大脑和小脑梗死伴脑水肿的管理推荐科学声明

Taylor Kimberly, Stefan Schwab, Eric E. Smith, Rafael J. Tamargo and Max Wintermark Eelco F. M. Wijdicks, Kevin N. Sheth, Bob S. Carter, David M. Greer, Scott E. Kasner, W. Association/American Stroke Association Swelling: A Statement for Healthcare Professionals From the American Heart Recommendations for the Management of Cerebral and Cerebellar Infarction With Print ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 2014 American Heart Association, Inc. All rights reserved. is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke published online January 30, 2014;Stroke. http://stroke.ahajournals.org/content/early/2014/01/30/01.str.0000441965.15164.d6 World Wide Web at: The online version of this article, along with updated information and services, is located on the http://stroke.ahajournals.org//subscriptions/ is online at: Stroke Information about subscribing to Subscriptions: http://www.lww.com/reprints Information about reprints can be found online at: Reprints: document. Permissions and Rights Question and Answer process is available in the Request Permissions in the middle column of the Web page under Services. Further information about this Once the online version of the published article for which permission is being requested is located, click can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Strokein Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions: by guest on February 12, 2014http://stroke.ahajournals.org/Downloaded from by guest on February 12, 2014http://stroke.ahajournals.org/Downloaded from guide.medlive.cn 1 Background and Purpose—There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. Methods—The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review. Results—Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Endorsed by the American Association of Neurological Surgeons and Congress of Neurological Surgeons Endorsed by the Neurocritical Care Society Eelco F. M. Wijdicks, MD, PhD, FAHA, Chair; Kevin N. Sheth, MD, FAHA, Co-Chair; Bob S. Carter, MD, PhD; David M. Greer, MD, MA, FAHA; Scott E. Kasner, MD, FAHA; W. Taylor Kimberly, MD, PhD; Stefan Schwab, MD; Eric E. Smith, MD, MPH, FAHA; Rafael J. Tamargo, MD, FAANS; Max Wintermark, MD, MAS; on behalf of the American Heart Association Stroke Council The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee October 15, 2013. A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. The American Heart Association requests that this document be cited as follows: Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M; on behalf of the American Heart Association Stroke Council. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:XXX–XXX. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. © 2014 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/01.str.0000441965.15164.d6 AHA/ASA Scientific Statement by guest on February 12, 2014http://stroke.ahajournals.org/Downloaded from guide.medlive.cn 2 Stroke April 2014 The emergence of brain swelling is the most troublesome and even life-threatening consequence of a large-territory isch- emic stroke. Brain swelling occurs as a result of loss of func- tion of membrane transporters, causing sodium and water influx into the necrotic or ischemic cell, leading to cytotoxic edema. Unrelenting swelling disrupts the blood- brain barrier (BBB); therefore, a component of vasogenic edema may coexist.1 The development of clinically significant cerebral edema is expected only in large-territory cerebral infarcts and can be observed by the clinician in 3 ways: a rapid and fulminant course (within 24–36 hours), a gradually progressive course (over several days), or an initially worsening course followed by a plateau and resolution (about a week).2–5 Currently, no methods are available to predict the course of brain swelling reliably. There is a clinical perception that when brain swell- ing occurs in the cerebral or cerebellar hemisphere, medical management to reduce brain swelling is not successful in changing outcome.4,6 Therefore, a decompressive craniectomy is offered to relieve the mass effect of the swollen hemisphere on the thalamus, brainstem, and network projections to the cortex, manifested mainly by a decreased level of arousal. Decompressive craniectomy for cerebral edema after ischemic hemispheric stroke has significantly increased in US hospitals.7 Clinical experience has matured over the years, but there are uncertainties about how to approach a patient with neuro- imaging and clinical evidence of emerging brain swelling after an ischemic stroke. These include recognition of key warning neurological signs, comprehensive evaluation of changing neu- roimaging patterns, prevention of clinically significant swelling, options for reducing cerebral edema by pharmacological means, and selection of patients for decompressive craniectomy and methods to measure the degree of postoperative morbidity. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in the cerebellum and cerebral hemisphere. It provides a guideline on how to provide the best comprehensive care and how to manage this complication. Communicating prognosis with family members is also dis- cussed. The level of evidence is rated for all recommendations. Methods Writing group members were nominated by the committee chair and co-chair because of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supple- mentary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence (Tables 1 and 2). All members of the writing group approved the final ver- sion of this document. