脑出血管理指南GuidelinesfortheManagementofICH课件.ppt

1、Guidelines for the Management of SpontaneousIntracerebral Hemorrhage(ICH)Purpose The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous ICHMethods A formal literature search of PubMed was performed from 2009 through 2013Result

2、s Evidence-based guidelines are presented for the care of patients with acute ICHConclusions ICH remains a serious condition for which early aggressive care is warranted.These guidelines provide a framework for goal-directed treatment of the patient with ICHRecommendations follow the American Heart

3、Association(AHA)/American Stroke Association(ASA)smethods of classifying the level of certainty of the treatment effect and the class of evidenceEmergency Diagnosis and AssessmentRecommendations1.A baseline severity score should be performed as part of the initial evaluation of patients with ICH(Cla

4、ss I;Level of Evidence B).(New recommendation)2.Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from ICH(Class I;Level of Evidence A).(Unchanged from the previous guideline)3.CTA and contrast-enhanced CT may be considered to help identify patients at risk for hematoma

5、 expansion(Class IIb;Level of Evidence B),CTA,CT venography,contrast-enhanced CT,contrastenhanced MRI,magnetic resonance angiography and magnetic resonance venography,and catheter angiography can be useful to evaluate for underlying structural lesions including vascular malformations and tumors when

6、 there is clinical or radiological suspicion(Class IIa;Level of Evidence B).(Unchanged from the previous guideline)Medical Treatment for ICH Hemostasis and Coagulopathy,Antiplatelet Agents,and(deep vein thrombosis,DVT)ProphylaxisRecommendations1.Patients with a severe coagulation factor deficiency o

7、r severe thrombocytopenia should receive appropriate factor replacement therapy or platelets,respectively(Class I;Level of Evidence C).(Unchanged from the previous guideline)2.The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is uncertain(Class IIb;Level of E

8、vidence C).(Revised from the previous guideline)3.Patients with ICH whose(international normalized ratio,INR)is elevated because of(Vitamin K antagonists,VKA)should have their VKA withheld,receive therapy to replace vitamin Kdependent factors and correct the INR,and receive intravenous vitamin K(Cla

9、ss I;Level of Evidence C).4.Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission(Class I;Level of Evidence A).Graduated compression stockings are not beneficial to reduce DVT or improve outcome(Class III;Lev

10、el of Evidence A).(Revised from the previous guideline)5.After documentation of cessation of bleeding,lowdose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset(

11、Class IIb;Level of Evidence B).(Unchanged from the previous guideline)6.Systemic anticoagulation or(inferior vena cava,IVC)filter placement is probably indicated in ICH patients with symptomatic DVT or(pulmonary embolism,PE)(Class IIa;Level of Evidence C)BP and Outcome in ICH:Recommendations1.For IC

12、H patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment,acute lowering of SBP to 140mmHg is safe(Class I;Level of Evidence A)and can be effective for improving functional outcome(Class IIa;Level of Evidence B).(Revised from the previous guideline)2.

13、For ICH patients presenting with SBP 220 mmHg,it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring(Class IIb;Level of Evidence C).(New recommendation)General Monitoring and Nursing Care:RecommendationInitial monitoring and mana

14、gement of ICH patients should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise(Class I;Level of Evidence B).(Revised from the previous guideline)Glucose Management:Recommendation Glucose should be monitored.Both hyperglycemia

15、and hypoglycemia should be avoided(ClassI;Level of Evidence C).(Revised from the previous guideline)Temperature Management:Recommendation Treatment of fever after ICH may be reasonable(Class IIb;Level of Evidence C).(New recommendation)Seizures and Antiseizure Drugs:Recommendations1.Clinical seizure

16、s should be treated with antiseizure drugs(Class I;Level of Evidence A).(Unchanged from the previous guideline)2.Patients with a change in mental status who are found to have electrographic seizures on(Electroencephalography,EEG)should be treated with antiseizure drugs(Class I;Level of Evidence C).(

