急性脑卒中救治规范与流程英文演示幻灯片

WenguiYu,

MD,

PhDDivision

of

Neurological

Critical

CareDepartments

of

Neurological

Surgery

and

NeurologyNeurocritical

Care

of

Acute

StrokeThe

Primary

Diagnoses

In

Neuro-ICUIntracerebral

hemorrhage

(ICH)Subarachnoid

hemorrhage

(SAH)Ischemic

stroke/TIAsStatus

post

craniotomy

for

tumor

resectionTraumatic

brain

injury

(SDH,

EDH)Status

post

coil

embolization,

angioplasty,

or

stentingThrombolysis

for

Ischemic

StrokeIntravenous

t-PAIntraarterial

t-PAEndovascular

therapyAngioplasty/StentingMERCI

RetrievalPenumbra

Clot

RetrievalCoil

embolization

of

aneurysmSurgical

treatmentHemicraniectomy

for

MCA

strokeAdvances

in

Stroke

ManagementS/p

IA

tPAThe

DWI

map

demonstrates

a

small

area

of

diffusion

restriction

in

theright

MCA

territory

consistent

with

acute

infarction.

The

MTT

mapdemonstrates

the

infarct

penumbra

which

is

larger

than

the

infarct,indicating

the

presence

of

salvageable

tissue.C).

MRI:

vasospasm/delayed

ischemic

deficitIntraventricular

catheterIntraparenchymal

catheterEpidural

DeviceSubdural

catheter3).

ICP

Monitoring4).

Transcranial

Doppler

(TCD)Non-invasive.Measure

the

velocity

of

flow

in

the

intracranial

circulation.

The

Doppler

shift

measured

is

inversely

proportional

to

the

diameter

ofthe

vessel.Figs

show

the

position

of

TCD

probes

and

a

sample

tracing

of

normal

MCAwaveform.TCD

Criteria

of

vasospasmVasospasmMean

blood

flow

velocityMild>120

cm/sSevere>180

cm/s5).

Electroencephalograph

(EEG)

Monitoring

EEG

of

a

comatose

patient

showed

generalized

sharp

theta

rhythmconsistent

with

non-convulsive

seizure

activity.Continuous

vEEG

monitoring:

status

epilepticus2.

Cardiac-Respiratory

Monitoring

Cardiac

arrhythmia,

stunned

myocardium,

and

ACS

are

commoncomplications

of

stroke.

Right

hemisphere

infarct

(insula)

increases

the

risk

of

cardiac

complica(autonomic

dysfunction).

ECG

changes

include

ST-segment

depression,

QT

dispersion,

inverted

Twaves,

and

prominent

U

waves.Elevated

levels

of

cardiac

enzymes

are

common

in

patients

with

SAH.Stroke

may

also

cause

respiratory

distress,

impaired

oropharyngeal

mobil airway

obstruction,

and

aspiration

pneumonia.3.

Critical

Care

of

Patient

with

Acute

StrokeInitiate

Neuro-Cardiac-Respiratory

monitoring,Intubate

for

airway

protection

if

comatose

or

GCS

<8,Manage

hypertensive

crisis

or

hypotension,Treat

headache,

agitation,

hyperglycemia,

and

aspiratio

Evaluate

electrolyte

imbalance,

seizure,

fever,

andinfection,GI

and

DVT

prophylaxis.4.

Management

of

Blood

Pressure

(BP)Both

elevated

and

low

BP

are

associated

with

poor

outcome

after

stroke.Thecommon

causes

of

elevated

BP:Stress

of

the

stroke

(large

infarct,

ICH,

SAH).Increased

intracranial

pressure.Hypoxia,

a

full

bladder,

nausea/vomiting,

pain/headache.preexisting

hypertension.Blood

pressure

reductionTo

prevent

hemorrhagic

conversion

or

rehemorrhage.To

prevent

hyperperfusion

syndrome.Blood

pressure

augmentationHypotension.Vasospasm.Management

of

Hypertensive

CrisisInitial

therapyLabetalol

10-20

mg

iv

q30

min

prnHydralazine

10-20

mg

iv

q30

min

prnFor

persistent

hypertensionNicardipine

2-15

mg/hr

iv

infusion

orNipride

0.3-10

mcg/kg/min

iv

infusionStart

and

titrate

oral

medicationsBB,

CCB,

ACEI,

hydralazine,

or

clonidine.In

case

of

hypotensionReduce

anti-hypertensive

and

IV

fluid

bolus.Indications:Prevention

of

hemorrhage

or

hematoma

expansionUrgentneurosurgical

interventionCoagulopathy

from

warfarin

or

hepatic

failureFactor

VIIa

40-80

µg/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

coagulopathyProtamine

sulfate

1mg

for

each

100

U

heparin

received

in

the

last

3ht-PA

induced

thrombolysisCryoprecipitates

6-8

unitsThrombocytopenia

or

platelet

dysfunctionSingle

donor

platelets

2-6

units5.

