ESO卒中指南英文.pptx

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1、ESO Guidelines 2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitation第1页/共150页ESO Writing CommitteeChair:WernerHacke,Heidelberg,GermanyCo-Chairs:Marie-GermaineBousser,Paris,FranceGaryFord,Newcastle,

2、UK第2页/共150页ESO Writing CommitteeEducation,ReferralandEmergencyroomCo-Chairs:MichaelBrainin,Krems,Austria;JosFerro,Lisbon,PortugalMembers:CharlotteCordonnier,Lille,France;HeinrichP.Mattle,Bern,Switzerland;KeithMuir,Glasgow,UK;PeterD.Schellinger,Erlangen,GermanyStrokeUnitsCo-Chairs:Hans-ChristophDiene

3、r,Essen,Germany;PeterLanghorne,Glasgow,UKMembers:AntonyDavalos,Barcelona,Spain;GaryFord,Newcastle,UK;VeronikaSkvortsova,Moscow,Russia第3页/共150页ESO Writing CommitteeImagingandDiagnosticsCo-Chairs:MichaelHennerici,Mannheim,Germany;MarkkuKaste,Helsinki,FinlandMembers:HughS.Markus,London,UK;E.BerndRingel

4、stein,Mnster,Germany;RdigervonKummer,Dresden,Germany;JoannaWardlaw,Edinburgh,UKPreventionCo-Chairs:PhilBath,Nottingham,UK;DidierLeys,Lille,FranceMembers:lvaroCervera,Barcelona,Spain;LszlCsiba,Debrecen,Hungary;JanLodder,Maastricht,TheNetherlands;NilsGunnarWahlgren,Stockholm第4页/共150页ESO Writing Commit

5、teeGeneralTreatmentCo-Chairs:ChristophDiener,Essen,Germany;PeterLanghorne,Glasgow,UKMembers:AntonyDavalos,Barcelona,Spain;GaryFord,Newcastle,UK;VeronikaSkvortsova,Moscow,RussiaAcuteTreatmentandTreatmentofComplicationsCo-Chairs:AngelChamorro,Barcelona,Spain;BoNorrving,Lund,SwedenMembers:ValericaCaso,

6、Perugia,Italy;Jean-LouisMas,Paris,France;VictorObach,Barcelona,Spain;PeterA.Ringleb,Heidelberg,Germany;LarsThomassen,Bergen,Norway第5页/共150页ESO Writing CommitteeRehabilitationCo-Chairs:KennedyLees,Glasgow,UK;DaniloToni,Rome,ItalyMembers:StefanoPaolucci,Rome,Italy;JuhaniSivenius,Kuopio,Finland;Kathari

7、naStibrantSunnerhagen,Gteborg,Sweden;MarionF.Walker,Nottingham,UK;Substantial assistance:YvonneTeuschl,IsabelHenriques,TerenceQuinn第6页/共150页Definitions of Levels of EvidenceLevel AEstablished as useful/predictive or not useful/predictive for a diagnostic measure or established as effective,ineffecti

8、ve or harmful for a therapeutic intervention;requires at least one convincing Class I study or at least two consistent,convincing Class II studies.Level BEstablished as useful/predictive or not useful/predictive for a diagnostic measure or established as effective,ineffective or harmful for a therap

9、eutic intervention;requires at least one convincing Class II study or overwhelming Class III evidence.Level CEstablished as useful/predictive or not useful/predictive for a diagnostic measure or established as effective,ineffective or harmful for a therapeutic intervention;requires at least two Clas

10、s III studies.Good Clinical Practice(GCP)Recommended best practice based on the experience of the guideline development group.Usually based on Class IV evidence indicating large clinical uncertainty,such GCP points can be useful for health workers.第7页/共150页Classification of EvidenceEvidence classifi

11、cation scheme for a therapeutic interventionClass IAn adequately powered,prospective,randomized,controlled clinical trial with masked outcome assessment in a representative population or an adequately powered systematic review of prospective randomized controlled clinical trials with masked outcome

12、assessment in representative populations.Class IIProspective matched-group cohort study in a representative population with masked outcome assessment or a randomized,controlled trial in a representative population that lacks one criterion for class I evidence.Class IIIAll other controlled trials(inc

13、luding well-defined natural history controls or patients serving as own controls)in a representative population,where outcome assessment is independent of patient treatment.Class IVEvidence from uncontrolled studies,case series,case reports,or expert opinion.第8页/共150页Classification of EvidenceEviden

14、ce classification scheme for a diagnostic measureClass IA prospective study in a broad spectrum of persons with the suspected condition,using a gold standard for case definition,where the test is applied in a blinded evaluation,and enabling the assessment of appropriate tests of diagnostic accuracy.

