急性脑卒中救治规范与流程(英文)课件.ppt

1、急性脑卒中救治规范与流程(英文）Wengui Yu,MD,PhDDivision of Neurological Critical CareDepartments of Neurological Surgery and Neurology Neurocritical Care of Acute Stroke急性脑卒中救治规范与流程(英文）The Primary Diagnoses In Neuro-ICU Intracerebral hemorrhage(ICH)Subarachnoid hemorrhage(SAH)Ischemic stroke/TIAs Status post crani

2、otomy for tumor resection Traumatic brain injury(SDH,EDH)Status post coil embolization,angioplasty,or stenting.急性脑卒中救治规范与流程(英文）Thrombolysis for Ischemic Stroke Intravenous t-PA Intraarterial t-PAEndovascular therapy Angioplasty/Stenting MERCI Retrieval Penumbra Clot Retrieval Coil embolization of an

3、eurysmSurgical treatment Hemicraniectomy for MCA strokeAdvances in Stroke ManagementS/p IA tPA急性脑卒中救治规范与流程(英文）1.Neuro-monitoring1).Neuro Exam Simple and effectiveNeurologic changes that need immediate attention Mental status change Decreased levels of consciousness:lethargy,stupor,coma.Disorientatio

4、n:name,place,time,and event.Speech difficulty:expressive or receptive aphasia Cranial nerve palsy:dilated and fixed pupil(s)New weakness/numbness急性脑卒中救治规范与流程(英文）2).Neuroimagingsa).CT To follow hematoma expansion,cerebral edema,mass effect,herniation,or hydrocephalus.Indicated in First few days after

5、 stroke,Deterioration on neuro exam,Sedated and paralyzed patient.急性脑卒中救治规范与流程(英文）b).CTA Contrast extravasation predicts hematoma expansionCT demonstrates a left putaminal hematoma(A).A small focus of enhancement isseen on CTA(B),consistent with extravasation on postcontrast CT(C).UnenhancedCT image

6、 1 day after presentation reveals hematoma enlargement and IVH(D).-Wada et al.Stroke.2007;38:1257-Golstein et al.Neurology.2007;20;68(12):889-94.急性脑卒中救治规范与流程(英文）Contrast extravasation predicts mortality in ICH A 69-yo man underwent imaging 2 hrs following onset of right-sided paralysis.Admission NCC

7、T demonstrates a left thalamic hematoma with extension into the thirdVentricle(A).CTA(B)and CECT(C),respectively,show 2 foci of active extravasation(arrows).Follow-up NCCT 12 hrs later shows marked hematoma growth with hemorrhagein both lateral ventricles and severe hydrocephalus(D).The patient had

8、a fatal outcome.Becker et al.Stroke 1999;30:2025-2032 Kim et al.American Journal of Neuroradiology 2008;29:520-525.急性脑卒中救治规范与流程(英文）The DWI map demonstrates a small area of diffusion restriction in the right MCA territory consistent with acute infarction.The MTT map demonstrates the infarct penumbra

9、which is larger than the infarct,indicating the presence of salvageable tissue.C).MRI:vasospasm/delayed ischemic deficit急性脑卒中救治规范与流程(英文）Intraventricular catheterIntraparenchymal catheterEpidural DeviceSubdural catheter3).ICP Monitoring急性脑卒中救治规范与流程(英文）4).Transcranial Doppler(TCD)Non-invasive.Measure

10、the velocity of flow in the intracranial circulation.The Doppler shift measured is inversely proportional to the diameter of the vessel.Figs show the position of TCD probes and a sample tracing of normal MCA waveform.急性脑卒中救治规范与流程(英文）TCD Criteria of vasospasmVasospasmMean blood flow velocity Mild120

11、cm/s Severe180 cm/s急性脑卒中救治规范与流程(英文）5).Electroencephalograph(EEG)MonitoringEEG of a comatose patient showed generalized sharp theta rhythm consistent with non-convulsive seizure activity.急性脑卒中救治规范与流程(英文）Continuous vEEG monitoring:status epilepticus急性脑卒中救治规范与流程(英文）2.Cardiac-Respiratory Monitoring Card

12、iac arrhythmia,stunned myocardium,and ACS are common complications of stroke.Right hemisphere infarct(insula)increases the risk of cardiac complications(autonomic dysfunction).ECG changes include ST-segment depression,QT dispersion,inverted T waves,and prominent U waves.Elevated levels of cardiac en

