大面積腦梗死診療指南

1、Evidence-Based Guidelines for the Management of LargeHemispheric Infarction,The sixth affiliated hospital of KMU Wang hao 2015.05.21,Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality.

2、current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients The purpose of this guideline is to provide evidence-based recommendations for the critical care management of patients following LHI,Airway Management,What are the indicati

3、ons for intubation and extubation in LHI? What is the best timing for tracheostomy in LHI?,What are the indications for intubation and extubation in LHI?,1.存在呼吸功能不全或神經(jīng)功能惡化的LHI 患者應(yīng)該立即氣管插管。（強(qiáng)推薦，極低質(zhì)量證據(jù)）。 2.即使不能交流和配合，符合以下標(biāo)準(zhǔn)者應(yīng)該嘗試拔管（強(qiáng)推薦，極低質(zhì)量證據(jù)）： （1）自主呼吸試驗(yàn)成功 （2）口咽部無分泌物聚集 （3）咳嗽反射存在，插管不耐受 （4）無鎮(zhèn)靜和鎮(zhèn)痛,What is t

4、he best timing for tracheostomy in LHI?,拔管失敗或插管后7-14 天不能拔管的LHI 患者可以考慮氣管切開。（弱推薦，低質(zhì)量證據(jù)）。,Hyperventilation,Hyperventilation is often employed in increased ICP to induce hypocarbia and cerebral vasoconstriction. The effect on ICP isusually seen within minutes, but it is short-lived.,Does hyperventilatio

5、n effectively treat increased ICP in LHI?,1.LHI 患者不應(yīng)該預(yù)防性過度換氣。（強(qiáng)推薦，極低質(zhì)量證據(jù)） 2.短期過度換氣可以作為挽救腦疝的方法。（弱推薦，極低質(zhì)量證據(jù)）,Analgesia and Sedation,sedation and analgesia may facilitate medical goals such as lowering ICP, enabling procedures and operations, or terminating seizures,Should analgesia and/or sedation be

6、administered in LHI patients? If so, which pharmacologic agents should be used?,1.疼痛、焦慮、躁動(dòng)者推薦給予鎮(zhèn)靜和鎮(zhèn)痛。（強(qiáng)推薦，極低質(zhì)量證據(jù)） 2.盡可能給予最低強(qiáng)度的鎮(zhèn)靜治療，盡可能盡早停止鎮(zhèn)靜治療，同時(shí)應(yīng)保持生理學(xué)穩(wěn)定，防治患者的不適感。（強(qiáng)推薦，極低質(zhì)量證據(jù)）,Are daily wake-up trials recommended?,Wake-up trials were initially reported to be beneficial regarding reduction of ventila

7、tion duration and outcome for some ICU populations. 對(duì)于LHI 患者，不推薦每天常規(guī)進(jìn)行喚醒試驗(yàn)。存在ICP 危象者采取俯臥位通氣應(yīng)謹(jǐn)慎。推薦進(jìn)行神經(jīng)功能監(jiān)測（至少包括ICP 和CPP）以指導(dǎo)鎮(zhèn)靜治療，生理學(xué)不穩(wěn)定或不舒適的患者每天喚醒試驗(yàn)應(yīng)避免或者延期執(zhí)行。（強(qiáng)推薦，極低質(zhì)量證據(jù)）,Gastrointestinal Tract,Dysphagia affects 3050 % of acute stroke patients.Screening for dysphagia has been reported to decrease pneu

8、monia in the general stroke population; Dysphagia screening tests such as the gugging swallowing screen have been found useful in acute stroke patients, but patients with large or multiple strokes or rapid decline in LOC were not included. Thus, it is difficult to estimate the validity of these test

