急性脑卒中救治规范与流程(英文）.ppt

1、Wengui Yu, MD, PhD Division of Neurological Critical Care Departments of Neurological Surgery and Neurology,Neurocritical Care of Acute Stroke,The Primary Diagnoses In Neuro-ICU,Intracerebral hemorrhage (ICH) Subarachnoid hemorrhage (SAH) Ischemic stroke/TIAs Status post craniotomy for tumor resecti

2、on Traumatic brain injury (SDH, EDH) Status post coil embolization, angioplasty, or stenting.,Thrombolysis for Ischemic Stroke Intravenous t-PA Intraarterial t-PA Endovascular therapy Angioplasty/Stenting MERCI Retrieval Penumbra Clot Retrieval Coil embolization of aneurysm Surgical treatment Hemicr

3、aniectomy for MCA stroke,Advances in Stroke Management,S/p IA tPA,1. Neuro-monitoring,1). Neuro Exam Simple and effective Neurologic changes that need immediate attention Mental status change Decreased levels of consciousness: lethargy, stupor, coma. Disorientation: name, place, time, and event. Spe

4、ech difficulty: expressive or receptive aphasia Cranial nerve palsy: dilated and fixed pupil(s) New weakness/numbness,2). Neuroimagings,a). CT To follow hematoma expansion, cerebral edema, mass effect, herniation, or hydrocephalus. Indicated in First few days after stroke, Deterioration on neuro exa

5、m, Sedated and paralyzed patient.,b). CTA Contrast extravasation predicts hematoma expansion,CT demonstrates a left putaminal hematoma (A). A small focus of enhancement is seen on CTA (B), consistent with extravasation on postcontrast CT (C). Unenhanced CT image 1 day after presentation reveals hema

6、toma enlargement and IVH (D). - Wada et al. Stroke. 2007;38:1257 - Golstein et al. Neurology. 2007;20;68(12):889-94.,Contrast extravasation predicts mortality in ICH,A 69-yo man underwent imaging 2 hrs following onset of right-sided paralysis. Admission NCCT demonstrates a left thalamic hematoma wit

7、h extension into the third Ventricle (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 hemorrhage in both lateral ventricles and severe hydrocephalus (D). The patient had a fatal outcome. Becker et al.

8、 Stroke 1999;30:2025-2032 Kim et al. American Journal of Neuroradiology 2008; 29:520-525.,The DWI map demonstrates a small area of diffusion restriction in the right MCA territory consistent with acute infarction. The MTT map demonstrates the infarct penumbra which is larger than the infarct, indica

9、ting the presence of salvageable tissue.,C). MRI: vasospasm/delayed ischemic deficit,Intraventricular catheter Intraparenchymal catheter Epidural Device Subdural catheter,3). ICP Monitoring,4). Transcranial Doppler (TCD),Non-invasive. Measure the velocity of flow in the intracranial circulation. The

10、 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.,TCD Criteria of vasospasm,5). Electroencephalograph (EEG) Monitoring,EEG of a comatose patient showed generalized sharp theta rhythm cons

11、istent with non-convulsive seizure activity.,Continuous vEEG monitoring: status epilepticus,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 d

12、ysfunction). ECG changes include ST-segment depression, 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 pneumoni

13、a.,3. Critical Care of Patient with Acute 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, an

14、d infection, GI and DVT prophylaxis.,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/vomitin

15、g, pain/headache. preexisting hypertension. Blood pressure reduction To prevent hemorrhagic conversion or rehemorrhage. To prevent hyperperfusion syndrome. Blood pressure augmentation Hypotension. Vasospasm.,Management of Hypertensive Crisis,Initial therapy Labetalol 10-20 mg iv q30 min prn Hydralaz

16、ine 10-20 mg iv q30 min prn For persistent hypertension Nicardipine 2-15 mg/hr iv infusion or Nipride 0.3-10 mcg/kg/min iv infusion Start and titrate oral medications BB, CCB, ACEI, hydralazine, or clonidine. In case of hypotension Reduce anti-hypertensive and IV fluid bolus.,Indications: Prevention

17、 of hemorrhage or hematoma expansion Urgent neurosurgical intervention Coagulopathy 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/kg Heparin-induced coagulopathy

18、Protamine sulfate 1mg for each 100 U heparin received in the last 3h t-PA induced thrombolysis Cryoprecipitates 6-8 units Thrombocytopenia or platelet dysfunction Single donor platelets 2-6 units,5. Urgent Reversal of Coagulopathy,6. Management of Elevated ICP/Hydrocephalus,External ventricular drai

19、nage (EVD): open at 0-20 cm H2O. Osmolar therapy: Mannitol 0.5-1 gm/kg iv q4h Hypertonic saline: 3% or 23.4% NaCl Hyperventilation (short term use prior to emergent surgery): - Hypocarbia (pCO2 30-35) reduction of CBF Sedatives/paralytic agents Pentobarbital coma,7. Decompressive Craniectomy,Large c

