Intensive Care for Hemorrhagic Stroke

高醫神經外科 林志隆1030410台東馬偕醫院

2014年度進階重症護理訓練(神經系統)

本文有關病因檢查、診斷及治療的證據等級及建議強度，係根據美國心臟協會的建議

Stroke. 2010;41:2108-29

腦血管疾病(Cerebrovascular disease ; CVD)

• 腦血管意外(Cerebrovascular accident; CVA)

• 腦中風(Stroke , apoplexy)

• CVD分為1. 腦梗塞(Cerebral Infarction)

2. 腦出血(Cerebral Hemorrhage)

3. 蜘蛛膜下腔出血(Subarachnoid Hemorrhage ;

SAH)

www.lookfordiagnosis.com

Background knowledge of intracerebralhaemorrhage (ICH)

• Annual incidence of 10–30/100,000, about 2 million (10–15%) of about 15 million strokes worldwide each yearQureshi AI. Et al. Lancet. 2009; 373: 1632–44

• Intracerebral haemorrhage - a subtype of stroke about 15% of all deaths from strokeKase C.S. et al. Intracerebral hemorrhage. Boston: Butterworth-Heinemann, 1994

• In Taiwan, 73/100,000 (>35y/o), incidence 22% in stroke, Mortality – 26-30% (<1 month)Hu H.H. et al. Incidence of Stroke in Taiwan. Stroke. 1992;23:1237-1241

Hemorrhagic stroke的病理機轉與分類

1. 腦內出血(Intracerebral hemorrhage; ICH)

(一)高血壓, 動脈硬化

(二)基底核(Basal ganglion)中又以被殼(putamen)最常見,其它好發部位為丘腦(thalamus) 、尾狀核(caudal nucleus) 、小腦(cerebellum)及橋腦(pons)

2. 蜘蛛膜下腔出血(SAH): 動脈瘤(aneurysm)

3. 血管畸型:動靜脈畸型瘤(arteriovenous malformation ; AVM)

Intracerebral Hemorrhage (ICH) in Adults

Locations of hemorrhage

Common arteries feeders of ICHs

• Lenticulostriate (B)

• Thalamoperforators ( C)

• paramedian branches of basilar artery (D)

Common sites for ICHs

• basal ganglia : 50% (putamen most common) (B)

thalamus : 15% (C)

pons : 10-15% (D)

cerebellum : 10% (E)

cerebral white matter : 10-20% (A)

B

D

CA

Etiologies of ICHs

• Hypertension

• Acutely increased cerebral blood flow

• vascular anomalies

• Arteriopathies

• Brain tumor

• Coagulation or clotting disorder

• Infection

• Venous or dural sinus thrombosis

• Drug abuse

• Post-traumatic

• Eclampsia

Clinical presentation of ICHs (I)• In general, the neurologic deficit is characterized by a

smooth progressive onset over minutes to hours.

• Headache, vomiting, and alterations in level of

consciousness

1. Putaminal hemorrhage:

contralateral hemiparesis →hemiplegia,

may→coma or death

Right putaminal hemorrhage

Clinical presentation of ICHs (II)

2. Thalamic hemorrhage :

contralateral hemisensory loss, hemiparesis (internal

capsule involved)

hydrocephalus (CSF path compression)

extension into upper brain stem: vertical gaze palsy

Left thalamic hemorrhageLeft thalamic hemorrhage with rupture into

ventricle (RIV)

Clinical presentation of ICHs (III)

3. Cerebellar hemorrhage: headache,

cerebellar and brain stem signs (ataxia, dysarthria, nystagmus, vertigo, and vomiting)

CSF obstruction → hydrocephalus, s/s of IICP

direct compression of brain stem → classically become comatous without first having hemiparesis

Cerebellar hemorrhage

with acute

hydrocephalus

Clinical presentation of ICHs (IV)4. Lobar hemorrhage:

1) frontal lobe: frontal headache with contralateral hemiparesis, usually in the arm with mild leg and facial weakness

2) parietal lobe: contralateral hemisensory deficit and mild hemiparesis

3) occipital lobe: contralateral homonymous hemianopsia

4) temporal lobe: on dominant side produces fluent dysphasia with poor auditory comprehension but relatively good repetition