9、s in LHI patients endoscopic swallowing tests，F(xiàn)iberoptic endoscopic evaluation of swallowing,How should dysphagia be assessed in LHI patients?,The swallowing provocation test, endoscopic swallowing tests Fiberoptic endoscopic evaluation of swallowing LHI 早期應(yīng)該進(jìn)行吞咽功能篩查。一旦撤掉鎮(zhèn)靜和機(jī)械通氣，應(yīng)該進(jìn)行吞咽功能評(píng)價(jià)。（弱推薦，極低質(zhì)量

10、證據(jù)）,When should LHI patients receive a nasogastric tube?,吞咽功能障礙的LHI 者盡可能使用鼻胃管。（弱推薦，極低質(zhì)量證據(jù)）,When should LHI patients receive a percutaneous enterogastric tube?,對(duì)于NIHSS 評(píng)分較高以及內(nèi)窺鏡檢查發(fā)現(xiàn)持續(xù)吞咽功能障礙者，應(yīng)該在ICU 主要1-3 周內(nèi)和家屬討論放置PEG。（弱推薦，極低質(zhì)量證據(jù)）,Glucose Control,Both hyperglycemia and hypoglycemia have been associate

11、d with increased morbidity and mortality in acute ischemic stroke. The panel concluded that intermediate glucose control(140180 mg/dl) is most appropriate for this patient population,How should glucose be controlled in LHI patients?,1.應(yīng)該避免低血糖和高血糖。采用胰島素控制血糖，血糖目標(biāo)為140-180 mg/dl。（強(qiáng)推薦，極低質(zhì)量證據(jù)） 2. 在LHI 患者，

12、避免靜脈內(nèi)輸注糖溶液。（強(qiáng)推薦，極低質(zhì)量證據(jù)）,Hemoglobin Control,Anemia is associated with worse outcome in ischemic stroke, both in the acute and subacute phases.,What is the optimal hemoglobin level in LHI patients?,1.應(yīng)該把LHI 患者的血紅蛋白維持在7g/dl 或以上。（強(qiáng)推薦，極低質(zhì)量證據(jù)） 2.制定血紅蛋白的理想目標(biāo)時(shí)，臨床醫(yī)生應(yīng)該考慮患者的特殊情況，比如有外科手術(shù)計(jì)劃、血流動(dòng)力學(xué)、心肌缺血、活動(dòng)性嚴(yán)重出血、動(dòng)靜

13、脈氧攝取不良。（弱推薦，極低質(zhì)量證據(jù)） 3.盡少抽取血液樣本，以降低LHI 患者貧血的風(fēng)險(xiǎn)。（弱推薦，極低質(zhì)量證據(jù)）,Deep Venous Thrombosis Prophylaxis,Even though DVT prophylaxis is standard of care. the incidence of DVT in the stroke patient is approximately 3 % In the CLOTS1 trial,incidence of DVT was 11.4 % during days 710 poststroke,as compared to 3.1

14、 % during days 2530 poststroke. the CLOTS1 investigators recommended that DVT prophylaxis should be started early and continued for at least 4 weeks,How should deep venous thrombosis (DVT) prophylaxis be administered to LHI patients?,1.血流動(dòng)力學(xué)穩(wěn)定且ICP 不高的LHI 患者，推薦早日活動(dòng)以預(yù)防DVT。（強(qiáng)推薦，極低質(zhì)量證據(jù)） 2.LHI 患者的DVT 預(yù)防應(yīng)

15、該從入住ICU 開始，包括整個(gè)不能活動(dòng)期間。（強(qiáng)推薦，極低質(zhì)量證據(jù)） 3.推薦使用IPC 預(yù)防DVT。（強(qiáng)推薦，極低質(zhì)量證據(jù)） 4.推薦使用LMWH 預(yù)防DVT。（強(qiáng)推薦，低質(zhì)量證據(jù)） 5.不推薦使用彈力襪預(yù)防DVT。（強(qiáng)推薦，中等質(zhì)量證據(jù)）,Anticoagulation,The HAEST study of patients with ischemic stroke and AF demonstrated a stroke recurrence rate of 8.5 % within 14 days even in spite of LMWH prophylaxis, thereby i

