美国自发性脑出血指南.docx
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美国自发性脑出血指南
∙AHA/ASAGuideline
GuidelinesfortheManagementofSpontaneousIntracerebralHemorrhage
AGuidelineforHealthcareProfessionalsFromtheAmericanHeartAssociation/AmericanStrokeAssociation
1.J.ClaudeHemphillIII,MD,MAS,FAHA,Chair;
2.StevenM.Greenberg,MD,PhD,Vice-Chair;
3.CraigS.Anderson,MD,PhD;
4.KyraBecker,MD,FAHA;
5.BernardR.Bendok,MD,MS,FAHA;
6.MaryCushman,MD,MSc,FAHA;
7.GordonL.Fung,MD,MPH,PhD,FAHA;
8.JoshuaN.Goldstein,MD,PhD,FAHA;
9.R.LochMacdonald,MD,PhD,FRCS;
10.PamelaH.Mitchell,RN,PhD,FAHA;
11.PhillipA.Scott,MD,FAHA;
12.MagdyH.Selim,MD,PhD;
13.DanielWoo,MD,MS;
14.onbehalfoftheAmericanHeartAssociationStrokeCouncil,CouncilonCardiovascularandStrokeNursing,andCouncilonClinicalCardiology
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Abstract
Purpose—Theaimofthisguidelineistopresentcurrentandcomprehensiverecommendationsforthediagnosisandtreatmentofspontaneousintracerebralhemorrhage.
Methods—AformalliteraturesearchofPubMedwasperformedthroughtheendofAugust2013.Thewritingcommitteemetbyteleconferencetodiscussnarrativetextandrecommendations.RecommendationsfollowtheAmericanHeartAssociation/AmericanStrokeAssociationmethodsofclassifyingthelevelofcertaintyofthetreatmenteffectandtheclassofevidence.Prereleasereviewofthedraftguidelinewasperformedby6expertpeerreviewersandbythemembersoftheStrokeCouncilScientificOversightCommitteeandStrokeCouncilLeadershipCommittee.
Results—Evidence-basedguidelinesarepresentedforthecareofpatientswithacuteintracerebralhemorrhage.Topicsfocusedondiagnosis,managementofcoagulopathyandbloodpressure,preventionandcontrolofsecondarybraininjuryandintracranialpressure,theroleofsurgery,outcomeprediction,rehabilitation,secondaryprevention,andfutureconsiderations.Resultsofnewphase3trialswereincorporated.
Conclusions—Intracerebralhemorrhageremainsaseriousconditionforwhichearlyaggressivecareiswarranted.Theseguidelinesprovideaframeworkforgoal-directedtreatmentofthepatientwithintracerebralhemorrhage.
KeyWords:
∙AHAScientificStatements
∙bloodpressure
∙coagulopathy
∙diagnosis
∙intracerebralhemorrhage
∙intraventricularhemorrhage
∙surgery
∙treatment
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Introduction
Spontaneous,nontraumaticintracerebralhemorrhage(ICH)remainsasignificantcauseofmorbidityandmortalitythroughouttheworld.AlthoughICHhastraditionallylaggedbehindischemicstrokeandaneurysmalsubarachnoidhemorrhageintermsofevidencefromclinicaltrialstoguidemanagement,thepastdecadehasseenadramaticincreaseinstudiesofICHintervention.Population-basedstudiesshowthatmostpatientspresentwithsmallICHsthatarereadilysurvivablewithgoodmedicalcare.1Thissuggeststhatexcellentmedicalcarelikelyhasapotent,directimpactonICHmorbidityandmortality.Thisguidelineservesseveralpurposes.OneistoprovideanupdatetothelastAmericanHeartAssociation/AmericanStrokeAssociationICHguideline,publishedin2010,incorporatingtheresultsofnewstudiespublishedintheinterim.2AnotherequallyimportantpurposeistoremindcliniciansoftheimportanceoftheircareindeterminingICHoutcomeandtoprovideanevidence-basedframeworkforthatcare.
