急性脑卒中救治规范与流程英文课件

WenguiYu,MD,PhDDivisionofNeurologicalCriticalCareDepartmentsofNeurologicalSurgeryandNeurologyNeurocriticalCareofAcuteStrokeWenguiYu,MD,PhDNeurocritica1ThePrimaryDiagnosesInNeuro-ICUIntracerebralhemorrhage(ICH)Subarachnoidhemorrhage(SAH)Ischemicstroke/TIAsStatuspostcraniotomyfortumorresectionTraumaticbraininjury(SDH,EDH)Statuspostcoilembolization,angioplasty,orstenting.ThePrimaryDiagnosesInNeuro2ThrombolysisforIschemicStroke

Intravenoust-PAIntraarterialt-PAEndovasculartherapyAngioplasty/StentingMERCIRetrievalPenumbraClotRetrievalCoilembolizationofaneurysmSurgicaltreatmentHemicraniectomyforMCAstrokeAdvancesinStrokeManagementS/pIAtPAThrombolysisforIschemicStro31.Neuro-monitoring1).NeuroExam

SimpleandeffectiveNeurologicchangesthatneedimmediateattentionMentalstatuschangeDecreasedlevelsofconsciousness:lethargy,stupor,coma.Disorientation:name,place,time,andevent.Speechdifficulty:expressiveorreceptiveaphasiaCranialnervepalsy:dilatedandfixedpupil(s)Newweakness/numbness1.Neuro-monitoring1).NeuroE42).Neuroimagings

a).CT

Tofollowhematomaexpansion,cerebraledema,masseffect,herniation,orhydrocephalus.IndicatedinFirstfewdaysafterstroke,Deteriorationonneuroexam,Sedatedandparalyzedpatient.2).Neuroimagings a).CT 5b).CTA

ContrastextravasationpredictshematomaexpansionCTdemonstratesaleftputaminalhematoma(A).AsmallfocusofenhancementisseenonCTA(B),consistentwithextravasationonpostcontrastCT(C).UnenhancedCTimage1dayafterpresentationrevealshematomaenlargementandIVH(D). -Wadaetal.Stroke.2007;38:1257 -Golsteinetal.

Neurology.2007;20;68(12):889-94.b).CTA

Contrastextravasatio6ContrastextravasationpredictsmortalityinICH

A69-yomanunderwentimaging2hrsfollowingonsetofright-sidedparalysis.AdmissionNCCTdemonstratesaleftthalamichematomawithextensionintothethirdVentricle(A).CTA(B)andCECT(C),respectively,show2fociofactiveextravasation(arrows).Follow-upNCCT12hrslatershowsmarkedhematomagrowthwithhemorrhageinbothlateralventriclesandseverehydrocephalus(D).Thepatienthadafataloutcome.Beckeretal.Stroke1999;30:2025-2032Kimetal.AmericanJournalofNeuroradiology2008;29:520-525.Contrastextravasationpredict7TheDWImapdemonstratesasmallareaofdiffusionrestrictionintherightMCAterritoryconsistentwithacuteinfarction.TheMTTmapdemonstratestheinfarctpenumbrawhichislargerthantheinfarct,indicatingthepresenceofsalvageabletissue.C).MRI:vasospasm/delayedischemicdeficit

TheDWImapdemonstratesasma8IntraventricularcatheterIntraparenchymalcatheterEpiduralDeviceSubduralcatheter3).ICPMonitoring3).ICPMonitoring94).TranscranialDoppler(TCD)Non-invasive.Measurethevelocityofflowintheintracranialcirculation.TheDopplershiftmeasuredisinverselyproportionaltothediameterofthevessel.

