血压控制在脑出血治疗和预防(55)课件.ppt
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- 血压 控制 脑出血 治疗 预防 55 课件
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1、血压控制在脑出血治疗和预防北京大学第一医院神经科黄一宁教授Primary Intracerebral Haemorrhage10-15%all strokes(Caucasians)20-30%in Asian/AfricanPathology(80-90%of all ICH)Hypertensive angiopathy Amyloid angiopathySitesBasal Ganglia Putamen(40%),thalamus(15%),caudate(5-10%)Cerebellum(10%),pons(10%)Lobar(10-20%)Haematoma evolutionE
2、arly haematoma expansionOnset-CT interval(h)ProspectiveRetrospectiveBrottFujiiKazuiTakizawa 0-338%18%36%17%3-6N/A8%16%6%6-24N/A2%10%0%Peri-haematomal oedema in ICH Precise aetiology unclear cytotoxic vs vasogenic Is there a peri-haematomal ischaemic penumbra?Rational acute BP lowering requires bette
3、r understanding of peri-haematomal oedemaSurgical treatmentSTICH trial resultsMedical treatmentrFVII(NovoSeven)Mayer et al.NEJM 2005;352:777-85Reduction of haematoma expansionMayer et al.NEJM 2005;352:777-85Role of blood pressureobservational studies-mortalitySBP(mm Hg)1 month mortality(%)FogelholmV
4、emmosOnset of ICH3-6 6-12 hours12hrs to one week1-4 weeksmonthsBP loweringhaemorrhagerebleedingoedemastroke recurrenceGuidelines for Acute BP ManagementStart medicationTargetICHAHA(1999)180/105 mm Hg 180/105 mm Hg ISH(2003)180/105 mm Hg 180/105 mm HgNZ (2003)Mean BP 130 mm HgMean BP 220/120 mm Hg180
5、/100-105 mm Hg(HT)160-180/90-105 mm Hg(non-HT)UK(2004)if complications are apparentNot described拉贝洛尔labetalol 5100mg/h,间断注入,每次1040mg,或者 连续点滴 28mg/min 我国药典禁忌在脑出血使用拉贝咯尔 艾司洛尔esmolol 负荷量500mcg/kg;维持量 50200 mcg.kg-1min 硝普钠 nitroprusside 0.5-10 mcg.kg-1min-1 尼卡地平 nicardipine 5mg/h,每15分钟增加 2.5mg/h,最大量为15mg
6、/h 肼苯哒嗪 hydralazine 10-20mg,q4-6h 依那普利 0.625-1.2 mg q6h,根据需要调节剂量INTERACT pilot phase(Lancet Neurology 2008;7:391-399.)Vanguard PhaseProtocol SchemaRandomisationAcute ICH-onset within 6 hoursSBP 150 and 220 mmHgRepeat CT scans 24+72 hrsVital signs and BP over 7 days28 day and 3 month follow-upIntensi
7、ve BP loweringTarget SBP 140mmHgGuideline-based BP managementTarget SBP 180 mmHgSystolic blood pressure differencesMean systolic BP over time including 95%CITimeMean BP130140150160170180190Systolic BP:ControlSystolic BP:TreatmentTime 0Time 115min30min45min1hr6hr12hr18hr24hrday2amday2pmday3amday3pmda
8、y4amday4pmday5amday5pmday6amday6pmday7amday7pmday28amday28pmCrude mean(SD)change in hematoma volume by groupVolume(ml)Guideline groupIntensive groupBaseline24 hours12.715.414.215.2 Clinical outcomes at 90 daysStandard(n=201)Intensive(n=203)pDeath or dependency49480.81Death12100.51Dependency41360.98M
9、odified Rankin Score,median 2 20.66NIHSS,median220.97Barthel Index score,median95950.77MMSE,median28270.97EuroQoL,EQ5D,median,%78750.97Early intensive blood pressure lowering enhances hematoma resolution but does not affect perihematoma edema:Yining HuangPeking University First Hospital,Beijing,Chin
10、aOn behalf of C Anderson,Q Li,E Heeley,B Peng,C Skulina,J Wang,for the INTERACT Investigators Stroke 2009,acceptedSecondary aimsTo determine the effects of early intensive blood pressure lowering treatment on hematoma and perihematoma edema growth over 72 hoursSecondary analyses:patient flow404 Pati
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