13、zymes are common in patients with SAH.Stroke may also cause respiratory distress,impaired oropharyngeal mobility,airway obstruction,and aspiration pneumonia.急性脑卒中救治规范与流程(英文）3.Critical Care of Patient with Acute Stroke Initiate Neuro-Cardiac-Respiratory monitoring,Intubate for airway protection if co

14、matose or GCS 8,Manage hypertensive crisis or hypotension,Treat headache,agitation,hyperglycemia,and aspiration,Evaluate electrolyte imbalance,seizure,fever,and infection,GI and DVT prophylaxis.急性脑卒中救治规范与流程(英文）4.Management of Blood Pressure(BP)Both elevated and low BP are associated with poor outcom

15、e after stroke.The common causes of elevated BP:Stress of the stroke(large infarct,ICH,SAH).Increased intracranial pressure.Hypoxia,a full bladder,nausea/vomiting,pain/headache.preexisting hypertension.Blood pressure reduction To prevent hemorrhagic conversion or rehemorrhage.To prevent hyperperfusi

16、on syndrome.Blood pressure augmentation Hypotension.Vasospasm.急性脑卒中救治规范与流程(英文）Management of Hypertensive CrisisInitial therapy Labetalol 10-20 mg iv q30 min prn Hydralazine 10-20 mg iv q30 min prnFor persistent hypertension Nicardipine 2-15 mg/hr iv infusion or Nipride 0.3-10 mcg/kg/min iv infusionS

17、tart and titrate oral medications BB,CCB,ACEI,hydralazine,or clonidine.In case of hypotension Reduce anti-hypertensive and IV fluid bolus.急性脑卒中救治规范与流程(英文）Indications:Prevention of hemorrhage or hematoma expansion Urgent neurosurgical interventionCoagulopathy from warfarin or hepatic failure Factor V

18、IIa 40-80 g/kg iv+Vitamin K 10 mg iv daily x 3.Prothrombin complex concentrate(PCC):25-50 units/kg iv.Fresh frozen plasma(FFP)10-20 ml/kgHeparin-induced coagulopathy Protamine sulfate 1mg for each 100 U heparin received in the last 3ht-PA induced thrombolysis Cryoprecipitates 6-8 unitsThrombocytopen

19、ia or platelet dysfunction Single donor platelets 2-6 units5.Urgent Reversal of Coagulopathy急性脑卒中救治规范与流程(英文）6.Management of Elevated ICP/HydrocephalusExternal ventricular drainage(EVD):open at 0-20 cm H2O.Osmolar therapy:Mannitol 0.5-1 gm/kg iv q4hHypertonic saline:3%or 23.4%NaClHyperventilation(sho

20、rt term use prior to emergent surgery):-Hypocarbia(pCO2 30-35)reduction of CBFSedatives/paralytic agentsPentobarbital coma急性脑卒中救治规范与流程(英文）7.Decompressive Craniectomy Large cerebellar infarct or hemorrhage.Hemisphere infarct with edema and potential herniation.Jauss et al.J Neurol 1999;246:257-64Raco

21、 et al.Neurosurgery.2003;53(5):1061.Robertson et al.Neurosurgery.2004;55(1):55.急性脑卒中救治规范与流程(英文）Hemicraniectomy for MCA Stroke3 clinical trials:DECIMAL,HAMLET,and DESTINY.93 patients randomized to surgical or medical therapy.Patients 60 years of age.The timing of surgery 48 hrs after stroke onset.Out

22、come with mRS at 1 yr.2007;6(3):215-22 急性脑卒中救治规范与流程(英文）1033 patients with supertentorial ICH enrolled in 87 centersRandomized within 72 hr of ICH onset Early surgery No surgery early(but 20%had later surgery)Showed no benefit in Mortality Good outcomeSurgical Treatment of ICH(STICH Trial)Mendel AD,e

23、t al.Lancet 2005,365:387急性脑卒中救治规范与流程(英文）8.Intra-ventricular t-PA for IVHIntraventricular hemorrhage(IVH)Occurs in 15-40%of patients with ICH or SAH.Severe IVH causes hydrocephalus,increased ICP or herniation.Death occurs in all patients with GCS less than 8 and severe IVH.Intra-ventricular t-PA Faci