FigsshowthepositionofTCDprobesandasampletracingofnormalMCAwaveform.4).TranscranialDoppler(TCD)10TCDCriteriaofvasospasmVasospasmMeanbloodflowvelocityMild>120cm/sSevere>180cm/sTCDCriteriaofvasospasmVasos115).Electroencephalograph(EEG)MonitoringEEGofacomatosepatientshowedgeneralizedsharpthetarhythmconsistentwithnon-convulsiveseizureactivity.5).Electroencephalograph(EEG12ContinuousvEEGmonitoring:statusepilepticusContinuousvEEGmonitoring:st132.Cardiac-RespiratoryMonitoring

Cardiacarrhythmia,stunnedmyocardium,andACSarecommoncomplicationsofstroke.Righthemisphereinfarct(insula)increasestheriskofcardiaccomplications(autonomicdysfunction).ECGchangesincludeST-segmentdepression,QTdispersion,invertedTwaves,andprominentUwaves.ElevatedlevelsofcardiacenzymesarecommoninpatientswithSAH.Strokemayalsocauserespiratorydistress,impairedoropharyngealmobility,airwayobstruction,andaspirationpneumonia.2.Cardiac-RespiratoryMonitor143.CriticalCareofPatientwithAcuteStrokeInitiateNeuro-Cardiac-Respiratorymonitoring,IntubateforairwayprotectionifcomatoseorGCS<8,Managehypertensivecrisisorhypotension,Treatheadache,agitation,hyperglycemia,andaspiration,Evaluateelectrolyteimbalance,seizure,fever,andinfection,GIandDVTprophylaxis.3.CriticalCareofPatientwi154.ManagementofBloodPressure(BP)BothelevatedandlowBPareassociatedwithpooroutcomeafterstroke.ThecommoncausesofelevatedBP:Stressofthestroke(largeinfarct,ICH,SAH).Increasedintracranialpressure.Hypoxia,afullbladder,nausea/vomiting,pain/headache.preexistinghypertension.BloodpressurereductionTopreventhemorrhagicconversionorrehemorrhage.Topreventhyperperfusionsyndrome.BloodpressureaugmentationHypotension.Vasospasm.4.ManagementofBloodPressur16ManagementofHypertensiveCrisisInitialtherapyLabetalol10-20mgivq30minprnHydralazine10-20mgivq30minprnForpersistenthypertensionNicardipine2-15mg/hrivinfusionorNipride0.3-10mcg/kg/minivinfusionStartandtitrateoralmedicationsBB,CCB,ACEI,hydralazine,orclonidine.IncaseofhypotensionReduceanti-hypertensiveandIVfluidbolus.ManagementofHypertensiveCri17Indications:PreventionofhemorrhageorhematomaexpansionUrgentneurosurgicalinterventionCoagulopathyfromwarfarinorhepaticfailureFactorVIIa40-80µg/kgiv+VitaminK10mgivdailyx3.Prothrombincomplexconcentrate(PCC):25-50units/kgiv.Freshfrozenplasma(FFP)10-20ml/kgHeparin-inducedcoagulopathyProtaminesulfate1mgforeach100Uheparinreceivedinthelast3ht-PAinducedthrombolysisCryoprecipitates6-8unitsThrombocytopeniaorplateletdysfunctionSingledonorplatelets2-6units5.UrgentReversalofCoagulopathyIndications:5.UrgentReversal186.ManagementofElevatedICP/HydrocephalusExternalventriculardrainage(EVD):openat0-20cmH2O.Osmolartherapy:Mannitol0.5-1gm/kgivq4hHypertonicsaline:3%or23.4%NaClHyperventilation(shorttermusepriortoemergentsurgery):-Hypocarbia(pCO230-35)reductionofCBFSedatives/paralyticagentsPentobarbitalcoma6.ManagementofElevatedICP/197.DecompressiveCraniectomy

Largecerebellarinfarctorhemorrhage.Hemisphereinfarctwithedemaandpotentialherniation.Jaussetal.JNeurol1999;246:257-64Racoetal.Neurosurgery.2003;53(5):1061.

