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1、Evidence-Based Guidelines for the Management of LargeHemispheric InfarctionThe sixth affiliated hospital of KMUWang hao2015.05.211;.2Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality.c
2、urrent stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patientsThe purpose of this guideline is to provide evidence-based recommendations for the critical care management of patients following LHI3Airway ManagementWhat are the indications
3、 for intubation and extubation in LHI? What is the best timing for tracheostomy in LHI?4What are the indications for intubation and extubation in LHI?1.存在呼吸功能不全或神经功能恶化的LHI 患者应该立即气管插管。（强推荐，极低质量证据）。2.即使不能交流和配合，符合以下标准者应该尝试拔管（强推荐，极低质量证据）：（1）自主呼吸试验成功（2）口咽部无分泌物聚集（3）咳嗽反射存在，插管不耐受（4）无镇静和镇痛5What is the best t
4、iming for tracheostomy in LHI?拔管失败或插管后7-14 天不能拔管的LHI 患者可以考虑气管切开。（弱推荐，低质量证据）。6HyperventilationHyperventilation is often employed in increased ICP to induce hypocarbia and cerebral vasoconstriction. The effect on ICP isusually seen within minutes, but it is short-lived.7Does hyperventilation effective
5、ly treat increased ICP in LHI?1.LHI 患者不应该预防性过度换气。（强推荐，极低质量证据）2.短期过度换气可以作为挽救脑疝的方法。（弱推荐，极低质量证据）8Analgesia and Sedationsedation and analgesia may facilitate medical goals such as lowering ICP, enabling procedures and operations, or terminating seizures9Should analgesia and/or sedation be administered i
6、n LHI patients? If so, which pharmacologic agents should be used?1.疼痛、焦虑、躁动者推荐给予镇静和镇痛。（强推荐，极低质量证据）2.尽可能给予最低强度的镇静治疗，尽可能尽早停止镇静治疗，同时应保持生理学稳定，防治患者的不适感。（强推荐，极低质量证据）10Are daily wake-up trials recommended?Wake-up trials were initially reported to be beneficial regarding reduction of ventilation duration an
7、d outcome for some ICU populations.对于LHI 患者，不推荐每天常规进行唤醒试验。存在ICP 危象者采取俯卧位通气应谨慎。推荐进行神经功能监测（至少包括ICP 和CPP）以指导镇静治疗，生理学不稳定或不舒适的患者每天唤醒试验应避免或者延期执行。（强推荐，极低质量证据）11Gastrointestinal TractDysphagia affects 3050 % of acute stroke patients.Screening for dysphagia has been reported to decrease pneumonia in the gene
8、ral stroke population;Dysphagia screening tests such as the gugging swallowing screen have been found useful in acute stroke patients, but patients with large or multiple strokes or rapid decline in LOC were not included. Thus, it is difficult to estimate the validity of these tests in LHI patientse
9、ndoscopic swallowing tests，Fiberoptic endoscopic evaluation of swallowing12How should dysphagia be assessed in LHI patients?The swallowing provocation test,endoscopic swallowing testsFiberopticendoscopic evaluation of swallowingLHI 早期应该进行吞咽功能筛查。一旦撤掉镇静和机械通气，应该进行吞咽功能评价。（弱推荐，极低质量证据）13When should LHI pa
10、tients receive a nasogastric tube?吞咽功能障碍的LHI 者尽可能使用鼻胃管。（弱推荐，极低质量证据）14When should LHI patients receive a percutaneous enterogastric tube?对于NIHSS 评分较高以及内窥镜检查发现持续吞咽功能障碍者，应该在ICU 主要1-3 周内和家属讨论放置PEG。（弱推荐，极低质量证据）15Glucose ControlBoth hyperglycemia and hypoglycemia have been associated with increased morbid
11、ity and mortality in acute ischemic stroke.The panel concluded that intermediate glucose control(140180 mg/dl) is most appropriate for this patient population16How should glucose be controlled in LHI patients?1.应该避免低血糖和高血糖。采用胰岛素控制血糖，血糖目标为140-180 mg/dl。（强推荐，极低质量证据）2. 在LHI 患者，避免静脉内输注糖溶液。（强推荐，极低质量证据）17
12、Hemoglobin ControlAnemia is associated with worse outcome in ischemic stroke, both in the acute and subacute phases.18What is the optimal hemoglobin level in LHI patients?1.应该把LHI 患者的血红蛋白维持在7g/dl 或以上。（强推荐，极低质量证据）2.制定血红蛋白的理想目标时，临床医生应该考虑患者的特殊情况，比如有外科手术计划、血流动力学、心肌缺血、活动性严重出血、动静脉氧摄取不良。（弱推荐，极低质量证据）3.尽少抽取血
13、液样本，以降低LHI 患者贫血的风险。（弱推荐，极低质量证据）19Deep Venous Thrombosis ProphylaxisEven though DVT prophylaxis is standard of care.the incidence of DVT in the stroke patient is approximately 3 %In the CLOTS1 trial,incidence of DVT was 11.4 % during days 710 poststroke,as compared to 3.1 % during days 2530 poststrok
14、e.the CLOTS1 investigators recommended that DVT prophylaxis should be started early and continued for at least 4 weeks20How should deep venous thrombosis (DVT) prophylaxis be administered to LHI patients?1.血流动力学稳定且ICP 不高的LHI 患者，推荐早日活动以预防DVT。（强推荐，极低质量证据）2.LHI 患者的DVT 预防应该从入住ICU 开始，包括整个不能活动期间。（强推荐，极低质量