17、Unchanged from the previous guideline)3.Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status that is out of proportion to the degree of brain injury(Class IIa;Level of Evidence C).(Revised from the previous guideline)4.Prophylactic antiseizure medication is no

18、t recommended(Class III;Level of Evidence B).(Unchanged from the previous guideline)Management of Medical Complications:Recommendations1.A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk of pneumonia(Class I;Level o

19、f Evidence B).(New recommendation)2.Systematic screening for myocardial ischemia or infarction with electrocardiogram and cardiac enzyme testing after ICH is reasonable(Class IIa;Level of Evidence C).(New recommendation)(Intracranial pressure,ICP)Monitoring and Treatment:Recommendations1.Ventricular

20、 drainage as treatment for hydrocephalus is reasonable,especially in patients with decreased level of consciousness(Class IIa;Level of Evidence B).(Revised from the previous guideline)2.Patients with a GCS score of 8,those with clinical evidence of transtentorial herniation,or those with significant

21、(Intraventricular hemorrhage,IVH)or hydrocephalus might be considered for ICP monitoring and treatment.(Class IIb;Level of Evidence C).(Unchanged from the previous guideline)3.Corticosteroids should not be administered for treatment of elevated ICP in ICH(Class III;Level of Evidence B).(New recommen

22、dation)Surgical Treatment of ICH:Recommendations1.Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible(Class I;Level of Eviden

23、ce B).Initial treatment of these patients with ventricular drainage rather than surgical evacuation is not recommended(Class III;Level of Evidence C).(Unchanged from the previous guideline)2.For most patients with supratentorial ICH,the usefulness of surgery is not well established(Class IIb;Level o

24、f Evidence A).(Revised from the previous guideline)Specific exceptions and potential subgroup considerations are outlined below in recommendations3 through 63.A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacuation when patients deteriorate(Class IIb;Level o

25、f Evidence A).(New recommendation)4.Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure(Class IIb;Level of Evidence C).(New recommendation)5.hematoma evacuation might reduce mortality for patients with supratentorial ICH who are in a coma,have la

26、rge hematomas with significant midline shift,or have elevated ICP refractory to medical management(Class IIb;Level of Evidence C).(New recommendation)6.The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration is uncertain(Class IIb;Level of Evidence B).(Revi

27、sed from the previous guideline)Prevention of Recurrent ICH:Recommendations1.BP should be controlled in all ICH patients(Class I;Level of Evidence A).(Revised from the previous guideline)Measures to control BP should begin immediately after ICH onset(Class I;Level of Evidence A).(New recommendation)

28、A long-term goal of BP 130 mm Hg systolic and 80 mmHg diastolic is reasonable(Class IIa;Level of Evidence B).(New recommendation)2.Lifestyle modifications,including avoidance of alcohol use greater than 2 drinks per day,tobacco use,and illicit drug use,as well as treatment of obstructive sleep apnea

29、,are probably beneficial(Class IIa;Level of Evidence B).(Revised from previous guideline)3.Avoidance of long-term anticoagulation with warfarin as a treatment for nonvalvular atrial fibrillation is probably recommended after warfarin-associated spontaneous lobar ICH because of the relatively high ri

30、sk of recurrence(Class IIa;Level of Evidence B).(Unchanged from the previous guideline)4.antiplatelet monotherapy after any ICH might be considered，particularly when there are strong indications for these agents(Class IIb;Level of Evidence B).(Revised from the previous guideline)5.The optimal timing

31、 to resume oral anticoagulation after anticoagulant-related ICH is uncertain.Avoidance of oral anticoagulation for at least 4 weeks,in patients without mechanical heart valves,might decrease the risk of ICH recurrence(Class IIb;Level of Evidence B).(New recommendation)Rehabilitation and Recovery:Rec

32、ommendationsGiven the potentially serious nature and complex pattern of evolving disability and the increasing evidence for efficacy,it is recommended that all patients with ICH have access to multidisciplinary rehabilitation(Class I;Level of Evidence A).(Revised from the previous guideline)thank you