Robertsonetal.Neurosurgery.2004;55(1):55.7.DecompressiveCraniectomyL20HemicraniectomyforMCAStroke3clinicaltrials:DECIMAL,HAMLET,andDESTINY.93patientsrandomizedtosurgicalormedicaltherapy.Patients≤60yearsofage.Thetimingofsurgery<48hrsafterstrokeonset.OutcomewithmRSat1yr.

2007;6(3):215-22

HemicraniectomyforMCAStroke211033patientswithsupertentorialICHenrolledin87centersRandomizedwithin72hrofICHonsetEarlysurgeryNosurgeryearly(but20%hadlatersurgery)ShowednobenefitinMortalityGoodoutcomeSurgicalTreatmentofICH(STICHTrial)

MendelAD,etal.Lancet2005,365:3871033patientswithsupertentor228.Intra-ventriculart-PAforIVHIntraventricularhemorrhage(IVH)Occursin15-40%ofpatientswithICHorSAH.SevereIVHcauseshydrocephalus,increasedICPorherniation.DeathoccursinallpatientswithGCSlessthan8andsevereIVH.Intra-ventriculart-PAFacilitatetheclearanceofIVHImproveoutcome.Findlayetal.Neurosurgery74:803–807,1991Rohdeetal,JNeurolNeurosurgPsychiatry1995;58:447–451Naffetal.Neurosurgery2004;54:577–838.Intra-ventriculart-PAfor239.VasospasmandDelayedIschemicDeficit

DiagnosisOccuratday3-10,Neuorologicdeterioration.TCD,CTAorcerebralangiography.

PreventionandtreatmentNimodipine60mgq4h,TripleH(hypervolemia,hypertension,andhemodilution)KeepCVP8-12,RaiseMAPby15-20%toimprovecerebralperfusion.Endovasculartherapy:balloonangioplastyorIAnicardipine.L-VABasilarArteryVasospasm9.VasospasmandDelayedIsche2410.CerebralSaltWastingSyndromeHyponatremia,hypovolemia,andelevatedserumBNP.Associatedwithbrainedema,vasospasmandpooroutcome.Aggressivetreatmentwith3%NaClinfusionSalttabletsFlorinef0.1-0.2mg/day10.CerebralSaltWastingSynd2511.TherapeuticHypothermiaHypothermiainglobalischemiaModeratehypothermia(32-34oC)for12-24hrsincreasesfavorableneurologicoutcomeat6monthsincomatosesurvivorsofout-of-hospitalcardiacarrest.BernardSA,etal.

NEJM

2002;346:557-563.MichaelHolzeretal.NEJM2002;346:549-556.

Hypothermiainischemicstroke.Safeandfeasible.EffectiveincontrollingICPduetothemasseffectoflargeinfarct.ReduceMCAstrokemortality.Schwabetal.Stroke2001;32:2033-5.Schwabetal.Stroke1998;29:2461-6.Schwabetal.Stroke1998;29:1988-93.Gumulaetal.AcadEmergMed.2006;13(8):820-7.FavorableoutcomeSurvivalHome/Rehab11.TherapeuticHypothermiaHyp2612.ManagementofSeizure12.ManagementofSeizureTreatmentofStatusEpilepticus1).Lorazepam2mgivq2min,upto0.1mg/kg.2).Fosphenytoin20mg/kgiv,@150mg/min.3).Fosphenytoin10mg/kg4).Intubatepatientifnotdoneyet. 5).Phenobarbital20mg/kg@50mg/min 6).Phenobarbital10mg/kgMidazolam7).Anesthesia:Pentobarbitalburstsuppression PropofolorMidazolam12.ManagementofSeizure12.M27TreatmentofNonconvulsiveStatusEpilepticusTreatmentofNonconvulsiveStatusEpilepticus1).Lorazepam2mgivq2min,upto0.1mg/kg.2).Valproate25mg/kgover4-8min.3).Phenobarbital20mg/kg@50mg/min.4).Intubatepatientifnotdoneyet. 5).Phenobarbital10mg/kg. 6).PropofolorMidazolam.

