1、腦出血指南知識(shí)講座腦出血指南知識(shí)講座A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association給予來(lái)自美國(guó)心臟協(xié)會(huì)/美國(guó)卒中協(xié)會(huì)的衛(wèi)生保健專(zhuān)業(yè)人員的指南腦出血指南知識(shí)講座2A Guideline for Healthcare Pro一、Emergency Diagnosis and Assessment of ICH and Its Causes Recommendations關(guān)于腦出血的緊急診斷和評(píng)估的建議腦出血指南知識(shí)講座3一、Emergen

2、cy Diagnosis and Asse1. Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke p1 from ICHp2 (Class I; Level of Evidence: A). (Unchanged from the previous guideline)CT或MRI（核磁共振成像）的快速成像便于很好地區(qū)分缺血性中風(fēng)和腦出血（出血性腦中風(fēng)）。（與先前的指南并無(wú)差異）腦出血指南知識(shí)講座41. Rapid neuroimaging with CT 2. CT angiogra

3、phy and contrast-enhanced CTp3 may be considered to help identify patients at risk for hematoma expansion (Class IIb; Level of Evidence: B), CT血管造影術(shù)和強(qiáng)化CT或許可以輔助鑒別有血腫擴(kuò)散危險(xiǎn)的病人and CT angiography, CT venography, contrast-enhanced CT, contrast-enhanced MRI, magnetic resonance angiography, and magnetic reso

4、nance venography can be useful to evaluate for underlying structural lesions, including vascular malformations and tumors when there is clinical or radiological suspicion (Class IIa;Level of Evidence: B). (New recommendation)同時(shí)，CT血管造影術(shù)、CT靜脈造影術(shù)、加強(qiáng)CT、加強(qiáng)MRI（核磁共振）、磁共振血管造影、磁共振靜脈造影，可以檢查到潛在的結(jié)構(gòu)損傷，包括臨床上或放射學(xué)上

5、懷疑的血管畸形和腫瘤。（新推薦）腦出血指南知識(shí)講座52. CT angiography and contrast二、Medical Treatment for ICH Recommendations 關(guān)于腦出血內(nèi)科治療的建議p4 腦出血指南知識(shí)講座6二、Medical Treatment for ICH Re1. Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or plate

6、lets, respectively (Class I;Level of Evidence: C). (New recommendation)嚴(yán)重缺乏凝血因子或者說(shuō)有嚴(yán)重血小板減少癥的病人，應(yīng)該適當(dāng)?shù)亟邮芡鈦?lái)因子或者血小板來(lái)進(jìn)行治療。（新推薦）腦出血指南知識(shí)講座71. Patients with a severe coag2. Patients with ICH whose INRp5 is elevated due to OACsp6 should have their warfarin withheld, receive therapy to replace vitamin Kdepend

7、ent factors and correct the INR, and receive intravenous vitamin K (Class I; Level of Evidence: C). 對(duì)于那些由口服抗凝劑OACsp7 導(dǎo)致INR（國(guó)際標(biāo)準(zhǔn)化比值）升高的腦出血病人，不應(yīng)該再用華法令，而該接受上述治療來(lái)取代維生素K依賴(lài)性因子，同時(shí)，該改善INR水平、接受靜脈內(nèi)維生素K治療。PCCsp8 血漿凝固劑have not shown improved outcome compared with新鮮冷凍血漿 FFPp9 but may have fewer complications com

8、pared with FFP and are reasonable to consider as an alternative to FFP (Class IIa; Level of Evidence: B). 與新鮮血漿相比，血液凝固劑并沒(méi)有顯示出明顯改善的治療成果，但是可能并發(fā)癥更少，是值得考慮的新鮮血漿替代物。腦出血指南知識(shí)講座82. Patients with ICH whose INRrFVIIap10 does not replace all clotting factors, and although the INR may be lowered, clotting may no

9、t be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH (Class III; Level of Evidence: C). (Revisedfrom the previous guideline).重組凝血因子VII并不能替代所有的凝結(jié)因子；雖然INR可能會(huì)被降低，但是體內(nèi)的血凝塊并不能消除。所以，并不推薦把rFvlla作為腦出血病人OAC逆轉(zhuǎn)的唯一藥劑。（由先前指南修訂）腦出血指南知識(shí)講座9rFVIIap10 does not

10、replace a3. Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, thereis an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus rFVIIa is not recommended in unselected patients. (Class III; Level of Evidence:

11、A). (New recommendation) Further research to determine whether any selected group of patients may benefitfrom this therapy is needed before any recommendation for its use can be made. 雖然重組凝血因子VII可以限制非凝血異常性腦出血病人血腫擴(kuò)大，但是應(yīng)用rFVlla 時(shí)發(fā)生血栓的危險(xiǎn)性卻增加了，同時(shí)，對(duì)于隨機(jī)選定的患者沒(méi)有明顯的臨床利益。（新推薦）在可以得出有關(guān)其應(yīng)用的任何推薦之前，需要做更深層次的研究來(lái)驗(yàn)證是否

12、任何被選定的病人群體都可以從這種治療獲益。腦出血指南知識(shí)講座103. Although rFVIIa can limit t4. The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is unclear and is considered investigational (Class IIb; Level of Evidence: B). (New recommend)對(duì)于有抗血小板治療病史的腦出血病人，給予輸液血小板治療的有效性并不清楚、有待于研究。（新推薦）5.

