急性脑卒中救治规范与流程(英文).ppt
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1、Wengui Yu, MD, PhD Division of Neurological Critical Care Departments of Neurological Surgery and Neurology,Neurocritical Care of Acute Stroke,The Primary Diagnoses In Neuro-ICU,Intracerebral hemorrhage (ICH) Subarachnoid hemorrhage (SAH) Ischemic stroke/TIAs Status post craniotomy for tumor resecti
2、on Traumatic brain injury (SDH, EDH) Status post coil embolization, angioplasty, or stenting.,Thrombolysis for Ischemic Stroke Intravenous t-PA Intraarterial t-PA Endovascular therapy Angioplasty/Stenting MERCI Retrieval Penumbra Clot Retrieval Coil embolization of aneurysm Surgical treatment Hemicr
3、aniectomy for MCA stroke,Advances in Stroke Management,S/p IA tPA,1. Neuro-monitoring,1). Neuro Exam Simple and effective Neurologic changes that need immediate attention Mental status change Decreased levels of consciousness: lethargy, stupor, coma. Disorientation: name, place, time, and event. Spe
4、ech difficulty: expressive or receptive aphasia Cranial nerve palsy: dilated and fixed pupil(s) New weakness/numbness,2). Neuroimagings,a). CT To follow hematoma expansion, cerebral edema, mass effect, herniation, or hydrocephalus. Indicated in First few days after stroke, Deterioration on neuro exa
5、m, Sedated and paralyzed patient.,b). CTA Contrast extravasation predicts hematoma expansion,CT demonstrates a left putaminal hematoma (A). A small focus of enhancement is seen on CTA (B), consistent with extravasation on postcontrast CT (C). Unenhanced CT image 1 day after presentation reveals hema
6、toma enlargement and IVH (D). - Wada et al. Stroke. 2007;38:1257 - Golstein et al. Neurology. 2007;20;68(12):889-94.,Contrast extravasation predicts mortality in ICH,A 69-yo man underwent imaging 2 hrs following onset of right-sided paralysis. Admission NCCT demonstrates a left thalamic hematoma wit
7、h extension into the third Ventricle (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 hemorrhage in both lateral ventricles and severe hydrocephalus (D). The patient had a fatal outcome. Becker et al.
8、 Stroke 1999;30:2025-2032 Kim et al. American Journal of Neuroradiology 2008; 29:520-525.,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 which is larger than the infarct, indica
9、ting the presence of salvageable tissue.,C). MRI: vasospasm/delayed ischemic deficit,Intraventricular catheter Intraparenchymal catheter Epidural Device Subdural catheter,3). ICP Monitoring,4). Transcranial Doppler (TCD),Non-invasive. Measure the velocity of flow in the intracranial circulation. The
10、 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.,TCD Criteria of vasospasm,5). Electroencephalograph (EEG) Monitoring,EEG of a comatose patient showed generalized sharp theta rhythm cons
11、istent with non-convulsive seizure activity.,Continuous vEEG monitoring: status epilepticus,2. Cardiac-Respiratory Monitoring,Cardiac arrhythmia, stunned myocardium, and ACS are common complications of stroke. Right hemisphere infarct (insula) increases the risk of cardiac complications (autonomic d
12、ysfunction). ECG changes include ST-segment depression, QT dispersion, inverted T waves, and prominent U waves. Elevated levels of cardiac enzymes are common in patients with SAH. Stroke may also cause respiratory distress, impaired oropharyngeal mobility, airway obstruction, and aspiration pneumoni
13、a.,3. Critical Care of Patient with Acute Stroke,Initiate Neuro-Cardiac-Respiratory monitoring, Intubate for airway protection if comatose or GCS 8, Manage hypertensive crisis or hypotension, Treat headache, agitation, hyperglycemia, and aspiration, Evaluate electrolyte imbalance, seizure, fever, an
14、d infection, GI and DVT prophylaxis.,4. Management of Blood Pressure (BP),Both elevated and low BP are associated with poor outcome after stroke. The common causes of elevated BP: Stress of the stroke (large infarct, ICH, SAH). Increased intracranial pressure. Hypoxia, a full bladder, nausea/vomitin
15、g, pain/headache. preexisting hypertension. Blood pressure reduction To prevent hemorrhagic conversion or rehemorrhage. To prevent hyperperfusion syndrome. Blood pressure augmentation Hypotension. Vasospasm.,Management of Hypertensive Crisis,Initial therapy Labetalol 10-20 mg iv q30 min prn Hydralaz
16、ine 10-20 mg iv q30 min prn For persistent hypertension Nicardipine 2-15 mg/hr iv infusion or Nipride 0.3-10 mcg/kg/min iv infusion Start and titrate oral medications BB, CCB, ACEI, hydralazine, or clonidine. In case of hypotension Reduce anti-hypertensive and IV fluid bolus.,Indications: Prevention
17、 of hemorrhage or hematoma expansion Urgent neurosurgical intervention Coagulopathy from warfarin or hepatic failure Factor VIIa 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/kg Heparin-induced coagulopathy
18、Protamine sulfate 1mg for each 100 U heparin received in the last 3h t-PA induced thrombolysis Cryoprecipitates 6-8 units Thrombocytopenia or platelet dysfunction Single donor platelets 2-6 units,5. Urgent Reversal of Coagulopathy,6. Management of Elevated ICP/Hydrocephalus,External ventricular drai
19、nage (EVD): open at 0-20 cm H2O. Osmolar therapy: Mannitol 0.5-1 gm/kg iv q4h Hypertonic saline: 3% or 23.4% NaCl Hyperventilation (short term use prior to emergent surgery): - Hypocarbia (pCO2 30-35) reduction of CBF Sedatives/paralytic agents Pentobarbital coma,7. Decompressive Craniectomy,Large c
20、erebellar infarct or hemorrhage. Hemisphere infarct with edema and potential herniation.,Jauss et al. J Neurol 1999; 246:257-64 Raco et al. Neurosurgery. 2003;53(5):1061. Robertson et al. Neurosurgery. 2004;55(1):55.,Hemicraniectomy for MCA Stroke,3 clinical trials: DECIMAL, HAMLET, and DESTINY. 93
21、patients randomized to surgical or medical therapy. Patients 60 years of age. The timing of surgery 48 hrs after stroke onset. Outcome with mRS at 1 yr.,2007;6(3):215-22,1033 patients with supertentorial ICH enrolled in 87 centers Randomized within 72 hr of ICH onset Early surgery No surgery early (
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