TreatmentofNonconvulsiveSta2813.RecombinantFactorVIIaforAcuteICH

Mayeretal.2005;352:777-85Phase2Btrial399patientswererandomizedtoreceiveplacebo,or40,80,and160µg/kgofrFVIIawithin4hsymptomonset.Primaryoutcome:ICHvolumeat24hClinicaloutcomeat90days

13.RecombinantFactorVIIafo29EffectsofrFVIIaonICHvolumes

VolumePlacebo40µg/kg80µg/kg160µg/kgbaseline24±2222±2223±2426±3024hr32±2926±2928±3128±32Meanincrease2.9Pvalue,vsplacebo0.130.040.008EffectsofrFVIIaonICHvolum30rFVIIalimitsthegrowthofhematomaandreducesmortalitybyapproximately35%.Mayeretal.2005;352:777-85rFVIIalimitsthegrowthofhe31FactorSevenforAcuteHemorrhagicStroke(FAST)Phase3trial841patientswithICHwererandomizedtoreceivePlacebo20µg/kgofrFVIIa80µg/kgofrFVIIaPrimaryendpoint:Pooroutcome,definedasseveredisabilityordeath90daysafterthestrokeMayeretal.2008;358:2127-37FactorSevenforAcuteHemorrh32Figure3.Clinicaloutcomeat90daysaccordingtotheModifiedRankinScale.rFVIIadoesnotreducetherateofdeathorseveredisabilityafterICH.Figure3.Clinicaloutcomeat33ClinicalCenters(withnumbersofpatientsinparentheses)WangYJ,BeijingTiantanHospital,Beijing(73);Selchen,TrilliumHealthCentre,Mississauga,ON,Canada(25);ÁlvarezSabin,HospitalValld'Hebron,Barcelona(24);Steiner,UniversitätsklinikumundMedizinischeFakultätHeidelberg,Germany(22);Hill,FoothillsMedicalCentre,Calgary,AB,Canada(21);…………………………Hennerici,UnivofHeidelberg,Mannheim,Germany(16);NgHua,NationalNeuroscienceInstitute,Singapore(16); ……………Toni,UniversitàLaSapienza,Rome(10); Woolfenden,VancouverGeneralHospital,Canada(10)Flaherty,UniversityofCincinnati,Cincinnati(9) Hall,MedicalCollegeofGeorgia,Augusta(9);Gladstone,SunnybrookandWomen'sCollege,Toronto(9) WashingtonUniversity,St.Louis(9);Rosand,MassachusettsGeneralHospital,Boston(5); Parra,ColumbiaUniversity,NewYork(2) Grotta,UniversityofTexas,Houston(2) Hemphill,UniversityofCalifornia,SanFrancisco,(1)ClinicalCenters(withnumbers3414.PrognosticateOutcomeofComaDependsoncauseratherthanthedepthofthecoma.Comafromdrugintoxicationandmetaboliccausescarriesthebestprognosis.Comafromglobalhypoxia-ischemiacarriestheleastfavorableprognosis.14.PrognosticateOutcomeofC35A51yearoldwomanwascomatosefor8weeksaftercardiacbypasssurgery.Thefollow-upCT13yearslaterareshownbelow.FunctionalOutcome:mRS1A51yearoldwomanwascomato36CaseStudy#1A44yomanwithh/oHTNandpriorR-MCAstrokewaslastseennormal7:30AM.FoundunresponsivewithR-sidedweaknessand911activationtoEDat11:30AM.InitialNIHstrokescale21.IntubatedtoCTscan.CaseStudy#1A44yomanwith37CTheadat11:46AMCTheadat11:46AM38PriortoIAthrombolysis S/PIAt-PA/ReoproPriortoIAthrombolysis S/PI39RepeatCT24hafterIAt-PAshowedasmallMCAstroke.

Hewasextubatedwithmildexpressiveaphasia.

TreatedwithanticoagulationforLVthrombus.