13、 Patients with ICH should have intermittent pneumatic compressionp11 for prevention of venous thromboembolism in addition to elastic stockingsp12 (Class I;Level of Evidence: B). (Unchanged from the previousguideline)為了預(yù)防腦出血病人出現(xiàn)下肢靜脈栓塞p13 ，除了下肢要穿彈力襪子、也要進(jìn)行間歇性的充氣壓迫治療（與先前的指南并無(wú)差異） 腦出血指南知識(shí)講座114. The useful

14、ness of platelet 6. 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 (ClassIIb; Level of Evidence: B). (R

15、evised from the previousguideline)在確定病人出血停止后，皮下注射低劑量的低分子量的肝素或者肝素，可能用于防止病人發(fā)病后1到4天后發(fā)生靜脈栓塞。（由先前指南修訂）腦出血指南知識(shí)講座126. After documentation of cess三、Blood Pressure Recommendations（有關(guān)血壓方面的建議）1. Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of th

16、e present incomplete efficacy evidence.Current suggested recommendations for target BP in various situations are listed in Table 6 and may be considered (Class IIb; Level of Evidence: C). (Unchangedfrom the previous guideline)在正在進(jìn)行的腦出血病人血壓干預(yù)臨床試驗(yàn)完成之前，醫(yī)師必須依據(jù)目前不完善的循證醫(yī)學(xué)證據(jù)的基礎(chǔ)，來(lái)適當(dāng)控制血壓。目前，對(duì)于不同情況下所推薦的血壓處理方法

17、，請(qǐng)見(jiàn)表6，值得借鑒。（與先前的指南并無(wú)差異）腦出血指南知識(shí)講座13三、Blood Pressure Recommendatio2. In patients presenting with a systolic BP of 150 to 220 mm Hg, acute lowering of systolic BP to 140 mm Hg is probably safe (Class IIa; Level of Evidence: B). (New recommendation)對(duì)于收縮壓在150到220mmHg之間的病人，收縮壓迅速降低到140mmHg或許是安全的。（新推薦）腦出血指南

18、知識(shí)講座142. In patients presenting with四、Inpatient Managementp14 and Prevention of Secondary Brain Injury Recommendations關(guān)于住院病人的處理治療和預(yù)防二次腦損傷的建議腦出血指南知識(shí)講座15四、Inpatient Managementp14 an1. Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursi

19、ng neuroscience intensive care expertise (Class I; Level of Evidence: B). (Unchanged from the previous guideline）腦出血病人最初的監(jiān)測(cè)和管理，應(yīng)該在一個(gè)擁有神經(jīng)科學(xué)重專(zhuān)業(yè)護(hù)理人員和內(nèi)科醫(yī)生的加強(qiáng)治療中心ICU。（與先前的指南并無(wú)差異）腦出血指南知識(shí)講座161. Initial monitoring and manaManagement of Glucose（血糖控制）1. Glucose should be monitored and normoglycemia is recomme

20、nded (Class I: Level of Evidence: C). (New recommendation)應(yīng)該監(jiān)測(cè)血糖，保證血糖的正常。（新推薦）腦出血指南知識(shí)講座17Management of Glucose（血糖控制）腦出血Seizures and Antiepileptic Drugsp15 （控制驚厥及抗癲癇藥物）1. Clinical seizures should be treated with antiepileptic drugs (Class I; Level of Evidence: A). (Revised from the previous guideline

21、) Continuous EEGp16 monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury (Class IIa; Level of Evidence: B). Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with ant

22、iepileptic drugs (Class I; Level of Evidence: C). Prophylactic anticonvulsant medication should not be used (Class III; Level of Evidence:B). (New recommendation）臨床的癲癇發(fā)作應(yīng)該給予抗癲癇藥物；（一級(jí)推薦A級(jí)證據(jù)）對(duì)那些精神狀態(tài)抑制與腦損傷程度不相符合的腦出血病人，進(jìn)行持續(xù)的腦電圖監(jiān)視可能會(huì)有一定的診斷預(yù)警作用。p17 那些發(fā)現(xiàn)有腦電圖癇性異常的精神狀態(tài)改變的病人，應(yīng)該用抗癲癇藥物（C級(jí)證據(jù)一級(jí)推薦）；不建議預(yù)防性應(yīng)用抗痙攣劑。（新

23、推薦）腦出血指南知識(shí)講座18Seizures and Antiepileptic Dru六、Procedures/Surgery Recommendations（關(guān)于手術(shù)程序的建議）腦出血指南知識(shí)講座19六、Procedures/Surgery Recommend1. Patients with a GCSp18 score of 30 mL and within 1 cm of the surface, evacuation of supratentorialp28 ICH by standard craniotomy might be considered(Class IIb; Level

