XUẤT HUYẾT NÃO: Chẩn đoán,

tiên lương và điều trị

(sau đại học)

PGS.TS Cao Phi Phong

2017

Ca lâm sàng

Bn nam 70 tuổi

Bệnh khởi phát đột ngột đau đầu nhiều, uống aspirin giảm đau.

BN rơi vào bất tỉnh,

Nhiệt độ 38 độ, Mạch 61l/p, Nhịp thở 16l/p, HA 201/96 mmHg

Khám: đồng tử đều 2 bên, còn đáp ứng pxas yếu, mất px nôn,

kích thích đau còn co lại(withdraws), Babinsky (+) phải, GCS: E

0, V=0, M=4. NIHSS: 38

Tiền sử: HA cao uống thuốc không đều, uống rượu và hút

thuốc

Chẩn đoán: ?

(T) (P)

Câu hỏi thảo luận:

1. Dịch tễ học XHN ?

2. Sinh lý bệnh XHN ?

3. Nguyên nhân thường gặp XHN ?

4. Lâm sàng XHN ?

+ thể tích khối máu tụ và GCS trong tiên lượng ?

+ thể tích khối máu tụ tăng theo thời gian?

+ cái gì trông đợi cho kết cục bn XHN?

5. Điều trị XHN ?

• Sinh lý bệnh (Pathophysiology)

• Dịch tễ học(Epidemiology)

• Nguyên nhân/yếu tố nguy cơ

• Lâm sàng(Clinical features)

• Điều trị

MỤC TIÊU

Xuất huyết não

Xuất huyết não tự phát, không chấn thương là nguyên

nhân quan trọng gây bệnh tật và tử vong trên toàn thế giới

Chăm sóc và điều trị tốt về nội khoa có hiệu lực, tác động

trực tiếp đến bệnh tật và tử vong do XHN, ngay cả trước khi

tìm được điều trị chuyên biệt

Chăm sóc tích cực toàn diện XHN liên quan trực tiếp đến

tử vong của bệnh này

Hướng dẫn điều trị này cập nhật hướng dẫn điều trị trước

của AHA-2010

1. Dịch tễ học

10-15% toàn bộ đột quỵ (80% thiếu máu)

Nam nhiều hơn nữ

Thường nhiều hơn sau 55 tuổi

Gia tăng người Mỹ da đen, Nhật, Hispanic

Tử vong 30 ngày: 35-52%

- 50% trong số này trong 48 giờ đầu

10% độc lập( không phụ thuộc) ở 1 tháng

1/5 số sống sót độc lập ở 6 tháng

7000 ca phẫu thuật lấy máu tụ hàng năm ở USA

2. Sinh lý bệnh

• Thrombin và iron, phóng thích khi hồng cầu phân hủy,

là 2 yếu tố quan trong gây tổn thương não sau XHN

• Thrombin nồng độ cao giết neurons và astrocytes in vitro.

• Thoái biến hemoglobin kết quả phóng thích iron. Iron gây

phù não ngay cả nồng độ thấp

Ya Hua, “Intracerebral hemorrhage: introduction brain injury afteriIntracerebral

hemorrhage, ther role of Thrombin and Iron” Stroke.2007; 38: 759-762

Tổn thương nguyên phát -

ảnh hưởng tức thì

Xuất huyết phát triển

Gia tăng áp lực nội sọ

Hematoma lan rộng ≥ 80 ml: tử vong

Ảnh hưởng thứ phát

Ảnh hưởng xuôi dòng

.

Phù não

Thiếu máu

Hematoma khởi đầu phù

Phù do hoạt động thẩm thấu của protein từ cục máu

động(osmotically active proteins)

Vasogenic và cytotoxic edema phá vỡ hàng rào máu não

và chết neuron

Có thể không xác định mediators thứ phát cả tổn thương

neuron và phù (nuclear factor kappa-beta)

3. Nguyên nhân XHN

Nguyên phát

(78-88%)

Hypertensive angiopathy

(fibrohyalinosis)

Amyloid angiopathy

Liên quan Anticoagulant (?)

Thứ phát

AVM

Aneurysm

Cavernoma

Neoplasm

Coagulopathy

Alcoholic liver disease

Hemophilia

Hemorrhagic infarct

Toxic-cocaine

Granulomatous angiitis &

vasculitides

Hyalinosis: hyaline degeneration

XHN nguyên phát

Yếu tố nguy cơ

• Tuổi: tỷ lệ mới mắc tăng gấp đôi cho mỗi thập kỷ

sau 55 tuổi. Trên 80 tuổi nguy cơ tăng gấp 25 lần

• Giới tính: nhiều ở nam hơn

• Chủng tộc: nhiều hơn người da đen, hispanics,

asians, ít gặp da trắng

• Tiền sử đột quỵ

• Uống rượu (Alcohol consumption): >3

lần/ngày gia tăng nguy cơ XHN gấp 7 lần

(>3 drinks per day increases the risk of ICH by 7 folds)

• Thuốc: cocaine, amphetamine

• Hút thuốc lá không gia tăng nguy cơ XHN

• Oral Anticoagulant: warfarin nguy cơ chảy máu

bn rung nhĩ 2.2% /năm

• Antiplatelets: ASA đơn thuần (1.3%/năm) ASA

phối hợp plavix tăng nguy cơ 2.4%/năm.