Recoveredwithmildcognitiveproblemat3month-f/u.RepeatCT24hafterIAt-PAsh40Whoistheluckypatient?Whoistheluckypatient?41CaseStudy#2A67yomanwithh/oCADandDMpresentedwithsuddenonsetHA,vertigo,slurredspeechandrightsidedweakness.CaseStudy#2A67yomanwith42MRI/MRA:pontineinfarct,L-ICAstenosis,R-VAocclusionandL-distalVAstenosis.

MRI/MRA:pontineinfarct,L-IC43Developedincompletelocked-insyndrome

whileonmedicaltherapy.Developedincompletelocked-in44VertebralarterystentingVertebralarterystenting45ICAStenosis:StentingICAStenosis:Stenting46急性脑卒中救治规范与流程英文课件47Afterweeks’ICUcareandrehabilitation,thepatientrecoveredwithmoderateR-sidedweakness/dysarthriaintwomonths.Afterweeks’ICUcareandreha48Case#350y/omanwithh/oHTNpresentedwithneckpainandlossofconsciousness

Case#350y/omanwithh/oHTN49CTshowsdiffusesubarachnoidhemorrhageandhydrocephalus.

*CTAandcerebralangioshowednoaneurysmCTshowsdiffusesubarachnoid50MRAshowedL-distalVAirregularities.Fat-saturatedT1MRI

revealedintramuralthrombus,indicativeofVAdissection.MRAshowedL-distalVAirregul51CoilembolizationofdistalL-VAdissectionCoilembolizationofdistalL-52Despitecomatoseandventilator-dependenceformorethan2weeks,herecoveredfullyin2months.Despitecomatoseandventilato53SUMMARYNeurocriticalcareprovidescomprehensiveAirwayandhemodynamicmanagement,Neuro-monitoringandbrainresuscitation,Periproceduralmonitoringandmanagement.NeurocriticalcareisassociatedwithReducemortality,Improvedoutcome,ReducedventilatordaysandICUlengthofstay.Diringer

etal.Criticalcaremedicine

2001,

29:635-640.

Juarezetal.CritCareMed2004;32:2311-2317.Varelasetal.CritCareMed2004;32:2191-2198.

SUMMARYNeurocriticalcareprov54WenguiYu,MD,PhDDivisionofNeurologicalCriticalCareDepartmentsofNeurologicalSurgeryandNeurologyNeurocriticalCareofAcuteStrokeWenguiYu,MD,PhDNeurocritica55ThePrimaryDiagnosesInNeuro-ICUIntracerebralhemorrhage(ICH)Subarachnoidhemorrhage(SAH)Ischemicstroke/TIAsStatuspostcraniotomyfortumorresectionTraumaticbraininjury(SDH,EDH)Statuspostcoilembolization,angioplasty,orstenting.ThePrimaryDiagnosesInNeuro56ThrombolysisforIschemicStroke

Intravenoust-PAIntraarterialt-PAEndovasculartherapyAngioplasty/StentingMERCIRetrievalPenumbraClotRetrievalCoilembolizationofaneurysmSurgicaltreatmentHemicraniectomyforMCAstrokeAdvancesinStrokeManagementS/pIAtPAThrombolysisforIschemicStro571.Neuro-monitoring1).NeuroExam

SimpleandeffectiveNeurologicchangesthatneedimmediateattentionMentalstatuschangeDecreasedlevelsofconsciousness:lethargy,stupor,coma.Disorientation:name,place,time,andevent.Speechdifficulty:expressiveorreceptiveaphasiaCranialnervepalsy:dilatedandfixedpupil(s)Newweakness/numbness1.Neuro-monitoring1).NeuroE582).Neuroimagings

a).CT

Tofollowhematomaexpansion,cerebraledema,masseffect,herniation,orhydrocephalus.IndicatedinFirstfewdaysafterstroke,Deteriorationonneuroexam,Sedatedandparalyzedpatient.2).Neuroimagings a).CT 59b).CTA

ContrastextravasationpredictshematomaexpansionCTdemonstratesaleftputaminalhematoma(A).AsmallfocusofenhancementisseenonCTA(B),consistentwithextravasationonpostcontrastCT(C).UnenhancedCTimage1dayafterpresentationrevealshematomaenlargementandIVH(D). -Wadaetal.Stroke.2007;38:1257 -Golsteinetal.