15、Class IIA prospective study of a narrow spectrum of persons with the suspected condition,or a well-designed retrospective study of a broad spectrum of persons with an established condition(by gold standard)compared to a broad spectrum of controls,where test is applied in a blinded evaluation,and ena

16、bling the assessment of appropriate tests of diagnostic accuracy.Class IIIEvidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum,and where test is applied in a blinded evaluation.Class IVEvidence from uncontrolled studies,c

17、ase series,case reports,or expert opinion.第9页/共150页ESO Guidelines 2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitation第10页/共150页Stroke as an EmergencyBackgroundStrokeisthemostimportantcauseofmorbi

18、dityandlongtermdisabilityinEurope1DemographicchangesarelikelytoresultinanincreaseinbothincidenceandprevalenceStrokeisalsothesecondmostcommoncauseofdementia,themostfrequentcauseofepilepsyintheelderly,andafrequentcauseofdepression2,31:Lopez AD et al.Lancet(2006)367:1747-17572:Rothwell PM et al.Lancet(

19、2005)366:1773-17833:OBrien JT et al.Lancet Neurol(2003)2:89-98第11页/共150页Stroke as an EmergencyBackgroundStrokeisamedicalandoccasionallyasurgicalemergencyThemajorityofischaemicstrokepatientsdonotreachthehospitalquicklyenoughThedelaybetweenstrokeonsetandhospitaladmissionis;reducediftheEmergencyMedical

20、Systems(EMS)areusedincreasedifdoctorsoutsidethehospitalareconsultedfirst第12页/共150页Stroke as an EmergencyEmergencycareinacutestrokedependsonafour-stepchain:Rapidrecognitionof,andreactionto,strokesignsandsymptomsImmediateEMScontactandpriorityEMSdispatchPrioritytransportwithnotificationofthereceivingho

21、spitalImmediateemergencyroomtriage,clinical,laboratoryandimagingevaluation,accuratediagnosis,andadministrationofappropriatetreatmentsatthereceivinghospital.第13页/共150页Stroke as an EmergencyDelaysduringacutestrokemanagementhavebeenidentifiedatthreedifferentlevels1atthepopulationlevel,duetofailuretorec

22、ognizethesymptomsofstrokeandcontactemergencyservicesattheleveloftheemergencyservicesandemergencyphysicians,duetoafailuretoprioritizetransportofstrokepatientsatthehospitallevel,duetodelaysinneuroimagingandinefficientin-hospitalcare1:Kwan J et al.Age Ageing(2004)33:116-121第14页/共150页EducationRecommenda

23、tionsEducational programmes to increase awarenessofstrokeatthepopulationlevelarerecommended(Class II,Level B)Educational programmes to increase strokeawareness among professionals(paramedics,emergencyphysicians)arerecommended(Class II,Level B)第15页/共150页Referral Recommendations(1/2)ImmediateEMScontac

24、tandpriorityEMSdispatcharerecommended(Class II,Level B)Priority transport with advance notification ofthe receiving hospital is recommended(Class III,Level B)Suspectedstrokevictimsshouldbetransportedwithout delay to the nearest medical centrewith a stroke unit that can provide ultra-earlytreatment(C

25、lass III,Level B)Patients with suspected TIA should be referredwithout delay to a TIA clinic or a stroke unit(Class III,Level B)第16页/共150页Referral Recommendations(2/2)Dispatchers and ambulance personnel shouldbe trained to recognise stroke using simpleinstruments such as the Face-Arm-Speech-Test(Cla

26、ss IV,GCP)Immediate emergency room triage,clinical,laboratory and imaging evaluation,accuratediagnosis,therapeuticdecisionandadministration of appropriate treatments arerecommended(Class III,Level B)Inremoteorruralareashelicoptertransferandtelemedicine should be considered to improveaccesstotreatmen

27、t(Class III,Level C)第17页/共150页Emergency ManagementThetimewindowfortreatmentofpatientswithacutestrokeisnarrowAcuteemergencymanagementofstrokerequiresparallelprocessesoperatingatdifferentlevelsofpatientmanagementAcuteassessmentofneurologicalandvitalfunctionsparallelsthetreatmentofacutelylife-threateni

