自发性脑出血

自发性脑出血第一页，共四十八页，编辑于2023年，星期三第二页，共四十八页，编辑于2023年，星期三Evidence-basedguidelinesDiagnosisHemostasisBloodpressuremanagementInpatientandnursingmanagement,PreventingmedicalcomorbiditiesSurgicaltreatmentOutcomepredictionRehabilitationPreventionofrecurrenceFutureconsiderations.第三页，共四十八页，编辑于2023年，星期三DefinitionofClassesandLevelsofEvidenceUsedinAHAStrokeCouncilRecommendationsClassI:evidenceforand/orgeneralagreementthattheprocedureortreatmentisusefulandeffectiveClassII:conflictingevidenceand/oradivergenceofopinionabouttheusefulness/efficacyofaprocedureortreatmentClassIIaTheweightofevidenceoropinionisinfavoroftheprocedureortreatmentClassIIbUsefulness/efficacyislesswellestablishedbyevidenceoropinionClassIIIConditionsforwhichthereisevidenceand/orgeneralagreementthattheprocedureortreatmentisnotuseful/effectiveandinsomecasesmaybeharmfulLevelofEvidenceA--multipleRCTsormeta-analysesLevelofEvidenceB--asinglerandomizedtrialornonrandomizedstudiesLevelofEvidenceC--Consensusopinionofexperts,casestudies,orstandardofcare第四页，共四十八页，编辑于2023年，星期三EmergencyDiagnosisandAssessmentofICH

andItsCauses

PrehospitalManagementEDManagementNeuroimaging第五页，共四十八页，编辑于2023年，星期三Recommendations

RapidneuroimagingwithCTorMRIisrecommendedtodistinguishischemicstrokefromICH(I-A).(Unchanged!)CTAandcontrast-enhancedCTmaybeconsideredtohelpidentifypatientsatriskforhematomaexpansion(IIb-B);CTA,CTV,contrast-enhancedCT,contrast-enhancedMRI,MRA,MRVcanbeusefultoevaluateforunderlyingstructurallesions,includingvascularmalformationsandtumorswhenthereisclinicalorradiologicalsuspicion(IIa-B).(New!)

第六页，共四十八页，编辑于2023年，星期三Hemostasis/Antiplatelets/DeepVein

ThrombosisProphylaxis---Recommendations1.Ptswithaseverecoagulationfactordeficiencyorseverethrombocytopeniashouldreceiveappropriatefactorreplacementtherapyorplatelets,respectively(I-C).

(New!)

2.PtswithICHwhoseINRiselevatedduetoOACsshouldhavetheirwarfarinwithheld,receivetherapytoreplacevitaminK–dependentfactorsandcorrecttheINR,andreceivei.v.vitaminK(I-C).PCCshavenotshownimprovedoutcomecomparedwithFFPbutmayhavefewercomplicationsandareconsideredasanalternativetoFFP(IIa-B).rFVIIadoesnotreplaceallclottingfactors,andalthoughtheINRmaybelowered,clottingmaynotberestoredinvivo;rFVIIaisnotroutinelyrecommendedasasoleagentforOACreversalinICH(III-C).(Revised!).

第七页，共四十八页，编辑于2023年，星期三Hemostasis/Antiplatelets/DeepVein

ThrombosisProphylaxis---Recommendations3.rFVIIacanlimittheextentofhematomaexpansioninnoncoagulopathicICHpts,thereisanincreaseinthromboembolicriskandnoclearclinicalbenefitinunselectedpatients.rFVIIaisnotrecommendedinunselectedpts.(III-A).

(New!)Furtherresearchneeded4.TheusefulnessofplatelettransfusionsinICHptswithahistoryofantiplateletuseisunclearandisconsideredinvestigational(IIb-B).

(New!)

第八页，共四十八页，编辑于2023年，星期三Hemostasis/Antiplatelets/DeepVein

ThrombosisProphylaxis---Recommendations5.PtswithICHshouldhaveIPCforpreventionofvenousthromboembolisminadditiontoelasticstockings(I-B).(Unchanged!)