Neurology.2007;20;68(12):889-94.b).CTA

Contrastextravasatio60ContrastextravasationpredictsmortalityinICH

A69-yomanunderwentimaging2hrsfollowingonsetofright-sidedparalysis.AdmissionNCCTdemonstratesaleftthalamichematomawithextensionintothethirdVentricle(A).CTA(B)andCECT(C),respectively,show2fociofactiveextravasation(arrows).Follow-upNCCT12hrslatershowsmarkedhematomagrowthwithhemorrhageinbothlateralventriclesandseverehydrocephalus(D).Thepatienthadafataloutcome.Beckeretal.Stroke1999;30:2025-2032Kimetal.AmericanJournalofNeuroradiology2008;29:520-525.Contrastextravasationpredict61TheDWImapdemonstratesasmallareaofdiffusionrestrictionintherightMCAterritoryconsistentwithacuteinfarction.TheMTTmapdemonstratestheinfarctpenumbrawhichislargerthantheinfarct,indicatingthepresenceofsalvageabletissue.C).MRI:vasospasm/delayedischemicdeficit

TheDWImapdemonstratesasma62IntraventricularcatheterIntraparenchymalcatheterEpiduralDeviceSubduralcatheter3).ICPMonitoring3).ICPMonitoring634).TranscranialDoppler(TCD)Non-invasive.Measurethevelocityofflowintheintracranialcirculation.TheDopplershiftmeasuredisinverselyproportionaltothediameterofthevessel.

FigsshowthepositionofTCDprobesandasampletracingofnormalMCAwaveform.4).TranscranialDoppler(TCD)64TCDCriteriaofvasospasmVasospasmMeanbloodflowvelocityMild>120cm/sSevere>180cm/sTCDCriteriaofvasospasmVasos655).Electroencephalograph(EEG)MonitoringEEGofacomatosepatientshowedgeneralizedsharpthetarhythmconsistentwithnon-convulsiveseizureactivity.5).Electroencephalograph(EEG66ContinuousvEEGmonitoring:statusepilepticusContinuousvEEGmonitoring:st672.Cardiac-RespiratoryMonitoring