28、ngconditionsTimeisthemostimportantfactor第18页/共150页Emergency ManagementTheinitialexaminationshouldincludeObservationofbreathingandpulmonaryfunctionandconcomitantheartdiseaseAssessmentofbloodpressureandheartrateDeterminationofarterialoxygensaturationBloodsamplesforclinicalchemistry,coagulationandhaema

29、tologystudiesObservationofearlysignsofdysphagiaTargetedneurologicalexaminationCarefulmedicalhistoryfocussingonriskfactorsforarteriosclerosisandcardiacdisease第19页/共150页Ancillary Diagnostic TestsInallpatientsBrainImaging:CTorMRIECGLaboratoryTestsCompletebloodcountandplateletcount,prothrombintimeorINR,

30、PTTSerumelectrolytes,bloodglucoseCRPorsedimentationrateHepaticandrenalchemicalanalysis第20页/共150页Ancillary Diagnostic TestsInselectedpatientsDuplex/DopplerultrasoundMRAorCTADiffusionandperfusionMRorperfusionCTEchocardiography,ChestX-rayPulseoximetryandarterialbloodgasanalysisLumbarpunctureEEGToxicolo

31、gyscreen第21页/共150页Emergency ManagementRecommendationsOrganizationofpre-hospitalandin-hospitalpathwaysandsystemsforacutestrokepatientsisrecommended(Class III,Level C)Allpatientsshouldreceivebrainimaging,ECG,andlaboratorytests.Additionaldiagnosticexaminationsarenecessaryinselectedpatients(Class IV,GCP

32、)第22页/共150页ESO Guidelines 2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitation第23页/共150页Stroke UnitAstrokeunitIsadedicatedandgeographicallydefinedpartofahospitalthattakescareofstrokepatientsHasspe

33、cialisedstaffwithcoordinatedmultidisciplinaryexpertapproachtotreatmentandcareComprisescoredisciplines:medical,nursing,physiotherapy,occupationaltherapy,speechandlanguagetherapy,socialwork11:Langhorne P et al.Age Ageing(2002)31:365-371第24页/共150页Stroke UnitTypicalcomponentsofstrokeunitsincludeAssessme

34、ntMedicalassessmentanddiagnosis,earlyassessmentofnursingandtherapyneedsEarlymanagementpoliciesEarlymobilisation,preventionofcomplications,treatmentofhypoxia,hyperglycaemia,pyrexiaanddehydrationOngoingrehabilitationpoliciesCoordinatedmultidisciplinaryteamcareEarlyassessmentsofneedsafterdischarge第25页/

35、共150页Stroke UnitTreatmentatastrokeunitcomparedtotreatmentinageneralward1reducesmortality(absoluteriskreductionof3%)reducesdependency(5%)reducesneedforinstitutionalcare(2%)Alltypesofpatients,irrespectiveofgender,age,strokesubtypeandstrokeseverity,appeartobenefitfromtreatmentinstrokeunits11:Stroke Uni

36、t Trialists Collaboration Cochrane Rev(2007)第26页/共150页Stroke Services and Stroke UnitsRecommendationsAllstrokepatientsshouldbetreatedinastrokeunit(Class I,Level A)Healthcare systems must ensure that acutestroke patients can access high technologymedicalandsurgicalstroke carewhenrequired(Class III,Le

37、vel B)Thedevelopmentofclinicalnetworks,includingtelemedicine,is recommended to expand theaccesstohightechnologyspecialiststrokecare(Class II,Level B)第27页/共150页ESO Guidelines 2008Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagemen

38、tofComplicationsRehabilitation第28页/共150页Emergency Diagnostic TestsDifferentiatebetweendifferenttypesofstrokeAssesstheunderlyingcauseofbrainischaemiaAssessprognosisProvideabasisforphysiologicalmonitoringofthestrokepatientIdentifyconcurrentdiseasesorcomplicationsassociatedwithstrokeRuleoutotherbraindi

39、seases第29页/共150页Emergency Diagnostic TestsCranialComputedTomography(CT)ImmediateplainCTscanningdistinguishesreliablybetweenhaemorrhagicandischaemicstrokeDetectssignsofischaemiaasearlyas2hafterstrokeonset1Helpstoidentifyotherneurologicaldiseases(e.g.neoplasms)Mostcost-effectivestrategyforimagingacute

