GuidelinesfortheManagementofSpontaneousIntracerebralHemorrhage（自发性脑内出血的治疗指南）2010年美国卒中协和脑出血临床指南摘译孙芸芸梁志刚AGuidelineforHealthcareProfessionalsFromtheAmericanHeartAssociation/AmericanStrokeAssociation给予来自美国心脏协会/美国卒中协会的卫生保健专业人员的指南
一、EmergencyDiagnosisandAssessmentofICHandItsCausesRecommendations关于脑出血的紧急诊断和评估的建议1.RapidneuroimagingwithCTorMRIisrecommendedtodistinguishischemicstroke[p1]fromICH[p2](ClassI;LevelofEvidence:A).(Unchangedfromthepreviousguideline)CT或MRI（核磁共振成像）的快速成像便于很好地区分缺血性中风和脑出血（出血性脑中风）。（与先前的指南并无差异）2.CTangiographyandcontrast-enhancedCT[p3]maybeconsideredtohelpidentifypatientsatriskforhematomaexpansion(ClassIIb;LevelofEvidence:B),CT血管造影术和强化CT或许可以辅助鉴别有血肿扩散危险的病人andCTangiography,CTvenography,contrast-enhancedCT,contrast-enhancedMRI,magneticresonanceangiography,andmagneticresonancevenographycanbeusefultoevaluateforunderlyingstructurallesions,includingvascularmalformationsandtumorswhenthereisclinicalorradiologicalsuspicion(ClassIIa;LevelofEvidence:B).(Newrecommendation)同时，CT血管造影术、CT静脉造影术、加强CT、加强MRI（核磁共振）、磁共振血管造影、磁共振静脉造影，可以检查到潜在的结构损伤，包括临床上或放射学上怀疑的血管畸形和肿瘤。（新推荐）
二、MedicalTreatmentforICHRecommendations关于脑出血内科治疗的建议[p4]1.Patientswithaseverecoagulationfactordeficiencyorseverethrombocytopeniashouldreceiveappropriatefactorreplacementtherapyorplatelets,respectively(ClassI;LevelofEvidence:C).(Newrecommendation)严重缺乏凝血因子或者说有严重血小板减少症的病人，应该适当地接受外来因子或者血小板来进行治疗。（新推荐）2.PatientswithICHwhoseINR[p5]iselevatedduetoOACs[p6]shouldhavetheirwarfarinwithheld,receivetherapytoreplacevitaminK–dependentfactorsandcorrecttheINR,andreceiveintravenousvitaminK(ClassI;LevelofEvidence:C).对于那些由口服抗凝剂OACs[p7]导致INR（国际标准化比值）升高的脑出血病人，不应该再用华法令，而该接受上述治疗来取代维生素K依赖性因子，同时，该改善INR水平、接受静脉内维生素K治疗。PCCs[p8]血浆凝固剂havenotshownimprovedoutcomecomparedwith新鲜冷冻血浆FFP[p9]butmayhavefewercomplicationscomparedwithFFPandarereasonabletoconsiderasanalternativetoFFP(ClassIIa;LevelofEvidence:B).与新鲜血浆相比，血液凝固剂并没有显示出明显改善的治疗成果，但是可能并发症更少，是值得考虑的新鲜血浆替代物。rFVIIa[p10]doesnotreplaceallclottingfactors,andalthoughtheINRmaybelowered,clottingmaynotberestoredinvivo;therefore,rFVIIaisnotroutinelyrecommendedasasoleagentforOACreversalinICH(ClassIII;LevelofEvidence:C).(Revisedfromthepreviousguideline).重组凝血因子VII并不能替代所有的凝结因子；虽然INR可能会被降低，但是体内的血凝块并不能消除。所以，并不推荐把rFvlla作为脑出血病人OAC逆转的唯一药剂。（由先前指南修订）3.AlthoughrFVIIacanlimittheextentofhematomaexpansioninnoncoagulopathicICHpatients,thereisanincreaseinthromboembolicriskwithrFVIIaandnoclearclinicalbenefitinunselectedpatients.ThusrFVIIaisnotrecommendedinunselectedpatients.(ClassIII;LevelofEvidence:A).(Newrecommendation)Furtherresearchtodeterminewhetheranyselectedgroupofpatientsmaybenefitfromthistherapyisneededbeforeanyrecommendationforitsusecanbemade.虽然重组凝血因子VII可以限制非凝血异常性脑出血病人血肿扩大，但是应用rFVlla时发生血栓的危险性却增加了，同时，对于随机选定的患者没有明显的临床利益。（新推荐）在可以得出有关其应用的任何推荐之前，需要做更深层次的研究来验证是否任何被选定的病人群体都可以从这种治疗获益。4.TheusefulnessofplatelettransfusionsinICHpatientswithahistoryofantiplateletuseisunclearandisconsideredinvestigational(ClassIIb;LevelofEvidence:B).(Newrecommend)对于有抗血小板治疗病史的脑出血病人，给予输液血小板治疗的有效性并不清楚、有待于研究。（新推荐）5.PatientswithICHshouldhaveintermittentpneumaticcompression[p11]forpreventionofvenousthromboembolisminadditiontoelasticstockings[p12](ClassI;LevelofEvidence:B).(Unchangedfromthepreviousguideline)为了预防脑出血病人出现下肢静脉栓塞[p13]，除了下肢要穿弹力袜子、也要进行间歇性的充气压迫治疗（与先前的指南并无差异）6.Afterdocumentationofcessationofbleeding,lowdosesubcutaneouslow-molecular-weightheparinorunfractionatedheparinmaybeconsideredforpreventionofvenousthromboembolisminpatientswithlackofmobilityafter1to4daysfromonset(ClassIIb;LevelofEvidence:B).(Revisedfromthepreviousguideline)在确定病人出血停止后，皮下注射低剂量的低分子量的肝素或者肝素，可能用于防止病人发病后1到4天后发生静脉栓塞。（由先前指南修订）
三、BloodPressureRecommendations（有关血压方面的建议）
1.UntilongoingclinicaltrialsofBPinterventionforICHarecompleted,physiciansmustmanageBPonthebasisofthepresentincompleteefficacyevidence.CurrentsuggestedrecommendationsfortargetBPinvarioussituationsarelistedinTable6andmaybeconsidered(ClassIIb;LevelofEvidence:C).(Unchangedfromthepreviousguideline)在正在进行的脑出血病人血压干预临床试验完成之前，医师必须依据目前不完善的循证医学证据的基础，来适当控制血压。目前，对于不同情况下所推荐的血压处理方法，请见表6，值得借鉴。（与先前的指南并无差异）
2.InpatientspresentingwithasystolicBPof150to220mmHg,acuteloweringofsystolicBPto140mmHgispr
标签：ICH,指南