Cardiacarrhythmia,stunnedmyocardium,andACSarecommoncomplicationsofstroke.Righthemisphereinfarct(insula)increasestheriskofcardiaccomplications(autonomicdysfunction).ECGchangesincludeST-segmentdepression,QTdispersion,invertedTwaves,andprominentUwaves.ElevatedlevelsofcardiacenzymesarecommoninpatientswithSAH.Strokemayalsocauserespiratorydistress,impairedoropharyngealmobility,airwayobstruction,andaspirationpneumonia.2.Cardiac-RespiratoryMonitor683.CriticalCareofPatientwithAcuteStrokeInitiateNeuro-Cardiac-Respiratorymonitoring,IntubateforairwayprotectionifcomatoseorGCS<8,Managehypertensivecrisisorhypotension,Treatheadache,agitation,hyperglycemia,andaspiration,Evaluateelectrolyteimbalance,seizure,fever,andinfection,GIandDVTprophylaxis.3.CriticalCareofPatientwi694.ManagementofBloodPressure(BP)BothelevatedandlowBPareassociatedwithpooroutcomeafterstroke.ThecommoncausesofelevatedBP:Stressofthestroke(largeinfarct,ICH,SAH).Increasedintracranialpressure.Hypoxia,afullbladder,nausea/vomiting,pain/headache.preexistinghypertension.BloodpressurereductionTopreventhemorrhagicconversionorrehemorrhage.Topreventhyperperfusionsyndrome.BloodpressureaugmentationHypotension.Vasospasm.4.ManagementofBloodPressur70ManagementofHypertensiveCrisisInitialtherapyLabetalol10-20mgivq30minprnHydralazine10-20mgivq30minprnForpersistenthypertensionNicardipine2-15mg/hrivinfusionorNipride0.3-10mcg/kg/minivinfusionStartandtitrateoralmedicationsBB,CCB,ACEI,hydralazine,orclonidine.IncaseofhypotensionReduceanti-hypertensiveandIVfluidbolus.ManagementofHypertensiveCri71Indications:PreventionofhemorrhageorhematomaexpansionUrgentneurosurgicalinterventionCoagulopathyfromwarfarinorhepaticfailureFactorVIIa40-80µg/kgiv+VitaminK10mgivdailyx3.Prothrombincomplexconcentrate(PCC):25-50units/kgiv.Freshfrozenplasma(FFP)10-20ml/kgHeparin-inducedcoagulopathyProtaminesulfate1mgforeach100Uheparinreceivedinthelast3ht-PAinducedthrombolysisCryoprecipitates6-8unitsThrombocytopeniaorplateletdysfunctionSingledonorplatelets2-6units5.UrgentReversalofCoagulopathyIndications:5.UrgentReversal726.ManagementofElevatedICP/HydrocephalusExternalventriculardrainage(EVD):openat0-20cmH2O.Osmolartherapy:Mannitol0.5-1gm/kgivq4hHypertonicsaline:3%or23.4%NaClHyperventilation(shorttermusepriortoemergentsurgery):-Hypocarbia(pCO230-35)reductionofCBFSedatives/paralyticagentsPentobarbitalcoma6.ManagementofElevatedICP/737.DecompressiveCraniectomy

Largecerebellarinfarctorhemorrhage.Hemisphereinfarctwithedemaandpotentialherniation.Jaussetal.JNeurol1999;246:257-64Racoetal.Neurosurgery.2003;53(5):1061.

Robertsonetal.Neurosurgery.2004;55(1):55.7.DecompressiveCraniectomyL74HemicraniectomyforMCAStroke3clinicaltrials:DECIMAL,HAMLET,andDESTINY.93patientsrandomizedtosurgicalormedicaltherapy.Patients≤60yearsofage.Thetimingofsurgery<48hrsafterstrokeonset.OutcomewithmRSat1yr.

2007;6(3):215-22

HemicraniectomyforMCAStroke751033patientswithsupertentorialICHenrolledin87centersRandomizedwithin72hrofICHonsetEarlysurgeryNosurgeryearly(but20%hadlatersurgery)ShowednobenefitinMortalityGoodoutcomeSurgicalTreatmentofICH(STICHTrial)

MendelAD,etal.Lancet2005,365:3871033patientswithsupertentor768.Intra-ventriculart-PAforIVHIntraventricularhemorrhage(IVH)Occursin15-40%ofpatientswithICHorSAH.SevereIVHcauseshydrocephalus,increasedICPorherniation.DeathoccursinallpatientswithGCSlessthan8andsevereIVH.Intra-ventriculart-PAFacilitatetheclearanceofIVHImproveoutcome.Findlayetal.Neurosurgery74:803–807,1991Rohdeetal,JNeurolNeurosurgPsychiatry1995;58:447–451Naffetal.Neurosurgery2004;54:577–838.Intra-ventriculart-PAfor779.VasospasmandDelayedIschemicDeficit

DiagnosisOccuratday3-10,Neuorologicdeterioration.TCD,CTAorcerebralangiography.

