神經外科重症病患之評估與處理

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田兰捷
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1 Intensive Care for Hemorrhagic Stroke 高醫神經外科林志隆台東馬偕醫院 2014 年度進階重症護理訓練 ( 神經系統 )

2 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

3 Stroke. 2010;41:

4 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)

Background knowledge of intracerebral haemorrhage (ICH) Annual incidence of 10 30/100,000, about 2 million (10 15%) of about 15 million strokes worldwide each year Qureshi AI. Et al. Lancet.

5 Background knowledge of intracerebral haemorrhage (ICH) Annual incidence of 10 30/100,000, about 2 million (10 15%) of about 15 million strokes worldwide each year Qureshi AI. Et al. Lancet. 2009; 373: Intracerebral haemorrhage - a subtype of stroke about 15% of all deaths from stroke Kase 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:

6 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)

7 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) A C B D

8 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

9 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

10 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 hemorrhage Left thalamic hemorrhage with rupture into ventricle (RIV)

11 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

12 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

13 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

14 Right putaminal hemorrhage Cerebellar hemorrhage Subcortical hemorrhage Brain stem hemorrhage

15 Left thalamic hemorrhage Left thalamic hemorrhage with rupture into ventricle (RIV) Left caudate nucleus hemorrhage with RIV

16 AVM without contrast AVM with contrast

17 Aneurysaml SAH

18 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

19 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)

20 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

22 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 (PO 2 <60mmHg 或 PCO 2 >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 )

23 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

24 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 ug/kg/min 收縮壓在 mmHg 之間, 舒張壓在 mmHg 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 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

25 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 220ug/kg/min或Norepinephrine ug/kg/min 將血壓提升至systolic pressure100mmhg以上

26 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).

27 Blood pressure management - Guideline 考 (Class IIb; Level of Evidence: C).

28 Blood pressure management - Guideline

29 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

30 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 PaCO 2 降至 30-35mmHg 約可降低顱內壓 % 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

31 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

32 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

33 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 outcomes Guidelines 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).

34 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:

35 Seizures and Antiepileptic Drugs Clinical seizures should be treated with antiepileptic drugs (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).

36 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 : Naidech A.M. et al. Stroke.2009;40:

37 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:

38 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).

39 Recommendation - Coagulopathy 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).

40 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).

41 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).

42 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).

43 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).

44 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).

45 B Set up the ICP monitor H.O.B. 30 o, keep CVP at 8-12 mmhg and R/O hyponatremia and fever when CPP > 60 mmhg 考 ICP > 20 mmhg B CSF drainage ( with ventricular drain, if available) of 3-5cc each time B Use sedatives and analgesics; use neuromuscular blockade agents when necessary

Light hyperventilation to keep PaCO2 30-35mmHg Mannitol 0.

46 Light hyperventilation to keep PaCO mmHg Mannitol g/kg/intravenous injection Craniotomy or decompressive craniectomy Cranial CT brain edema or ICH 考 Second tier therapy

47 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 (>38 o C) in NICU Kilpatrick MM. et al. Neurosurgery. 2000; 47:

48 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).

49 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

50 不宜外科手術的情況小出血 (<10cm 3 ) 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

51 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 50cm 3, 且 GCS 14; 或出血量 30-50cm 3,GCS<12 可考慮外科手術而 30cm 3 以下或高齡患者則視個別情況而定

52 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).

53 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).

54 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).

55 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

56 Neurocritical care Multimodality monitoring

57 方法 ( Method) : 1. Intraventricular 2. Parenchymal 3. Epidural bolt 4. Subdural bolt 5. Subarachnoid ( Lumbar drain )

58 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).

59 Intraparenchymal type (Codman) Codman pressure monitor ICP transducer

60 Intraventricular (EVD)

61 Transcranial Doppler 釘子波 vs To and Fro pattern

62 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.

63 謝謝同學的捧場

Untitiled

Untitiled 230 中国现代神经疾病杂志 2011 年 4 月第 11 卷第 2 期 Chin J Contemp Neurol Neurosurg, April 2011, Vol. 11, No. 2 论著穿刺引流术对脑出血后脑水肿及预后的影响王雪原杨树源黄楹孙梅赵蕾卓杰高满摘要目的探讨基底节高