2010美国自发性脑出血处理指南
血压—尚不充分的证据
• • SBP>200mmHg或MAP>150mmHg, 持续 静脉应用降压药物快速降压 SBP>180mmHg或MAP>130mmHg
– 存在颅内高压，监测颅内压，间断或持续静 脉应用降压药物，保持脑灌注压不低于 60mmHg. 没有颅内高压，间断或持续应用降压药物温 和降压
破入脑室，内引流者
CT增强 ―Spot Sign‖ 提示血肿扩大
CT平扫
CTA
CT增强
1d CT平扫
CT增强 ―Spot Sign‖ 提示血肿扩大
CT平扫
CTA
增强CT 12h后CT平扫
神经影像—病因鉴别
继发性颅内出血的常见病因 • 动静脉畸形 • 肿瘤 • Moyamoya • 脑静脉血栓形成
高颅压的治疗
渗透性治疗 最常见的药物是甘露醇 • 使液体从水肿及非水肿的脑组织中渗透 到血液中 • 提高心脏的前负荷及脑灌注压 • 降低血粘度，导致反射性血管收缩和血 管体积减小 • 缺点：副作用较多
高颅压的治疗
渗透性治疗 • 高渗盐
– – – – 有效降低颅内压 确切机制仍不明 最佳剂量不明 最佳浓度不明：7.5~23.4% ；
2010美国自发性脑出血处理指南
南昌大学第二附属医院 唐震宇
内容
• 脑出血概述
– 流行病学 – 病理 – 病理生理
• 诊断
– 临床医师头痛的问题—血肿扩大
• 治疗 • 展望—路在何方
流行病学特征
• 发病率： 10–30/10万 人 • 全世界每年卒中病人约1500万，其中脑 出血患者约2百万 (10–15%)
高颅压的治疗
过渡通气 • 最有效的快速降低颅内压的方法之一 • PaC02：30-35mmHg • 缺点： 侵入性 低二氧化碳水平 脑的血流量下降 作用短暂
止血治疗
• ICH患者中12%--14%具有口服抗凝药物 的病史 • 口服抗凝药物治疗并发生致命性出血时， 以最快的速度纠正INR • 常用药物
早期血肿扩大
超早期
151 min
232 min
308 min
血肿扩大及血肿周围水肿
脑出血前 4h
14h
28h
73h
7d
血肿扩大
• 发生时间 绝大部分血肿扩大在3小时内，也可发生于12 小时内 • 判定标准 V2-V1≥12.5cm3 或V2/V1≥1.4 (V1 、V2为别为第1、2次扫描体积)
– 脑叶>基底节、丘脑、脑干
• 其他因素：年龄，抗凝药的应用，颅内 出血史、载脂蛋白Eε2 或ε4携带，MR梯 度回波脑微出血灶的数目
预防
• 无明显禁忌，应控制血压
– 目标：小于140/90mmHg，合并糖尿病和慢性 肾损害者小于130/80mmHg
• 非瓣膜性房颤患者避免长期服用抗凝药物
预防
• 可以考虑非脑叶性ICH患者应用抗凝药物 • 所有ICH患者可以应用抗血小板药物 • 避免大量饮酒 • 没有充足的证据来推荐限制应用他汀类药 物或减少体力活动、性活动
• 出现以下情况应考虑ICP监测和处理
– – – – ICH患者GCS评分小于或等于8 出现小脑幕疝的临床表现 严重IVH 脑积水
• 保持脑灌注压在50-70mmHg
脑室内出血（IVH）
• ICH患者45%发生IVH • 原发或继发 • 脑室内应用r-tPA并发症发生率不高，但 有效性和安全性仍处于研究阶段
手
术
颅内压（ICP）监测和治疗
• ICH患者ICP梯度：
– 血肿内及周围ICP可能增高 – 距血肿较远的部位ICP可能正常
• 监测设备
– 置入脑实质内的光纤技术 – 侧脑室内导管（VC）
• 主要风险：感染和脑室内出血，VC高于脑 实质内设备 • 置入监测设备前，应评估患者的凝血功能
颅内压（ICP）监测和治疗
康复
• 所有的ICH患者都应当接受多方面的康 复训练
• 康复应该尽早开始并于出院后继续进行
展望
• 完全预防
– 降低血压—可能大大降低ICH的发病率 – 预防淀粉样脑血管病
• 筛选继续出血的患者,选择需要应用止血 药物的患者 • 降压治疗 • 血肿清除
血管周围巨噬细胞清除淀粉样蛋白
正常血管
血管周围巨噬 细胞↓
– – – – 维生素K 新鲜冰冻血浆 凝血酶原复合物 VIIa
止血治疗
• 维生素K
– 静脉应用维生素K，纠正INR需要数小时
– 只能作为其他治疗的辅助治疗
• 新鲜冰冻血浆（ FFP ）
– 过敏
– 输血传染疾病
– 获得所需时间
– 纠正INR需要量
止血治疗
凝血酶原复合物（ PCCs ） • 血浆来源的凝血因子提取物 • 含有凝血因子II, VII, 和 X • 用于纠正华法令引起的凝血异常 • 优点
神经影像—病因鉴别
下述情况提示颅内出血为继发性 • 临床证据
– 以头痛为前驱症状
• 影像学证据
– – – – 蛛网膜下腔出血 非圆形血肿 初次影像学检查发现与ICH不相称的水肿 其它脑内异常结构
神经影像诊断
• CT是首选检查方法
• MRI梯度回波序列能分辨超早期出现，对小出 血更加敏感 • 增强CT能发现继续出血 • 脑血管造影对于诊断继发出血是必须的 • CTA、MRI+MRA 也能用于继发出血的诊断
血肿继续扩大的危险因素
明显高血压 糖尿病 基础病变 急骤过度脱水治疗 肝病 年龄较轻 饮酒 病前服用阿司匹林或 其他抗血小板药 病变部位较深： 凝血、肝肾功能 丘脑 异常 血肿不规则 壳核 血糖 ＞ 7.8mmol 脑干
血管畸形、动脉瘤
血压过高 >200/120mmHg
止血治疗
INR升高的OACs相关ICH患者 • 停用华法林 • 补充维生素K依赖的凝血因子
– PCCs与FFP相比，临床预后无明显差异， 但并发症少；
• •
静脉应用维生素K rFVIIa并不能纠正全部的凝血异常，不 常规应用
血小板
• 合并严重血小板减少的患者应该补充血 小板
• 曾经应用抗血小板药物治疗的ICH 患者， 输血小板的有效性不清楚
–
收缩压150-220mmHg的住院患者，快速降 压至140mmHg可能是安全的
抽搐和抗癫痫药物应用
• 2周内抽搐的发生率：2.7%~17%
• 动态脑电图：28%-31%出现癫痫样放电
• 预防性应用抗癫痫药物大大减少抽搐的发生
但是，抽搐与预后差和死亡率增高无相关性
• EEG发现的亚临床抽搐的临床意义不明确
– 中青年ICH患者 血肿较大
– 脑疝风险较高
不适宜保守治疗者
血肿清除—推荐意见
• 大多数ICH患者手术的作用尚不确定 • 小脑出血
– 伴神经功能恶化、脑干受压和/或脑室梗阻 致脑积水者
– 不推荐以脑室引流作为该组患者的初始治疗
• 脑叶出血
– 超过30ml
– 血肿距皮层表面1cm以内
血肿清除—推荐意见
0-4h
神经元、胶 质细胞机械 性压迫
4h-7d
凝血酶 亚铁离子 氯化血红素
PMNS 巨噬细胞 聚集
补体
病理生理变化
• 止血机制
– 凝血途径激活 – 血肿机械填塞
• 血肿扩大
– 与3小时内CT检查相比，73%的患者在随后 的CT检查中发现血肿扩大，其中有临床症 状者为35%；
• 水肿
– 24小时，血肿周围水肿增加体积75% – 5-6天达到高峰（2-3倍），持续至14天
血肿清除
• 多因素参与ICH后的组织损伤
– 占位效应 – 血肿的毒性作用 – 周围组织的移位
• 清除血肿是一种简单的解决办法
血肿清除—概况
• 是否手术及手术时机仍有争议 • 早期手术可以解除占位效应和周围脑组织的 中毒反应，活动性出血的患者手术风险高 • 手术清除血肿可造成新的出血
• 目前手术的指征，但推荐意见尚不确定
– – – – 代谢快 可迅速应用 凝血因子浓度高而体积小 不会造成传染性疾病传播
FVIIa
• 治疗自发性或OAC相关的ICH有效手段之一
• 可以迅速纠正OAC相关的ICH患者的INR
• 不能补充所有维生素K相关的凝血因子
• 不推荐应用FVIIa来纠正华法林导致的凝血异常
• 用于非OAC相关ICH的治疗研究—无效
脯氨酸羟化酶通路—神经保护
血肿溶解释放毒性物质血红蛋白、血红素、 铁离子
巨噬细胞、小胶质细胞吞噬红细胞可以促进血 肿吸收，减轻脑损伤
小结
• 颅内出血是严重的疾病 • 早期、积极干预可改善其结局 • 指南提供了颅内出血病人管理的决策框 架
体温管理
• 动物模型研究表明发热预示较差的预后 • 72小时仍存活的患者，发热持续时间与 预后相关 • 但没有治疗发热与预后关系的证据 • 治疗性降温需要进一步证据
深静脉血栓形成
• ICH患者血栓形成疾病风险升高
• 单用弹力袜不能预防深静脉血栓形成
• 推荐：
– 间断气压动力治疗联合弹力袜有效 – 1-4天后活动较少者，出血停止后，可应用 小剂量低分子肝素或普通肝素预防静脉血栓 形成
• 无癫痫发作者应用抗癫痫药（大部分为苯妥英 钠），90天死亡和残疾率增加
抽搐和抗癫痫药物应用
推荐
• 抽搐的患者应该应用抗癫痫药物 • 精神抑郁超过脑损伤程度的患者，精神 状态改变且EEG捕捉到癫痫样放电可应 用抗癫痫药物 • 不建议预防性应用抗癫痫药物
高颅压的治疗
抬高床头 • 床头抬高30度可增加颈静脉回流和降低 颅内压 • 注意：头部应在中线位置 排除低血容量 止痛镇静
治
解读2010年美国心脏协会_美国中风协会《自发性脑出血诊疗指南》
２０１１－０５－１５解读２０１０年美国心脏协会／美国中风协会《自发性脑出血诊疗指南》杜伟范存刚张庆俊 自发性脑出血（ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ， ＩＣＨ）是导致人类致死致残的重要原因。
然而，迄今为止神经内、外科的治疗效果并不令人满意［１］。
为此，美国心脏协会／美国中风协会（ＡＨＡ／ＡＳＡ）对２００７年初版《成人自发性脑出血诊疗指南》［２］进行重大更新，制定了２０１０年新版《自发性脑出血诊疗指南》［３］。
新指南以循证医学为依据，在ＩＣＨ急诊诊断、评估和病因分析，神经内、外科治疗中的相关问题，再出血的预防，康复期的管理，以及ＩＣＨ诊疗展望等环节提出了极具参考价值的建议，对提高ＩＣＨ诊疗水平具有重要的指导意义。
现结合国内新近发表的相关文献解读如下，供同道们参考。
１０． ３７６０／ｃｍａ． ｊ． ｉｓｓｎ． １００１－２３４６． ２０１１． １０． ０３４１０００４４ 北京大学人民医院神经外科万方数据・１０７５・万方数据＠＠［１］赵继宗，周定标，周良辅，等．２４６４例高血压脑出血外科治 疗多中心单盲研究．中华医学杂志，２００５， ８５： ２２３８－２２４２．＠＠［２］ Ｂｒｏｄｅｒｉｃｋ Ｊ， Ｃｏｎｎｏｌｌｙ Ｓ， Ｆｅｌｄｍａｎｎ Ｅ， ｅｔ ａｌ． Ｇｕｉｄｅｌｉｎｅｓ ｆｏｒ ｔｈｅ ｍａｎａｇｅｍｅｎｔ ｏｆ ｓｐｏｎｔａｎｅｏｕｓ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ ｉｎ ａｄｕｌｔｓ： ２００７ ｕｐｄａｔｅ； ａ ｇｕｉｄｅｌｉｎｅ ｆｒｏｍ ｔｈｅ Ａｍｅｒｉｃａｎ Ｈｅａｒｔ Ａｓｓｏｃｉａｔｉｏｎ／ Ａｍｅｒｉｃａｎ Ｓｔｒｏｋｅ Ａｓｓｏｃｉａｔｉｏｎ Ｓｔｒｏｋｅ Ｃｏｕｎｃｉｌ， Ｈｉｇｈ Ｂｌｏｏｄ Ｐｒｅｓｓｕｒｅ Ｒｅｓｅａｒｃｈ Ｃｏｕｎｃｉｌ， ａｎｄ ｔｈｅ Ｑｕａｌｉｔｙ ｏｆ Ｃａｒｅ ａｎｄ Ｏｕｔｃｏｍｅｓ ｉｎ Ｒｅｓｅａｒｃｈ Ｉｎｔｅｒｄｉｓｃｉｐｌｉｎａｒｙ Ｗｏｒｋｉｎｇ Ｇｒｏｕｐ． Ｓｔｒｏｋｅ， ２００７， ３８： ２００１－２０２３． ＠＠［３］ Ｍｏｒｇｅｎｓｔｅｒｎ ＬＢ， Ｈｅｍｐｈｉｌｌ ＪＣ ３ｒｄ， Ａｎｄｅｒｓｏｎ Ｃ， ｅｔ ａｌ． Ｇｕｉｄ ｅｌｉｎｅｓ ｆｏｒ ｔｈｅ ｍａｎａｇｅｍｅｎｔ ｏｆ ｓｐｏｎｔａｎｅｏｕｓ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ： ａ ｇｕｉｄｅｌｉｎｅ ｆｏｒ ｈｅａｌｔｈｃａｒｅ ｐｒｏｆｅｓｓｉｏｎａｌｓ ｆｒｏｍ ｔｈｅ Ａｍｅｒｉｃａｎ Ｈｅａｒｔ Ａｓｓｏｃｉａｔｉｏｎ／Ａｍｅｒｉｃａｎ Ｓｔｒｏｋｅ Ａｓｓｏｃｉａｔｉｏｎ． Ｓｔｒｏｋｅ，２０１０， ４１ ： ２１０８－２１２９． ＠＠［４］ Ｍｏｏｎ ＪＳ， Ｊａｎｊｕａ Ｎ， Ａｈｍｅｄ Ｓ， ｅｔ ａｌ． Ｐｒｅｈｏｓｐｉｔａｌ ｎｅｕｒｏｌｏｇｉｃ ｄｅ ｔｅｒｉｏｒａｔｉｏｎ ｉｎ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ． Ｃｒｉｔ Ｃａｒｅ Ｍｅｄ， ２００８， ３６： １７２－１７５． ＠＠［５］ Ｂｒｏｔｔ Ｔ， Ｂｒｏｄｅｒｉｃｋ Ｊ， Ｋｏｔｈａｒｉ Ｒ， ｅｔ ａｌ． Ｅａｒｌｙ ｈｅｍｏｒｒｈａｇｅ ｇｒｏｗｔｈ ｉｎ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ． Ｓｔｒｏｋｅ， １９９７， ２８ ： １－５． ＠＠［６］ Ｆｌａｈｅｒｔｙ ＭＬ， Ｋｉｓｓｅｌａ Ｂ， Ｗｏｏ Ｄ， ｅｔ ａｌ． Ｔｈｅ ｉｎｃｒｅａｓｉｎｇ ｉｎｃｉｄｅｎｃｅ ｏｆ ａｎｔｉｃｏａｇｕｌａｎｔ－ａｓｓｏｃｉａｔｅｄ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ． Ｎｅｕｒｏｌｏｇｙ， ２００７， ６８：１１６－１２１．