2018 Stroke Guidelines from Sun Yai-Cheng

2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Stroke. 2018 Mar;49(3):e46-e110

2018 Stroke Guidelines

 

Class I

• CT within 20 mins ≥50%
• Door-to-needle time within 60 mins ≥50%
• EVT, ECG, troponin should not delay IV t-PA
• Only the assessment of blood glucose must precede the initiation of IV t-PA
• Receive IV t-PA: BP < 185/110 mmHg
• IV t-PA for AIS < 3 hr

IV t-PA for AIS < 3 – 4.5 hr

• for pts ≤ 80 y/o, without both DM and stroke hx, NIHSS ≤ 25, not taking any OACs, < 1/3 MCA territory by CT or MRI (Class I)
• for pts > 80 y/o (Class IIa)
• taking OACs and INR ≤ 1.7 and/or PT < 15 s (Class IIb)
• with both DM and stroke hx (Class IIb)

Endovascular Therapy

• AIS < 6 hr (Class I)
• AIS < 6-16 hr: DAWN or DEFUSE 3 criteria (Class I)
• AIS < 6-24 hr: DAWN criteria (Class IIa)

2018 Acute Stroke Guidelines 重要更新摘要

• 對於 3 – 4.5 小時 的中風，年紀大於80歲 (Class IIa)，服用抗凝血劑且 INR ≤ 1.7 and/or PT < 15 秒 (Class IIb)，同時有糖尿病和中風病史 (Class IIb)，IV t-PA 不再是禁忌症。

• Endovascular Therapy 適應症 延長至 6 – 24小時。中風 6 –16小時 需符合 DAWN or DEFUSE 3 criteria (Class I)；中風 6–24 小時 需符合 DAWN criteria (Class IIa)

DAWN and DEFUSE 3 trial

DAWN and DEFUSE 3 trial from Sun Yai-Cheng

DAWN trial

The first RCT evidence of a group identifiable by clinical and imaging criteria who derive benefit from mechanical thrombectomy after 6 hours

General Inclusion Criteria

• Age ≥ 18;
• failed or contraindicated for IV t-PA
• NIHSS ≥10
• Pre-stroke –mRS 0-1
• Time last seen well to randomization: 6-24 hrs

Imaging Inclusion criteria

• < 1/3 MCA territory by CT or MRI
• ICA and/or MCA-M1 occlusion
• Clinical Imaging Mismatch
  
  • group A: age ≥ 80 y/o, NIHSS ≥ 10 and core infarct size < 20 ml
  • group B: age < 80 y/o, NIHSS ≥ 10 and core infarct size < 30 ml
  • group C: age < 80 y/o, NIHSS ≥ 20 and core infarct size < 50 ml 

Exclusion Criteria

• similar to IV alteplase exclusions

End Point Results

 Co-1 end points:

90-day disability assessed by utility weighted mRS: 5.5 +/- 3.8 vs 3.4 +/- 3.1
Adjusted Difference 2.0, 95% CI, 1.1-3.0
Posterior probability of superiority >0.999

mRS 0-2 at 90 d: 49% vs 13%
Adjusted Difference 33%, 95% CI, 21%-44%
posterior probability of superiority >0.999

Safety end point:

Mortality at 90 d: 19% vs 18%, P=1.00
sICH: 6% vs 3%, P=0.50

Subgroups by time:

90-day mRS 0-2

6-12 hrs: 55.1% vs 20.0%,posterior probability of superiority >0.99
12-24 hrs: 43.1% vs 7.4%, posterior probability of superiority >0.99

Stopped early at first interim analysis

DEFUSE 3 trial

Expands criteria to identify patients who benefit from mechanical thrombectomy
after 6 hours

Inclusion Criteria

• Age 18-90 years
• NIHSSS ≥ 6
• Femoral puncture within 6 -16 hours of stroke onset/last known well
• Premorbid mRS2 ≤2
• ICA or M1 occlusion by MRA or CTA AND Target Mismatch Profile on CT perfusion or MRI (ischemic core volume < 70 ml, mismatch ratio > 1.8 and mismatch volume > 15 ml)

Exclusion Criteria

similar to IV alteplase exclusions, including:

• BP > 185/110
• treated with tPA >4.5 hours after time last known well
• treated with tPA 3-4.5 hours after last known well AND any of the following: age >80, current anticoagulant use, history of diabetes AND prior stroke
• NIHSS >25
• ASPECT score < 6
• Significant mass effect with midline shift
• acute symptomatic arterial occlusions in more than one vascular territory

End Point Results

mRS 0-2 at 90d: 44.6% % vs 16.7%, Relative risk: 2.67; 95% CI 1.60-4.48; P< 0.0001
Mortality at 90 d: 14% vs 26%; P= 0.053
sICH: 6.5% vs 4.4%; P= 0.75

Stopped early at first interim analysis

Reference

Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.