PreventionandtreatmentNimodipine60mgq4h,TripleH(hypervolemia,hypertension,andhemodilution)KeepCVP8-12,RaiseMAPby15-20%toimprovecerebralperfusion.Endovasculartherapy:balloonangioplastyorIAnicardipine.L-VABasilarArteryVasospasm9.VasospasmandDelayedIsche7810.CerebralSaltWastingSyndromeHyponatremia,hypovolemia,andelevatedserumBNP.Associatedwithbrainedema,vasospasmandpooroutcome.Aggressivetreatmentwith3%NaClinfusionSalttabletsFlorinef0.1-0.2mg/day10.CerebralSaltWastingSynd7911.TherapeuticHypothermiaHypothermiainglobalischemiaModeratehypothermia(32-34oC)for12-24hrsincreasesfavorableneurologicoutcomeat6monthsincomatosesurvivorsofout-of-hospitalcardiacarrest.BernardSA,etal.

NEJM

2002;346:557-563.MichaelHolzeretal.NEJM2002;346:549-556.

Hypothermiainischemicstroke.Safeandfeasible.EffectiveincontrollingICPduetothemasseffectoflargeinfarct.ReduceMCAstrokemortality.Schwabetal.Stroke2001;32:2033-5.Schwabetal.Stroke1998;29:2461-6.Schwabetal.Stroke1998;29:1988-93.Gumulaetal.AcadEmergMed.2006;13(8):820-7.FavorableoutcomeSurvivalHome/Rehab11.TherapeuticHypothermiaHyp8012.ManagementofSeizure12.ManagementofSeizureTreatmentofStatusEpilepticus1).Lorazepam2mgivq2min,upto0.1mg/kg.2).Fosphenytoin20mg/kgiv,@150mg/min.3).Fosphenytoin10mg/kg4).Intubatepatientifnotdoneyet. 5).Phenobarbital20mg/kg@50mg/min 6).Phenobarbital10mg/kgMidazolam7).Anesthesia:Pentobarbitalburstsuppression PropofolorMidazolam12.ManagementofSeizure12.M81TreatmentofNonconvulsiveStatusEpilepticusTreatmentofNonconvulsiveStatusEpilepticus1).Lorazepam2mgivq2min,upto0.1mg/kg.2).Valproate25mg/kgover4-8min.3).Phenobarbital20mg/kg@50mg/min.4).Intubatepatientifnotdoneyet. 5).Phenobarbital10mg/kg. 6).PropofolorMidazolam.

TreatmentofNonconvulsiveSta8213.RecombinantFactorVIIaforAcuteICH

Mayeretal.2005;352:777-85Phase2Btrial399patientswererandomizedtoreceiveplacebo,or40,80,and160µg/kgofrFVIIawithin4hsymptomonset.Primaryoutcome:ICHvolumeat24hClinicaloutcomeat90days

13.RecombinantFactorVIIafo83EffectsofrFVIIaonICHvolumes

VolumePlacebo40µg/kg80µg/kg160µg/kgbaseline24±2222±2223±2426±3024hr32±2926±2928±3128±32Meanincrease2.9Pvalue,vsplacebo0.130.040.008EffectsofrFVIIaonICHvolum84rFVIIalimitsthegrowthofhematomaandreducesmortalitybyapproximately35%.Mayeretal.2005;352:777-85rFVIIalimitsthegrowthofhe85FactorSevenforAcuteHemorrhagicStroke(FAST)Phase3trial841patientswithICHwererandomizedtoreceivePlacebo20µg/kgofrFVIIa80µg/kgofrFVIIaPrimaryendpoint:Pooroutcome,definedasseveredisabilityordeath90daysafterthestrokeMayeretal.2008;358:2127-37FactorSevenforAcuteHemorrh86Figure3.Clinicaloutcomeat90daysaccordingtotheModifiedRankinScale.rFVIIadoesnotreducetherateofdeathorseveredisabilityafterICH.Figure3.Clinicaloutcomeat87ClinicalCenters(withnumbersofpatientsinparentheses)WangYJ,BeijingTiantanHospital,Beijing(73);Selchen,TrilliumHealthCentre,Mississauga,ON,Canada(25);ÁlvarezSabin,HospitalValld'Hebron,Barcelona(24);Steiner,UniversitätsklinikumundMedizinischeFakultätHeidelberg,Germany(22);Hill,Foothil