腦內出血的診斷

• 電腦斷層或磁震造影檢查

• 腦部血管攝影 CTA, MRA, CT venography,

contrast-enhanced CT, contrast-enhanced MRI,

and magnetic resonance venography: 年青、無

高血壓病史或無其他腦出血危險因素之患者

• 一般生化檢查、CBC、PT及 APTT、electrolyte、 EKG、 chest x-ray

Right putaminal hemorrhage Cerebellar hemorrhage

Subcortical hemorrhage Brain stem hemorrhage

Left thalamic hemorrhage Left thalamic hemorrhage with

rupture into ventricle (RIV)

Left caudate nucleus hemorrhage with RIV

AVM without contrast AVM with contrast

Aneurysaml SAH

CVD的臨床表徵(Ⅰ)1.腦神經障礙

2.運動障礙

i. 麻痺(plegia, paralysis):指運動功能喪失,單側麻痺hemiplegia (muscle power 0-1)

ii. 輕癱(paresis):運動功能輕度喪失(muscle power 2-3)

iii.運動失調(ataxia):肢體抖動或跳躍,致動作不能順利完成.

iv. 肢體痙攣(spasticity)或僵硬(rigidity):搬動病患患側手腳有阻力存在.

3.吞嚥功能障礙

CVD的臨床表徵(Ⅱ)4.感覺障礙

5. 語言障礙

i. 構音障礙(Dysarthria)

ii. 失語症(Aphasia)

(一)非流利型失語症(nonfluent aphasia): 伯克氏失語(Broca Aphasia),運動性失語症,表達性失語症

(二)流利型失語症(fluent aphasia)

a.衛爾尼克氏(Wernicke aphasia)或感覺性失語症

b.傳導性失語症(Conduction aphasia)

C.舉名不能(Anomia)或記憶性失語症(amnesic

aphasia)

(三)總體(球)性失語症(global aphasia)

CVD的臨床表徵(Ⅲ)

6.智力障礙

7.視力障礙

8.排尿功能障礙

9.排便功能障礙

10.情緒功能障礙

急性腦出血的內科治療1. 急診室的第一線處理仍是基本的ABC，即為保持呼吸道暢

通、維持適當的呼吸換氣及循環。此外也應注意病人是否

有頭部外傷。同時也要避免褥瘡、compartment

syndromes等併發症

2. 昏迷的病人或有腦幹功能障礙者需特別注意呼吸道的暢通，

假如有缺氧現象（PO2<60mmHg 或PCO2>50mmHg），

或有吸入性肺炎的病人均應給予氣管插管，但需注意先給

高濃度氧氣及避免造成反射性心律不整或腦壓升高的藥物

(如atropine, thiopental, midazolam, propofol or

succinylcholine )

3.血壓的控制：腦內出血病人血壓的控制並

無一定的標準，應視病患個人的年齡、有

無慢性高血壓、有無顱內壓增高、出血原

因、發病時間及病人術前術後的情況而定

。對有高血壓病史的病人，平均動脈壓大

於130mmHg 即需開始降血壓，對於剛開顱

手術者其平均動脈壓盡量不要高於

110mmHg

• 若收縮壓>230mmHg或舒張壓>140 mmHg，且重覆5分鐘

測量，連續2次都高需快速降壓時，可給予nitroprusside

0.5-10ug/kg/min

• 收縮壓在180-230mmHg之間，舒張壓在105-140mmHg之

間，或平均動脈壓>130mmHg，且每20分鐘重覆測量，連

續2次都高時，可給予Labetalol 10-40 mg bolus 後，再5-

100mg/h間歇性靜脈注射，或2-8mg/min連續點滴。若有

氣喘病不能使用Labetalol時，可使用esmolol, enalapril,

diltiazem, lisinopril或verapamil 靜脈注射。

•收縮壓＜180mmHg，或舒張壓＜105mmHg，暫時尚可不必使用降壓藥。•若有顱內壓監視器，則應使大腦灌注壓（平均動脈壓減腦壓）＞70mmHg。•若血壓（收縮壓）＜90mmHg時，則必須給升壓劑。首先應先給補充體液，以增加體液容量，如等張生理食塩水isotonic-saline、colloids或FFP，且以CVP或 pulmonary

artery wedge pressure做監測。若此法尚不能提升血壓，則可給phenylepinephrine 2-10ug/kg/min 、 Dopamine 2-

20ug/kg/min或Norepinephrine 0.05-0.2 ug/kg/min。將血壓提升至systolic pressure100mmHg以上。

Blood pressure management- Guideline

Until ongoing clinical trials of BP intervention

for ICH are completed, physicians must

manage BP on the basis of the present

incomplete efficacy evidence.