＠＠ ［ ７ ］ Ｌｅｉｓｓｉｎｇｅｒ ＣＡ， Ｂｌａｔｔ ＰＭ， Ｈｏｏｔｓ ＷＫ， ｅｔ ａｌ． Ｒｏｌｅ ｏｆ ｐｒｏｔｈｒｏｍｂｉｎ ｃｏｍｐｌｅｘ ｃｏｎｃｅｎｔｒａｔｅｓ ｉｎ ｒｅｖｅｒｓｉｎｇ ｗａｒｆａｒｉｎ ａｎｔｉｃｏａｇｕｌａｔｉｏｎ： ａ ｒｅｖｉｅｗ ｏｆ ｔｈｅ ｌｉｔｅｒａｔｕｒｅ． Ａｍ Ｊ Ｈｅｍａｔｏｌ， ２００８， ８３：１３７－１４３． ＠＠［ ８ ］ ＣＬＯＴＳ Ｔｒｉａｌｓ Ｃｏｌｌａｂｏｒａｔｉｏｎ， Ｄｅｎｎｉｓ Ｍ， Ｓａｎｄｅｒｃｏｃｋ ＰＡ， ｅｔ ａｌ． Ｅｆｆｅｃｔｉｖｅｎｅｓｓ ｏｆ ｔｈｉｇｈ－ｌｅｎｇｔｈ ｇｒａｄｕａｔｅｄ ｃｏｍｐｒｅｓｓｉｏｎ ｓｔｏｃｋｉｎｇｓ ｔｏ ｒｅｄｕｃｅ ｔｈｅ ｒｉｓｋ ｏｆ ｄｅｅｐ ｖｅｉｎ ｔｈｒｏｍｂｏｓｉｓ ａｆｔｅｒ ｓｔｒｏｋｅ（ ＣＬＯＴＳ ｔｒｉａｌ １ ）： ａ ｍｕｌｔｉｃｅｎｔｒｅ， ｒａｎｄｏｍｉｓｅｄ ｃｏｎｔｒｏｌｌｅｄ ｔｒｉａｌ． Ｌａｎｃｅｔ， ２００９， ３７３ ： １９５８－１９６５． ＠＠［９］ Ｌａｃｕｔ Ｋ， Ｂｒｅｓｓｏｌｌｅｔｔｅ Ｌ， Ｌｅ Ｇａｌ Ｇ， ｅｔ ａｌ． Ｐｒｅｖｅｎｔｉｏｎ ｏｆ ｖｅｎｏｕｓ ｔｈｒｏｍｂｏｓｉｓ ｉｎ ｐａｔｉｅｎｔｓ ｗｉｔｈ ａｃｕｔｅ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ． Ｎｅｕｒｏｌｏｇｙ， ２００５， ６５：８６５－８６９．＠＠［ １０］ Ｂｏｅｅｒ Ａ， Ｖｏｔｈ Ｅ， Ｈｅｎｚｅ Ｔ， ｅｔ ａｌ． Ｅａｒｌｙ ｈｅｐａｒｉｎ ｔｈｅｒａｐｙ ｉｎ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｓｐｏｎｔａｎｅｏｕｓ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈａｅｍｏｒｒｈａｇｅ． Ｊ Ｎｅｕｒｏｌ Ｎｅｕｒｏｓｕｒｇ Ｐｓｙｃｈｉａｔｒｙ， １９９１，５４：４６６－４６７．＠＠［ １１ ］ Ｍｅｓｓé ＳＲ， Ｓａｎｓｉｎｇ ＬＨ， Ｃｕｃｃｈｉａｒａ ＢＬ， ｅｔ ａｌ． Ｐｒｏｐｈｙｌａｃｔｉｃ ａｎ ｔｉｅｐｉｌｅｐｔｉｃ ｄｒｕｇ ｕｓｅ ｉｓ ａｓｓｏｃｉａｔｅｄ ｗｉｔｈ ｐｏｏｒ ｏｕｔｃｏｍｅ ｆｏｌｌｏｗｉｎｇ ＩＣＨ． Ｎｅｕｒｏｃｒｉｔ Ｃａｒｅ， ２００９， １１：３８－４４．＠＠［ １２］ Ｈｕｔｔｎｅｒ ＨＢ， Ｋ（ｏ）ｈｒｍａｎｎ Ｍ， Ｂｅｒｇｅｒ Ｃ， ｅｔ ａｌ． Ｉｎｆｌｕｅｎｃｅ ｏｆ ｉｎｔｒ ａｖｅｎｔｒｉｃｕｌａｒ ｈｅｍｏｒｒｈａｇｅ ａｎｄ ｏｃｃｌｕｓｉｖｅ ｈｙｄｒｏｃｅｐｈａｌｕｓ ｏｎ ｔｈｅ ｌｏｎｇ ｔｅｒｍ ｏｕｔｃｏｍｅ ｏｆ ｔｒｅａｔｅｄ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｂａｓａｌ ｇａｎｇｌｉａ ｈｅｍｏｒｒｈａｇｅ：ａ ｃａｓｅ－ｃｏｎｔｒｏｌ ｓｔｕｄｙ． Ｊ Ｎｅｕｒｏｓｕｒｇ， ２００６， １０５：４１２－ ４１７．＠＠［１３］ Ｍｏｒｇａｎ Ｔ， Ａｗａｄ Ｉ， Ｋｅｙｌ Ｐ， ｅｔ ａｌ． Ｐｒｅｌｉｍｉｎａｒｙ ｒｅｐｏｒｔ ｏｆｔｈｅｃｌｏｔ ｌｙｓｉｓ ｅｖａｌｕａｔｉｎｇ ａｃｃｅｌｅｒａｔｅｄ ｒｅｓｏｌｕｔｉｏｎ ｏｆ ｉｎｔｒａｖｅｎｔｒｉｃｕｌａｒ ｈｅｍｏｒｒｈａｇｅ（ ＣＬＥＡＲ－ＩＶＨ ） ｃｌｉｎｉｃａｌ ｔｒｉａｌ． Ａｃｔａ Ｎｅｕｒｏｃｈｉｒ Ｓｕｐｐｌ， ２００８， １０５：２１７－２２０．＠＠［ １４］ Ｐａｎｔａｚｉｓ Ｇ， Ｔｓｉｔｓｏｐｏｕｌｏｓ Ｐ， Ｍｉｈａｓ Ｃ， ｅｔ ａｌ． Ｅａｒｌｙ ｓｕｒｇｉｃａｌ ｔｒｅ ａｔｍｅｎｔ ｖｓ ｃｏｎｓｅｒｖａｔｉｖｅ ｍａｎａｇｅｍｅｎｔ ｆｏｒ ｓｐｏｎｔａｎｅｏｕｓ ｓｕｐｒａｔｅｎｔｏｒｉａｌ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍａｔｏｍａｓ： Ａ ｐｒｏｓｐｅｃｔｉｖｅ ｒａｎｄｏｍｉｚｅｄ ｓｔｕｄｙ． Ｓｕｒｇ Ｎｅｕｒｏｌ， ２００６， ６６ ： ４９２－５０１ ；ｄｉｓｃｕｓｓｉｏｎ ５０１－５０２．＠＠［ １５ ］ Ｍｅｎｄｅｌｏｗ ＡＤ， Ｇｒｅｇｓｏｎ ＢＡ， Ｆｅｍａｎｄｅｓ ＨＭ， ｅｔ ａｌ． Ｅａｒｌｙ ｓｕｒｇｅｒｙ ｖｅｒｓｕｓ ｉｎｉｔｉａｌ ｃｏｎｓｅｒｖａｔｉｖｅ ｔｒｅａｔｍｅｎｔ ｉｎ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｓｐｏｎｔａｎｅｏｕｓ ｓｕｐｒａｔｅｎｔｏｒｉａｌ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈａｅｍａｔｏｍａｓ ｉｎ ｔｈｅ Ｉｎｔｅｒｎａｔｉｏｎａｌ Ｓｕｒｇｉｃａｌ Ｔｒｉａｌ ｉｎ Ｉｎｔｒａｃｅｒｅｂｒａｌ Ｈａｅｍｏｒｒｈａｇｅ （ＳＴＩＣＨ）： ａ ｒａｎｄｏｍｉｓｅｄ ｔｒｉａｌ． Ｌａｎｃｅｔ ，２００５， ３６５：３８７－３９７．＠＠［ １６ ］ Ｒｏｓｔ ＮＳ， Ｓｍｉｔｈ ＥＥ， Ｃｈａｎｇ Ｙ， ｅｔ ａｌ． Ｐｒｅｄｉｃｔｉｏｎ ｏｆ ｆｕｎｃｔｉｏｎａｌ ｏｕｔｃｏｍｅ ｉｎ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｐｒｉｍａｒｙ ｉｎｔｒａｃｅｒｅｂｒａｌ ｈｅｍｏｒｒｈａｇｅ： ｔｈｅ ＦＵＮＣ ｓｃｏｒｅ． Ｓｔｒｏｋｅ， ２００８， ３９：２３０４－２３０９．＠＠［１７］ 彭化生，袁春兰．老年脑出血患者康复介入时间不同对功能 恢复影响的对照研究．中华神经医学杂志，２００６，５： １０２６－１０２８．＠＠［１８］刘兆平，曾满萍．社区康复对脑出血偏瘫患者整体功能和生 活质量的影响．卒中与神经疾病，２０１０，１７：３９－４２．２０１０－１２－１４２０１１－０３－１０万方数据解读2010年美国心脏协会/美国中风协会《自发性脑出血诊疗指南》作者：杜伟， 范存刚， 张庆俊作者单位：100044,北京大学人民医院神经外科刊名：中华神经外科杂志英文刊名：Chinese Journal of Neurosurgery年，卷(期)：2011,27(10)本文链接：/Periodical_zhsjwkzz98201110034.aspx。
【指南】最新美国自发性脑出血诊疗指南-急诊部分
【指南】最新美国自发性脑出血诊疗指南-急诊部分成人自发性脑出血诊疗指南--急诊诊断与评估ICH是一种临床急症，迅速诊断和慎重处理十分重要，因为ICH 发病后几小时内早期恶化很常见。
约20%的ICH 患者在急救医疗服务（emergencymedicalservices,EMS)初步评估至医院急诊的过程中，格拉斯哥昏迷量表（GCS)评分下降>2分，另有15%~23%的患者在到院后的最初几小时内病情继续恶化。
因此,早期的积极处理至关重要。
1 院前处置ICH的院前处置推荐意见类似于缺血性卒中（见近期AHA/ASA 急性缺血性卒中早期诊疗指南)。
EMS最主要的任务是气道管理及循环支持,并将患者就近转运至有条件处理急性卒中的医疗机构?。
其次是采集简要的病史，包括症状出现的时间（或最后1次正常的时间）、病史、所服用的药物以及患者家属的联系方式。
EMS机构工作人员应当向医院急诊预警以便迅速启动绿色通道并通知相应机构人员。
已有研究证明，院前预警可显著缩短急诊人院至CT 检查时间。
两项研究结果表明，通过对在急救车上装配CT及相应设备，以在院前完成CT检查是可行的，并且有利于将患者准确分诊到合适的医院以接受进一步ICH 专业治疗。
2 急诊处置急诊应当具备处理ICH患者的能力或具有迅速转运至三级医院的方案。
处理ICH患者必须具备神经科、神经放射科、神经外科、急诊等机构及相应的训练有素的医护人员。
患者到达急诊后，应当由医师与护士尽快接诊或会诊，并进行简短而高效的临床评估。
对于无条件进行院内会诊的机构，通过远程医疗进行会诊也是一种有效的手段。
ICH评估应当包括标准化严重程度评分，以利于连续的评估及医务人员间的交流。
美国国立卫生研究院卒中量表(NIHSS)常用于缺血性卒中，在ICH患者中也可能有效。
但ICH患者就诊时通常伴有意识障碍，可能使 NIHSS评分的准确性受限。
对于ICH的评估，也有很多专用的量表,但何种量表最为准确，尚存争议。
2010脑出血指南
ISSN: 1524-4628Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0039-2499. OnlineStroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514DOI: 10.1161/STR.0b013e3181ec611bpublished online Jul 22, 2010; Stroke Cardiovascular Nursingand on behalf of the American Heart Association Stroke Council and Council onMacdonald, Steven R. Messé, Pamela H. Mitchell, Magdy Selim, Rafael J. Tamargo Loch P. Broderick, E. Sander Connolly, Jr, Steven M. Greenberg, James N. Huang, R. Lewis B. Morgenstern, J. Claude Hemphill, III, Craig Anderson, Kyra Becker, JosephAssociation/American Stroke Association Guideline for Healthcare Professionals From the American HeartGuidelines for the Management of Spontaneous Intracerebral Hemorrhage. A located on the World Wide Web at:The online version of this article, along with updated information and services, is/reprints Reprints: Information about reprints can be found online atjournalpermissions@ 410-528-8550. E-mail:Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters/subscriptions/Subscriptions: Information about subscribing to Stroke is online atGuidelines for the Management of SpontaneousIntracerebral HemorrhageA Guideline for Healthcare Professionals From the American HeartAssociation/American Stroke AssociationThe American Academy of Neurology affirms the value of this guideline as an educationaltool for neurologists.The American Association of Neurological Surgeons and the Congress of Neurological Surgeons have reviewed this document and affirm its educational content.Lewis B.Morgenstern,MD,FAHA,FAAN,Chair;J.Claude Hemphill III,MD,MAS,FAAN,Vice-Chair;Craig Anderson,MBBS,PhD,FRACP;Kyra Becker,MD;Joseph P.Broderick,MD,FAHA;E.Sander Connolly,Jr,MD,FAHA; Steven M.Greenberg,MD,PhD,FAHA,FAAN;James N.Huang,MD;R.Loch Macdonald,MD,PhD;Steven R.Messé,MD,FAHA;Pamela