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美国心脏病协会最新自发性颅内出血指南

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美国心脏病协会最新自发性颅内出血指南 ISSN: 1524-4628 Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0039-2499. Online Stroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 DOI: 10.1161/STR.0b013e3181ec611b published online Ju...
美国心脏病协会最新自发性颅内出血指南
ISSN: 1524-4628 Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0039-2499. Online Stroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 DOI: 10.1161/STR.0b013e3181ec611b published online Jul 22, 2010; Stroke Cardiovascular Nursing and on behalf of the American Heart Association Stroke Council and Council on Macdonald, Steven R. Messé, Pamela H. Mitchell, Magdy Selim, Rafael J. Tamargo LochP. Broderick, E. Sander Connolly, Jr, Steven M. Greenberg, James N. Huang, R. Lewis B. Morgenstern, J. Claude Hemphill, III, Craig Anderson, Kyra Becker, Joseph Association/American Stroke Association Guideline for Healthcare Professionals From the American Heart Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A http://stroke.ahajournals.org located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 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 http://stroke.ahajournals.org/subscriptions/ Subscriptions: Information about subscribing to Stroke is online at by MICHAEL BRUNKE on July 22, 2010 stroke.ahajournals.orgDownloaded from AHA/ASA Guideline Guidelines for the Management of Spontaneous Intracerebral Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association The American Academy of Neurology affirms the value of this guideline as an educational tool 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 Association Stroke Council and Council on Cardiovascular Nursing Purpose—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 by 6 expert 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 in 3 years’ 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 Statements � intracerebral hemorrhage � treatment � diagnosis � intracranial pressure � hydrocephalus � surgery The 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 May 19, 2010. A copy of the statement is available at http://www.americanheart.org/presenter.jhtml?identifier�3003999 by selecting either the “topic list” link or the “chronological list” link (No. KB-0044). To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. The American Heart Association requests that this document be cited as follows: Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, Greenberg SM, Huang JN, Macdonald RL, Messé SR, 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 http://www.americanheart.org/presenter.jhtml?identifier�3023366. 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 http://www.americanheart.org/presenter.jhtml? identifier�4431. A link to the “Permission Request Form” appears on the right side of the page. © 2010 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STR.0b013e3181ec611b 1 by MICHAEL BRUNKE on July 22, 2010 stroke.ahajournals.orgDownloaded from Spontaneous, 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.1 This 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.2 One 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.1,3,4 Similarly, 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 http://www.strokecenter.org/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 published5 that obviates the need to repeat the issues of pediatric ICH here. The last ICH Guidelines were published in 2007,6 and 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 with 1 or 2 additional 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 comment. Comments 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 (Tables 1 and 2). All Class I recommendations are listed in Table 3. Emergency Diagnosis and Assessment of ICH and Its Causes ICH 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 than 20% of patients will experience a decrease in the Glasgow Coma Scale (GCS) score of �2 points between the prehospital emergency medical services assess- ment and the initial evaluation in the emergency department (ED).7 Among those patients with prehospital neurological decline, the GCS score decreases by an average of 6 points and the mortality rate is �75%. Further, within the first hour of presentation to a hospital, 15% of patients demonstrate a decrease in the GCS score of �2 points.8 The risk for early neurological deterioration and the high rate of poor long-term outcomes underscores the need for aggressive early management. Prehospital Management The 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 Management It 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. Table 4 describes 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.18 Such pathways may allow for more efficient, standardized, and integrated management of critically ill patients with ICH. Neuroimaging The 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 BP �220 mm 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; 2 Stroke September 2010 by MICHAEL BRUNKE on July 22, 2010 stroke.ahajournals.orgDownloaded from neuroimaging is thus mandatory.19 CT 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.22 The 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.15,23,24 Among patients undergoing head CT within 3 hours of ICH onset, 28% to 38% have hematoma expansion of greater than one third on follow-up CT.8,25 Hematoma expansion is predictive of clinical deterioration and increased morbidity and mortali- ty.8,10,15,25 As 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.26–30 MRI/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.31–33 A 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 be Table 1. Applying Classification of Recommendations and Level of Evidence *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. †In 2003, 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 Guideline 3 by MICHAEL BRUNKE on July 22, 2010 stroke.ahajournals.orgDownloaded from invoked 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. Recommendations 1. Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from ICH (Class I; Level of Evidence: A). (Unchanged from the previous guideline) 2. CT angiography and contrast-enhanced CT may be considered 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 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) Medical Treatment for ICH Hemostasis/Antiplatelets/Deep Vein Thrombosis Prophylaxis Underlying 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 constitute 12% to 14% of patients with ICH,34,35 and with increased use of warfarin, the proportion appears to be increasing.36 Recognition 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.37,38 Infusions 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.39–41 The 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 24 hours was linked to time to FFP administration in 1 study, although 17% of patients still did not have an INR �1.4 at this time, suggesting that FFP administered in this manner may be insufficient for rapid correction of coagulopathy.42 PCCs 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 o
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