Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, UK.
Anesth Analg. 2010 May 1;110(5):1419-27. doi: 10.1213/ANE.0b013e3181d568c8. Epub 2010 Mar 23.
Intracerebral hemorrhage (ICH) is a devastating disease with high rates of mortality and morbidity. The major risk factors for ICH include chronic arterial hypertension and oral anticoagulation. After the initial hemorrhage, hematoma expansion and perihematoma edema result in secondary brain damage and worsened outcome. A rapid onset of focal neurological deficit with clinical signs of increased intracranial pressure is strongly suggestive of a diagnosis of ICH, although cranial imaging is required to differentiate it from ischemic stroke. ICH is a medical emergency and initial management should focus on urgent stabilization of cardiorespiratory variables and treatment of intracranial complications. More than 90% of patients present with acute hypertension, and there is some evidence that acute arterial blood pressure reduction is safe and associated with slowed hematoma growth and reduced risk of early neurological deterioration. However, early optimism that outcome might be improved by the early administration of recombinant factor VIIa (rFVIIa) has not been substantiated by a large phase III study. ICH is the most feared complication of warfarin anticoagulation, and the need to arrest intracranial bleeding outweighs all other considerations. Treatment options for warfarin reversal include vitamin K, fresh frozen plasma, prothrombin complex concentrates, and rFVIIa. There is no evidence to guide the specific management of antiplatelet therapy-related ICH. With the exceptions of placement of a ventricular drain in patients with hydrocephalus and evacuation of a large posterior fossa hematoma, the timing and nature of other neurosurgical interventions is also controversial. There is substantial evidence that management of patients with ICH in a specialist neurointensive care unit, where treatment is directed toward monitoring and managing cardiorespiratory variables and intracranial pressure, is associated with improved outcomes. Attention must be given to fluid and glycemic management, minimizing the risk of ventilator-acquired pneumonia, fever control, provision of enteral nutrition, and thromboembolic prophylaxis. There is an increasing awareness that aggressive management in the acute phase can translate into improved outcomes after ICH.
脑出血 (ICH) 是一种死亡率和发病率都很高的破坏性疾病。ICH 的主要危险因素包括慢性动脉高血压和口服抗凝剂。在初始出血后，血肿扩大和血肿周围水肿导致继发性脑损伤和预后恶化。迅速出现局灶性神经功能缺损，伴有颅内压升高的临床体征，强烈提示ICH 诊断，尽管需要颅成像来将其与缺血性中风区分开来。ICH 是一种医疗急救，初始管理应侧重于紧急稳定心肺变量和治疗颅内并发症。超过 90%的患者出现急性高血压，有一些证据表明急性动脉血压降低是安全的，与血肿生长减慢和早期神经恶化风险降低相关。然而，早期乐观地认为通过早期给予重组因子 VIIa(rFVIIa)可能改善预后，但一项大型 III 期研究并未证实这一点。ICH 是华法林抗凝的最可怕并发症，停止颅内出血的必要性超过了所有其他考虑因素。华法林逆转的治疗选择包括维生素 K、新鲜冷冻血浆、凝血酶原复合物浓缩物和 rFVIIa。没有证据指导抗血小板治疗相关 ICH 的具体管理。除了脑积水患者放置脑室引流管和清除大的后颅窝血肿外，其他神经外科干预的时机和性质也存在争议。有大量证据表明，将 ICH 患者置于神经重症监护病房进行管理，治疗方向是监测和管理心肺变量和颅内压，与改善预后相关。必须注意液体和血糖管理，最大程度地降低呼吸机相关性肺炎、控制发热、提供肠内营养和预防血栓栓塞的风险。人们越来越意识到，在急性期积极治疗可以转化为 ICH 后更好的预后。