A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.

Related Articles: 2018 Stroke Guidelines

2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding Endovascular Treatment

2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding Endovascular Treatment from Sun YaiCheng

2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

Stroke. 2015;46:3020-3035.

• Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I). (New recommendation):

1. pre-stroke Modified Rankin Scale score 0 to 1
2. acute ischemic stroke receiving IV r-tPA within 4.5 hours of onset according to guidelines from professional medical societies
3. causative occlusion of the ICA or proximal MCA
4. age ≥18 years
5. NIHSS score ≥6
6. Alberta Stroke Program Early CT score (ASPECTS) ≥6
7. treatment can be initiated (groin puncture) within 6 hours of symptom onset

• Observing patients after IV r-tPA to assess for clinical response before pursuing endovascular therapy is not required to achieve beneficial outcomes and is not recommended. (Class III). (New recommendation)

• If endovascular therapy is contemplated, a non-invasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient but should not delay IV r-tPA if indicated. For patients who qualify for IV r-tPA according to guidelines from professional medical societies, initiating IV rtPA before non-invasive vascular imaging is recommended for patients who have not had non-invasive vascular imaging as part of their initial imaging assessment for stroke. Non-invasive intracranial vascular imaging should then be obtained as quickly as possible (Class I). (New recommendation)

---

【摘要】

• 病患若符合 endovascular therapy 條件，打完 IV tPA 後無需觀察對治療的反應，應盡快安排 endovascular therapy. (Class III)
• 若考慮做 endovascular therapy，強烈建議 CTA or MRA 腦血管評估。但 CTA or MRA 不應延誤 IV tPA 的治療。打完 IV tPA 後，即應盡快安排 CTA or MRA。 (Class I)

Use of tPA for the Management of Acute Ischemic Stroke in ED

Use of tPA for the Management of Acute Ischemic Stroke in the ED: ACEP Policy from Sun YaiCheng

ACEP Clinical Policy:

Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department

Ann Emerg Med. 2015;66:322-333

臨床問題

Q1. 對於症狀3小時內的缺血性中風，IV tPA 的安全性與效益？

A: 症狀3小時內的缺血性中風，為改善神經功能預後，IV tPA 應該給予 (should be offered)。IV tPA 需在有充分照護能力及系統支援的醫療單位安全施打。給予 IV tPA 應該考量 symptomatic ICH 的風險。﹝建議等級 B﹞

Q2. 對於症狀3到 4.5小時的缺血性中風，IV tPA 的安全性與效益？

A: 症狀3到4.5小時內的缺血性中風，IV tPA 可以給予 (may be offered)。﹝建議等級 B﹞

效益與風險

1. IV tPA 對於3小時內的缺血性中風：

• 可改善長期神經功能預後：numbers needed to treat; NNT= 8
• 增加早期 symptomatic ICH 的風險：numbers needed to harm; NNH= 17

2. IV tPA 對於3到4.5小時的缺血性中風：

• 改善神經功能預後：NNT= 14
• 增加 symptomatic ICH 風險：NNH= 23

新版改變

• 症狀3小時內的缺血性中風， tPA 的安全性與效益，從建議等級 A 調降為 B
• 強調 tPA 需在有充分照護能力及系統支援的醫療單位安全施打
• 施打 tPA 之前，需和家屬充分討論其效益與風險，讓病患及家屬參與治療決策

Management of Seizures in ED

Management of Seizures in ED from Sun YaiCheng

 

ACEP Clinical Policy

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures

Ann Emerg Med. 2014;63:437-447

This clinical policy from the ACEP is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the ED to help clinicians answer the following critical questions:

1. In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?

• Emergency physicians need not initiate antiepileptic medication in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated. (Level C)
  
• Emergency physicians need not initiate antiepileptic medication in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury. (Level C)
  
• Emergency physicians may initiate antiepileptic medication in the ED, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury. (Level C)

2. In patients with a first unprovoked seizure who have returned to their baseline clinical status in the ED, should the patient be admitted to the hospital to prevent adverse events?

• Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED. (Level C)

3. In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?

• When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion. (Level C)

4. In ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures?

• Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines. (Level A)
• Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines. (Level B)
• Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines. (Level C)

---

【摘要】

ACEP Policy: Management of Seizures in ED 

• 第一次seizure 的急診就醫病患，不需要給予預防性的抗癲癇藥物 

• 第一次seizure 的急診就醫病患，若 CBC、血糖、腎功能、電解質、鈣離子、心電圖、CT (若符合適應症) 皆正常，病人意識完全恢復平常水準，無神經學症狀，生命徵象正常，有可信任的照護者，衛教勿騎車駕駛後，可急診出院門診追蹤 

• Status epilepticus 若使用 BZD 無效，可給予 dilantin, cerebyx, depakine (level B) or keppra, propofol, barbiturate (level C)，並同時尋找可能誘發癲癇的原因﹝電解質異常 (血糖、血鈉...)、缺氧、藥物毒性/戒斷、感染、中風...﹞

Definition and Evaluation of Transient Ischemic Attack

Definition and Evaluation of Transient Ischemic Attack

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AHA/ASA Scientific Statement
Definition and Evaluation of Transient Ischemic Attack

Stroke. 2009;40:2276-2293


Traditional Definition

Transient Ischemic Attack (TIA) was a sudden, focal neurological deficit of presumed vascular origin lasting <24 hours

2002 AHA-Endorsed Revised Definition of TIA

a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction

Risk Stratification

Patients with TIAs are at high risk of early stroke, and their risk may be stratified by clinical scale, vessel imaging, and diffusion MRI

The California score and the ABCD2 scores

• Age ≥60 years (1)
• Blood pressure ≥140/90 mmHg on first evaluation (1)
• Clinical symptoms of focal weakness with the spell (2) or speech impairment without weakness (1)
• Duration ≥60 minutes (2) or 10 to 59 minutes (1)
• Diabetes (1)

Hospitalization

It is reasonable to hospitalize patients with TIA if they present within 72 hours of the event and any of the following criteria are present:    

• ABCD2 scores of 3 (Class IIa, Level of Evidence C)
• ABCD2 scores of 0 to 2 and uncertainty that diagnostic workup can be completed within 2 days as an outpatient (Class IIa, Level of Evidence C)
• ABCD2 scores of 0 to 2 and other evidence that indicates the patient’s event was caused by focal ischemia (Class IIa, Level of Evidence C)

Patients with TIA or minor stroke who have DWI lesions, especially when multiple, are at higher risk of recurrent ischemic events

Diagnostic Evaluation

• Patients with TIA should preferably undergo neuroimaging evaluation within 24 hours of symptom onset 

• MRI, including DWI, is the preferred brain diagnostic imaging modality. If MRI is not available, CT should be performed (Class I, Level of Evidence B) 

• Noninvasive imaging of the cervicocephalic vessels should be performed routinely as part of the evaluation of patients with suspected TIAs (Class I, Level of Evidence A) 

• Initial assessment of the extracranial vasculature may involve any of the following: carotid ultrasound/ transcranial Doppler (CUS/TCD), MRA, or CTA, depending on local availability and expertise, and characteristics of the patient (Class IIa, Level of Evidence B)

• ECG and prolonged cardiac monitoring 

• Echocardiography (TTE or TEE) 

• Routine blood tests (CBC, chemistry panel, PT and aPPT, and fasting lipid panel) 

• Optional Coagulation Screening Tests 

Consider in Younger Patients With TIAs, Particularly When No Vascular Risk Factors Exist and No Underlying Cause Is Identified

• Protein C, protein S, antithrombin III activities
• Activated protein C resistance/factor V Leiden
• Fibrinogen
• D-Dimer
• Anticardiolipin antibody
• Lupus anticoagulant
• Homocysteine
• Prothrombin gene G20210A mutation
• Factor VIII
• Von Willebrand factor
• Plasminogen activator inhibitor-1
• Endogenous tissue plasminogen activator activity

意識不清與昏迷

Altered Mental Status and Coma from Sun YaiCheng

意識不清與昏迷
Altered Mental Status (AMS) and Coma

Mnemonic for Treatable Causes of AMS (AEIOU-TIPS)

• A Alcohol
• E Endocrine, Electrolytes, Encephalopathy
• I  Insulin
• O O2, Opiates
• U Uremia