H.Mitchell,RN,PhD,FAHA,FAAN;Magdy Selim,MD,PhD,FAHA;Rafael J.Tamargo,MD;on behalf of the American Heart AssociationStroke Council and Council on Cardiovascular NursingPurpose—The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.Methods—A formal literature search of MEDLINE was performed.Data were synthesized with the use of evidence tables.Writing committee members met by teleconference to discuss data-derived recommendations.The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation.Prerelease review of the draft guideline was performed by6expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee.It is intended that this guideline be fully updated in3years’time.Results—Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage.The focus was subdivided into diagnosis,hemostasis,blood pressure management,inpatient and nursing management, preventing medical comorbidities,surgical treatment,outcome prediction,rehabilitation,prevention of recurrence,and future considerations.Conclusions—Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care.The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.(Stroke.2010;41:00-00.)Key Words:AHA Scientific StatementsⅢintracerebral hemorrhageⅢtreatmentⅢdiagnosisⅢintracranial pressureⅢhydrocephalusⅢsurgeryThe American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal,professional,or business interest of a member of the writing panel.Specifically,all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on May19,2010.A copy of the statement is available at /presenter.jhtml?identifierϭ3003999by selecting either the“topic list”link or the“chronological list”link(No.KB-0044).To purchase additional reprints,call843-216-2533or e-mail kelle.ramsay@.The American Heart Association requests that this document be cited as follows:Morgenstern LB,Hemphill JC3rd,Anderson C,Becker K,Broderick JP,Connolly ES Jr,Greenberg SM,Huang JN,Macdonald RL,MesséSR,Mitchell PH,Selim M,Tamargo RJ;on behalf of the American Heart Association Stroke Council and Council on Cardiovascular Nursing.Guidelines for the management of spontaneous intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke.2010;41:●●●–●●●.Expert peer review of AHA Scientific Statements is conducted at the AHA National Center.For more on AHA statements and guidelines development, visit /presenter.jhtml?identifierϭ3023366.Permissions:Multiple copies,modification,alteration,enhancement,and/or distribution of this document are not permitted without the express permission of the American Heart Association.Instructions for obtaining permission are located at /presenter.jhtml? identifierϭ4431.A link to the“Permission Request Form”appears on the right side of the page.©2010American Heart Association,Inc.Stroke is available at DOI:10.1161/STR.0b013e3181ec611bS pontaneous,nontraumatic intracerebral hemorrhage(ICH) is a significant cause of morbidity and mortality throughout the world.Although much has been made of the lack of a specific targeted therapy,much less is written about the success and goals of aggressive medical and surgical care for this disease.Recent population-based studies suggest that most patients present with small ICHs that are readily survivable with good medical care.1This suggests that excellent medical care likely has a potent,direct impact on ICH morbidity and mortality now,even before a specific therapy is found.Indeed,as discussed later,the overall aggressiveness of ICH care is directly related to mortality from this disease.2One of the purposes of this guideline,therefore,is to remind clinicians of the impor-tance of their care in determining ICH outcome and to provide an evidence-based framework for that care.In order to make this review brief and readily useful to practicing clinicians,the reader is referred elsewhere for the details of ICH epidemiology.1,3,4Similarly,there are many ongoing clinical studies throughout the world related to this disease.The reader is encouraged to consider referring patients to these important efforts,which can be found at /trials/.We will not discuss on-going studies because we cannot cover them all;the focus of this statement is on currently available therapies.Finally,a recent guideline on pediatric stroke was published5that obviates the need to repeat the issues of pediatric ICH here. The last ICH Guidelines were published in2007,6and this current article serves to update those guidelines.As such, differences from former recommendations are specified in the current work.The writing group met by phone to determine subcategories to evaluate.These included emergency diagnosis and assessment of ICH and its causes;hemostasis,blood pressure(BP);intracranial pressure(ICP)/fever/glucose/ seizures/hydrocephalus;iron;ICP monitors/tissue oxygenation; clot removal;intraventricular hemorrhage(IVH);withdrawal of technological support;prevention of recurrent ICH;nursing care;rehab/recovery;future considerations.Each subcategory was led by an author with1or2additional authors making contributions.Full MEDLINE searches were done of all English-language articles regarding relevant human disease treatment.Drafts of summaries and recommendations were circulated to the whole writing group for feedback.A conference call was held to discuss controversial issues.Sections were revised and merged by the Chair.The resulting draft was sent to the whole writing group for ments were incor-porated by the Vice Chair and Chair,and the entire committee was asked to approve the final draft.Changes to the document were