24、 of Evidence: B). (Revised from the previous guideline)對(duì)于那些血腫體積大于30ml 、靠近腦表面小于1cm的腦葉出血的病人，可以考慮用標(biāo)準(zhǔn)的開(kāi)顱手術(shù)治療幕上腦出血。（由先前指南修訂） 腦出血指南知識(shí)講座253. For patients presenting wit4. The effectiveness of minimally invasive clot evacuation utilizing either stereotacticp29 or endoscopic aspiration with or without thromb

25、olytic usage is uncertain and is considered investigational (Class IIb; Level of Evidence: B). (New recommendation)應(yīng)用輔用溶栓劑或者不用溶栓劑的的立體定位方法或者內(nèi)窺抽吸法，來(lái)盡可能地清除的血凝塊的療效并不確定、尚值得探究。腦出血指南知識(shí)講座264. The effectiveness of minima5. Although theoretically attractive, no clear evidence at present indicates that ultra-e

26、arly removal of supratentorialp30 ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding (Class III; Level of Evidence: B). (Revised from the previous guideline)雖然理論上很有吸引性，但是目前沒(méi)有明確的證據(jù)表明，盡早清除幕上腦出血血腫能夠改善腦功能、降低死亡率。過(guò)早的開(kāi)顱手術(shù)增加了再發(fā)

27、性腦出血的風(fēng)險(xiǎn)，因而可能會(huì)對(duì)病人有害。（由先前指南修訂） 腦出血指南知識(shí)講座275. Although theoretically attr九、Outcome Prediction and Withdrawal of Technological Support Recommendation腦出血指南知識(shí)講座28九、Outcome Prediction and Withd1. Aggressive full care early after ICH onset and postponement of new DNR ordersp31 until at least the second full

28、 day of hospitalization is probably recommended(Class IIa; Level of Evidence: B). Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withd

29、rawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.(Revised from the previous guideline)在腦出血發(fā)生后無(wú)法復(fù)蘇的延緩期中，至少到住院治療第二天之前，都應(yīng)該采用早期迅速而全面的護(hù)理。那些先前存在無(wú)法復(fù)蘇情況的病人并不包括在這

30、推薦之內(nèi)。目前對(duì)特定腦出血病人早期進(jìn)行預(yù)測(cè)的方法p32 可能是有失偏頗的，因?yàn)椴荒苷f(shuō)明停止使用有效藥物后對(duì)病人的影響和早期的無(wú)法復(fù)蘇情況。任何被醫(yī)生定為無(wú)法復(fù)蘇的病人都應(yīng)該接受所有其他形式的藥物和手術(shù)干預(yù)，除非有其明確的原因。腦出血指南知識(shí)講座291. Aggressive full care early 十、Prevention of Recurrent ICH Recommendations關(guān)于預(yù)防再發(fā)性腦出血的建議腦出血指南知識(shí)講座30十、Prevention of Recurrent ICH 1. In situations where stratifying a patients r

31、isk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E 2 or 4 alleles, and greater number of microbleeds on MRI p33 (Cl

32、ass IIa; Level of Evidence: B). (New recommendation)把病人再發(fā)性腦出血的風(fēng)險(xiǎn)進(jìn)行分類(lèi)可能會(huì)影響其他治療決定的狀態(tài)，應(yīng)該考慮如下引起復(fù)發(fā)的危險(xiǎn)因子：原發(fā)性腦葉出血的位置，老年人，正在進(jìn)行的抗凝治療，載脂脂蛋白E2或者E4等位基因的存在，以及核磁共振成像顯現(xiàn)的大量微出血。（新推薦）腦出血指南知識(shí)講座311. In situations where stratif2. After the acute ICH period, absent medical contraindications, BP should be well controlled,

33、 particularly for patients with ICH location typical of hypertensive vasculopathy (Class I; Level of Evidence: A).(New recommendation)在腦出血急性期之后，沒(méi)有醫(yī)學(xué)上的禁忌癥的時(shí)候，應(yīng)該好好控制血壓，尤其對(duì)于那些腦出血部位在高血壓導(dǎo)致的血管病變的病人。3. After the acute ICH period, a goal target of a normal BP of 140/90 (130/80 if diabetes or chronic kidney

34、disease) is reasonable (Class IIa; Level of Evidence: B). (New recommendation)在腦出血急性期之后，血壓應(yīng)該控制在收縮壓低于140mmHg、舒張壓低于90mmHg的水平（如果有糖尿病或者慢性腎病的病人，是低于13080）。（新推薦）腦出血指南知識(shí)講座322. After the acute ICH period,4. Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably re

35、commended after spontaneous lobar ICH because of the relatively high risk of recurrence (Class IIa; Level of Evidence: B). Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents (Class IIb; Level of Evidence:B). (Unchanged from the previous guideline)因?yàn)榇嬖趶?fù)發(fā)相關(guān)的高風(fēng)險(xiǎn)，對(duì)于非瓣膜