Urgent

Reversal

of

Coagulopathy6.

Management

of

Elevated

ICP/Hydrocephalus•External

ventricular

drainage

(EVD):

open

at

0-20

cm

H2O.Osmolar

therapy:

Mannitol

0.5-1gm/kg

iv

q4hHypertonic

saline:

3%

or

23.4%

NaCl•Hyperventilation

(short

term

use

prior

toemergent

surgery):-

Hypocarbia

(pCO2

30-35)

reduction

of

CBFSedatives/paralytic

agentsPentobarbital

coma7.

Decompressive

CraniectomyLarge

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.Hemicraniectomy

for

MCA

Stroke3

clinical

trials:

DECIMAL,

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):215-221033

patients

with

supertentorial

ICH

enrolled

in

87

centersRandomizedwithin

72

hr

of

ICH

onsetEarly

surgeryNo

surgery

early

(but

20%

had

later

surgery)Showed

no

benefit

inMortalityGood

outcomeSurgical

Treatment

of

ICH

(STICH

Trial)Mendel

AD,

et

al.

Lancet

2005,

365:3878.

Intra-ventricular

t-PA

for

IVHIntraventricular

hemorrhage

(IVH)Occurs

in

15-40%

of

patients

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-PAFacilitate

the

clearance

of

IVHImprove

outcome.Findlay

et

al.

Neurosurgery

74:803–807,

1991Rohde

et

al,

J

Neurol

Neurosurg

Psychiatry

1995;58:

447–451Naff

et

al.

Neurosurgery

2004;54:577–839.

Vasospasm

and

Delayed

Ischemic

Deficit.DiagnosisOccur

at

day

3-10,Neuorologic

deterioration.TCD,

CTA

or

cerebral

angiographyPrevention

and

treatmentNimodipine

60

mg

q4h,Triple

H

(hypervolemia,

hypertension,

and

hemodilution)Keep

CVP

8-12,Raise

MAP

by

15-20%

to

improve

cerebral

perfusion.Endovascular

therapy:

balloon

angioplasty

or

IA

nicardipine.Basilar

ArteryL-VA

Vasospasm10.

Cerebral

Salt

Wasting

SyndromeHyponatremia,

hypovolemia,

and

elevated

serum

BNP.

Associated

with

brain

edema,

vasospasm

and

pooroutcome.Aggressive

treatment

with3%

NaCl

infusionSalt

tabletsFlorinef

0.1-0.2

mg

/day11.

Therapeutic

HypothermiaHypothermia

in

ischemic

stroke.– Safe

and

feasible.

Effective

in

controlling

ICP

due

to

the

mass

effect

of

largeinfarct.Reduce

MCA

stroke

mortality.Schwab

et

al.

Stroke

2001;

32:2033-5.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.Favorable

outcomeHypothermia

in

global

ischemiaSurvival

Home/RehabModerate

hypothermia

(32-34

oC)

for

12-24

hrs

increasesfavorable

neurologic

outcome

at

6

months

in

comatosesurvivors

of

out-of-hospital

cardiac

arrest.Bernard

SA,

et

al.

NEJM

2002;

346:557-563.Michael

Holzer

et

al.

NEJM

2002;

346:549-556.12.

Management

of

SeizureTreatment

of

Status

EpilepticusLorazepam

2

mg

iv

q

2

min,

up

to

0.1

mg/kg.Fosphenytoin

20mg/kgiv,

@150

mg/min.Fosphenytoin

10

mg/kgIntubate

patient

if

not

done

yet.Phenobarbital

20

mg/kg

@50

mg/minPhenobarbital

10

mg/kgMidazolam7).

