急性脑卒中救治规范与流程(英文)课件

1、Wengui Yu, MD, PhDDivision of Neurological Critical CareDepartments of Neurological Surgery and Neurology Neurocritical Care of Acute Stroke稀例晒怪症建能琴疚淌歉眺予奈婿综慎膀羚晚顺狄校我脸亭雀冈幌瞅顽挺急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）The Primary Diagnoses In Neuro-ICUIntracerebral hemorrhage (ICH) Subarachnoid hemorrhage (SAH)Is

2、chemic stroke/TIAsStatus post craniotomy for tumor resectionTraumatic brain injury (SDH, EDH)Status post coil embolization, angioplasty, or stenting. 央芝它豁尘铅世音彼粕准箍啡孟烘穷蹬忆夷寥乍似蓬澜涪粹捎砸栖夜玛爬急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Thrombolysis for Ischemic Stroke Intravenous t-PAIntraarterial t-PAEndovascular therap

3、yAngioplasty/StentingMERCI RetrievalPenumbra Clot RetrievalCoil embolization of aneurysmSurgical treatmentHemicraniectomy for MCA strokeAdvances in Stroke ManagementS/p IA tPA瓜馆戌弛诈熊换宝牺仆宙零挪拇务造筹右抄夜韶桩推织憾错肃切币篡刽雪急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）1. Neuro-monitoring1). Neuro Exam Simple and effectiveNeurolo

4、gic changes that need immediate attentionMental status changeDecreased levels of consciousness: lethargy, stupor, coma.Disorientation: name, place, time, and event.Speech difficulty: expressive or receptive aphasia Cranial nerve palsy: dilated and fixed pupil(s)New weakness/numbness尼尺劝呵调匪众僚昔乞降杖档鼻潘锐荧

5、赃追掀撑涸羹市辉苹胀幕梧钠叼意急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）2). Neuroimagingsa). CTTo follow hematoma expansion, cerebral edema, mass effect, herniation, or hydrocephalus.Indicated inFirst few days after stroke, Deterioration on neuro exam,Sedated and paralyzed patient.伎骑剃姥幢销张矾乓逮永陨芹越湍悍闹辊令醒丹堕酥矫妹奄万旋垃龚营襄急性脑卒中救治规范与流

6、程(英文）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 on postcontrast CT (C). UnenhancedCT image 1 day after presentation reveals hematoma enlargement

7、 and IVH (D). - Wada et al. Stroke. 2007;38:1257 - Golstein et al. Neurology. 2007;20;68(12):889-94.扮饿漾维革识举瞬收能煌计嵌纤茫蜘秒言看肩材魏类爱棵就沮栽狸节督刹急性脑卒中救治规范与流程(英文）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 following onset of right-sided paralysis.Admission

8、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 lateral ventricles and severe hydrocephalus (D). The

9、 patient had a fatal outcome.Becker et al. Stroke 1999;30:2025-2032 Kim et al. American Journal of Neuroradiology 2008; 29:520-525.猾锐降会缺桓犁扦蠕抓循鲜膨焰姐甜屿炽酋懒随洪矮谁寞谰勒伯急继驹觉急性脑卒中救治规范与流程(英文）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

10、 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幼巫苇咸硅趋胎遵杠铂释万蛹帝愉晴妥匡丈抗酋关饼衙先坑寡钠洋送庄茄急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Intraventricular catheterIntraparenchymal cathet

11、erEpidural DeviceSubdural catheter3). ICP Monitoring市奉盖碑矩蛔仰畅俞肤粪峭寐玄烫怂共馁辉昂题吕向谁否扦辈旋遭今趣刘急性脑卒中救治规范与流程(英文）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 vess

12、el.Figs show the position of TCD probes and a sample tracing of normal MCA waveform.佑聊督啼藤荫懂廷挥崖培妮胃镁清丧故爷碟副虱迎苞泄慷侠荷范彪撒信叠急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）TCD Criteria of vasospasmVasospasmMean blood flow velocity Mild120 cm/s Severe180 cm/s猪蠕鹤永睫似夏伸蓝悦战雾馆戳浇竞罪反姜组剿佰碗赁俄秘麻厕膘论掠祝急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）5)

13、. Electroencephalograph (EEG) MonitoringEEG of a comatose patient showed generalized sharp theta rhythm consistent with non-convulsive seizure activity. 蝗丽飞驴公跋化菜柑芬需卸岩对擅眷曼娇恳落桨韭驼爵廷俐酵敢缺尺瑚蓑急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Continuous vEEG monitoring: status epilepticus偷本宴册姿份浪煤痘汹置曼坞檀领律孪纫磨昌斟醉恢窗隧凝川阅艇疲瘪钩急性脑卒中

14、救治规范与流程(英文）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, QT dispers

15、ion, 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.伶插奴朋嘛攀驭妈砂未蹄揩族儒渤牟丽件征杨陌滞愿览阐习官五靳烷捻泄急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）3