made by the Chair and Vice Chair in response to peer review,and the document was again sent to the entire writing group for suggested changes and approval.Recommendations follow the American Heart Association Stroke Council’s methods of classifying the level of certainty of the treatment effect and the class of evidence(Tables1and2).All Class I recommendations are listed in Table3.Emergency Diagnosis and Assessment of ICHand Its CausesICH is a medical emergency.Rapid diagnosis and attentive management of patients with ICH is crucial because early deterioration is common in the first few hours after ICH onset.More than20%of patients will experience a decrease in the Glasgow Coma Scale(GCS)score ofՆ2points between the prehospital emergency medical services assess-ment and the initial evaluation in the emergency department (ED).7Among those patients with prehospital neurological decline,the GCS score decreases by an average of6points and the mortality rate isϾ75%.Further,within the first hour of presentation to a hospital,15%of patients demonstrate a decrease in the GCS score ofՆ2points.8The risk for early neurological deterioration and the high rate of poor long-term outcomes underscores the need for aggressive early management.Prehospital ManagementThe primary objective in the prehospital setting is to provide ventilatory and cardiovascular support and to transport the patient to the closest facility prepared to care for patients with acute stroke (see ED Management section that follows).Secondary priorities for emergency medical services providers include obtaining a focused history regarding the timing of symptom onset(or the time the patient was last normal)and information about medical history, medication,and drug use.Finally,emergency medical services providers should provide advance notice to the ED of the impending arrival of a potential stroke patient so that critical pathways can be initiated and consulting services can be alerted.Advance notice by emergency medical services has been demonstrated to significantly shorten time to computed tomography(CT)scanning in the ED.9 ED ManagementIt is of the utmost importance that every ED be prepared to treat patients with ICH or have a plan for rapid transfer to a tertiary care center.The crucial resources necessary to man-age patients with ICH include neurology,neuroradiology, neurosurgery,and critical care facilities including adequately trained nurses and physicians.In the ED,appropriate consul-tative services should be contacted as quickly as possible and the clinical evaluation should be performed efficiently,with physicians and nurses working in parallel.Table4describes the integral components of the history,physical examination, and diagnostic studies that should be obtained in the ED. For patients with ICH,emergency management may in-clude neurosurgical interventions for hematoma evacuation, external ventricular drainage or invasive monitoring and treatment of ICP,BP management,intubation,and reversal of coagulopathy.Although many centers have critical pathways developed for the treatment of acute ischemic stroke,few have protocols for the management of ICH.18Such pathways may allow for more efficient,standardized,and integrated management of critically ill patients with ICH. NeuroimagingThe abrupt onset of focal neurological symptoms is presumed to be vascular in origin until proven otherwise.However,it is impossible to know whether symptoms are due to ischemia or hemorrhage based on clinical characteristics alone.Vomiting, systolic BPϾ220mm Hg,severe headache,coma or decreased level of consciousness,and progression over minutes or hours all suggest ICH,although none of these findings are specific;2Stroke September2010neuroimaging is thus mandatory.19CT and magnetic resonance imaging(MRI)are both reasonable for initial evaluation.CT is very sensitive for identifying acute hemorrhage and is consid-ered the gold standard;gradient echo and T2*susceptibility-weighted MRI are as sensitive as CT for detection of acute blood and are more sensitive for identification of prior hemorrhage.20,21 Time,cost,proximity to the ED,patient tolerance,clinical status, and MRI availability may,however,preclude emergent MRI in a sizeable proportion of cases.22The high rate of early neurological deterioration after ICH is in part related to active bleeding that may proceed for hours after symptom onset.The earlier time from symptom onset to first neuroimage,the more likely subsequent neuroimages will demonstrate hematoma expansion.15,23,24Among patients undergoing head CT within3hours of ICH onset,28%to 38%have hematoma expansion of greater than one third on follow-up CT.8,25Hematoma expansion is predictive of clinical deterioration and increased morbidity and mortali-ty.8,10,15,25As such,identifying patients at risk for hematoma expansion is an active area of research.CT angiography and contrast-enhanced CT may identify patients at high risk of ICH expansion based on the presence of contrast extravasa-tion within the hematoma.26–30MRI/angiogram/venogram and CT angiogram/venogram are reasonably sensitive at identifying secondary causes of hemorrhage,including arte-riovenous malformations,tumors,moyamoya,and cerebral vein thrombosis.31–33A catheter angiogram may be consid-ered if clinical suspicion is high or noninvasive studies are suggestive of an underlying vascular cause.Clinical suspicion of a secondary cause of ICH may include a prodrome of headache,neurological,or constitutional