• rTPA: tăng nguy cơ XHN 6.4% trong 36 giờ kế

tiếp

Dễ mắc bênh (bẩm chất) di truyền

(Genetic predisposition)

• E2 và E4 alleles(gen tương ứng) của apolipoprotein

E gene giữ vai trò quan trọng xảy ra các thể xuất

huyết như xuất huyết lúc sanh (labor hemorrhages)

O’Donnel et al, 2000

4. Lâm sàng XHN

• Đột ngột đau đầu +/- buồn nôn & nôn

• Khởi phát diễn tiến thầm lặng nhiều phút đến giờ

• Thường trong lúc hoạt động

• Lẩn lộn(confusion)

• Thiếu hụt thần kinh: hemiplegia

• Giảm mực độ ý thức

• Cơn động kinh

Các loại xuất huyết trong não

• Putaminal hemorrhage (35%)

• Caudate Hemorrhage (5%)

• Thalamic Hemorrhage (10-15%)

• Mesencephalic Hemorrhages (rare)

• Pontine Hemorrhage (5%)

• Medullary Hemorrhages (rare)

• Cerebellar Hemorrhage (5-10%)

• Lobar Hemorrhage (25%)

Xuất huyết trong não thất(IVH)

• XHN lan vào trong não thất thường gặp trong

xuất huyết nhân đuôi và đồi thị (caudate and

thalamic) và xuất huyết lớn nhân vỏ hến và thùy

(putaminal and lobar)

Xuất huyết thùy (Lobar Hemorrhages)

• Thường gặp thứ 2 (25%)

• Cơ chế không tăng huyết áp :

- người trẻ (AVM, sympathomimetic agents)

- người già: cerebral amyloid angiopathy

• Thường dưới vỏ thùy trán, đỉnh, thái dương và

chẩm

• Cơn động kinh chiếm 28%

• Tỷ lệ tử vong thấp hơn xuất huyết khác, dự hậu

chức năng lâu dài có thể tốt hơn

N Engl J Med 2001;344(19):1450–1460

Lobar hemorrhage 25%

• - Penetrating cortical

branches of ACA, MCA, &

PCA

• - Peripheral location lower

frequency of coma

• - Lower mortality

• - Better functional outcome

N Engl J Med 2001;344(19):1450–1460

Basal ganglia 35-40%

- Ascending lenticulostriate

branches of MCA

- Wide spectrum of severity

extending to coma and

decerebrate rigidity

- Ventricular extension

carries very poor prognosis

N Engl J Med 2001;344(19):1450–1460

Thalamus 10-15%

- Ascending thalamogeniculate

branches of PCA

- Abrupt hydrocephalus from

aqueductal obstruction from

intraventricular clot

- Responds to ventriculostomy

N Engl J Med 2001;344(19):1450–1460

Pons 5%

- Paramedian branches of

the basilar artery

- Bilateral carries very poor

prognosis (coma,

quadriplegia, decerebrate

posturing, horizontal

ophthalmoplegia, pinpoint

reactive pupils)

N Engl J Med 2001;344(19):1450–1460

Cerebellum 5-10%

- Penetrating branches of the

PICA, AICA, SCA

- Abrupt onset vertigo, h/a, n/v,

inability to walk in absence

of weakness

Ipsilateral ataxia, horizontal

gaze palsy, peripheral facial

palsy

- Unpredictable deterioration to

coma

XHN do tăng huyết áp

• Yếu tố nguy cơ quan trọng nhất (>70% XHN)

• Chia đôi đm xuyên thấu nhỏ (50–700 μm diameter)

• Atherosclerosis – Lipid deposition, layering of platelet and fibrin aggregates,

breakage of elastic lamina, atrophy and fragmentation of smooth muscle, dissections, and granular or vesicular cellular degeneration

• Charcot and Bouchard aneurysm – Fibrinoid necrosis of the subendothelium focal dilatations rupture of microaneurysm

Dị dạng mạch máu (Vascular malformations)

• Aneurysms, AVM, cavernous angiomas

• Người trẻ, bn nữ, tiền sử gia đình

• Hình ảnh có thể biểu hiện đồng thời XHDN

• Chẩn đoán MRI và cerebral angiography

– Usually supratentorial, lobar ICH

– Cavernous angioma: on MRI (T2) central nidus of irregular bright signal mixed with mottled hypointensity, surrounded by peripheral hypointense ring (ổ tín hiệu sáng không đều lẩn giảm đâm độ)

cavernous angiomas (CT)

Vascular malformations (MRI)

U nội sọ (Intracranial tumour)

• Chiếm 10% trường hợp

• GBM hay metastases (melanoma, bronchogenic carcinoma, renal cell carcinoma)

• Hình ảnh gợi ý: – Papilledema

– Atypical location (e.g. corpus callosum)

– Disproportionate amount of surrounding edema

– Multiple sites simultaneously

– Non-contrast CT: ring of high-density hemorrhage with low-density center

– Contrast CT/MRI: presence of enhancing nodules

5. Điều trị XHN

These guidelines provide a framework for goal-directed treatment of the patient with intracerebral

hemorrhage. (Stroke. 2015;46:000-000. DOI: 10.1161/STR.0000000000000069.)