• T Trauma
• I  Infection, Intra-cranial
• P Poisoning
• S Seizure, Stroke, Sepsis, Shock

Reversible cause of AMS

• Hypoglycemia, narcotic overdose, hypoxia, hypercarbia should be quickly investigation and treatment

• If structural lesion etiology is indicated → non-contrast head CT

Delirium

Diffuse metabolic and multifocal cerebral lesion, generalized impairment of brain functions or at least a bilateral involvement limbic structure

Major brainstem reflexes used in coma examination

• oculocephalic reflex
• pupillary light reflex
• corneal reflex
• oculovestiblar reflex
• gag reflex
• apnea test

Adapted from Rosen's Emergency Medicine, 7E
Chapter 14 Depressed Consciousness and Coma

相關文章：急診神經學檢查

急診神經學檢查

Neurological Examination in the Emergency Room from Sun YaiCheng

急診神經學檢查

Neurological Examination in the Emergency Room

General Considerations 主要原則：

• Always consider left to right symmetry 比較左右對稱

• Consider central vs. peripheral deficits 區分中樞或週邊缺損

Organize your thinking into six categories:

1. Mental Status 意識狀態
2. Cranial Nerves 顱神經檢查
3. Motor Exam 運動功能檢查
4. Reflexes 反射
5. Coordination and Gait 協調性及步態
6. Sensory Exam 感覺功能檢查

Patient with unilateral facial weakness

Adapted from Tintinalli‘s Emergency Medicine: A Comprehensive Study Guide, 7E
Chapter e158.1  The Neurologic Examination in the Emergency Setting

Adult Stroke

Stroke (2010 Guideline for CPR & ECC)

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Adult Strok
2010 AHA Guidelines for CPR and ECC 
Circulation. 2010;122:S818-S828 

The “D's of Stroke Care”

1. Detection: Rapid recognition of stroke symptoms
2. Dispatch: Early activation and dispatch of EMS system by calling 911
3. Delivery: Rapid EMS identification, management, and transport
4. Door: Appropriate triage to stroke center
5. Data: Rapid triage, evaluation, and management within the ED
6. Decision: Stroke expertise and therapy selection
7. Drug: Fibrinolytic therapy, intra-arterial strategies
8. Disposition: Rapid admission to stroke unit or ICU

Management Goals

• Time is Brain
• Minimize acute brain injury and maximize patient recovery
• Stroke Chain of Survival

EMS Stroke Recognition

• Cincinnati Prehospital Stroke Scale (CPSS)

Sensitivity: 59%; Specificity: 89%

• Los Angeles Prehospital Stroke Screen (LAPSS)

Sensitivity: 93%; Specificity: 97%

In-Hospital Care

• Protocols should be used in the ED to minimize delay to definitive diagnosis and therapy.
• ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED.
• The EP should perform a neurologic screening assessment, order emergent CT, and activate the stroke team.

Approach To Arterial Hypertension In Acute Ischemic Stroke For Patients Potentially Eligible for Acute Reperfusion Therapy

• Patient eligible for acute reperfusion therapy except that BP >185/110 mmHg
• Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat ×1
• If BP does not below 185/110 mmHg, do not administer rtPA

Management of BP During and After rtPA or Other Acute Reperfusion Therapy

• If SBP 180–230 mmHg or DBP 105–120 mmHg
• Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min
• If BP not controlled or diastolic BP >140 mmHg, consider sodium nitroprusside

For Patients Not Potential Candidates for Acute Reperfusion Therapy

• Consider lowering BP in acute ischemic stroke if BP >220/120 mmHg
• A reasonable target is to lower BP by 15% to 25% within the first day

CT should be completed within 25 minutes and should be interpreted within 45 minutes of the patient's arrival in the ED.


Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA within 3 Hours from Symptom Onset
Inclusion Criteria

1. Diagnosis of ischemic stroke causing measurable neurologic deficit
2. Onset of symptoms <3 hours before beginning treatment 
3. Age >18 years

Exclusion Criteria

• Head trauma or prior stroke in previous 3 months
• Symptoms suggest SAH
• Arterial puncture at non-compressible site in previous 7 days
• History of previous ICH
• Elevated BP (systolic >185 mmHg or diastolic >110 mmHg)
• Evidence of active bleeding on examination
• Acute bleeding diathesis, including but not limited to

• Platelet count <100,000/mm3
• Heparin received within 48 hours, resulting in aPTT >upper limit of normal
• Current use of anticoagulant with INR >1.7 or PT >15 seconds 