16、llustrating the importance of anticoagulation in this population.,If LHI is due to a cardioembolic mechanism or if the patient has high thromboembolic risk, when should anticoagulation be initiated after LHI?,1.對(duì)于高血栓風(fēng)險(xiǎn)的患者，推薦LHI 發(fā)病后2-4 周重啟口服抗凝治療。（弱推薦，極低質(zhì)量證據(jù)） 2.早期口服抗凝治療應(yīng)該基于患者的臨床風(fēng)險(xiǎn)評(píng)估和其他檢查結(jié)果（如人工瓣膜、急性DVT

17、、急性PE、或TEE 發(fā)現(xiàn)心臟內(nèi)血栓）。（弱推薦，極低質(zhì)量證據(jù)） 3.在外科治療不迫切的情況下，LHI 合并AF 或血栓風(fēng)險(xiǎn)的患者無抗凝期間應(yīng)給予阿司匹林治療。（弱推薦，極低質(zhì)量證據(jù)）,Blood Pressure Management,While optimal blood pressure (BP) targets are theoretically important in the management of acute ischemic stroke, specific goals have not been established for LHI patients.,What is

18、the optimal blood pressure in LHI patients?,一般來講，LHI 患者應(yīng)該遵循目前缺血性卒中指南管理血壓。缺血性卒中不合并出血轉(zhuǎn)換者M(jìn)AP 應(yīng)該維持在85mmHg 以上，SBP 維持在220 mmHg 以內(nèi)。（強(qiáng)推薦，低質(zhì)量證據(jù)） 2.避免血壓過度波動(dòng)，特別在LHI 的早期階段。（弱推薦，低質(zhì)量證據(jù)）,Steroid Therapy,The use of corticosteroids for acute stroke was reviewed by Cochrane group The only data that could be pooled in

19、 their review pertained to the outcome of death at 1 year;there was no difference with steroid treatment (OR 0.97;95 % CI 0.571.34). Only one of the seven included trials reported non-fatal adverse effects, which were limited to gastrointestinal bleeding,hyperglycemia, and infection in about 10 % of

20、 the patients enrolled,Do steroids effectively reduce brain edema in LHI?,不推薦使用激素治療LHI 患者的腦水腫。（強(qiáng)推薦，低質(zhì)量證據(jù)）,Barbiturate Therapy,Barbiturates are often thought to be a therapeutic option for treating cerebral edema refractory to other interventions. study suggested that barbiturate coma has no benefit

21、in the management of increased ICP in LHI and was associated with significant hypotension.,Do barbiturates effectively treat brain edema in LHI?,因?yàn)轱L(fēng)險(xiǎn)大于獲益，不推薦巴比妥鹽用于LHI 患者。（強(qiáng)推薦，低質(zhì)量證據(jù)）,Temperature Control,some studies found hypothermia to be generally, hypotension, hematologic effects, and infections w

22、ere common side effects Hypothermia was found to significantly reduce ICP in patients with LHI but is not as effective as hemicraniectomy,Does hypothermia or normothermia have any role in the management of brain edema after LHI?,1.不適于外科治療的患者，可以考慮低溫治療。（弱推薦，低質(zhì)量證據(jù)） 2.低溫治療的目標(biāo)體溫為33-36C，持續(xù)24-72h。（弱推薦，低質(zhì)量證

23、據(jù)） 3.推薦保持體溫正常。（弱推薦，極低質(zhì)量證據(jù)）,Head Position,In one observational study, investigators assessed backrest elevation of 15 and 30, and then a return to 0while continuously recording ICP, MAP, CPP, and MCA peak mean flow velocity Intracranial pressure was significantly decreased with the 30 backrest elevat