Chẩn đoán và đánh giá cấp cứu

1.Đánh giá “Thang điểm độ nặng” bn XHN : NIHSS, ICH score

(Class I; Level of Evidence B).

(khuyến cáo mới)

2. CT hay MRI phân biệt nhồi máu hay XHN

(Class I; Level of Evidence A).

(Không thay đổi so khuyến cáo trước)

ABC of hematoma size • Bedside ABC/2 method for hemorrhage volume in cm3 1. Identify the CT slice with the largest area of hemorrhage 2. Measure the largest diameter of the hemorrhage on this slice (A) 3. Measure the largest diameter 90° to (A) on the same slice (B) 4. Approximate number of 10-mm slices on which the ICH was seen

was calculated (C) – If area > 75% compared to where the hemorrhage was

largest, the slice was considered 1 hemorrhage slice – If area 25% to 75%, the slice was considered 1/2 a slice – If area < 25%, the slice was not considered a slice

• A, B, and C were then multiplied and the product divided by 2

3. CTA và contrast-enhanced CT có thể giúp xác định nguy

cơ hematoma phát triển (Class IIb; Level of Evidence B),

CTA, CT venography, contrast-enhanced CT, contrast

enhanced MRI, magnetic resonance angiography và

magnetic resonance venography, và catheter angiography

giúp đánh giá sang thương cấu trúc: dị dạng mạch máu, u khi

lâm sàng hay hình ảnh nghi ngờ

(Class IIa; Level of Evidence B). (Unchanged from the previous guideline)

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 hematoma expansion

Class IIb, Level of Evidence B

3.CT angiography, CT venography, contrast-enhanced CT, contrast-enhanced MRI, MRA and MRV can be useful to evaluate for underlying structural lesions including vascular malformations and tumors when there is clinical or radiologic suspicion

Class IIa, Level of Evidence B (New recommendation).

Khuyến cáo chẩn đoán hình ảnh trong XHN

5.1 Điều trị nội khoa XHN

Chăm sóc trước bệnh viện

“Guidelines for the Early Management of Patients

With Acute Ischemic Stroke.”

Chăm sóc ở cấp cứu

Khí đạo và oxy

. Bảo vệ khí đạo và thông khí đầy đủ khẩn cấp

. Điều trị khí đạo tích cực nếu giảm mức độ ý thức hay

rối loạn chức năng thân não

. Các thuốc dùng trước đặt nội khí quản tránh gây

loạn nhịp và /hay làm xáo trộn huyết động học

ABC

1. Duy trì oxygen bảo hòa ≥92%

2. Nhanh chóng đặt nội khí quản

Endotracheal intubation bn GCS 8 hay thấp hơn hay

không thể điều trị sự bài tiết dịch, nếu cần chuyển từ nơi

theo dõi tích cực, hay thiếu phương tiện, nguy cơ tổn

thương khí đạo bệnh nhân, xem xét bn trạng thái trơ

(obtund)

(ít nhất 20% bn điểm GCS giảm ≥2 điểm từ khởi phát trước bv đến khi

được đánh giá ở cấp cứu)

Endotracheal intubation

. Đặt nội khí quản không đòi hỏi, nhưng bảo vệ

khí đạo và bảo đảm thông khí là cần thiết

. Dựa vào lâm sàng nghi ngờ, không phải GCS

. pCO2 duy trì từ 30-35

- tránh dưới 30

Gây tê trước khi intubation, dùng lidocaine không chứng

minh phòng ngừa tăng áp lực nội sọ và ích lợi còn bàn cải ?

Thuốc tác dụng ngắn, không gia tăng áp lực nội sọ, khuyến

cáo hiện nay: etomidate hay propofol trong XHN cấp (propofol có thể giảm nhanh HA, midazolam nên tránh tác dụng không

mong muốn tăng áp lực nội sọ)

Thuốc tác dụng ngắn không khử cực (nondepolarizing) như

rocuronium thích hợp bn nguy cơ tăng áp lực nội sọ (succinylcholine có thể gây tăng áp lực nội sọ)

Lidocaine : ức chế phản xạ ho, ức chế gia tăng áp lực nội sọ bn đặt nội

khí quản với sang thương chiếm chổ, dùng 3 phút trước laryngoscopy

Sự cầm máu và bệnh lý đông máu, thuốc chống tiểu cầu và phòng ngừa DVT

(Hemostasis and Coagulopathy, Antiplatelet Agents, and

DVT Prophylaxis)

1.BN thiếu hụt các yếu tố đông máu năng hay giảm tiểu cầu

năng (thrombocytopenia) điều trị thay thế các yếu tố thích

hợp hay tiểu cầu tương ứng (Class I; Level of Evidence C). (Unchanged from the previous guideline)