6.Afterdocumentationofcessationofbleeding,low-dosesubcutaneousLMWHorunfractionatedheparinmaybeconsideredforpreventionofvenousthromboembolisminptswithlackofmobilityafter1to4daysfromonset(IIb-B).(Revised!)第九页，共四十八页，编辑于2023年，星期三BloodPressure---Recommendations1.UntilongoingclinicaltrialsofBPinterventionforICHarecompleted,physiciansmustmanageBPonthebasisofthepresentincompleteefficacyevidence.CurrentsuggestedrecommendationsfortargetBPlistedinTable6andmaybeconsidered(IIb-C).(Unchanged!)

2.InpatientspresentingwithasystolicBPof150to220mmHg,acuteloweringofsystolicBPto140mmHgisprobablysafe(IIa-B).(New!)

第十页，共四十八页，编辑于2023年，星期三SuggestedGuidelinesforTreatingElevatedBPins-ICH

1.IfSBPis>200mmHgorMAPis>150mmHg,consideraggressivereductionofBPwithcontinuousi.v.infusion,withfrequentBPmonitoringevery5min.2.IfSBPis>180mmHgorMAPis>130mmHgandthereisthepossibilityofelevatedICP,considermonitoringICPandreducingBPusingintermittentorcontinuousi.v.medicationswhilemaintainingaCPP>60mmHg.3.IfSBPis>180mmHgorMAPis>130mmHgandthereisnotevidenceofelevatedICP,thenconsideramodestreductionofBP(eg:MAPof110mmHgortargetBPof160/90mmHg)usingintermittentorcontinuousi.v.medicationstocontrolBPandclinicallyreexaminethepatientevery15min.第十一页，共四十八页，编辑于2023年，星期三NursingCare---RecommendationsInitialmonitoringandmanagementofICHptsshouldtakeplaceinanintensivecareunitwithphysicianandnursingneuroscienceintensivecareexpertise(I-B).(Unchanged!)第十二页，共四十八页，编辑于2023年，星期三ManagementofGlucose---RecommendationsGlucoseshouldbemonitoredandnormoglycemiaisrecommended

(I-C).(New!)第十三页，共四十八页，编辑于2023年，星期三SeizuresandAntiepilepticDrugs---Recommendations

1.Clinicalseizuresshouldbetreatedwithantiepilepticdrugs(I-A).(Revised!)ContinuousEEGmonitoringisprobablyindicatedinICHpatientswithdepressedmentalstatusoutofproportiontothedegreeofbraininjury(IIa-B).PtswithachangeinmentalstatuswhoarefoundtohaveelectrographicseizuresonEEGshouldbetreatedwithantiepilepticdrugs(I-C).Prophylacticanticonvulsantmedicationshouldnotbeused(III-B).(New!)

第十四页，共四十八页，编辑于2023年，星期三TemperatureManagement---Recommendations

AggressivetreatmenttomaintainnormothermiainptswithICH;nodatalinkingfevertreatmentwithoutcome.TherapeuticcoolinghasnotbeensystematicallyinvestigatedinICHpts.第十五页，共四十八页，编辑于2023年，星期三Iron---noRecommendations

AfewstudieshaveexaminedtheroleofironinICHptsandreportedthathighserumferritinlevelsareassociatedwithpooroutcomeafterICHandcorrelatewiththeperihematomaedema.Limitingiron-mediatedtoxicityisapromisingtherapeutictargetinICH.第十六页，共四十八页，编辑于2023年，星期三ICPMonitoringandTreatment---Recommendations

1.PtswithaGCS<8,thosewithclinicalevidenceoftranstentorialherniation,orsignificantIVHorhydrocephalusmightbeconsideredforICPmonitoringandtreatment.ACPPof50to70mmHgmaybereasonabletomaintaindependingonthestatusofcerebralautoregulation(IIb-C).(New!)

2.Ventriculardrainageastreatmentforhydrocephalusisreasonableinptswithdecreasedlevelofconsciousness(IIa-B).(New!)