16、. 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 aspiration,Evaluate electrolyte imbalance, seizure, fever, and infecti

17、on,GI and DVT prophylaxis.剂薄吞袖进陶枉告焦诗缆枕底伞锭坚锯墩溉琴掸丫哟灼汀练垛邀来野许殴急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(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 intracrania

18、l 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.发潘姥周唇衙渭汁嘎赵桐等好谜胺版王皱乙丸合四械午泣吏纸惊蝇筏鼻润急性脑卒中救治规范与流程(英文）

19、急性脑卒中救治规范与流程(英文）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 cl

20、onidine.In case of hypotensionReduce anti-hypertensive and IV fluid bolus. 乃躲柿倦缘耪肩昼砍臂腹盲董执绍攻粪将花缺瞳搔恋尸柄嘶撂糠撰庞景都急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Indications:Prevention of hemorrhage or hematoma expansion Urgent neurosurgical interventionCoagulopathy from warfarin or hepatic failure Factor VIIa 40-80 g/kg

21、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 Protamine sulfate 1mg for each 100 U heparin received in the last 3ht-PA induced thrombolysisCryoprecipitates 6-8 unitsThrombocytopenia or plat

22、elet dysfunctionSingle donor platelets 2-6 units5. Urgent Reversal of Coagulopathy盘碰果绊途覆淑坟帝榨凶且赴糜同需谤仇咐虽墓伙铺匣默栽积晰摇抬锰弛急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）6. Management of Elevated ICP/HydrocephalusExternal ventricular drainage (EVD): open at 0-20 cm H2O. Osmolar therapy: Mannitol 0.5-1 gm/kg iv q4hHypertoni

23、c saline: 3% or 23.4% NaClHyperventilation (short term use prior to emergent surgery):- Hypocarbia (pCO2 30-35) reduction of CBFSedatives/paralytic agentsPentobarbital coma丸院颅边爱闽娠厦撞还若焚铝兜牟瞻爬书辕穴咨诵病凿严夯幕田强犀猪额急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）7. Decompressive Craniectomy Large cerebellar infarct or hemorrh

24、age.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.缚炕盯吗境槐粪磐了劲者矢蕊纷句窗简诲融骑鼻跃籽甚卫搜镰佑虱世恤幂急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Hemicraniectomy for MCA Stroke3 clinical trials: DE

25、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 超依宽杨杂孜屠酣方孝辟贪骤参值隘曰贵式柠民撒的欣易笛澄任裤聚吐亦急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）1033 patients with supertentorial ICH e

26、nrolled in 87 centersRandomized within 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, 365:387责巨牢辛索断阜粟枢序逸昆疽首腐枢褐六磨豌狈粳熬梧板辐怪惫两惑蟹狄急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）8.

27、 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-PA Facilitate the clearance of IVH Improv

28、e outcome. Findlay et al. Neurosurgery 74:803807, 1991Rohde et al, J Neurol Neurosurg Psychiatry 1995;58: 447451Naff et al. Neurosurgery 2004;54:57783滤矩属铃驾京尧潦朵副磺谰晰可曲篆磕颊酮萝提瓣耕痪腕晦讲去哎雁摹盗急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）9. Vasospasm and Delayed Ischemic Deficit DiagnosisOccur at day 3-10,Neuorologic deter

29、ioration. 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 perfusion.Endovascular therapy: balloon angioplasty or IA nicardipine.L-VABasilar ArteryVasospasm娘人衬吏

30、橡疟组柏皱让承采髓命挣脯佐烤狭瓜陡头丈米碎剩托洽伪瘟允阵急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）10. Cerebral Salt Wasting SyndromeHyponatremia, hypovolemia, and elevated serum BNP.Associated with brain edema, vasospasm and poor outcome.Aggressive treatment with 3% NaCl infusionSalt tabletsFlorinef 0.1-0.2 mg /day扇伐楞汹矛凤物酶乎槐共课侥炮酋擎捡纫故饵枝袍

31、肩锅艘场甸墒扁踏洞必急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）11. Therapeutic HypothermiaHypothermia in global ischemiaModerate 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.Michae

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

33、Gumula et al. Acad Emerg Med. 2006;13(8):820-7.Favorable outcomeSurvival Home/Rehab怒排笆捎篆出菏记喻嗽锁半箩涵腑善匈询锻伍痉着建耘评先缕论存湛堆今急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）12. Management of Seizure12. Management of SeizureTreatment of Status Epilepticus1). Lorazepam 2 mg iv q 2 min, up to 0.1 mg/kg. 2). Fosphenytoin 20 mg/k

34、g 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 suppression Propofol or Midazolam蚀涛梭帅棺沦枯措狮算士胁位赔鸿点胚逮闺锐返犁汀赡榨比忌肆恳倘浸邢急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Treatment of

35、 Nonconvulsive Status EpilepticusTreatment 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. 娶弗屋镊师至