2. BN XHN có INR tăng do dùng VKA, ngưng VKA điều trị

vitamin K–dependent factors, điều chỉnh INR, và intravenous

vitamin K (Class I; Level of Evidence C). (Unchanged from the previous guideline)

3. Phòng ngừa venous thromboembolism Bn XHN bắt đầu

ngày nhập viện bằng intermittent pneumatic compression (Class I; Level of Evidence A). (Revised from the previous guideline)

Kháng đông và XHN

• Anticoagulation gây phát

triển hematoma và tử

vong cao hơn

– Reverse warfarin

promptly and

aggressively

– FFP or prothrombin

complex concentrates

(PCCs)

– IV vitamin K

• Faster than SQ/PO but

a small risk of

anaphylactoid reaction

Khuyến cáo:

Hemostasis and Coagulopathy, Antiplatelet Agents, and

DVT Prophylaxis

1. Patients with a severe coagulation factor deficiency or

severe thrombocytopenia should receive appropriate

factor replacement therapy or platelets, respectively

(Class I; Level of Evidence C).

(Unchanged from the previous guideline)

2. Patients with ICH whose INR is elevated because of

VKA should have their VKA 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 may have fewer complications and correct the INR more

rapidly than FFP and might be considered over FFP (Class IIb; 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 recommended for VKA reversal in ICH (Class III; Level of Evidence C).

(Revised from the previous guideline)

Prothrombin complex concentrates

(PCCs)

recombinant activated factor VIIa

(rFVIIa)

Fresh frozen plasma (FFP),

3. For patients with ICH who are taking dabigatran,

rivaroxaban, or apixaban, treatment with FEIBA, other PCCs,

or rFVIIa might be considered on an individual basis.

Activated charcoal might be used if the most recent dose of

dabigatran, apixaban, or rivaroxaban was taken <2 hours

earlier. Hemodialysis might be considered for dabigatran (Class IIb; Level of Evidence C).

(New recommendation)

4. Protamine sulfate may be considered to reverse heparin

in patients with acute ICH (Class IIb; Level of Evidence C).

(New recommendation) FEIBA

(factor VIII inhibitor bypassing activity)

5. The usefulness of platelet transfusions in ICH patients

with a history of antiplatelet use is uncertain (Class IIb; Level of Evidence C).

(Revised from the previous guideline)

6. Although rFVIIa can limit the extent of hematoma

expansion in noncoagulopathic ICH patients, there is an

increase in thromboembolic risk with rFVIIa and no clear

clinical benefit in unselected patients. Thus, rFVIIa is not

recommended (Class III; Level of Evidence A).

(Unchanged from the previous guideline)

7. Patients with ICH should have intermittent pneumatic

compression for prevention of venous thromboembolism

beginning the day of hospital admission

(Class I; Level of Evidence A).

Graduated compression stockings are not beneficial to reduce

DVT or improve outcome (Class III; Level of Evidence A).

(Revised from the previous guideline)

8. After documentation of cessation of bleeding, low dose

subcutaneous low-molecular-weight heparin or

unfractionated heparin may be considered for prevention

of venous thromboembolism in patients with lack of mobility

after 1 to 4 days from onset (Class IIb; Level of Evidence B).

(Unchanged from the previous guideline)

9. Systemic anticoagulation or IVC filter placement is

probably indicated in ICH patients with symptomatic

DVT or PE (Class IIa; Level of Evidence C). The decision

between these 2 options should take into account several

factors, including time from hemorrhage onset, hematoma

stability, cause of hemorrhage, and overall patient condition (Class IIa; Level of Evidence C).

(New recommendation)

inferior vena cava (IVC) filter

Tiềm năng điều trị XHN: vấn đề khối máu tụ lan rộng

Khối máu tụ lan rộng rất thường gặp

Brott, et al., 1997 103 pts., prospective observational study with serial CT scanning (baseline, 1 hr and 20 hrs following ICH) 26% showed >33% enlargement on 1 hr CT 38% showed >33% enlargement on 20 hr CT Neurologic deterioration correlated with hematoma expansion

Brott T et al, Stroke. 1997 Jan;28(1):1-5.

Khối máu tụ lan rộng trong XHN

Tiên lương khối máu tụ lan rộng

Thể tích khối máu tụ và tử vong

Recombinant Activated Factor VII

rFVIIa, NovoSeven©

Used for hemophilia

Induces local hemostasis

when it binds to tissue

factor - The complex can activate

Factors IX and X

- Factor Xa helps convert

prothrombin to thrombin

*Not FDA approved for ICH

“FAST” Trials

A phase II randomized trial showed that treatment with rFVIIa

within four hours after ICH onset limited hematoma growth

improved clinical outcomes relative to placebo

increased frequency of thromboembolic events (7% vs. 2%)

A subsequent phase III study comparing placebo to 20 μg/kg

and 80 μg/kg of rFVIIa:

both doses diminished hematoma enlargement

failed to show differences in clinical outcome

Overall serious thromboembolic adverse event rates were similar, the

higher rFVIIa (80 μg/kg) group had significantly more arterial events

than placebo.