第十七页，共四十八页，编辑于2023年，星期三IntraventricularHemorrhage--RecommendationsAlthoughintraventricularadministrationofr-tPAinIVHappearstohaveafairlylowcomplicationrate,efficacyandsafetyofthistreatmentisuncertainandisconsideredinvestigational(IIb-B).(New!)第十八页，共四十八页，编辑于2023年，星期三SurgicalTreatmentofICH---RecommendationsFormostptswithICH,theusefulnessofsurgeryisuncertain(IIb-C).(New!)第十九页，共四十八页，编辑于2023年，星期三CraniotomybyLocationofICH---RecommendationsPtswithcerebellarhemorrhagewhoaredeterioratingneurologicallyorwhohavebrainstemcompressionand/orhydrocephalusfromventricularobstructionshouldundergosurgicalremovalofthehemorrhageassoonaspossible(I-B).(Revised!)Initialtreatmentoftheseptswithventriculardrainagealoneratherthansurgicalevacuationisnotrecommended(III-C).(New!)

Forptspresentingwithlobarclots>30mLandwithin1cmofthesurface,evacuationofsupratentorialICHbystandardcraniotomymightbeconsidered(IIb-B).(Revised!)

第二十页，共四十八页，编辑于2023年，星期三MinimallyInvasiveSurgicalRemovalofICH--Recommendations

Theeffectivenessofminimallyinvasiveclotevacuationutilizingeitherstereotacticorendoscopicaspirationwithorwithoutthrombolyticusageisuncertainandisconsideredinvestigational(IIb-B).(New!)第二十一页，共四十八页，编辑于2023年，星期三TimingofSurgery---RecommendationsAlthoughtheoreticallyattractive,noclearevidenceatpresentindicatesthatultra-earlyremovalofsupratentorialICHimprovesfunctionaloutcomeormortalityrate.Veryearlycraniotomymaybeharmfulduetoincreasedriskofrecurrentbleeding(III-B).(Revised!)

第二十二页，共四十八页，编辑于2023年，星期三OutcomePredictionandWithdrawalof

TechnologicalSupport---RecommendationsAggressivefullcareearlyafterICHonsetandpostponementofnewDNRordersuntilatleastthesecondfulldayofhospitalizationisprobablyrecommended(IIa-B).PtswithpreexistingDNRordersarenotincludedinthisrecommendation.CurrentmethodsofprognosticationinindividualptsearlyafterICHarelikelybiasedbyfailuretoaccountfortheinfluenceofwithdrawalofsupportandearlyDNRorders.PtswhoaregivenDNRstatusatanypointshouldreceiveallotherappropriatemedicalandsurgicalinterventionsunlessotherwiseexplicitlyindicated.(Revised!)第二十三页，共四十八页，编辑于2023年，星期三PreventionofRecurrentICH---RecommendationsStratifyingapt’sriskofrecurrentICHmayaffectothermanagementdecisions,thefollowingriskfactorsforrecurrenceas:lobarlocationoftheinitialICH,olderage,ongoinganticoagulation,presenceoftheapolipoproteinE2orE4alleles,andgreaternumberofmicrobleedsonMRI(IIa-B).(New!)

BPshouldbewellcontrolled,forptswithICHlocationtypicalofhypertensivevasculopathy(I-A).(New!)

AgoaltargetofBPof<140/90(<130/80ifdiabetesorchronickidneydisease)isreasonable(IIa-B).(New!)

第二十四页，共四十八页，编辑于2023年，星期三PreventionofRecurrentICH---Recommendations4.Avoidlong-termanticoagulationastreatmentfornonvalvularatrialfibrillationafterspontaneouslobarICHbecauseofhigherriskofrecurrence(IIa-B).AnticoagulationafternonlobarICHandantiplatelettherapyafterallICHmightbeconsidered,asindicatedfortheseagents(IIb-B).(Unchanged!)

5.Avoidheavyalcoholuse(IIa-B).Insufficientdatatorecommendrestrictionsonuseofstatinagentsorphysicalorsexualactivity(IIb-C).(New!)

第二十五页，共四十八页，编辑于2023年，星期三RehabilitationandRecovery

Giventhepotentiallyseriousnatureandcomplexpatternofevolvingdisability,itisreasonablethatallptswithICHhaveaccesstomultidisciplinaryrehabilitation(IIa-B).Rehabilitationcanbebeneficialwhenbegunasearlyaspossibleandcontinuedinthecommunityaspartofawell-coordinated(seamless)programofacceleratedhospitaldischargeandhome-basedresettlementtopromoteongoi