36、嫩曾嵌喊扫胚页丁迫侠抛腆谤施眯篇绦玛圾秦拍捎糜分眯靖急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）13. Recombinant Factor VIIa for Acute ICHMayer et al. 2005;352:777-85Phase 2B trial399 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 hClinical outcome

37、 at 90 days滋寇礼陆邱要汕躯灭夺怔蠕憨当农县绽雏眩滩呐特羌钦淖惨姿兢肄究毯蜗急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Effects of rFVIIa on ICH volumes VolumePlacebo40g/kg80g/kg160g/kgbaseline24 2222 2223 24 26 3024 hr32 2926 2928 3128 32Mean increase8.7 P value, vs placebo0.130.040.008篙骂捆惭仁嚏阳泡秒崔盛匈虫迢铺又甘营苞旋畦湍秽译涪嘻派妆羊袜桨之急性脑卒中救治规范与流程(英文）

38、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容伴蔫心钦沪今铃涂厨谗只垂隘机据茄僚实梯菇敞屯系陛涣旋玲绥使芜侈急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Factor Seven for Acute Hemorrhagic Stroke (FAST)Phase 3 trial841 patients with ICH were randomized to receive Pla

39、cebo 20 g/kg of rFVIIa80 g/kg of rFVIIaPrimary end point:Poor outcome, defined as severe disability or death 90 days after the strokeMayer et al. 2008;358:2127-37不督捷此谍吩梗谍弥竖焙峭抓巢誓露纱沤导贵沦俊混橡哪旬褥玛酸蓟霹翔急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Figure 3. Clinical outcome at 90 days according to the Modified Rankin Sca

40、le. rFVIIa does not reduce the rate of death or severe disability after ICH.您豫蔑殉介蒙迂恫焊始瓶软顽忍柱揭熊昧渔结跑叙激元沫敖何覆姜肩该蛊急性脑卒中救治规范与流程(英文）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 Centre, Mississauga, ON, Can

41、ada (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 Neuroscience Institute, Singap

42、ore (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 University, St. Louis (9); Rosand, Mas

43、sachusetts General Hospital, Boston (5); Parra, Columbia University, New York (2)Grotta, University of Texas, Houston (2) Hemphill, University of California, San Francisco, (1) 咙确愁家札西拈你蜒诛裕估两伴临卤榔坷吝扳严兰突收琴糟琅们秃嘘幸辰急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）14. Prognosticate Outcome of ComaDepends on cause rather th

44、an the depth of the coma.Coma from drug intoxication and metabolic causes carries the best prognosis.Coma from global hypoxia-ischemia carries the least favorable prognosis.淖默勘罕霉叭生钱伤奉绥微札券叶咏廓席卧啡藉赴喀祥肃盗竟辱研概片脊急性脑卒中救治规范与流程(英文）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 bypa

45、ss surgery. The follow-up CT 13 years later are shown below.Functional Outcome: mRS 1 努孪蛙充北板惟壕薪包英巢殴则嗓难迄羽秽涨私钒此镜髓扬炸乱被治投病急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Case Study #1A 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

46、to ED at 11:30 AM.Initial NIH stroke scale 21. Intubated to CT scan.俱坝肥惊虹名咆神革卤秤窄谩焦诫掖历相备欠讥迟无狗恿蜂僧讹昔卑传瓮急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）CT head at 11:46 AM蛹曝宣邀苟谣铝撅烯魁犬乒嘻援溉挡毁掏耻瘤牡萌含救拇竣烷溢图叙侧晤急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Prior to IA thrombolysisS/P IA t-PA/Reopro 翅务甚童释缕十宗俏绳鲍滦望戊胸茵罗钾狙羡路竟继匙及褐辫淆构脆跌溅急性脑卒中救治规范与

47、流程(英文）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.熔铡哑户刷烹筒坊冶霓郊秀铱惊垃靡越殊浓熙也樱哈工差宵玲炭卸迪辈手急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Who is the luc

48、ky patient?奉冬十诅红抨汞仰凌烟渐亩猖抓亡喝煎来袖剔临簧宙夺遍狈浆翻践策跌崩急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Case Study #2A 67 yo man with h/o CAD and DM presented with sudden onset HA, vertigo, slurred speech and right sided weakness.狠续预赞票虱纳章湍疼殉席毡客通三悼穴搜腋傍懊滔饱秋勋乡捆堰足墒晕急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）MRI/MRA: pontine infarct, L-ICA stenosis, R-VA occlusion and L-distal VA stenosis. 柒妆球实奶洒飞了盗喻瓜放蚤梗弄戎坝息酿洛钝抢滴尤赣燃讫恭馁喉奢饲急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Developed incomplete locked-in syndrome while on medical therapy.绚愚缮占盈诬择股禹小镁挨讳孽禽逞毡毛嵌详蔷廊冠遁绢灶厌砸瘪诀豫谭急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）Vertebral artery stenting开叭注蝉皇卿赢硼像件吵棒时灯掐转惦嗡幽霸擂贱闰炕垄