The authors noted imbalances in treatment groups, particularly

intraventricular hemorrhage in the higher dose rFVIIa group

Mayer SA, et al for the FAST Trial Investigators., N Engl J Med. 2008 May 15;358(20):2127-37.

Mayer SA for the FAST Trial Investigators. N Engl J Med. 2005 Feb 24;352(8):777-85.

Factor VIIa

Factor VIIa can limit hematoma expansion in non-

coagulopathic patients, but also increases

thromboembolic risk.

rFVIIa is not recommended in unselected patients

rFVIIa does NOT replace clotting factors, even

though INR normalizes

rFVIIa is not recommended as the only agent to

reverse INR in ICH patients

Mayer SA, et al for the FAST Trial Investigators., N Engl J Med. 2008 May 15;358(20):2127-37.

Mayer SA for the FAST Trial Investigators. N Engl J Med. 2005 Feb 24;352(8):777-85.

Huyết áp

Is it safe to lower BP in the acute setting?

Safety of Early Intensive BP-Lowering Treatment

Điều trị HA cấp

Cerebral autoregulatory curve

CPP = MAP – ICP

Both the Antihypertensive Treatment of Acute Cerebral

Hemorrhage (ATACH) trial, a 4-tier dose escalation study of

intravenous nicardipine-based BP lowering in 80 patients within

3 hours of ICH,130 and the pilot phase Intensive Blood

Pressure Reduction in Acute Cerebral Hemorrhage

(INTERACT1) trial in 404 mainly Chinese patients within 6

hours of ICH131 found rapid reduction of SBP to <140 mm Hg

to be safe

Most recently, the main phase INTERACT2 trial has shown

no increase in death or serious adverse events from early

intensive BP lowering in eligible patients with elevated SBP.

Nghiên cứu ATACH , INTERACT 1 & 2

A randomized clinical trial using CT perfusion in primarily

small and medium ICH found no clinically significant

reduction in cerebral blood flow within the perihematomal

region related to early intensive BP lowering to an SBP target

of <140 mm Hg within several hours of ICH

In a clinical cohort of 211 patients who received a standard

protocol of nicardipine-based BP lowering to reach an SBP

target of <160 mm Hg at a mean of 30 minutes (range, 15–

45 minutes) within 3 hours of the onset of ICH, the best

outcomes were seen in the group with the lowest achieved

SBP (<135 mm Hg).

BN XHN có HA tâm thu từ 150 đến 220 mmHg và không có

chống chỉ định điều trị HA cấp, hạ huyết áp tâm thu xuống

140 mmHg là an toàn,

(Class I; Level of Evidence A)

và có thể hiệu quả cải thiện dự hậu chức năng

(Class IIa; Level of Evidence B).

(Revised from the previous guideline)

BP: Recommendations

1. For ICH patients presenting with SBP between 150

and 220 mm Hg and without contraindication to acute BP

treatment, acute lowering of SBP to 140 mm Hg is safe (Class

I; Level of Evidence A)

and can be effective for improving functional outcome (Class IIa; Level of Evidence B). (Revised from the previous guideline)

2. For ICH patients presenting with SBP >220 mm Hg,

it may be reasonable to consider aggressive reduction

of BP with a continuous intravenous infusion and frequent BP

monitoring

(Class IIb; Level of Evidence C). (New recommendation)

Blood Pressure Recommendations(2010)

1. Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence.

Class IIb, Level of Evidence C Unchanged from the previous guideline

2. In patients presenting with a systolic BP of 150-220 mmHg, acute lowering of systolic BP to 140 mmHg is probably safe

Class IIa, Level of Evidence B New recommendation

If SBP is >200 mmHg or MAP is >150 mm Hg, then

consider aggressive reduction of blood pressure with

continuous intravenous infusion, with frequent blood

pressure monitoring every 5 minutes.

If SBP is >180 mmHg or MAP is >130 mm Hg and there is

the possibility of elevated ICP, then consider monitoring

ICP and reducing blood pressure using intermittent or

continuous intravenous medications while maintaining a

cerebral perfusion pressure > 60 mmHg

If SBP is >180 mmHg or MAP is >130 mm Hg and

there is not evidence of elevated ICP, then consider a

modest reduction of blood pressure (eg, MAP of 110

mm Hg or target blood pressure of 160/90 mm Hg)

using intermittent or continuous intravenous

medications to control blood pressure, and clinically

reexamine the patient every 15 minutes.

© 2010 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited

Theo dõi tổng quát và chăm sóc điều dưỡng

(General Monitoring and Nursing Care)

Theo dõi và chăm sóc ban đầu BN XHN ở ICU ( intensive

care unit hay đơn vị đột quỵ(stroke unit) do BS và Điều

dưỡng chuyên khoa về đột quỵ chăm sóc (Class I; Level of Evidence B).

(Revised from the previous guideline)

Điều trị đường huyết

Theo dõi Glucose, nên tránh cả hyperglycemia và

hypoglycemia. Khuyến cáo mức glucose bình thường

(Class I; Level of Evidence C).