• Blood glucose <50 mg/dl
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative Exclusion Criteria

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Seizure at onset with postictal residual neurologic impairments
• Major surgery or serious trauma within previous 14 days
• Recent GI or urinary tract hemorrhage (within previous 21 days)
• Recent AMI (within previous 3 months)

Additional Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA from 3 to 4.5 Hours from Symptom Onset
Inclusion Criteria

• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Onset of symptoms 3 to 4.5 hours before beginning treatment

Exclusion Criteria

1. Age >80 years
2. Severe stroke (NIHSS >25)
3. Taking an oral anticoagulant regardless of INR
4. History of both DM and prior ischemic stroke

At present, use of IV rtPA within 3 to 4.5 hour has not yet been FDA approved, although it is recommended by current AHA/ASA science advisory

General Stroke Care

• BP Management
• Glycemic Control: hyperglycemia should be treated with insulin when glucose >185 mg/dL
• Temperature Control: treat fever >37.5°C
• Dysphagia Screening
• Observe for signs of IICP: severe stroke, posterior circulation, stroke younger patient

Treatment of Acute Ischemic Stroke: IV rtPA

• Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose given as a bolus over 1 minute. 

延伸閱讀：AHA/ASA 2007 Guidelines for Ischemic Stroke

2010 Guidelines for Management of Spontaneous ICH

2010 Guidelines for Management of Spontaneous ICH from Sun YaiCheng

AHA/ASA Guideline for the Management of Spontaneous Intracerebral Hemorrhage
Stroke September 1, 2010;41:2108-29

Emergency Diagnosis and Assessment of ICH

• Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from ICH (Class I; Level of Evidence: A).
• CT angiography and contrast CT may be considered to help identify patients at risk for hematoma expansion (Class IIb; Level of Evidence: B), and CT angiography,CT venography,contrast-enhanced CT, contrast MRI, MRA, and magnetic resonance venography can be useful to evaluate for underlying structural lesions,including vascular malformations and tumors when there is clinical or radiological suspicion (Class IIa; Level of Evidence: B).(New recommendation)

Medical Treatment of ICH

• 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). (New recommendation)
• Patients with ICH whose INR is elevated due to on oral anticoagulants (OACs) should have their warfarin withheld, receive therapy to replace vitamin K-dependent factors and correct the INR, and receive intravenous vitamin K (Class I; Level of Evidence: C).
• 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 routinely recommended as a sole agent for OAC reversal in ICH (Class III;Level of Evidence: C). (Revised from the previous guideline).

Suggested Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH (Class IIb, Level of Evidence C)

• If SBP >200 mmHg or MAP >150 mmHg, then consider aggressive reduction of BP with continuous intravenous infusion, with frequent BP monitoring every 5 minutes.
• If SBP >180 mmHg or MAP >130 mmHg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing BP using intermittent or continuous intravenous medications to keep cerebral perfusion pressure > 60-80 mmHg.
• If SBP >180 mmHg or MAP >130 mmHg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of BP (eg, MAP of 110 mmHg or target BP of 160/90 mmHg) using intermittent or continuous intravenous medications to control BP, and clinically reexamine the patient every 15 minutes.
• In patients presenting with SBP 150-220 mmHg, acute lowering of SBP to 140 mmHg is probably safe (Class IIa; Level of Evidence: B). (New recommendation)

Management of Glucose

• Glucose should be monitored and normoglycemia (range 80 to 110 mg/dL) is recommended(Class I: Level of Evidence: C). (New recommendation)

Seizures and Antiepileptic Drugs

• Clinical seizures should be treated with antiepileptic drugs(Class I; Level of Evidence: A). (Revised from the previous guideline) Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury (Class IIa; Level of Evidence:B). Prophylactic anticonvulsant medication should not be used (Class III; Level of Evidence:B). (New recommendation)

Procedure/Surgery

• Patients with a GCS 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 mmHg maybe 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)

Clot Removal

• For most patients with ICH, the usefulness of surgery is uncertain (Class IIb; Level of Evidence: C). (New recommendation). Specific exceptions to this recommendation follow:
• 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). (Revised from the previous guideline) Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended (Class III; Level of Evidence: C). (New recommendation)
• 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). (Revised from the previous guideline)

Prevention of Recurrent ICH

• In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E ε2 or ε4 alleles, and greater number of microbleeds on MRI (Class IIa; Level of Evidence:B). (New recommendation)
• After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy (Class I;Level of Evidence: A). (New recommendation)
• After the acute ICH period, a goal target of a normal BP of <140/90 mmHg (<130/80 mmHg if diabetes or chronic kidney disease) is reasonable (Class IIa; Level of Evidence: B). (New recommendation)
• Avoidance of long-term anticoagulation as treatment for non-valvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence (Class IIa; Level of Evidence: B).