Anesthesia:

Pentobarbital

burst

suppressionPropofol

or

MidazolamTreatment

of

Nonconvulsive

Status

EpilepticusLorazepam

2

mg

iv

q

2

min,

up

to

0.1

mg/kg.Valproate

25mg/kg

over

4-8

min.Phenobarbital

20

mg/kg

@50

mg/min.Intubate

patient

if

not

done

yet.Phenobarbital

10

mg/kg.Propofol

or

Midazolam.13.

Recombinant

Factor

VIIa

for

Acute

ICHMayer

et

al.

2005;352:777-85Phase

2B

trial399

patients

were

randomized

to

receive

placebo,

or

40,8 and

160

µg/kg

of

rFVIIa

within

4

h

symptom

onset.Primary

outcome:ICH

volume

at

24

hClinical

outcome

at

90

daysEffects

of

rFVIIa

on

ICH

volumesVolumePlacebo40µg/kg80µg/kg160µg/kgbaseline24

±

2222

±

2223

±

2426

±

3024

hr32

±

2926

±

2928

±

3128

±

32Meanincrease8.75.44.22.9P

value,

vsplacebo0.130.040.008rFVIIa

limits

the

growthof

hematoma

and

reduces

mortalityby

approximately

35%.–Mayer

et

al.

2005;352:777-85Factor

Seven

for

Acute

Hemorrhagic

Stroke

(FAST)Phase

3

trial841

patients

with

ICH

were

randomized

to

receivePlacebo20

µg/kg

of

rFVIIa80

µg/kg

of

rFVIIaPrimary

end

point:

Poor

outcome,

defined

as

severe

disability

or

death

90

days

afterthe

stroke–Mayer

et

al.

2008;358:2127-37Figure

3.

Clinical

outcome

at

90

days

according

to

the

Modified

RankinScale.

rFVIIa

does

not

reduce

the

rate

of

death

or

severe

disability

afterICH.Clinical

Centers

(with

numbers

of

patients

in

parenthesesWang

YJ,

Beijing

TiantanHospital,

Beijing

(73);

Selchen,

Trillium

Health

Centre,

Mississauga,

ON,

Canada

(25);Álvarez

Sabin,

Hospital

Vall

d"Hebron,

Barcelona

(24);Steiner,

Universitätsklinikum

und

Medizinische

Fakultät

Heidelberg,

Germany

(22);Hill,

Foothills

Medical

Centre,

Calgary,

AB,

Canada

(21);…………………………Hennerici,

Univ

of

Heidelberg,

Mannheim,

Germany

(16);

Ng

Hua,

National

Neuroscience

Institute,

Singapore

(16);……………Woolfenden,

Vancouver

General

Hospital,

Canada

(10)Hall,

Medical

College

of

Georgia,

Augusta

(9);Washington

University,

St.

Louis

(9);Parra,

Columbia

University,

New

York

(2)Toni,

Università

La

Sapienza,

Rome

(10);Flaherty,

University

of

Cincinnati,

Cincinnati

(9)Gladstone,

Sunnybrook

and

Women"s

College,

Toronto

(9)Rosand,

Massachusetts

General

Hospital,

Boston

(5);Grotta,

University

of

Texas,

Houston

(2)Hemphill,

University

of

California,

SanFrancisco,

(1)14.

Prognosticate

Outcome

of

ComaDepends

on

cause

rather

than

the

depth

of

the

coma.

Coma

from

drug

intoxication

and

metabolic

causescarries

the

best

prognosis.

Coma

from

global

hypoxia-ischemia

carries

the

leastfavorable

prognosis.A

51

year

old

woman

was

comatose

for

8

weeks

aftercardiac

bypass

surgery.

The

follow-up

CT

13

years

later

areshown

below.Functional

Outcome:

mRS

1Case

Study

#1

A

44

yo

man

with

h/o

HTN

and

prior

R-MCAstroke

was

last

seen

normal

7:30

AM.

Found

unresponsive

with

R-sided

weakness

and911

activation

to

ED

at

11:30

AM.Initial

NIH

stroke

scale

21.Intubated

to

CT

scan.CT

head

at

11:46

AMPrior

to

IA

thrombolysisS/P

IA

t-PA/ReoproRepeat

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.Who

is

the

lucky

patient?Case

Study

#2A

67

yo

man

with

h/o

CAD

and

DM

presented

withsudden

onset

HA,

vertigo,

slurred

speech

and

right

sidedweakness.MRI/MRA:

pontine

infarct,

L-ICA

stenosis,

R-VA

occlu