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Epidemiology Variation in terminology complicates the accurate estimation of the incidence of severe brain edema caused by massive infarction. The estimated prevalence of severe stroke may be affected by referral patterns because most data come from sin- gle tertiary care hospitals and thus may not be representative of the population as a whole. The term malignant middle cerebral artery (MCA) infarction, introduced in 1996, was originally defined as infarction of the entire MCA territory appearing on computed tomography (CT) within 48 hours, with or without infarction in other vascular territories.4 This term has been used frequently in the subsequent literature, along with closely related terms such as large hemispheric infarction, but almost best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients. Conclusions—Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent. (Stroke. 2014;45:00-00.) Key Words: AHA Scientific Statements ◼ brain edema ◼ decompressive craniectomy ◼ infarction ◼ patient care management ◼ prognosis ◼ stroke by guest on February 12, 2014http://stroke.ahajournals.org/Downloaded from guide.medlive.cn liu Jian 高亮 Wijdicks et al Management of Cerebral and Cerebellar Infarction 3 always with a study-specific definition that deviated from the original. These variable definitions were based on some com- bination of neurological symptoms or signs,8–13 MCA occlu- sion,10 involvement of some or all of the MCA-perfused brain territory based on either CT or magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI),4,8,13–16 radiographic evidence of brain edema,10,12,17 postadmission neurological deterioration,17,18 or use of decompressive craniectomy.9,11,19 The prevalence of hemispheric MCA infarction by these variable definitions has been reported to be 2% to 8% of all hos- pitalized ischemic stroke,4,10,11,14,17,18 10% to 15% of all MCA territory ischemic stroke,13,20 and 18% to 31% of all ischemic stroke caused by MCA occlusion.9,16,21 The risk of subsequent neurological deterioration and death is high, 40% to 80%.4,22 A population-based study estimated that 0.3% of all ischemic stroke patients may be eligible for decompressive craniec- tomy on the basis of criteria used in randomized, controlled trials.23 The actual frequency of decompressive craniectomy for malignant MCA infarction is estimated to have increased from 0.04% of all ischemic stroke admissions in 1999 to 2000 to 0.14% of all ischemic stroke admissions in 2007 to 2008.7 Data on the incidence of severe brain edema complicating cer- ebellar infarction and the frequency of decompressive craniec- tomy for cerebellar edema are sparse. Studies suggest that ~20% of patients will develop radiographic signs of mass effect accom- panied by neurological deterioration.24,25 One series of 84 patients Table 1 . Applying Classification of Recommendation and Level of Evidence A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. by guest on February 12, 2014http://stroke.ahajournals.org/Downloaded from guide.medlive.cn 4 Stroke April 2014 included 34 patients with craniectomies and 14 with ventriculos- tomies,26 but selection criteria for surgery remain arbitrary, with many neurosurgeons operating on comatose patients.27 Epidemiology: Recommendations 1. Standardized terms and definitions for severe hemi- spheric and cerebellar edema resulting from infarc- tion should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes (Class I; Level of Evidence C). 2. Additional data should be collected to determine the use of decompressive craniectomy in current clinical practice, including whether there is variation by phy- sician, hospital, health system, or patient character- istics and preferences (Class I; Level of Evidence C). Definition and Clinical Presentation The target population is defined as patients who are at high risk for or who ultimately suffer neurological deterioration attributable to cerebral swelling after ischemia. Hemispheric Stroke Patients with significant swelling typically have occlusions of the internal carotid artery, MCA, or both. The natural history of a large infarction after internal carotid artery versus MCA infarction is not clear, especially when independent of ante- rior cerebral artery territory infarction. Infarctions from MCA branch occlusions typically do not result in swelling with clinically significant mass effect.4 Additional vascular territo- ries, incomplete circle of Willis, and marginal leptomeningeal collateral supply are also risk factors for the development of cerebral edema after ischemia.28 Although baseline follow-up neuroimaging parameters have been described that identify stroke patients who experi- ence swelling with high specificity,16,29,30 a number of clinical features are commonly seen in this syndrome. The most com- mon findings are hemiplegia, global or expressive aphasia, severe dysarthria, neglect, gaze preference, and a visual field defect.4 Pupillary abnormalities are a reflection of significant brainstem shift, typically not expected on initial presenta- tion, and develop within the first 3 to 5 days. An early Horner syndrome may point to an acute carotid artery occlusion or dissection.4 The initial National Institutes of Health Stroke Scale score is often >20 with dominant hemispheric infarction and >15 with nondominant hemispheric infarction, although this clinical predictor has not undergone rigorous prospective validation.31–33 The initial score is a reflection of stroke sever- ity and infarct volume, not a marker of tissue swelling, and although sensitive, it is not highly specific. The most specific sign of significant cerebral swelling after stroke is a decline in the level of consciousness attrib- utable to brain edema shifting the thalamus and brainstem, where major components of the ascending arousal system are situated.34 Although right hemisphere infarction may result in a flattened affect, complete infarction of either hemi- sphere itself is rarely associated with diminished arousal.35 Responsiveness, however, is diminished early in combined MCA and anterior cerebral artery infarctions. Cerebral pto- sis (apraxia of eyelid opening) may be present and falsely suggest a decreased level of consciousness. It may appear de no