(Revised from the previous guideline)

Điều trị sốt

1. Điều trị sốt sau XHN có thể hợp lý

(Class IIb; Level of Evidence C).

(New recommendation

+ duy trì mức nhiệt độ bình thường

+ acetaminophen 650mg

+ chườm lạnh (cooling blankets)

Cơn động kinh và thuốc chống cơn động kinh (Seizures and Antiseizure Drugs)

Cơn động kinh lâm sàng sẽ được điều trị với thuốc chống cơn

động kinh (Class I; Level of Evidence A).

(Unchanged from the previous guideline)

Bn thay đổi tình trạng tâm thần (mental status) tìm thấy cơn

động kinh trên EEG được điều trị thuốc chống cơn động kinh (Class I; Level of Evidence C).

(Unchanged from the previous guideline)

Seizures and Antiseizure Drugs: Recommendations

1. Clinical seizures should be treated with antiseizure drugs (Class I; Level of Evidence A). (Unchanged from the previous guideline)

2. Patients with a change in mental status who are found to

have electrographic seizures on EEG should be treated with

antiseizure drugs (Class I; Level of Evidence C). (Unchanged from the

previous guideline)

3. Continuous EEG monitoring is probably indicated in ICH

patients with depressed mental status that is out of proportion

to the degree of brain injury (Class IIa; Level of Evidence C).

(Revised from the previous guideline)

4. Prophylactic antiseizure medication is not recommended (Class III; Level of Evidence B).

(Unchanged from the previous guideline)

Điều trị biến chứng nội khoa

Tầm soát nuốt khó cho tất cả bn trước khi cho ăn hay

uống bằng đường miệng để giảm nguy cơ viêm phổi (Class I; Level of Evidence B).

(New recommendation)

Dysphagia and aspiration are major risk

factors for the development of pneumonia

Serious cardiac events and cardiac death after stroke may be caused by

acute myocardial infarction (MI), heart failure, ventricular arrhythmias

including ventricular tachycardia/ fibrillation, and cardiac arrest. Concurrent

stroke and MI are not uncommon

Neurogenic pulmonary edema is an increase in interstitial and alveolar

fluid in the setting of an acute central nervous system injury well

documented in subarachnoid hemorrhage. Radiographically, it is

indistinguishable from cardiogenic pulmonary edema

Other medical complications in ICH patients include

acute kidney injury, hyponatremia, gastrointestinal bleeding,

impaired nutritional status, urinary tract infections, and

poststroke depression

Management of Medical Complications: Recommendations

1. A formal screening procedure for dysphagia should be

performed in all patients before the initiation of oral intake to

reduce the risk of pneumonia (Class I; Level of Evidence B).

(New recommendation)

2. Systematic screening for myocardial ischemia or infarction

with electrocardiogram and cardiac enzyme testing after ICH is

reasonable (Class IIa; Level of Evidence C).

(New recommendation)

Phẫu thuật/thủ thuật (Procedures/Surgery)

Theo dõi và chăm sóc tăng áp lực nội sọ

(ICP Monitoring and Treatment)

ICP Monitoring and Treatment: Recommendations

1. Ventricular drainage as treatment for hydrocephalus

is reasonable, especially in patients with decreased

level of consciousness (Class IIa; Level of Evidence B).

(Revised from the previous guideline)

2. Patients with a GCS score of ≤8, those with clinical

evidence of transtentorial herniation, or those with significant

IVH or hydrocephalus might be considered for ICP monitoring

and treatment. A CPP of 50 to 70 mm Hg may be reasonable

to maintain depending on the status of cerebral autoregulation (Class IIb; Level of Evidence C). (Unchanged from the previous guideline)

3. Corticosteroids should not be administered for treatment

of elevated ICP in ICH (Class III; Level of Evidence B). (New recommendation)

Tiếp cận điều trị TALNS

CSF volume • Mannitol or

hypertonic solution

• External CSF drainage

• Ventricular catheter

• Ventriculo -peritoneal or atrial shunt

• Lumbar drain • Serial lumbar

punctures

Brain volume • Mannitol or

hypertonic saline

• Decompressive craniectomy

• Resection of tumor or other mass lesion

Blood volume

+ Mannitol or

hypertonic saline

+ Hyperventilation

+ Hypothermia

+ Head elevation,

neutral neck

position

+ Deep propofol or

barbiturate

sedation ±

paralysis Seizure Control

Hyperventilation

• Useful in initial resuscitation: effectively and rapidly reduce ICP in acute rises until definitive therapy

• Generalized vasoconstriction: cerebral blood volume, ICP

• Chronic hyperventilation should be avoided because CBF puts the brain at risk of ischemia

– Safety of duration is uncertain

Cắt bỏ khối sang thương (Resection of mass lesion)

• Subdural or epidural hemorrhage

– Hematoma evacuation

• Tumours

– Surgical resection

Dẫn lưu DNT

• Communicating hydrocephalus (e.g. SAH, IVH)