symptoms.Radio-logical suspicions of secondary causes of ICH should beTable1.Applying Classification of Recommendations and Level ofEvidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations,such as sex,age,history of diabetes,history of prior myocardial infarction,history of heart failure,and prior aspirin use.A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials.Even though randomized trials are not available,there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In2003,the ACCF/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations.All guideline recommendations have been written in full sentences that express a complete thought,such that a recommendation,even if separated and presented apart from the rest of the document(including headings above sets of recommendations),would still convey the full intent of the recommendation.It is hoped that this will increase readers’comprehension of the guidelines and will allow queries at the individual recommendation level.Morgenstern et al Intracerebral Hemorrhage Guideline3invoked by the presence of subarachnoid hemorrhage,un-usual(noncircular)hematoma shape,the presence of edema out of proportion to the early time an ICH is first imaged,an unusual location for hemorrhage,and the presence of other abnormal structures in the brain like a mass.An MR or CT venogram should be performed if hemorrhage location,rela-tive edema volume,or abnormal signal in the cerebral sinuses on routine neuroimaging suggest cerebral vein thrombosis. In summary,ICH is a medical emergency,characterized by high morbidity and mortality,which should be promptly diagnosed and aggressively managed.Hematoma expansion and early deteriora-tion are common within the first few hours after onset. Recommendations1.Rapid neuroimaging with CT or MRI is recommendedto distinguish ischemic stroke from ICH(Class I;Level of Evidence:A).(Unchanged from the previous guideline) 2.CT angiography and contrast-enhanced CT may beconsidered to help identify patients at risk for hema-toma expansion(Class IIb;Level of Evidence:B),and CT angiography,CT venography,contrast-enhanced CT,contrast-enhanced MRI,magnetic resonance an-giography,and magnetic resonance venography can beuseful 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)Medical Treatment for ICH Hemostasis/Antiplatelets/Deep VeinThrombosis ProphylaxisUnderlying hemostatic abnormalities can contribute to ICH. Patients at risk include those on oral anticoagulants(OACs), those with acquired or congenital coagulation factor deficien-cies,and those with qualitative or quantitative platelet abnormal-ities.Patients undergoing treatment with OACs constitute12% to14%of patients with ICH,34,35and with increased use of warfarin,the proportion appears to be increasing.36Recognition of an underlying coagulopathy thus provides an opportunity to target correction in the treatment strategy.For patients with a coagulation factor deficiency and thrombocytopenia,replace-ment of the appropriate factor or platelets is indicated.For patients being treated with OACs who have life-threatening bleeding,such as intracranial hemorrhage,the general recommen-dation is to correct the international normalized ratio(INR)as rapidly as possible.37,38Infusions of vitamin K and fresh-frozen plasma(FFP)have historically been recommended,but more recently,prothrombin complex concentrates(PCCs)and recom-binant factor VIIa(rFVIIa)have emerged as potential therapies. Vitamin K remains an adjunct to more rapidly acting initial therapy for life-threatening OAC-associated hemorrhage be-cause even when given intravenously,it requires hours to correct the INR.39–41The efficacy of FFP is limited by risk of allergic and infectious transfusion reactions,processing time,and the volume required for correction.Likelihood of INR correction at 24hours was linked to time to FFP administration in1study, although17%of patients still did not have an INRՅ1.4at this time,suggesting that FFP administered in this manner may be insufficient for rapid correction of coagulopathy.42PCCs are plasma-derived factor concentrates primarily used to treat factor IX deficiency.Because PCCs also contain factors II,VII,and X in addition to IX,they are increasingly recommended for warfarin reversal.PCCs have the advan-tages of rapid reconstitution and administration,having high concentrations of coagulation factors in small volumes,and processing to inactivate infectious agents.Though different PCC preparations differ in relative amounts of factors(with VII the most likely to be low),several studies have shown that PCCs can rapidly normalize INR(within minutes)in patients taking OACs(reviewed in43–45).Nonrandomized retrospective reviews and a small case-control study have shown more rapid correction of INR with vitamin K and PCC than vitamin K and FFP,but have not revealed a difference in clinical outcome.46–48One randomized trial compared the use of a PCC(Konyne)to supplement FFP versus FFP alone in patients with OAC-related ICH,finding that those who received PCC had significantly shorter time to INR correction and received less volume of FFP.Although there was no difference in outcome,those who received FFP also had more adverse events,primarily attributable to fluid overload.49 Although PCCs may theoretically increase the risk of throm-botic complications,this risk appears relatively low.43De-Table2.Definition of Classes and Levels of Evidence Used in American Heart Association Stroke Council Recommendations Class