Tomakethisreviewbriefandreadilyusefultopracticingclinicians,backgrounddetailsofICHepidemiologyarelimited,withreferencesprovidedforreadersseekingmoredetails.1,3,4Ongoingstudiesarenotdiscussedsubstantivelybecausethefocusofthisguidelineisoncurrentlyavailabletherapies;however,theincreaseinclinicalstudiesrelatedtoICHisencouraging,andthoseinterestedmaygotohttp:
//www.strokecenter.org/trials/formoreinformation.Also,thisguidelineisgenerallyconcernedwithadults,withissuesofhemorrhagicstrokeinchildrenandneonatescoveredinaseparateAmericanHeartAssociationscientificstatementon“ManagementofStrokeinInfantsandChildren.”5
ThisdocumentservestoupdatethelastICHguidelinespublishedin2010,2andthereaderisreferredtotheseguidelinesforadditionalrelevantreferencesnotcontainedhere.Thedevelopmentofthisupdatewaspurposelydelayedfor1yearfromtheintended3-yearreviewcyclesothatresultsof2pivotalphase3ICHclinicaltrialscouldbeincorporated.Differencesfromrecommendationsinthe2010guidelinearespecifiedinthecurrentwork.Thewritinggroupmetbyphonetodeterminesubcategoriestoevaluate.Theseincluded15sectionsthatcoveredthefollowing:
emergencydiagnosisandassessmentofICHanditscauses;hemostasisandcoagulopathy;bloodpressure(BP)management;inpatientmanagement,includinggeneralmonitoringandnursingcare,glucose/temperature/seizuremanagement,andothermedicalcomplications;procedures,includingmanagementofintracranialpressure(ICP),intraventricularhemorrhage,andtheroleofsurgicalclotremoval;outcomeprediction;preventionofrecurrentICH;rehabilitation;andfutureconsiderations.Eachsubcategorywasledbyaprimaryauthor,with1or2additionalauthorsmakingcontributions.FullPubMedsearcheswereconductedofallEnglishlanguagearticlesregardingrelevanthumandiseasetreatmentfrom2009throughAugust2013.Draftsofsummariesandrecommendationswerecirculatedtotheentirewritinggroupforfeedback.Severalconferencecallswereheldtodiscussindividualsections,focusingoncontroversialissues.SectionswererevisedandmergedbytheChair.Theresultingdraftwassenttotheentirewritinggroupforcomment.CommentswereincorporatedbytheChairandVice-Chair,andtheentirecommitteewasaskedtoapprovethefinaldraft.ChangestothedocumentweremadebytheChairandVice-Chairinresponsetopeerreview,andthedocumentwasagainsenttotheentirewritinggroupforsuggestedchangesandapproval.RecommendationsfollowtheAmericanHeartAssociation/AmericanStrokeAssociation'smethodsofclassifyingthelevelofcertaintyofthetreatmenteffectandtheclassofevidence(Tables1and2).AllClassIrecommendationsarelistedinTable3.
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Table1.
ApplyingClassificationofRecommendationsandLevelofEvidence
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Table2.
DefinitionofClassesandLevelsofEvidenceUsedinAHA/ASARecommendations
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Table3.
ClassIRecommendations
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EmergencyDiagnosisandAssessment
ICHisamedicalemergency.RapiddiagnosisandattentivemanagementofpatientswithICHiscrucial,becauseearlydeteriorationiscommoninthefirstfewhoursafterICHonset.Morethan20%ofpatientswillexperienceadecreaseintheGlasgowComaScale(GCS)of2ormorepointsbetweentheprehospitalemergencymedicalservices(EMS)assessmentandtheinitialevaluationintheemergencydepartment(ED).6Furthermore,another15%to23%ofpatientsdemonstratecontinueddeteriorationwithinthefirsthoursafterhospitalarrival.7,8Theriskforearlyneurologicaldeteriorationandthehighrateofpoorlong-termoutcomesunderscoretheneedforaggressiveearlymanagement.
PrehospitalManagement
PrehospitalmanagementforICHissimilartothatforischemicstroke,asdetailedintherecentAmericanHeartAssociation“GuidelinesfortheEarlyManagementofPatientsWithAcuteIschemicStroke.”9Theprimaryobjectiveistoprovideairwaymanagementifneeded,providecardiovascularsupport,andtransportthepatienttotheclosestfacilitypreparedtocareforpatientswithacutestroke.10SecondaryprioritiesforEMSprovidersincludeobtainingafocusedhistoryregardingthetimingofsymptomonset(orthetimethepatientwaslastnormal);informationaboutmedicalhistory,medication,anddruguse;andcontactinformationforfamily.EMSprovidersshouldprovideadvancenoticetotheEDoftheimpendingarrivalofapotentialstrokepatientsothatcriticalpathwayscanbeinitiatedandconsultingservicesalerted.AdvancenoticebyEMShasbeendemonstratedtosignificantlyshortentimetocomputedtomography(CT)scanningintheED.11TwostudieshaveshownthatprehospitalCTscanningwithanappropriatelyequippedambulanceisfeasibleandmayallowfortriagetoanappropriatehospitalandinitiationofICH-specifictherapy.12,13
EDManagement
EveryEDshouldbepreparedtotreatpatientswithICHorhaveaplanforrapidtransfertoatertiarycarecenter.ThecrucialresourcesnecessarytomanagepatientswithICHincludeneurology,neuroradiology,neurosurgery,andcriticalcarefacilitiesthatincludeadequatelytrainednursesandphysicians.ConsultantsshouldbecontactedasquicklyaspossiblewhilethepatientisintheED,andtheclinicalevaluationshouldbeperformedefficiently,withphysiciansandnursesworkinginparallel.Consultationviatelemedicinecanbeavaluabletoolforhospitalswithouton-sitepresenceofconsultants.14,15Table4describestheintegralcomponentsofthehistory,physicalexamination,anddiagnosticstudiesthatshouldbeobtainedintheED.
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Table4.
IntegralComponentsoftheHistory,PhysicalExamination,andWorkupofthePatientWithICHintheEmergencyDepartment
Aroutinepartoftheevaluationshouldincludeastandardizedseverityscore,becausesuchscalescanhelpstreamlineassessmentandcommunicationbetweenproviders.TheNationalInstitutesofHealthStrokeScale(NIHSS)score,commonlyusedforischemicstroke,mayalsobeusefulinICH.24,25However,ICHpatientsmoreoftenhavedepressedconsciousnessoninitial