15、证据）3.推荐使用IPC 预防DVT。（强推荐，极低质量证据）4.推荐使用LMWH 预防DVT。（强推荐，低质量证据）5.不推荐使用弹力袜预防DVT。（强推荐，中等质量证据）21AnticoagulationThe HAEST study of patients with ischemic stroke and AF demonstrated a stroke recurrence rate of 8.5 % within 14 days even in spite of LMWH prophylaxis, thereby illustrating the importance of anti
16、coagulation in this population.22If LHI is due to a cardioembolic mechanism or if the patient has high thromboembolic risk, when should anticoagulation be initiated after LHI?1.对于高血栓风险的患者，推荐LHI 发病后2-4 周重启口服抗凝治疗。（弱推荐，极低质量证据）2.早期口服抗凝治疗应该基于患者的临床风险评估和其他检查结果（如人工瓣膜、急性DVT、急性PE、或TEE 发现心脏内血栓）。（弱推荐，极低质量证据）3.在
17、外科治疗不迫切的情况下，LHI 合并AF 或血栓风险的患者无抗凝期间应给予阿司匹林治疗。（弱推荐，极低质量证据）23Blood Pressure ManagementWhile optimal blood pressure (BP) targets are theoretically important in the management of acute ischemic stroke, specific goals have not been established for LHI patients.24What is the optimal blood pressure in LHI p
18、atients?一般来讲，LHI 患者应该遵循目前缺血性卒中指南管理血压。缺血性卒中不合并出血转换者MAP 应该维持在85mmHg 以上，SBP 维持在220 mmHg 以内。（强推荐，低质量证据）2.避免血压过度波动，特别在LHI 的早期阶段。（弱推荐，低质量证据）25Steroid TherapyThe use of corticosteroids for acute stroke was reviewed by Cochrane group The only data that could be pooled in their review pertained to the outcom
19、e of death at 1 year;there was no difference with steroid treatment (OR 0.97;95 % CI 0.571.34). Only one of the seven included trials reported non-fatal adverse effects, which were limited to gastrointestinal bleeding,hyperglycemia, and infection in about 10 % of the patients enrolled26Do steroids e
20、ffectively reduce brain edema in LHI?不推荐使用激素治疗LHI 患者的脑水肿。（强推荐，低质量证据）27Barbiturate TherapyBarbiturates are often thought to be a therapeutic option for treating cerebral edema refractory to other interventions.study suggested that barbiturate coma has no benefit in the management of increased ICP in
21、LHI and was associated with significant hypotension.28Do barbiturates effectively treat brain edema in LHI?因为风险大于获益，不推荐巴比妥盐用于LHI 患者。（强推荐，低质量证据）29Temperature Controlsome studies found hypothermia to be generally, hypotension, hematologic effects, and infections were common side effects Hypothermia wa
22、s found to significantly reduce ICP in patients with LHI but is not as effective as hemicraniectomy30Does hypothermia or normothermia have any role in the management of brain edema after LHI?1.不适于外科治疗的患者，可以考虑低温治疗。（弱推荐，低质量证据）2.低温治疗的目标体温为33-36C，持续24-72h。（弱推荐，低质量证据）3.推荐保持体温正常。（弱推荐，极低质量证据）31Head Positio
23、nIn one observational study, investigators assessed backrest elevation of 15 and 30, and then a return to 0while continuously recording ICP, MAP, CPP, and MCA peak mean flow velocity Intracranial pressure was significantly decreased with the 30 backrest elevation, however,MAP and CPP were significan
24、tly decreased as well.Cerebral perfusion pressure was maximal in the horizontal position but ICP was also at it highest value.32What is the optimal head position in patients with LHI?大部分LHI 患者都应该保持水平卧位，ICP 增高者建议床头抬高30。（弱推荐，极低质量证据）33Osmotic Therapy34Does osmotic therapy effectively treat brain edema
25、and improve outcome in LHI?1.存在脑水肿证据时，推荐使用甘露醇和高张盐水减轻脑水肿和组织移位。（强推荐，中等质量证据）2.推荐使用渗透压间隙（osmolar gap）代替血浆渗透压指导甘露醇剂量和治疗的持续时间。（弱推荐，低质量证据）3.推荐使用血浆渗透压和血钠水平指导高张盐水的剂量。（强推荐，中等质量证据）35What are the potential complications associated with the use of these agents?4.急性肾损伤者慎用甘露醇。（强推荐，中等质量证据）5.血容量超负荷者（比如心衰、肝硬化等）慎用高张盐水
26、。（强推荐，高质量证据）36Neuroimaging by CT and MRIA hypodensity covering 50 % of the MCA territory had an 85 % positive predictive value for fatal clinical outcome,with a sensitivity and specificity of 61 and 94 %, respectivelyPoor outcome was also associated with poor collateral blood flow, lack of recanaliz
27、ation, and distal ICA or proximal MCA occlusioncarotid T occlusion on angiography predicted fatal outcome with a positive predictive value of 47 %, a negative predictive value of 85 %Infarct volume 220 ml was found to be very predictive of brain edema and herniation 105, 106. Midline shift 3.9 mm wa
28、s also predictive of malignant infarction37Can neuroimaging by CT or MRI predict neurological deterioration and malignant course after LHI?推荐通过CT 和MRI 的早期表现预测LHI 后恶性水肿。（强推荐，低质量证据）38UltrasoundThe main advantages of ultrasound-based monitoring are its bedside availability and favorable safety profile.