20、erebellar infarct or hemorrhage. Hemisphere infarct with edema and potential herniation.,Jauss et al. J Neurol 1999; 246:257-64 Raco et al. Neurosurgery. 2003;53(5):1061. Robertson et al. Neurosurgery. 2004;55(1):55.,Hemicraniectomy for MCA Stroke,3 clinical trials: DECIMAL, HAMLET, and DESTINY. 93

21、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):215-22,1033 patients with supertentorial ICH enrolled in 87 centers Randomized within 72 hr of ICH onset Early surgery No surgery early (

22、but 20% had later surgery) Showed no benefit in Mortality Good outcome,Surgical Treatment of ICH (STICH Trial) Mendel AD, et al. Lancet 2005, 365:387,8. Intra-ventricular t-PA for IVH,Intraventricular hemorrhage (IVH) Occurs in 15-40% of patients with ICH or SAH. Severe IVH causes hydrocephalus, inc

23、reased 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, 1991 Rohde et al, J Neurol Neurosurg Psychiatry 1995;58: 447451 Naff et al. Neurosurgery 2004;54:

24、57783,9. 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 hemodilution) Keep CVP 8-12, Raise MAP by 15-20% to improve cerebral perf

25、usion. Endovascular therapy: balloon angioplasty or IA nicardipine.,L-VA,Basilar Artery,Vasospasm,10. Cerebral Salt Wasting Syndrome,Hyponatremia, hypovolemia, and elevated serum BNP. Associated with brain edema, vasospasm and poor outcome. Aggressive treatment with 3% NaCl infusion Salt tablets Flo

26、rinef 0.1-0.2 mg /day,11. Therapeutic Hypothermia,Hypothermia in global ischemia Moderate hypothermia (32-34 oC) for 12-24 hrs increases favorable neurologic outcome at 6 months in comatose survivors of out-of-hospital cardiac arrest. Bernard SA, et al. NEJM 2002; 346:557-563. Michael Holzer et al.

27、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; 32:2033-5. Schwab et al. Stroke 1998; 29:2461-6. Schwab et al. Stroke 1998; 29:1988-93. Gumula et a

28、l. Acad Emerg Med. 2006;13(8):820-7.,Favorable outcome,Survival Home/Rehab,12. Management of Seizure,12. Management of Seizure,Treatment of Status Epilepticus 1). 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 n

29、ot done yet. 5). Phenobarbital 20 mg/kg 50 mg/min 6). Phenobarbital 10 mg/kg Midazolam 7). Anesthesia: Pentobarbital burst suppression Propofol or Midazolam,Treatment of Nonconvulsive Status Epilepticus,Treatment of Nonconvulsive Status Epilepticus 1). Lorazepam 2 mg iv q 2 min, up to 0.1 mg/kg. 2).

30、 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.,13. Recombinant Factor VIIa for Acute ICHMayer et al. 2005;352:777-85,Phase 2B trial 399 patients were randomized to receive placebo, o

31、r 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,Effects of rFVIIa on ICH volumes,rFVIIa limits the growth of hematoma and reduces mortality by approximately 35%.,Mayer et al. 2005;352:777-85,Factor Seven for Acute Hemorrhagic

32、 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 stroke,Mayer et al. 2008;358:2127-37,Figure 3. Clinical outcome at 90 days according to t

33、he Modified Rankin Scale. rFVIIa does not reduce the rate of death or severe disability after ICH.,Clinical Centers (with numbers of patients in parentheses),Wang YJ, Beijing Tiantan Hospital, Beijing (73); Selchen, Trillium Health Centre, Mississauga, ON, Canada (25); lvarez Sabin, Hospital Vall dH

34、ebron, 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 Neuroscience Institute, Singapore (16); Toni, Universit La Sapienza

35、, 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 University, St. Louis (9); Rosand, Massachusetts General Hospital, Boston

36、(5); Parra, Columbia University, New York (2) Grotta, University of Texas, Houston (2) Hemphill, University of California, San Francisco, (1),14. Prognosticate Outcome of Coma,Depends on cause rather than the depth of the coma. Coma from drug intoxication and metabolic causes carries the best progno

37、sis. Coma from global hypoxia-ischemia carries the least favorable prognosis.,A 51 year old woman was comatose for 8 weeks after cardiac bypass surgery. The follow-up CT 13 years later are shown below.,Functional Outcome: mRS 1,Case Study #1,A 44 yo man with h/o HTN and prior R-MCA stroke was last s

38、een 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.,CT head at 11:46 AM,Prior to IA thrombolysisS/P IA t-PA/Reopro,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.,Who is the lucky patient?,Case Study #2,A 67 yo man with h/o CAD and DM pre