24、litate the clearance of IVH Improve outcome.Findlay et al.Neurosurgery 74:803807,1991Rohde et al,J Neurol Neurosurg Psychiatry 1995;58:447451Naff et al.Neurosurgery 2004;54:57783急性脑卒中救治规范与流程(英文）9.Vasospasm and Delayed Ischemic Deficit Diagnosis Occur at day 3-10,Neuorologic deterioration.TCD,CTA or

25、cerebral angiography.Prevention and treatment Nimodipine 60 mg q4h,Triple H(hypervolemia,hypertension,and hemodilution)Keep CVP 8-12,Raise MAP by 15-20%to improve cerebral perfusion.Endovascular therapy:balloon angioplasty or IA nicardipine.L-VABasilar ArteryVasospasm急性脑卒中救治规范与流程(英文）10.Cerebral Salt

26、 Wasting Syndrome Hyponatremia,hypovolemia,and elevated serum BNP.Associated with brain edema,vasospasm and poor outcome.Aggressive treatment with 3%NaCl infusion Salt tablets Florinef 0.1-0.2 mg/day急性脑卒中救治规范与流程(英文）11.Therapeutic HypothermiaHypothermia in global ischemia Moderate hypothermia(32-34 o

27、C)for 12-24 hrs increases favorable neurologic outcome at 6 months in comatose survivors of out-of-hospital cardiac arrest.Bernard SA,et al.NEJM 2002;346:557-563.Michael Holzer et al.NEJM 2002;346:549-556.Hypothermia in ischemic stroke.Safe and feasible.Effective in controlling ICP due to the mass e

28、ffect of large infarct.Reduce MCA stroke mortality.Schwab et al.Stroke 2001;32:2033-5.Schwab et al.Stroke 1998;29:2461-6.Schwab et al.Stroke 1998;29:1988-93.Gumula et al.Acad Emerg Med.2006;13(8):820-7.M acintosh PIC Tim age form atis not supportedFavorable outcomeM acintosh P IC Tim age form atis n

29、ot supportedSurvival Home/Rehab急性脑卒中救治规范与流程(英文）12.Management of SeizureTreatment of Status Epilepticus1).Lorazepam 2 mg iv q 2 min,up to 0.1 mg/kg.2).Fosphenytoin 20 mg/kg iv,150 mg/min.3).Fosphenytoin 10 mg/kg 4).Intubate patient if not done yet.5).Phenobarbital 20 mg/kg 50 mg/min 6).Phenobarbital

30、10 mg/kgMidazolam 7).Anesthesia:Pentobarbital burst suppression Propofol or Midazolam急性脑卒中救治规范与流程(英文）Treatment of Nonconvulsive Status Epilepticus1).Lorazepam 2 mg iv q 2 min,up to 0.1 mg/kg.2).Valproate 25 mg/kg over 4-8 min.3).Phenobarbital 20 mg/kg 50 mg/min.4).Intubate patient if not done yet.5)

31、.Phenobarbital 10 mg/kg.6).Propofol or Midazolam.急性脑卒中救治规范与流程(英文）13.Recombinant Factor VIIa for Acute ICHMayer et al.2005;352:777-85 Phase 2B trial 399 patients were randomized to receive placebo,or 40,80,and 160 g/kg of rFVIIa within 4 h symptom onset.Primary outcome:ICH volume at 24 h Clinical out

32、come at 90 days急性脑卒中救治规范与流程(英文）Effects of rFVIIa on ICH volumes VolumePlacebo40g/kg80g/kg160g/kgbaseline24 2222 2223 24 26 3024 hr32 2926 2928 3128 32Mean increase8.7 5.44.22.9P value,vs placebo0.130.040.008急性脑卒中救治规范与流程(英文）rFVIIa limits the growth of hematoma and reduces mortalityby approximately 35

33、%.Mayer et al.2005;352:777-85急性脑卒中救治规范与流程(英文）Factor Seven for Acute Hemorrhagic Stroke(FAST)Phase 3 trial 841 patients with ICH were randomized to receive Placebo 20 g/kg of rFVIIa 80 g/kg of rFVIIa Primary end point:Poor outcome,defined as severe disability or death 90 days after the strokeMayer et

34、 al.2008;358:2127-37急性脑卒中救治规范与流程(英文）Figure 3.Clinical outcome at 90 days according to the Modified Rankin Scale.rFVIIa does not reduce the rate of death or severe disability after ICH.急性脑卒中救治规范与流程(英文）Clinical Centers(with numbers of patients in parentheses)Wang YJ,Beijing Tiantan Hospital,Beijing(73