24、ion, however,MAP and CPP were significantly decreased as well. Cerebral perfusion pressure was maximal in the horizontal position but ICP was also at it highest value.,What is the optimal head position in patients with LHI?,大部分LHI 患者都應(yīng)該保持水平臥位，ICP 增高者建議床頭抬高30。（弱推薦，極低質(zhì)量證據(jù)）,Osmotic Therapy,Does osmotic

25、 therapy effectively treat brain edema and improve outcome in LHI?,1.存在腦水腫證據(jù)時(shí)，推薦使用甘露醇和高張鹽水減輕腦水腫和組織移位。（強(qiáng)推薦，中等質(zhì)量證據(jù)） 2.推薦使用滲透壓間隙（osmolar gap）代替血漿滲透壓指導(dǎo)甘露醇劑量和治療的持續(xù)時(shí)間。（弱推薦，低質(zhì)量證據(jù)） 3.推薦使用血漿滲透壓和血鈉水平指導(dǎo)高張鹽水的劑量。（強(qiáng)推薦，中等質(zhì)量證據(jù)）,What are the potential complications associated with the use of these agents?,4.急性腎損傷者慎用

26、甘露醇。（強(qiáng)推薦，中等質(zhì)量證據(jù)） 5.血容量超負(fù)荷者（比如心衰、肝硬化等）慎用高張鹽水。（強(qiáng)推薦，高質(zhì)量證據(jù)）,Neuroimaging by CT and MRI,A hypodensity covering 50 % of the MCA territory had an 85 % positive predictive value for fatal clinical outcome,with a sensitivity and specificity of 61 and 94 %, respectively Poor outcome was also associated with p

27、oor collateral blood flow, lack of recanalization, and distal ICA or proximal MCA occlusion carotid T occlusion on angiography predicted fatal outcome with a positive predictive value of 47 %, a negative predictive value of 85 % Infarct volume 220 ml was found to be very predictive of brain edema an

28、d herniation 105, 106. Midline shift 3.9 mm was also predictive of malignant infarction,Can neuroimaging by CT or MRI predict neurological deterioration and malignant course after LHI?,推薦通過CT 和MRI 的早期表現(xiàn)預(yù)測LHI 后惡性水腫。（強(qiáng)推薦，低質(zhì)量證據(jù)）,Ultrasound,The main advantages of ultrasound-based monitoring are its beds

29、ide availability and favorable safety profile. the reliable assessment of midline shift (MLS) by TCCS has been reproducible in several small prospective studies Some reported that all patients with a shift of less than 4 mm survived, while all patients with values exceeding 4 mm died of cerebral her

30、niation MCA occlusion on sonography within the first 12 h after MCA infarction and lack of recanalization within 24 h was associated with a mortality of 61 %.,What is the value of transcranial Doppler (TCD) and transcranial color-coded duplex (TCCS) sonography for the prediction of malignant course

31、after LHI?,推薦TCCS 檢查作為預(yù)測惡性水腫的補(bǔ)救檢查項(xiàng)目。如果患者病情不允許搬動(dòng)進(jìn)行神經(jīng)影像檢查，TCCS 可能是這些患者的主要檢查手段。（弱推薦，低質(zhì)量證據(jù)）,Evoked Potentials,One retrospective study demonstrated that pathologic Brainstem auditory evoked potentials (BAEPs) within 24 h of symptom onset with side-to-side difference of amplitudes of more than 50 % could

32、predict malignant course,whereas somatosensory evoked potential (SEP) findings were inconclusive,Can Evoked Potentials be used to predict malignant course after large hemispheric stroke?,推薦誘發(fā)電位檢查作為發(fā)病24h 內(nèi)預(yù)測惡性水腫的補(bǔ)救檢查項(xiàng)目，特別是對(duì)于病情不允許搬動(dòng)進(jìn)行神經(jīng)影像檢查的患者。（弱推薦，極低質(zhì)量證據(jù)）,EEG,The absence of delta and presence of theta, and fast beta frequencies within the lesion localization were significantly associated with benign course, wherea