I Conditions for which there is evidence forand/or general agreement that theprocedure or treatment is useful andeffectiveClass II Conditions for which there is conflictingevidence and/or a divergence ofopinion about the usefulness/efficacyof a procedure or treatmentClass IIa The weight of evidence or opinion is infavor of the procedure or treatment Class IIb Usefulness/efficacy is less wellestablished by evidence or opinion Class III Conditions for which there is evidenceand/or general agreement that theprocedure or treatment is notuseful/effective and in some casesmay be harmfulTherapeutic recommendationsLevel of Evidence A Data derived from multiple randomizedclinical trials or meta-analysesLevel of Evidence B Data derived from a single randomizedtrial or nonrandomized studiesLevel of Evidence C Consensus opinion of experts,casestudies,or standard of care Diagnostic recommendationsLevel of Evidence A Data derived from multiple prospectivecohort studies using a referencestandard applied by a maskedevaluatorLevel of Evidence B Data derived from a single grade A study,or one or more case-control studies,orstudies using a reference standardapplied by an unmasked evaluator Level of Evidence C Consensus opinion of experts4Stroke September2010spite the lack of large,well-controlled,randomized trials, PCCs are being increasingly recommended as an option in guidelines promulgated for warfarin reversal in the setting of OAC-associated life-threatening or intracranial hemor-rhages.37,38,50–52Table5provides a list of several products for factor replacement in warfarin reversal that are commer-cially available in the United States at the present time. rFVIIa,licensed to treat hemophilia patients with high titer inhibitors or congenital factor VII deficiency,has garnered attention as a potential treatment for spontaneous and OAC-associated ICH.Although rFVIIa can rapidly normalize INR in the setting of OAC-associated ICH,53–57it does not replenish all of the vitamin K–dependent factors and there-fore may not restore thrombin generation as well as PCCs.58 In light of the limited data,a recent American Society of Hematology evidence-based review recommended against routine use of rFVIIa for warfarin reversal.59rFVIIa has also been tested in patients with non-OAC ICH.A phase2randomized trial showed that treatment with rFVIIa within4hours after ICH onset limited hematoma growth and improved clinical outcomes relative to placebo, though with increased frequency of thromboembolic events (7%versus2%).60A subsequent phase3study comparing placebo with20g/kg and80g/kg of rFVIIa failed to show differences in clinical outcome,despite confirming the ability of both doses to diminish hematoma enlargement.61Although overall serious thromboembolic adverse events were similar, the higher rFVIIa(80g/kg)group had significantly more arterial events than the placebo group.The authors noted imbalances in the treatment groups,particularly the greater number of patients with IVH in the higher-dose rFVIIa group.60It remains to be determined whether rFVIIa will benefit a particular subset of patients with ICH,but currently its benefits in ICH patients,whether or not they are under-going treatment with OACs,remain unproven.Studies of the effect of prior antiplatelet agent use or platelet dysfunction on ICH hematoma growth and outcome have found conflicting results.Reported antiplatelet agent use was not associated with hematoma expansion or clinical outcome in the placebo group of an ICH neuroprotective study.62However,others have suggested that platelet dys-function as measured by platelet function assays may be associated with hematoma expansion and clinical out-come.63,64The utility and safety of platelet transfusion orTable3.Class I RecommendationsRecommendations Class/Level of EvidenceEmergency diagnosis and assessment of ICH and its causes Rapid neuroimaging with CT or MRI is recommended to distinguishischemic stroke from ICH.(Unchanged from the previousguideline)Class I,Level AMedical treatment for ICH Patients with a severe coagulation factor deficiency or severethrombocytopenia should receive appropriate factor replacementtherapy or platelets,respectively.(New recommendation)Class I,Level CHemostasis/antiplatelets/DVT prophylaxis Patients with ICH whose INR is elevated due to OAC should havetheir warfarin withheld,receive therapy to replace vitaminK–dependent factors and correct the INR,and receiveintravenous vitamin K.(Revised from the previous guideline)Class I,Level CPatients with ICH should have intermittent pneumatic compressionfor prevention of venous thromboembolism in addition to elasticstockings.(Unchanged from the previous guideline)Class I,Level BInpatient management and prevention ofsecondary brain injuryGeneral monitoring Initial monitoring and management of ICH patients should takeplace in an intensive care unit,preferably one with physicianand nursing neuroscience intensive care expertise.(Unchangedfrom the previous guideline)Class I,Level B Management of glucose Glucose should be monitored and normoglycemia is recommended Class I,Level CSeizures and antiepileptic drugs Patients with clinical seizures should be treated with antiepilepticdrugs.(Revised from previous guideline)Patients with a change in mental status who are found to haveelectrographic seizures on EEG should be treated withantiepileptic drugs Class I,Level A Class I,Level CProcedures/surgery—clot removal Patients with cerebellar hemorrhage who are deterioratingneurologically or who have brainstem compression and/orhydrocephalus from ventricular obstruction should undergosurgical removal of the hemorrhage as soon as possible.