29、the reliable assessment of midline shift (MLS) by TCCS has been reproducible in several small prospective studiesSome reported that all patients with a shift of less than 4 mm survived, while all patients with values exceeding 4 mm died of cerebral herniationMCA occlusion on sonography within the fi
30、rst 12 h after MCA infarction and lack of recanalization within 24 h was associated with a mortality of 61 %.39What is the value of transcranial Doppler (TCD) and transcranial color-coded duplex (TCCS) sonography for the prediction of malignant course after LHI?推荐TCCS 检查作为预测恶性水肿的补救检查项目。如果患者病情不允许搬动进行
31、神经影像检查，TCCS 可能是这些患者的主要检查手段。（弱推荐，低质量证据）40Evoked Potentials One retrospective study demonstrated that pathologic Brainstem auditory evoked potentials (BAEPs) within 24 h of symptom onset with side-to-side difference of amplitudes of more than 50 % could predict malignant course,whereas somatosensory e
32、voked potential (SEP) findings were inconclusive41Can Evoked Potentials be used to predict malignant course after large hemispheric stroke?推荐诱发电位检查作为发病24h 内预测恶性水肿的补救检查项目，特别是对于病情不允许搬动进行神经影像检查的患者。（弱推荐，极低质量证据）42EEGThe absence of delta and presence of theta, and fast beta frequencieswithin the lesion lo
33、calization were significantly associated with benign course, whereas diffuse slowing and delta activity within the focus were rather predictive for malignant course. However, the predictive values for malignant course were too low to form the basis for irrevocable treatment decisions.43Can EEG predi
34、ct a malignant course after LHI?推荐卒中第一个24h 进行EEG 检查，以协助预测LHI 患者的临床过程。（弱推荐，极低质量证据）44Is there a utility for continuous EEG monitoring in patients with LHI?推荐持续和定量EEG 监测，是一种评估LHI 患者预后的非侵袭性监测技术和工具，需要进一步研究证实其作用。（弱推荐，极低质量证据）45Invasive Multimodal Monitoringmultimodal monitoring (ICP, microdialysis,ptiO2)关于
35、侵袭性多模监测的研究并不充分，因此不推荐常规用于管理LHI 患者。（弱推荐，低质量证据）46Surgical Management1.不管患者的年龄多大，减压偏侧露骨切除术（DHC）能够改善LHI 患者的生存。（强推荐，高质量证据）2.对于年龄大于60 岁的患者，应该考虑患者和家庭的意愿，因为DHC 虽然能够降低死亡率，但是很可能遗留严重残疾。（强推荐，中等质量证据）3.目前尚无充分的证据反对优势半球LHI 患者进行DHC。（强推荐，低质量证据）4.为了达到最佳神经功能预后，应该在症状发作24-48h 内和脑疝形成前进行DHC。（强推荐，中等质量证据）475. DHC 切口最小直径为12cm。直径14-16cm 者预后更佳。（强推荐，中等质量证据）6.脑叶切除术或硬脑膜成形术仅能作为个体化治疗的选项。（弱推荐，低质量证据）7.颞肌切除术仅能作为个体化治疗的选项。（弱推荐，低质量证据）48Ethical Considerations决定DHC 手术时，应该充分考虑患者及家属关于生存和残疾方面的价值观和喜好。（弱推荐，低质量证据）49Quality of Life (QoL)在将来的研究中，应该以QoL 作为衡量LHI 预后的指标。（弱推荐，低质量证据）50THANKS51
