自發(fā)性腦出血第1頁，課件共48頁，創(chuàng)作于2023年2月第2頁，課件共48頁，創(chuàng)作于2023年2月Evidence-basedguidelinesDiagnosisHemostasisBloodpressuremanagementInpatientandnursingmanagement,PreventingmedicalcomorbiditiesSurgicaltreatmentOutcomepredictionRehabilitationPreventionofrecurrenceFutureconsiderations.第3頁，課件共48頁，創(chuàng)作于2023年2月DefinitionofClassesandLevelsofEvidenceUsedinAHAStrokeCouncilRecommendationsClassI:evidenceforand/orgeneralagreementthattheprocedureortreatmentisusefulandeffectiveClassII:conflictingevidenceand/oradivergenceofopinionabouttheusefulness/efficacyofaprocedureortreatmentClassIIaTheweightofevidenceoropinionisinfavoroftheprocedureortreatmentClassIIbUsefulness/efficacyislesswellestablishedbyevidenceoropinionClassIIIConditionsforwhichthereisevidenceand/orgeneralagreementthattheprocedureortreatmentisnotuseful/effectiveandinsomecasesmaybeharmfulLevelofEvidenceA--multipleRCTsormeta-analysesLevelofEvidenceB--asinglerandomizedtrialornonrandomizedstudiesLevelofEvidenceC--Consensusopinionofexperts,casestudies,orstandardofcare第4頁，課件共48頁，創(chuàng)作于2023年2月EmergencyDiagnosisandAssessmentofICH

andItsCauses

PrehospitalManagementEDManagementNeuroimaging第5頁，課件共48頁，創(chuàng)作于2023年2月Recommendations

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

第6頁，課件共48頁，創(chuàng)作于2023年2月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7頁，課件共48頁，創(chuàng)作于2023年2月Hemostasis/Antiplatelets/DeepVein

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

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

(New!)

第8頁，課件共48頁，創(chuàng)作于2023年2月Hemostasis/Antiplatelets/DeepVein

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

6.Afterdocumentationofcessationofbleeding,low-dosesubcutaneousLMWHorunfractionatedheparinmaybeconsideredforpreventionofvenousthromboembolisminptswithlackofmobilityafter1to4daysfromonset(IIb-B).(Revised!)第9頁，課件共48頁，創(chuàng)作于2023年2月BloodPressure---Recommendations1.UntilongoingclinicaltrialsofBPinterventionforICHarecompleted,physiciansmustmanageBPonthebasisofthepresentincompleteefficacyevidence.CurrentsuggestedrecommendationsfortargetBPlistedinTable6andmaybeconsidered(IIb-C).(Unchanged!)

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

第10頁，課件共48頁，創(chuàng)作于2023年2月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11頁，課件共48頁，創(chuàng)作于2023年2月NursingCare---RecommendationsInitialmonitoringandmanagementofICHptsshouldtakeplaceinanintensivecareunitwithphysicianandnursingneuroscienceintensivecareexpertise(I-B).(Unchanged!)第12頁，課件共48頁，創(chuàng)作于2023年2月ManagementofGlucose---RecommendationsGlucoseshouldbemonitoredandnormoglycemiaisrecommended

(I-C).(New!)第13頁，課件共48頁，創(chuàng)作于2023年2月SeizuresandAntiepilepticDrugs---Recommendations

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

第14頁，課件共48頁，創(chuàng)作于2023年2月TemperatureManagement---Recommendations

AggressivetreatmenttomaintainnormothermiainptswithICH;nodatalinkingfevertreatmentwithoutcome.TherapeuticcoolinghasnotbeensystematicallyinvestigatedinICHpts.第15頁，課件共48頁，創(chuàng)作于2023年2月Iron---noRecommendations

AfewstudieshaveexaminedtheroleofironinICHptsandreportedthathighserumferritinlevelsareassociatedwithpooroutcomeafterICHandcorrelatewiththeperihematomaedema.Limitingiron-mediatedtoxicityisapromisingtherapeutictargetinICH.第16頁，課件共48頁，創(chuàng)作于2023年2月ICPMonitoringandTreatment---Recommendations

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

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

第17頁，課件共48頁，創(chuàng)作于2023年2月IntraventricularHemorrhage--RecommendationsAlthoughintraventricularadministrationofr-tPAinIVHappearstohaveafairlylowcomplicationrate,efficacyandsafetyofthistreatmentisuncertainandisconsideredinvestigational(IIb-B).(New!)第18頁，課件共48頁，創(chuàng)作于2023年2月SurgicalTreatmentofICH---RecommendationsFormostptswithICH,theusefulnessofsurgeryisuncertain(IIb-C).(New!)第19頁，課件共48頁，創(chuàng)作于2023年2月CraniotomybyLocationofICH---RecommendationsPtswithcerebellarhemorrhagewhoaredeterioratingneurologicallyorwhohavebrainstemcompressionand/orhydrocephalusfromventricularobstructionshouldundergosurgicalremovalofthehemorrhageassoonaspossible(I-B).(Revised!)Initialtreatmentoftheseptswithventriculardrainagealoneratherthansurgicalevacuationisnotrecommended(III-C).(New!)

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

第20頁，課件共48頁，創(chuàng)作于2023年2月MinimallyInvasiveSurgicalRemovalofICH--Recommendations

Theeffectivenessofminimallyinvasiveclotevacuationutilizingeitherstereotacticorendoscopicaspirationwithorwithoutthrombolyticusageisuncertainandisconsideredinvestigational(IIb-B).(New!)第21頁，課件共48頁，創(chuàng)作于2023年2月TimingofSurgery---RecommendationsAlthoughtheoreticallyattractive,noclearevidenceatpresentindicatesthatultra-earlyremovalofsupratentorialICHimprovesfunctionaloutcomeormortalityrate.Veryearlycraniotomymaybeharmfulduetoincreasedriskofrecurrentbleeding(III-B).(Revised!)

第22頁，課件共48頁，創(chuàng)作于2023年2月OutcomePredictionandWithdrawalof

TechnologicalSupport---RecommendationsAggressivefullcareearlyafterICHonsetandpostponementofnewDNRordersuntilatleastthesecondfulldayofhospitalizationisprobablyrecommended(IIa-B).PtswithpreexistingDNRordersarenotincludedinthisrecommendation.CurrentmethodsofprognosticationinindividualptsearlyafterICHarelikelybiasedbyfailuretoaccountfortheinfluenceofwithdrawalofsupportandearlyDNRorders.PtswhoaregivenDNRstatusatanypointshouldreceiveallotherappropriatemedicalandsurgicalinterventionsunlessotherwiseexplicitlyindicated.(Revised!)第23頁，課件共48頁，創(chuàng)作于2023年2月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24頁，課件共48頁，創(chuàng)作于2023年2月PreventionofRecurrentICH---Recommendations4.Avoidlong-termanticoagulationastreatmentfornonvalvularatrialfibrillationafterspontaneouslobarICHbecauseofhigherriskofrecurrence(IIa-B).AnticoagulationafternonlobarICHandantiplatelettherapyafterallICHmightbeconsidered,asindicatedfortheseagents(IIb-B).(Unchanged!)

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

第25頁，課件共48頁，創(chuàng)作于2023年2月RehabilitationandRecovery

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