In patients presenting with a systolic BP of 150

to 220 mm Hg, acute lowering of systolic BP

to 140 mm Hg is probably safe (Class IIa;

Level of Evidence: B).

Blood pressure management- Guideline

(Class IIb; Level of Evidence: C).考

Blood pressure management- Guideline

4.控制顱內壓（ICP）：顱內壓升高的定義為ICP>20mmHg，

且時間持續5分鐘以上。治療的目標為ICP＜20mmHg及腦

灌注壓（CPP）＞70mmHg

• 除了血塊會造成水腫外，因腦出血後阻塞腦脊髓液通路而造成續發性水腦症，亦會產生顱內壓增加，此時則需做腦室引流手術，以減低顱內壓。一般引流最好不要超過7天，且需給予預防性抗生素以免感染。

• 腦出血的降顱內壓治療，首先以高滲透壓藥物如Glycerol或Mannitol為主。Mannitol因容易產生反彈效果，建議勿長期使用。Glycerol 較可長期使用且較少有反彈現象

• 類固醇（steroids）：建議儘量不使用類固醇，因其副作用太大，且降顱內壓效果不會比高滲透壓藥物效果好。

•持續過度換氣（hyperventilation）：過度換氣造成血中二氧化碳濃度降低，會使腦血管收縮，降低腦血流及血容積，而在30分鐘內可降低顱內壓。大部份的病人將PaCO2降至30-35mmHg約可降低顱內壓25-30﹪。

•神經肌肉鬆弛劑：使用神經肌肉鬆弛劑與少量的鎮靜劑可降低顱內壓。

•抽痰前應先使用神經肌肉鬆弛劑，如短效的巴比妥類藥物(thiopental）或 lidocaine。並注意在氣管、支氣管及鼻腔等部位之抽痰時間為5至10秒，口腔部位要在10至15秒內完成，以免造成顱內壓升高。

•高劑量巴比妥酸塩昏迷（barbiturate coma）治療為最後的選擇，它可降低腦細胞代謝，減少腦血流而降低顱內壓，但會使血壓降低，亦容易造成感染，導致敗血症而死亡。

5. 輸液治療（fluid management）：需維持等量體液

（euvolemia）的狀況，CVP維持在5-12mmHg，

pulmonary wedge pressure保持在10-14mmHg，

電解質及酸鹼平衡都需做監測調整，每天的攝取

與排出（intake and output）亦需視尿量做調整

（尿量加500cc，若有發燒，每度加300cc。)

6. 預防癲癇：腦出血病患視病情需要可給phenytoin

或其他抗癲癇葯物做預防性治療，使用一個月後

若無發作，才慢慢停藥。

7. 體溫控制：體溫應儘量維持在正常範圍，若高於

38.5℃時，可給予acetaminophen，或降溫毯將體

溫降低。需注意探討及預防各種感染的可能性，

及使用預防性抗生素以避免感染。

8. 其他內科療法：對於譫妄(delirium)或躁動不安的

病人，可使用短效的Benzodiazepines或propofol，

其他如止痛、鎮靜劑亦可視各種情況使用。其他

亦需注意深部靜脈阻塞、肺栓塞之預防，以及早

期做復健治療

Blood glucose control

1. Glucose should be monitored and normoglycemia is recommended (Class I: Level of Evidence: C).

2. Persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke poor outcomesGuidelines for ischemic stroke suggest that elevated glucose concentrations (>185 mg/dL and possibly >140 mg/dL) probably should trigger administration of insulin, similar to the procedure in other acute situations accompanied by hyperglycemia. Use of these guidelines for ICH as well is reasonable. Class IIa, Level of Evidence C).

Antiepileptic drugs

• Appropriate antiepileptic therapy should

always be used for treatment of clinical

seizures in patients with ICH (Class I, Level of

Evidence B).