– Temporary external ventricular drain

– Long term VP or VA shunt

• Obstructive hydrocephalus (e.g. tumours)

– Temporary external ventricular drain until definitive tumour resection

Nằm đầu cao

• Head of bed at 20 to 30 is optimizes cerebral venous return

• Ensure neutral neck position

• Caution in hypovolemic patients to avoid reduction in MAP and therefore CPP

– CPP = MAP – ICP

Paralysis, Sedation, Hypothermia

• To prevent excess motor activity (posturing, coughing, straining against ventilator)

• To cerebral metabolic rate and CBF (must maintain MAP to improve CPP, caution in HD unstable patients)

• Role of EEG

– Rule out ongoing seizure activity

– Titration of sedation with goal of achieving burst suppression

• Hypothermia, controversial

– Attenuates deleterious biochemical cascade

– cerebral metabolic rate

– risk pneumonia, wound infection, abnormal

lytes/coags

Mannitol and Hypertonic saline (HS)

• Mannitol 20% or 25% solution (0.25 – 1gm/kg IV) – Intravascular fluid shift from osmotic effect

– Decreased blood viscosity and improved flow (? reflex vasocontriction)

– Decreases production of CSF

• Follow serum osmolarity (<320 mOsm) – Avoid systemic dehydration & renal injury

• Can consider adding Furosemide

• Hypertonic saline, if refractory to mannitol – BBB is impermeable to Na+ ions Osmotic

gradient

– Less severe electrolyte disturbances, less brisk diuresis

– Lack of standard guideline (3-7.5% solution at 20-40cc/h)

– Slow taper to avoid rebound hyponatremia

Decompressive craniectomy

• Surgical removal of cranial bone flap to relieve

intracranial pressure

• Useful in large ischemic CVA with profound edema

• Role in traumatic brain injury still needs to be

established

Intraventricular Hemorrhage (IVH)

Hydrocephalus

Hydrocephalus có thể kết hợp

với XHN, đặc biệt vỡ trong não

thất (IVH)

Tăng ALNS

Kết quả dấu thần kinh xấu đi

sớm hay trễ

CLEAR-IVH Trial

52 pts with IVH

Open-label intra-ventricular rt-PA to accelerate blood

clearance and lysis

Adverse events

Symptomatic bleeding 4%

Bacterial ventriculitis 2%

30 day mortality 17%

Efficacy requires confirmation before use of

intraventricular fibrinolysis can be recommended,

Phase III trial in progress.

IVH: Recommendations

1. Although intraventricular administration of rtPA in

IVH appears to have a fairly low complication rate,

the efficacy and safety of this treatment are uncertain (Class IIb; Level of Evidence B). (Revised from

the previous recommendation)

2. The efficacy of endoscopic treatment of IVH is uncertain (Class IIb; Level of Evidence B).

(New recommendation)

Patients with a GCS score of 8 or less, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A CPP of 50-70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation

Class IIb, Level of Evidence C New recommendation

Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness

Class IIa, Level of Evidence B New Recommendation

Although intraventricular administration of rt-PA in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational

Class IIb, Level of Evidence B New Recommendation

ICP Monitoring and Ventriculostomy

©2010 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited

Surgical Treatment of ICH (Clot Removal)

STICH Trial

902 ICH pts randomized trial of early hematoma

evacuation (<96 hrs) vs medical

Excluded cerebellar ICH

If ICH >1 cm from cortical surface, OR

GCS < 8

Surgical patients tended to do worse than medical

If ICH < 1cm from surface

Trended toward better outcomes with surgery, but

not significant (OR 0.69, 95% CI 0.47-1.01)

Mendelow AD, et al for the STICH Investigators. Lancet

2005;365(9457):387-397

Surgical ICH Trials

Timing of surgery: What is “early”? - Trials have been done using <24, 48, 72, and 96 hours

- Regardless of definition, no clear benefit for surgery

Minimally invasive techniques are being studied

Minimally Invasive Surgical Evacuation of ICH

Several recent randomized studies have compared minimally

invasive aspiration to standard craniotomies and suggested

better outcomes with less invasive approaches

Timing of Surgery

Timing of surgery for ICH remains controversial

Patients with cerebellar hemorrhage who are deteriorating

neurologically or who have brainstem compression and/or

hydrocephalus from ventricular obstruction should undergo

surgical removal of the hemorrhage as soon as possible

(Class I; Level of Evidence B).

(Unchanged from the previous guideline)

Khuyến cáo Surgical Treatment of ICH

1. Patients with cerebellar hemorrhage who are deteriorating

neurologically or who have brainstem compression and/or

hydrocephalus from ventricular obstruction should undergo

surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence B).

Initial treatment of these patients with ventricular drainage

rather than surgical evacuation is not recommended (Class III; Level of Evidence C).

(Unchanged from the previous guideline)

Evacuation: sự thụt rửa)

2. For most patients with supratentorial ICH, the usefulness of

surgery is not well established (Class IIb; Level of Evidence A). (Revised from the previous

guideline). Specific exceptions and potential subgroup

considerations are outlined below in recommendations

3 through 6.