(Revised from the previous guideline)Class I,Level BPrevention of recurrent ICH After the acute ICH,absent medical contraindications,BP shouldbe well controlled,particularly for patients with ICH locationtypical of hypertensive vasculopathy.(New recommendation)Class I,Level ACT indicates computed tomography;MRI,magnetic resonance imaging;DVT,deep vein thrombosis;INR,international normalized ratio;OAC,oral anticoagulants; and EEG,electroencephalogram.Morgenstern et al Intracerebral Hemorrhage Guideline5other agents in patients with a normal platelet count,but use of antiplatelet agents or platelet dysfunction,is not known.Patients with ICH have a high risk of thromboembolic disease.65Women and African Americans appear to be at greater risk.65–67Intermittent pneumatic compression combined with elastic stockings has been shown by a randomized trial to be superior to elastic stockings alone in reducing occurrence of asymptomatic deep vein thrombosis after ICH (4.7%versus 15.9%).68Graduated compression stockings alone are ineffec-tive in preventing deep vein thrombosis.69Less clear,however,is the role of adding anticoagulation to pneumatic compression.Two small randomized studies found no difference in deep vein throm-bosis incidence,and no increase in bleeding,in patients given low-dose subcutaneous heparin initiated at day 4or at day 10after ICH.70,71An uncontrolled study of treatment initiated on day 2found a reduction in thromboembolic disease without increased rebleeding.70Recommendations1.Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate fac-tor replacement therapy or platelets,respectively (Class I;Level of Evidence:C).(New recommendation)2.Patients with ICH whose INR is elevated due to OACs should have their warfarin withheld,receive therapy to replace vitamin K–dependent factors and correct the INR,and receive intravenous vitamin K (Class I;Level of Evidence:C).PCCs have not shown improved outcome compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP (Class IIa;Level of Evidence:B).rFVIIa does not replace all clotting factors,and although the INR may be lowered,clotting may not be restored in vivo;therefore,rFVIIa is not routinely recommended as a sole agent for OAC re-versal in ICH (Class III;Level of Evidence:C).(Revised from the previous guideline).3.Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients,thereTable 4.Integral Components of the History,PhysicalExamination,and Work-Up of the Patient With ICH in the EDCommentsHistoryTime of symptom onset (or time the patient was last normal)Initial symptoms and progression of symptoms Vascular risk factors Hypertension,diabetes,hypercholesterolemia,and smoking MedicationsAnticoagulants,antiplatelet agents,decongestants,antihypertensivemedications,stimulants (including diet pills),sympathomimeticsRecent trauma or surgeryCarotid endarterectomy or carotid stenting in particular,as ICH may be related to hyperperfusion after such procedures DementiaAssociated with amyloid angiopathy Alcohol or illicit drug useCocaine and other sympathomimetic drugs are associated with ICH,stimulants Seizures Liver diseaseMay be associated with coagulopathy Cancer and hematologic disorders May be associated with coagulopathyPhysical examination Vital signsFever is associated with early neurologic deterioration 10Higher initial blood pressure is associated with early neurologic deterioration and increased mortality 11A general physicalexamination focusing on the head,heart,lungs,abdomen,and extremities A thorough but time-urgent neurologic examinationA structured examination such as the National Institutes of Health Stroke Scale can be completed in minutes and provides a quantification that allows easy communication of the severity of the event to other caregivers.GCS score is similarly well known and easily computed,and the initial GCS score is a strong predictor of long-term outcome.12,13These can be supplemented as needed Serum and urine tests Complete blood count,electrolytes,blood urea nitrogen and creatinine,and glucoseHigher creatinine is associated with hematoma expansion.Higher serum glucose is associated with hematoma expansion and worse outcome(although there are no data to suggest that normalization improves outcome)11,14Prothrombin time or INR and an activated partial thromboplastin timeWarfarin-related hemorrhages are associated with an increased hematoma volume,greater risk ofexpansion,and increased morbidity and mortality 15–17(Continued )Table 4.ContinuedCommentsToxicology screen in young or middle-aged patients to detect cocaine and other sympathomimetic drugs of abuseCocaine and other sympathomimetic drugs are associated with ICHUrinalysis and urine culture and a pregnancy test in a woman of childbearing age Other routine tests ECGTo assess for active coronary ischemia or prior cardiac injury that may indicate poor cardiac function and to obtain a baseline in the event ofcardiopulmonary issues during hospitalization Chest radiograph NeuroimagingAs described in the textGCS indicates Glasgow Coma Scale;ECG,electrocardiogram.6Stroke September 2010。
2010年美国脑出血诊治指南精要(中文版)
2010 年美国脑出血诊治指南精要丁香园站友脑壳译急诊诊断与评估：推荐迅速行CT 或MRI 以鉴别缺血性卒中和脑出血（I 类A 级证据）。
可行CTA 和增强CT 以帮助确定高危患者血肿扩大，CTA、CTV、增强CT、增强MRI、MRA 和MRV 有助于评估潜在的结构损害，包括血管畸形和肿瘤（若临床怀疑或影像学怀疑）（IIa 类 B 级证据）。
脑出血的药物治疗：患有严重凝血因子缺乏或血小板减少的患者需接受适当的凝血因子或血小板替代治疗（I 类 C 级证据）。