35、);Selchen,Trillium Health Centre,Mississauga,ON,Canada(25);lvarez Sabin,Hospital Vall dHebron,Barcelona(24);Steiner,Universittsklinikum und Medizinische Fakultt Heidelberg,Germany(22);Hill,Foothills Medical Centre,Calgary,AB,Canada(21);Hennerici,Univ of Heidelberg,Mannheim,Germany(16);Ng Hua,Nationa

36、l Neuroscience Institute,Singapore(16);Toni,Universit La Sapienza,Rome(10);Woolfenden,Vancouver General Hospital,Canada(10)Flaherty,University of Cincinnati,Cincinnati(9)Hall,Medical College of Georgia,Augusta(9);Gladstone,Sunnybrook and Womens College,Toronto(9)Washington University,St.Louis(9);Ros

37、and,Massachusetts General Hospital,Boston(5);Parra,Columbia University,New York(2)Grotta,University of Texas,Houston(2)Hemphill,University of California,San Francisco,(1)急性脑卒中救治规范与流程(英文）14.Prognosticate Outcome of Coma Depends on cause rather than the depth of the coma.Coma from drug intoxication an

38、d metabolic causes carries the best prognosis.Coma from global hypoxia-ischemia carries the least favorable prognosis.急性脑卒中救治规范与流程(英文）A 51 year old woman was comatose for 8 weeks after cardiac bypass surgery.The follow-up CT 13 years later are shown below.Functional Outcome:mRS 1 急性脑卒中救治规范与流程(英文）Cas

39、e Study#1 A 44 yo man with h/o HTN and prior R-MCA stroke was last seen normal 7:30 AM.Found unresponsive with R-sided weakness and 911 activation to ED at 11:30 AM.Initial NIH stroke scale 21.Intubated to CT scan.急性脑卒中救治规范与流程(英文）CT head at 11:46 AM急性脑卒中救治规范与流程(英文）Prior to IA thrombolysisS/P IA t-PA

40、/Reopro 急性脑卒中救治规范与流程(英文）Repeat CT 24h after IA t-PA showed a small MCA stroke.He was extubated with mild expressive aphasia.Treated with anticoagulation for LV thrombus.Recovered with mild cognitive problem at 3 month-f/u.急性脑卒中救治规范与流程(英文）Who is the lucky patient?急性脑卒中救治规范与流程(英文）Case Study#2 A 67 yo

41、man with h/o CAD and DM presented with sudden onset HA,vertigo,slurred speech and right sided weakness.急性脑卒中救治规范与流程(英文）MRI/MRA:pontine infarct,L-ICA stenosis,R-VA occlusion and L-distal VA stenosis.急性脑卒中救治规范与流程(英文）Developed incomplete locked-in syndrome while on medical therapy.急性脑卒中救治规范与流程(英文）Verte

42、bral artery stenting急性脑卒中救治规范与流程(英文）ICA Stenosis:Stenting急性脑卒中救治规范与流程(英文）急性脑卒中救治规范与流程(英文）After weeks ICU care and rehabilitation,the patient recovered with moderate R-sided weakness/dysarthria in two months.急性脑卒中救治规范与流程(英文）Case#3 50 y/o man with h/o HTN presented with neck pain and loss of conscious

43、ness急性脑卒中救治规范与流程(英文）CT shows diffuse subarachnoid hemorrhage and hydrocephalus.*CTA and cerebral angio showed no aneurysm急性脑卒中救治规范与流程(英文）MRA showed L-distal VA irregularities.Fat-saturated T1 MRI revealed intramural thrombus,indicative of VA dissection.急性脑卒中救治规范与流程(英文）Coil embolization of distal L-V

44、A dissection急性脑卒中救治规范与流程(英文）Despite comatose and ventilator-dependence for more than 2 weeks,he recovered fully in 2 months.急性脑卒中救治规范与流程(英文）SUMMARY Neurocritical care provides comprehensive Airway and hemodynamic management,Neuro-monitoring and brain resuscitation,Periprocedural monitoring and management.Neurocritical care is associated with Reduce mortality,Improved outcome,Reduced ventilator days and ICU length of stay.Diringer et al.Critical care medicine 2001,29:635-640.Juarez et al.Crit Care Med 2004;32:2311-2317.Varelas et al.Crit Care Med 2004;32:2191-2198.