美国自发性脑出血指南Word文件下载.docx

美国自发性脑出血指南Word文件下载.docx

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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.

Viewthistable:

∙Inthiswindow

∙Inanewwindow

Table1.

ApplyingClassificationofRecommendationsandLevelofEvidence

Table2.

DefinitionofClassesandLevelsofEvidenceUsedinAHA/ASARecommendations

Table3.

ClassIRecommendations

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.

Table4.

IntegralComponentsoftheHistory,PhysicalExamination,andWorkupofthePatientWithICHintheEmergencyDepartment

Aroutinepartoftheevaluationshouldincludeastandardizedseverityscore,becausesuchscalescanhelpstreamlineassessmentandcommunicationbetweenproviders.TheNationalInstitutesofHealthStrokeScale（NIHSS）score,commonlyusedforischemicstroke,mayalsobeusefulinICH.24,25However,ICHpatientsmoreoftenhavedepressedconsciousnessoninitial