40、strokepatients21:von Kummer R et al.Radiology(2001)219:95-1002:Wardlaw J et al.Stroke(2004)35:2477-2483第30页/共150页Emergency Diagnostic TestsMagneticResonanceImaging(MRI)Diffusion-weightedMRI(DWI)ismoresensitivefordetectionofearlyischaemicchangesthanCTDWIcanbenegativeinpatientswithdefinitestroke1Ident

41、ifiesischaemiclesionsintheposteriorfossareliablyDetectsevensmallintracerebralhaemorrhagesreliablyonT2*sequencesMRIisparticularlyimportantinacutestrokepatientswithunusualpresentations1:Ay H et al.Cerebrovasc Dis(2002)14:177-186第31页/共150页Emergency Diagnostic TestsMismatchConceptMismatchbetweentissueab

42、normalonDWIandtissuewithreducedperfusionmayreflecttissueatriskoffurtherischaemicdamage1Thereisdisagreementonhowtobestidentifyirreversibleischaemicbraininjuryandtodefinecriticallyimpairedbloodflow2Thereisnoclearevidencethatpatientswithparticularperfusionpatternsaremoreorlesslikelytobenefitfromthrombo

43、lysis31:Jansen O et al.Lancet(1999)353:2036-20372:Kane I et al.Stroke(2007)38:3158-31643:Albers GW et al.Ann Neurol(2006)60:508-517第32页/共150页Emergency Diagnostic TestsUltrasoundstudiesCerebrovascularultrasoundisfastandnon-invasiveandcanbeadministeredusingportablemachines.Itisthereforeapplicabletopat

44、ientsunabletoco-operatewithMRAorCTA1CombinationsofultrasoundimagingtechniquesandMRAcanproduceexcellentresultsthatareequaltoDigitalsubtractionangiography(DSA)21:Allendrfer J et al.Lancet Neurology(2005)5:835-8402:Nederkoorn P et al.Stroke(2003)34:1324-1332第33页/共150页Emergency Diagnostic TestsImagingin

45、TIA-patientsUpto10%recurrenceriskinthefirst48hours1Simpleclinicalscoringsystemscanbeusedtoidentifypatientsatparticularlyhighrisk1Upto50%ofpatientswithTIAshaveacuteischaemiclesionsonDWI.Thesepatientsareatincreasedriskofearlyrecurrentdisablingstroke2ThereiscurrentlynoevidencethatDWIprovidesbetterstrok

46、epredictionthanclinicalriskscores31:Rothwell P et al.Lancet Neurol(2005)5:323-3312:Coutts S et al.Ann Neurol(2005)57:848-8543:Redgrave J et al.Stroke(2007)38:1482-1488第34页/共150页Emergency Diagnostic TestsElectrocardiogram(ECG)Cardiacabnormalitiesarecommoninacutestrokepatients1Arrhythmiasmayinducestro

47、ke,strokemaycausearrhythmiasHoltermonitoringissuperiortoroutineECGforthedetectionofatrialfibrillation(AF)2ItisunclearwhethercontinuousECGrecordingatthebedsideisequivalenttoHoltermonitoringforthedetectionofAF1:Christensen H et al.Neurol Sci(2005)234:99 1032:Gunalp M et al.Adv Ther(2006)23:854-60第35页/

48、共150页Emergency Diagnostic TestsEchocardiography(TTE/TOE)Echocardiographycandetectmanypotentialcausesofstroke1Itisparticularlyrequiredinpatientswithhistoryofcardiacdisease,ECGpathologies,suspectedsourceofembolism,suspectedaorticdisease,suspectedparadoxicalembolismTransoesophagealechocardiography(TOE)

49、mightbesuperiortotransthoracicechocardiography(TTE)forthedetectionofpotentialcardiacsourcesofembolism21:Lerakis S et al.Am J Med Sci(2005)329:310-62:de Bruijn SF et al.Stroke(2006)37:2531-4第36页/共150页Emergency Diagnostic TestsLaboratorytestsHaematology(RBC,WBC,plateletcount)BasicclottingparametersEle

50、ctrolytesRenalandhepaticchemistryBloodGlucoseCRP,sedimentationrate第37页/共150页Diagnostic ImagingRecommendationsInpatientswithsuspectedTIAorstroke,urgentcranialCT(Class I),oralternativelyMRI(Class II),isrecommended(Level A)IfMRIisused,theinclusionofdiffusionweightedimaging(DWI)andT2*-weightedgradientec