• A series of 761p’ts, early seizures occurred in

4.2% of patients, and 8.1% had seizures within

30 days after onset.

Passero S. et al. Epilepsia. 2002;43:1175–1180.

Seizures and Antiepileptic Drugs

• Clinical seizures should be treated with antiepilepticdrugs

(Class I; Level of Evidence: A).

• Continuous EEG monitoring (cEEG) indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury

(Class IIa; Level of Evidence: B).

• Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs

(Class I; Level of Evidence: C).

Prophylaxis AED or not?

Prophylactic anticonvulsant medication should

not be used (Class III; Level of Evidence:B).

Messe´ S.R. et al. Neurocrit Care.

2009;11 :38–44.Naidech A.M. et al.

Stroke.2009;40:3810 –3815.

Effect of previous anticoagulant or antiplatelet use

• Warfarin or aspirin user risk of death after ICH ↑

• Warfarin-user associated with severe bleeding and

large hematoma size present at hospital admission

• Relative risk of aspirin-user for death after ICH was

2.5 (95% CI, 1.3 to 4.6) vs non-user

• Antiplatelet therapy user ICH was followed by

acute deterioration and increase in hematoma volume

(40%) within 2 days

Saloheimo P. et al. Stroke. 2006;37:129–133.

Recommendation - Coagulopathy

1. Severe coagulation factor deficiency or thrombocytopenia should

receive appropriate factor replacement therapy or platelets,

respectively (Class I; Level of Evidence: C).

2. INR elevated due to oral anticoagulant warfarin withheld

to replace vitamin K–dependent factors and intravenous vitamin

K (Class I; Level of Evidence: C).

Prothrombin complex concentrates have not shown improved outcome

compared with FFP but may have fewer complications compared with

FFP (Class IIa; Level of Evidence: B).

rFVIIa does not replace all clotting factors, and is not routinely

recommended as a sole agent for OAC reversal in ICH (Class III;

Level of Evidence: C).

3. rFVIIa can limit the extent of hematoma

expansion in noncoagulopathic ICH patients,

an increase in thromboembolic risk

with rFVIIa and no clear clinical benefit in

unselected patients.

Thus rFVIIa is not recommended in unselected

patients. (Class III; Level of Evidence: A).

Recommendation - Coagulopathy

The usefulness of platelet transfusions in

ICH patients with a history of antiplatelet

use is unclear and is considered

investigational

(Class IIb; Level of Evidence: B).

Recommendation - Coagulopathy

Anticoagulant therapy

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).

Reversal of anticoagulant

Protamine sulfate should be used to reverse heparin

associated ICH, with the dose depending on the

time from cessation of heparin

(Class I, Level of Evidence B).

Patients with warfarin-associated ICH should be

treated with intravenous vitamin K to reverse the

effects of warfarin and with treatment to replace

clotting factors

(Class I, Level of Evidence B).

Anticoagulation use

Avoidance of long-term anticoagulation as treatment

for nonvalvular atrial fibrillation is probably

recommended after spontaneous lobar ICH because

of the relatively high risk of recurrence

(Class IIa; Level of Evidence: B).

Anticoagulation after nonlobar ICH and antiplatelet

therapy after all ICH might be considered,

particularly when there are definite indications for

these agents (Class IIb; Level of Evidence: B).

Intraventricular Hemorrhage

• Recommendation

1. Although intraventricular administration of recombinant

tissue-type plasminogen activator 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).

Set up the ICP monitor

H.O.B. 30o, keep CVP at 8-12 mmHg and R/O

hyponatremia and fever when CPP > 60 mmHg

ICP > 20 mmHg

CSF drainage ( with ventricular drain, if available)

of 3-5cc each time

Use sedatives and analgesics; use neuromuscular

blockade agents when necessary

B

B

B

考

Light hyperventilation to keep PaCO2 30-35mmHg

Mannitol 0.25-1 g/kg/intravenous injection

Craniotomy or decompressive

craniectomy

Cranial CT –

brain edema

or ICH

Second tier therapy

考

Fever control

It is generally agreed that sources of fever should

be treated and antipyretic medications should be

administered to lower temperature in febrile

patients with stroke(Class I, Level of Evidence

C).