AHA/ASA Guidelines for Ischemic Stroke

AHA/ASA Guidelines for Ischemic Stroke from Sun YaiCheng

AHA/ASA Guidelines for the Early Management of Adults with Ischemic Stroke
 Stroke. May 2007;38:1655-1711

急性缺血性腦中風時，如收縮壓在 220 mmHg以下或舒張壓在 120 mmHg以下時，可以不需要立即藥物治療 (D, level 3)

降血壓可能使腦部的灌流壓力不足，加重腦缺血，所以一般建議，收縮壓在 220 mmHg或舒張壓在 120 mmHg以上才考慮給予降血壓治療。除非病人在發作3小時內需血栓溶解治療，且收縮壓仍在 185 mmHg或舒張壓在 110 mmHg以上時。

至於血栓溶解治療當中或之後，若收縮壓大於 180 mmHg或舒張壓大於 105 mmHg即需立即加以處理。

美國中風學會建議 血糖超過 140 mg/dl 需給予胰島素治療。


血栓溶解劑治療 (Thrombolysis 或稱 Fibrinolytic therapy)

台灣衛生署已於2004年核准rt-PA治療急性缺血性腦中風

用法與用量

• 在症狀出現後的 3小時內，應儘速開始治療
• 建議劑量 0.9 mg/kg (最大劑量為90 mg) 輸注(infusion) 60分鐘。總劑量的 10%為起始劑量，以靜脈注射 (IV bolus)投與

一般性禁忌症

• 目前或過去六個月內有顯著的凝血障礙、易出血體質
• 病人正接受口服抗凝血劑 (如warfarin sodium)且prothrombin time (INR ＞1.3)
• 中樞神經系統損傷之病史 (腫瘤、血管瘤、顱內或脊柱的手術)
• 懷疑或經證實包括蜘蛛膜下腔出血之顱內出血或其病史
• 嚴重且未被控制的動脈高血壓
• 過去10天內曾動過大手術或有嚴重創傷 (包括最近之急性心肌梗塞所伴隨的任何創傷)、最近頭部或顱部曾發生創傷
• 過久的或創傷性的心肺復甦術 (超過2分鐘)、分娩、過去10天內曾對無法壓制之部位施行血管穿刺 (如鎖骨下靜脈或頸靜脈穿刺)
• 嚴重肝病，包括肝衰竭、肝硬化、肝門脈高壓 (食道靜脈曲張) 及急性肝炎
• 出血性視網膜病變，如糖尿病性 (視覺障礙可能為出血性視網膜病變的指標) 或其他出血性眼疾
• 細菌性心內膜炎，心包炎
• 急性胰臟炎
• 最近三個月內曾患胃腸道潰瘍
• 動脈瘤，靜/動脈畸形
• 易出血之腫瘤
• 對本藥之主成份rt-PA或賦型劑過敏者

rt-PA 用於急性缺血性中風另有下列之禁忌症(舊有建議)

• 缺血性發作的時間已超過3小時或症狀發作時間不明
• 急性缺血性中風的症狀已迅速改善或症狀輕微者
• 臨床症狀太嚴重 (例如NIHSS＞25) 及/或適當之影像術評估為嚴重之腦中風，如腦梗塞區超過 1/3、出血性梗塞或早期出現腦梗塞
• 腦中風發作時併發癲癇
• 最近三個月內有中風病史或有嚴重性頭部創傷
• 過去曾中風及合併糖尿病
• 中風發作前48小時內使用 heparin，目前病人活化部份凝血原時間 (aPTT) 之值過高
• 血小板少於100,000/mm3
• 收縮壓大於 185 mmHg或舒張壓大於 110 mmHg，或需要積極的治療(靜脈給藥)以降低血壓至前述界限以下
• 血糖小於 50 mg/dL或大於 400 mg/dL
• rt-PA不適用於治療孩童及未滿 18歲之青少年
• rt-PA不適用於治療超過 80歲之老人

參考資料
台灣腦中風防治指引 2008