3. A policy of early hematoma evacuation is not clearly

beneficial compared with hematoma evacuation when patients

deteriorate (Class IIb; Level of Evidence A). (New recommendation)

4. Supratentorial hematoma evacuation in deteriorating

patients might be considered as a life-saving measure (Class IIb; Level of Evidence C). (New recommendation)

5. DC with or without hematoma evacuation might

reduce mortality for patients with supratentorial ICH who are

in a coma, have large hematomas with significant midline

shift, or have elevated ICP refractory to medical management (Class IIb; Level of Evidence C). (New recommendation)

6. The effectiveness of minimally invasive clot evacuation

with stereotactic or endoscopic aspiration with or without

thrombolytic usage is uncertain (Class IIb; Level of Evidence B).

(Revised from the previous guideline)

Outcome Prediction and Withdrawal of

Technological Support

Outcome Prediction and Withdrawal of Technological

Support: Recommendation

1. Aggressive care early after ICH onset and postponement

of new DNAR orders until at least the second full day of

hospitalization is probably recommended

(Class IIa; Level of Evidence B). Patients with preexisting

DNAR orders are not included in this recommendation.

Current prognostic models for individual patients early after

ICH are biased by failure to account for the influence of

withdrawal of support and early DNAR orders. DNAR status

should not limit appropriate medical and surgical interventions

unless otherwise explicitly indicated (Class III; Level of Evidence C). (Revised from the previous guideline)

Prevention of Recurrent ICH

BP should be controlled in all ICH patients

(Class I; Level of Evidence A). (Revised from the previous guideline)

Measures to control BP should begin immediately after ICH

onset

(Class I; Level of Evidence A). (New recommendation)

1. When stratifying a patient’s risk for recurrent ICH

may affect management decisions, it is reasonable

to consider the following risk factors for ICH recurrence:

(1) lobar location of the initial ICH;

(2) older age;

(3) presence and number of microbleeds on gradient

echo MRI;

(4) ongoing anticoagulation; and

(5) presence of apolipoprotein E ε2 or ε4 alleles

(Class IIa; Level of Evidence B).

(Revised from the previous guideline)

2. BP should be controlled in all ICH patients (Class I; Level of Evidence A). (Revised from the previous guideline)

Measures to control BP should begin immediately after

ICH onset (Class I; Level of Evidence A). (New recommendation)

A long-term goal of BP <130 mm Hg systolic and 80 mm

Hg diastolic is reasonable (Class IIa; Level of Evidence B). (New recommendation)

3. Lifestyle modifications, including avoidance of alcohol

use greater than 2 drinks per day, tobacco use,

and illicit drug use, as well as treatment of obstructive

sleep apnea, are probably beneficial

(Class IIa; Level of Evidence B).

(Revised from previous guideline)

4. Avoidance of long-term anticoagulation with warfarin

as a treatment for nonvalvular atrial fibrillation is probably

recommended after warfarin-associated spontaneous lobar

ICH because of the relatively high risk of recurrence (Class IIa; Level of Evidence B).

(Unchanged from the previous guideline)

5. Anticoagulation after nonlobar ICH and antiplatelet

monotherapy after any ICH might be considered, particularly

when there are strong indications for these agents (Class IIb; Level of Evidence B).

(Revised from the previous guideline)

6. The optimal timing to resume oral anticoagulation

after anticoagulant-related ICH is uncertain. Avoidance of

oral anticoagulation for at least 4 weeks, in patients without

mechanical heart valves, might decrease the risk of ICH

recurrence

(Class IIb; Level of Evidence B). (New recommendation), if indicated,

aspirin monotherapy can probably be restarted in the days

after ICH, although the optimal timing is uncertain (Class IIa; Level of Evidence B).

(New recommendation)

7. The usefulness of dabigatran, rivaroxaban, or apixaban

in patients with atrial fibrillation and past ICH to decrease

the risk of recurrence is uncertain (Class IIb; Level of Evidence C).

(New recommendation)

8. There are insufficient data to recommend restrictions

on the use of statins in ICH patients

(Class IIb; Level of Evidence C).

(Unchanged from the previous guideline)

Phục hồi chức năng và hồi phục (Rehabilitation and Recovery)

Given the potentially serious nature and complex pattern of

evolving disability and the increasing evidence for efficacy,

it is recommended that all patients with ICH have access to

multidisciplinary rehabilitation (Class I; Level of Evidence A).

(Revised from the previous guideline)

Rehabilitation and Recovery: Recommendations

1. Given the potentially serious nature and complex

pattern of evolving disability and the increasing evidence

for efficacy, it is recommended that all patients

with ICH have access to multidisciplinary rehabilitation (Class I; Level of Evidence A).

(Revised from the previous guideline)

2. Where possible, rehabilitation can be beneficial

when begun as early as possible and continued in the

community as part of a well-coordinated (“seamless”)

program of accelerated hospital discharge and home-

based resettlement to promote ongoing recovery

(Class IIa; Level of Evidence B).

(Unchanged from the previous guideline)

Thank you!