Nearly 47% patients developed fever (>38oC) in

NICU

Kilpatrick MM. et al. Neurosurgery. 2000; 47:850–885.

DVT prophylaxis

Patients with ICH should have intermittent

pneumatic compression for prevention of

venous thromboembolism in addition to

elastic stockings (Class I; Level of

Evidence: B).

急性腦出血的手術治療

•自發性腦出血的患者是否需手術，及手術

的時機為何，均尚無定論。一般是以減少

腦內血塊產生的併發症為目標，如進一步

壓迫周遭正常腦組織、水腦症或血塊導致

嚴重的腦水腫。估計腦內血塊大小的方法

以CT為主，即1/2（長×寬×高），即為血塊

體積。

不宜外科手術的情況•小出血（＜10cm3）或神經症狀很輕微者，但需注

意觀察超急性ICH（＜3小時）常會有擴大情況。

•昏迷指數（GCS）< 5，表示已太嚴重，手術效果

均不好。但若為小腦出血壓迫腦幹時，就另當別

論，需緊急開刀。

•視丘或腦幹出血，除非產生水腦症，需做引流手

術外，以不採開顱手術為原則。其他的手術療法，

如內視鏡或立體定位手術等可能可施用於視丘或

腦幹出血，但需有更多的臨床證據來支持。

宜外科手術者• 小腦出血＞3cm或＞30cc且有症狀惡化現象，如壓迫腦幹

或造成水腦症時。

• 動脈瘤（Aneurysm）、動靜脈畸形（AVM）、或海綿狀血管瘤（cavernous hemangioma）等特殊腦血管病變所造成的腦出血時，可視情況做外科手術。

• 較年青的病患（＜60歲者），中度至重度的腦葉或基底核的腦出血（lobar or basal ganglion hemorrhage）出血量超過50cm3，且GCS≦14；或出血量30-50cm3，GCS＜12

可考慮外科手術。而30cm3以下或高齡患者則視個別情況而定。

Surgical removal of clot I

For patients presenting with lobar clots >30

mL and within 1 cm of the surface,

evacuation of supratentorial ICH by

standard craniotomy might be considered

(Class IIb; Level of Evidence: B).

Surgical clot removal II

Patients with cerebellar hemorrhage >3 cm

who are deteriorating neurologically or

who have brain stem compression and/or

hydrocephalus from ventricular obstruction

should have surgical removal of the

hemorrhage as soon as possible

(Class I, Level of Evidence B).

Minimally invasive clot evacuation

Utilizing either stereotactic or endoscopic

aspiration with or without thrombolytic usage

is uncertain and is considered investigational

(Class IIb;Level of Evidence: B).

CVD外科手術術式

1. Craniotomy/Craniectomy

2. Intracerebral hematoma(ICH) removal

3. External ventricular drainage(EVD)

4. ICP monitoring

5. Stereotactic or endoscopic aspiration

6. AVM removal

7. Clipping/wrapping of aneurysm

Neurocritical care Multimodality monitoring

方法 ( Method) :

1. Intraventricular

2. Parenchymal

3. Epidural bolt

4. Subdural bolt

5. Subarachnoid ( Lumbar drain )

ICP Monitoring and Treatment

Recommendations

1. 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 cerebral perfusion

pressure of 50 to 70 mm Hg may be reasonable to maintain

depending on the status of cerebral autoregulation (Class

IIb; Level of Evidence:C).

2. Ventricular drainage as treatment for hydrocephalus

is reasonable in patients with decreased level of

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

Intraparenchymal type (Codman)

Codman pressure

monitor

ICP transducer

Intraventricular (EVD)

Transcranial Doppler

釘子波 vs To and Fro

pattern

Prophylactic hypothermia

Level III*

Pooled data indicate that prophylactic hypothermia is not

significantly associated with decreased mortality when compared

with normothermic controls.

However, preliminary findings suggest that a greater decrease

in mortality risk is observed when target temperatures are

maintained for more than 48 hours.

Significantly higher Glasgow Outcome Scale (GOS) scores

when compared to scores for normothermic controls.

Note: In this meta-analysis, although all included studies were

Class II, the sub-analyses findings introduced sufficient concern

about unknown influences to render the recommendation a Level

III.

謝謝同學的捧場