al. stroke 2001; 32:2033

29、-5. schwab et al. stroke 1998; 29:2461-6. schwab et al. stroke 1998; 29:1988-93. gumula et al. acad emerg med. 2006;13(8):820-7.m acintosh pic tim age form atis not supportedfavorable outcomem acintosh p ic tim age form atis not supportedsurvival home/rehab急性脑卒中救治规范与流程(英文）12. management of seizuretr

30、eatment of status epilepticus1). lorazepam 2 mg iv q 2 min, up to 0.1 mg/kg. 2). fosphenytoin 20 mg/kg iv, 150 mg/min. 3). fosphenytoin 10 mg/kg 4). intubate patient if not done yet. 5). phenobarbital 20 mg/kg 50 mg/min 6). phenobarbital 10 mg/kgmidazolam 7). anesthesia: pentobarbital burst suppress

31、ion propofol or midazolam急性脑卒中救治规范与流程(英文）treatment of nonconvulsive status epilepticus1). lorazepam 2 mg iv q 2 min, up to 0.1 mg/kg. 2). valproate 25 mg/kg over 4-8 min. 3). phenobarbital 20 mg/kg 50 mg/min. 4). intubate patient if not done yet. 5). phenobarbital 10 mg/kg. 6). propofol or midazolam

32、. 急性脑卒中救治规范与流程(英文）13. recombinant factor viia for acute ichmayer et al. 2005;352:777-85 phase 2b trial 399 patients were randomized to receive placebo, or 40, 80, and 160 g/kg of rfviia within 4 h symptom onset. primary outcome: ich volume at 24 h clinical outcome at 90 days急性脑卒中救治规范与流程(英文）effects o

33、f rfviia on ich volumes volumeplacebo40g/kg80g/kg160g/kgbaseline24 2222 2223 24 26 3024 hr32 2926 2928 3128 32mean increase8.7 5.44.22.9p value, vs placebo0.130.040.008急性脑卒中救治规范与流程(英文）rfviia limits the growth of hematoma and reduces mortalityby approximately 35%.mayer et al. 2005;352:777-85急性脑卒中救治规范

34、与流程(英文）factor seven for acute hemorrhagic stroke (fast) phase 3 trial 841 patients with ich were randomized to receive placebo 20 g/kg of rfviia 80 g/kg of rfviia primary end point: poor outcome, defined as severe disability or death 90 days after the strokemayer et al. 2008;358:2127-37急性脑卒中救治规范与流程(

35、英文）figure 3. clinical outcome at 90 days according to the modified rankin scale. rfviia does not reduce the rate of death or severe disability after ich.急性脑卒中救治规范与流程(英文）clinical centers (with numbers of patients in parentheses)wang yj, beijing tiantan hospital, beijing (73); selchen, trillium health

36、 centre, mississauga, on, canada (25);lvarez sabin, hospital vall dhebron, barcelona (24); steiner, universittsklinikum und medizinische fakultt heidelberg, germany (22);hill, foothills medical centre, calgary, ab, canada (21);hennerici, univ of heidelberg, mannheim, germany (16); ng hua, national n

37、euroscience institute, singapore (16); toni, universit la sapienza, rome (10); woolfenden, vancouver general hospital, canada (10)flaherty, university of cincinnati, cincinnati (9)hall, medical college of georgia, augusta (9); gladstone, sunnybrook and womens college, toronto (9)washington universit

38、y, st. louis (9); rosand, massachusetts general hospital, boston (5); parra, columbia university, new york (2)grotta, university of texas, houston (2) hemphill, university of california, san francisco, (1) 急性脑卒中救治规范与流程(英文）14. prognosticate outcome of coma depends on cause rather than the depth of th

39、e coma. coma from drug intoxication and metabolic causes carries the best prognosis. coma from global hypoxia-ischemia carries the least favorable prognosis.急性脑卒中救治规范与流程(英文）a 51 year old woman was comatose for 8 weeks after cardiac bypass surgery. the follow-up ct 13 years later are shown below.func

40、tional outcome: mrs 1 急性脑卒中救治规范与流程(英文）case study #1 a 44 yo man with h/o htn and prior r-mca stroke was last seen normal 7:30 am. found unresponsive with r-sided weakness and 911 activation to ed at 11:30 am. initial nih stroke scale 21. intubated to ct scan.急性脑卒中救治规范与流程(英文）ct head at 11:46 am急性脑卒中救

41、治规范与流程(英文）prior to ia thrombolysiss/p ia t-pa/reopro 急性脑卒中救治规范与流程(英文）repeat ct 24h after ia t-pa showed a small mca stroke. he was extubated with mild expressive aphasia. treated with anticoagulation for lv thrombus.recovered with mild cognitive problem at 3 month-f/u.急性脑卒中救治规范与流程(英文）who is the lucky patient?急性脑卒中救治规范与流程(英文）case study #2 a 67 yo man with h/o cad and dm presented with sudden onset ha, vertigo, slurred speech and right sided weakness.急性脑卒中救