由口服抗凝血药（OAC）导致INR 升高的脑出血患者需停止服用华法林，给予维生素K 依赖性因子替代治疗并纠正INR，同时静脉给予维生素K（I 类C 级证据）。
与新鲜冰冻血浆（FFP）相比，凝血酶原复合体浓缩物（PCC）并未提高患者预后，但患者并发症可能比使用FFP 者少，因此有理由将PCC作为FFP 的替代物（IIa 类 B 级证据）。
重组因子VIIa（rFVIIa）不能替代所有凝血因子，尽管其可能使INR 降低，但体内凝血功能可能尚未得到恢复，因此，对于需要逆转OAC 的脑出血患者来说，不建议常规将rFVIIa 作为唯一的药物（III 类 C 级证据）虽然对无凝血病的患者来说rFVIIa 可限制血肿体积增大，但血栓栓塞风险却有增加，并且对患者无选择地使用rFVIIa 并未获得明确的临床益处。
因此，不推荐对患者无选择地使用rFVIIa（III 类 A 级证据）。
在做出任何推荐使用rFVIIa 的决定之前，需进行进一步研究，以确定对筛选后的患者使用rFVIIa是否能够获益。
给予有抗血小板治疗史的脑出血患者输注血小板，其作用尚不明确，尚需深入研究（IIb 类 B 级证据）。
为预防脑出血患者静脉血栓栓塞，需给予间歇气压疗法并穿戴弹力袜（I 类B 级证据）对于脑出血发生后1-4 天无法活动的患者，在确认出血停止后，可考虑给予低剂量低分子肝素或普通肝素皮下注射以预防静脉血栓栓塞。
脑出血美国指南
2010年美国心脏病协会自发性颅 内出血指南
李露娜
Guidelines principle
Purpose 介绍目前急性自发性颅内出血的诊断和治疗建议
Methods
中华神经科杂志，2010，43（2）146-152
ED Management
Neuroimaging
快速影 像学检 查（CT 或MRI） 来鉴别 缺血性 中风和 ICH（Ⅰ， A）
行CT血管造 影和增强CT
以筛选具有 血肿扩大风 险的患者 （Ⅱb，B）
(New recommendation)
Emergency diagnosis and assessment of ICH and its causes
ICH的急诊诊断和评估及病因
Recognizing ICH
ICH？
呕吐，收缩压≥220mmHg，严重头痛， 昏迷，或不同程度的意识丧失，在数分 钟至数小时时间内进行性加重
1.CT 2.MRI梯度回波 T2加权像
Prehospital Management
ventilatory and cardiovascular support
prehospital setting
the timing of symptom onset medical history
medication, and drug use
emergency department(ED)
MEDLINE 证据列表 美国心脏协会中风分会的证据分级法则
Results 为自发性颅内出血病人的管理提供建议
2010自发性脑出血指南
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1.在患者风险分层将决定其它治疗措施的情况下，建议考虑以下因素： 初发ICH的出血部位，高龄，口服抗凝药物中，载脂蛋白Eε2 或ε4等位基 因的携带者，以及MRI的T2加权梯度回波显示的多发微出血灶（Ⅱa B） （新推荐） 2.ICH急性期后，如无明显禁忌，建议良好控制血压，尤其对于出血位于 高血压性血管病变部位者。（Ⅰ A）（新推荐） 3.ICH急性期后，推荐的血压控制目标是：小于140/90mmHg，合并糖尿 病和慢性肾损害者小于130/80mmHg（Ⅱa B）（新推荐） 4.非瓣膜性房颤患者建议考虑避免长期服用抗凝药物以防增加自发性脑 叶ICH患者复发的风险（Ⅱa B）。可以考虑非脑叶性ICH患者应用抗凝 药物，所有ICH患者应用抗血小板药物，尤其是具有应用这些药物的明 显指征时（Ⅱb B）（同前版指南） 5.避免大量饮酒可能使ICH患者受益（Ⅱa B）。没有充足的证据来推荐 限制应用他汀类药物或减少体力活动、性活动。（Ⅱb C）（新推荐）。
1. 病史： 发病时间或最后被发现正常的时间 初发症状及症状变化 危险因素 高血压、糖尿病、高脂血症、吸烟 服用药物史 抗凝药，抗血小板药，减充血药，降压药，stimulants（包括促进消化的 药物） 拟交感类药物 痴呆 淀粉样脑血管病相关痴呆 酒精及其它不良嗜好 可卡因及其它拟交感类药物抽搐 肝脏疾病 可能与凝血异常相关 肿瘤与血液系统疾病 可能与凝血异常相关 2. 查体 生命体征 发热与早期神经疾病进展有关，血压较高与早期病情进展及死亡率 增高相关 全身查体，以头，心、肺、四肢为重点 系统的快速神经系统专科查体 结构化的评估，比如国立中风健康量表可以在数分钟内 完成，并提供医护人员沟通病情严重程度的重要定量指标，GCS评分也被广泛熟知并 容易计算，且最初的GCS评分是预测长期临床预后的重要依据；这些必要时均可采用。 3. 实验室检查 血细胞计数、电解质，血尿素氮，肌酐、血糖 血肌酐升高与血肿扩大 相关，血糖升高与血肿扩大及较差的临床预后相关（尽管没有证据表明控制血糖正常 可以改善临床预后） 凝血酶原时间，INR，APTT 华法林相关的血肿与更大的血肿体积、更高的血肿扩大风 险、更高的致残率和致死率相关。 对于中青年患者行毒物筛查是否存在可卡因或其它拟交感类药物滥用 可卡因和其它拟 交感类药物与ICH相关 育龄妇女尿常规、尿培养及尿妊娠试验 4. 其它检查 ECG 评估是否存在可能导致心功能恶化的活动的心肌缺血或基础心脏损 害，获得住院期间心肺事件发生后的基线资料 胸片
美国自发性脑出血处理指南
2、ICH止血、抗血小板药和预防深静脉血栓形成
凝血功能异常可引起ICH。高危患者包括口服抗凝药 (oral micoagulant，OAc)、获得性或先天性凝血因子缺 乏症以及血小板质量或数量异常。12％～14％的ICH患 者正在接受OAC治疗，而且随着应用华法林患者的增加 ，这一比例似乎也在升高。因此，识别潜在的凝血障 碍可为治疗提供机会。对于凝血因子缺乏症和血小板 减少症患者，应给予适当的凝血因子或血小板替代治 疗。
病史 症状出现的时间(或已知患者正常的最后时间) 首发症状和症状的进展 血管性危险因素 药物史 近期外伤史或手术史 痴呆 饮酒或吸毒 痴性发作 肝脏疾病 癌症和血液系统疾病
体格检查 生命体征 重点在头部、心脏、肺、腹部和四肢的全身查体 全面和迅速的神经系统检查 血清和尿液化验 血常规、电解质、血尿素氮、肌酐和血糖 凝血酶原时间或INR、部分凝血活酶时间 在年轻或中年患者中进行毒理学筛查以检测可卡因 和其他拟交感神经药物的滥用情况 育龄期女性要进行尿液化验、尿培养和妊娠试验 其他常规检查心电图胸部x片、神经影像
评价是否存在可能提示心脏功能不良的急性冠状动脉 缺血或既往心脏损伤； 获得心脏的基线情况，以便于在人院后发生心肺问题 时进行比较 急诊室内必须完成的ICH患者的病史、体格检查和辅助 检查
ICH发病后的早期神经功能恶化发生率很高， 这部分与活动性出血有关，后者可在ICH发病后持 续数小时。发病后越早进行神经影像学检查，在复 查时发现血肿增大的概率就越高。在ICH发病后3 h 内接受CT扫描的患者中，高达28％一38％CT复查发 现血肿增大超过1／3。血肿增大是临床病情恶化以 及残疾率和病死率增高的预测因素。
自发性脑出血管理指南美国心脏协会_美国卒中协会针对医疗专业人员的指南
良的高发生率充分说明了早期积极管理的必要性。
１．１
院前管理 ＩＣＨ患者的院前管理与缺血性卒中患者类似，
８１ ｍｍＨｇ＝０．１３３ ｋＰａ
ＩＣＨ：脑出血；ｃＴ：计算机体层摄影；ＭＲＩ：磁共振成像；ＶＫＡ：维生素 Ｋ拮抗药；ＩＮＲ：国际标准化比率
详细内容可见ＡＨＡ近期发表的《急性缺血性卒中患
者早期处理指南》∽Ｊ。院前管理的首要目标是提供 气道管理（如果需要）和循环支持，并将患者转送至
转运），并且在患者等待床位期间就应开始早期治
疗。一项单中心研究显示延长患者在急诊室的停留
时间会导致转归恶化，但另一项研究则显示在急诊
万方数据
・７２４‘
国医膻鱼筻痘苤盍！！！！生！！旦筮垫鲞笠！Ｑ塑！堕』￡！！！！！！！箜！旦堡：Ｑ！！！ｂ！１ ２Ｑ！』：№！：１３，丛！：！Ｑ 表３在急诊室内必须完成的ＩＣＨ患者的病史 询问、体格检查和辅助检查
注释 病史 症状出现的时间（或已知患者
正常的最后时间）
作，尽快联系会诊并且高效地进行临床评价。当现
行更新，另一个同样重要的目的是提醒临床医生认 识到其医疗诊治对于ＩＣＨ转归的重要性，并且为这
种医疗诊治提供一个循证框架。 为了使本文更加简洁且方便被临床医生使用， 我们仅简要介绍了ＩＣＨ流行病学的背景资料，读者 可参考其他文献以获得更详细的资料０１，３－４］。本指南
没有纳入正在进行的研究，因为我们将重点放在现 有的治疗方面；然而，ＩＣＨ相关临床研究的不断增多 是振奋人心的，有兴趣的读者可在网上获得这方面 的更多信息（ｈｔｔｐ：ｌ／ｗｗｗ．ｓｔｒｏｋｅｃｅｎｔｅｒ．ｏｒｇ／ｔｒｉａｌｓ／）。此 外，本指南主要针对成年人群，对于儿童及新生儿出
血糖管理
ＧＣＳ）评分在从院前紧急医疗救护（ｅｍｅｒｇｅｎｃｙ
美国脑出血治疗指南
•监测颅内压、 脑灌注压和血 流动力学
执行颅内压、 血压、机械通 气、发热和血 糖调整的相关 医嘱并调定上 述指标
•通过特定体位 、保持气道通 畅和允许范围 内的适当活动 来预防长期卧 床导致的并发 症
•评估神经系统 功能包括标准 化评分，如国 立卫生研究院 中风评分， GCS评分， GCS预后评分 的能力
中华神经科杂志，2010，43（2）146-152
监护和护理
ICH患者的监护和管理应该在重症监 护病房展开，并配备具有神经重症专 业知识的医护人员。（Ⅰ B）
血糖管理
最近的很多研 究表明严密控 制血糖可能造 研究表明通过应 成全身或脑组 用胰岛素严密控 入院时高血糖 织低血糖事件 制术后患者血糖 均提示更高的 增加，并可能 目前ICH 患者血糖控制的最佳方案以及血糖控制目标仍有待明确。 （80死亡率和更差 增加死亡风险 低血糖应该尽量避免。 110mg/dl） 的临床预后 可改善临床预后
神经外科 介入医生
神经外科 介入医生
应具有血压管理，插管技术及调整凝血异常 的能力
中华神经科杂志，2010，43（2）146-152
影像学检查的重要性
突发局灶性神经症状提示脑血管病变 除非其他的疾病已被证实
单纯依靠临床表现很难确定中风 是缺血性的还是出血性的
呕吐，收缩压≥220mmHg， 严重头痛，昏迷， 或不同程度的意识丧失， 在数分钟至数小时时间内进行性 加重均提示ICH， 这些均无特异性
单用弹力袜
气压动力治疗时加用抗凝药物 皮下注射小剂量肝素
？
无症状性 深静脉血栓形成
？
出血风险
止血/抗血小板/预防深静脉血栓形成
1
合并严重凝血因子缺乏或严重血小板减 少的患者应该分别给予适当补充凝血因 子或血小板（Ⅰ C）
美国自发性脑出血处理指南要点
美国自发性脑出血处理指南要点自发性脑出血（ICH）是导致人类死亡和残疾的一种重要病因。
美国心脏协会/美国卒中协会（AHA/ASA）曾制定过3版《自发性ICH 处理指南》，现根据最新循证医学证据又制定了《自发性ICH处理指南》。
1急诊诊断与评估ICH患者常在起病后数小时内病情恶化，故强调院前急救、预警和医院急诊的紧密衔接。
院前处理重点包括气道管理、循环支持、迅速转运、有重点地询问发病情况、既往史、用药史和家属联系方式。
有条件者在急救车上完成CT检查并即刻启动ICH针对性治疗。
患者到达医院急诊后应医护同步且高效地完成评估，并进行基线严重程度评分（如NIHSS评分和ICH专用评分）（I类推荐，B 级证据；新推荐）。
强调神经内外科、神经影像和重症监护多学科合作，尽快将患者收入卒中单元或神经重症监护病房，尽快启动早期治疗（如降低血压和纠正凝血机制障碍）。
对急骤起病的局灶性神经系统功能障碍伴呕吐、收缩压＞220mmHg、剧烈头痛、昏迷或意识程度下降以及数分钟至数几小时出现症状进展者，均应首先考虑ICH。
推荐用CT或MRI鉴别缺血性和出血性脑卒中（I类推荐，A级证据）。
CT依然是诊断急性ICH的“金标准”。
梯度回波和T2磁敏感加权MRI对识别既往出血的敏感性优于CT。
CTA和增强CT检查时血肿内高密度的造影剂（“点征”）斑点数量越多，血肿扩大的风险也越高（IIb类推荐，B级证据）。
对年龄＜65岁、女性、非吸烟者、脑叶出血、破入脑室以及无高血压史或凝血功能障碍的ICH应考虑脑血管异常的可能，CTA、CTV、增强CT、增强MRI、MRA、MRV和DSA等检查有助于明确出血原因（如动静脉畸形、肿瘤、烟雾病和脑静脉血栓等）（IIa类推荐，B级证据）。
蛛网膜下腔出血、ICH边缘的血管扩张或钙化、静脉引流部位的硬脑膜静脉窦或皮层静脉内高密度影、非常见形态或常见部位的血肿、水肿范围与ICH的时间不成比例、脑内有其他结构异常（如占位病变）等影像学表现均提示可能为血管病变或肿瘤所继发的ICH。