Classification and phased treatment of stroke
Release date?
200 1
source
Chinese journal of nervous and mental diseases 200 1 Volume 27No. 1 Huang Ruxun Guo Yupu
Chinese text
Stroke is a group of diseases that cause cerebrovascular damage for many reasons, and brain tissue damage is the pathological basis of clinical symptoms. Brain injury has a dynamic process of occurrence and development, which can be divided into different stages in clinic, with corresponding main pathological changes, and its treatment must be emphasized. The treatment of acute phase is very important, and it is necessary to take more active and reasonable treatment measures to achieve better results, among which the most important thing is to classify according to clinical manifestations, etiology and pathology. In a word, the treatment goal of stroke is to reduce brain damage and restore normal function, so the treatment of stroke must choose a targeted individualized plan to achieve good results, and classification and staging are the core of individualized treatment.
Ischemic stroke
At present, the treatment mainly includes improving cerebral blood circulation, brain protection, anti-brain edema and reducing intracranial pressure, supportive therapy and symptomatic treatment.
1. 1 typing therapy
There are many types of cerebral infarction, most of which are divided into arterial thrombotic cerebral infarction, cardiogenic cerebral infarction and lacunar cerebral infarction. The most practical thing is to determine the location and size of acute infarction. However, in the early stage, especially in the 3-6 hour reflow window, conventional CT and MRT are not easy to show the infarct focus and determine the range. At present, MR or DWI/PWI-MR, DSA, SPECT and TCD are being studied to help determine, but due to the limitations of equipment, technology, manpower and economy, these methods are difficult to popularize and apply. From the clinical practice, we suggest OCSP classification and structural imaging CT classification.
1. 1. 1 OCSP classification ① total anterior circulation infarction (TACI): manifested as a triad, that is, complete middle cerebral artery (MCA) syndrome: a more higher nervous activity disorder in the brain; Homonymous hemianopia; Unilateral motor and/or sensory disorders. Most of them are the proximal trunk of MCA, and a few are massive cerebral infarction caused by occlusion of siphon segment of internal carotid artery. ② Partial anterior circulation infarction (PACI): There are two of the above triad, or only higher nervous activity's disorder, or sensorimotor disorder is more limited than TACI. It is suggested that occlusion of the distal trunk and branches of the middle cerebral artery or the anterior cerebral artery (ACA) and its branches can cause moderate and small infarctions. ③ Posterior circulation infarction (POCI): It showed different degrees of vertebrobasilar syndrome. There may be brainstem and cerebellar infarction of different sizes caused by occlusion of vertebrobasilar artery and its branches. ④ Lactic acid infarction: Lactic acid syndrome. Most of them are small lacunar lesions caused by small perforating branches of basal ganglia or pons.
1. 1.2 CT classification can be divided into cerebral infarction, cerebellar infarction and brain stem infarction according to anatomical location. Among them, cerebral infarction can be divided into: ① cerebral infarction: more than one leaf, more than 5cm. ② Middle infarction: less than one lobe, 3. 1 ~ 5 cm. ③ Small infarction: 1.6 ~ 3 cm. ④ Lacunar infarction: 1.5cm or less ⑤ Multiple infarction: multiple medium, small and lacunar infarction.
1. 1.3 In the implementation of treatment, besides general measures such as general support and brain protection, we should also pay attention to various key points: ① large area infarction (TACI or partial POCI): anti-cerebral edema can reduce intracranial pressure, and those who meet the requirements within the time window (3-6 hours) can be urgently thrombolytic. ② Middle infarction (PACI, severe POCI): Thrombolysis within the time window, and those with signs of brain edema must resist brain edema and reduce intracranial pressure. ③ Small infarction (limited PACI, mild POCI): slight improvement of cerebral blood circulation. ④ Lacunar cerebral infarction: improve cerebral blood circulation. ⑤ Multiple infarction: According to the severity of the disease, the treatment scheme of small infarction or medium infarction was adopted respectively.
1.2 staged treatment
Typical cerebral infarction, mainly large and moderate cerebral infarction (TACI, POCI and some areas of PACI), can be divided into three stages according to the course of disease.
1.2. 1 acute phase (1 month) is mainly treated according to the principle of classification, and the specific implementation can be basically divided into three stages.
1.2. 1. 1 those who meet the requirements in the first stage (within 24 hours or 48 hours of onset) within 13 to 6 hours can be treated with urokinase and tPA. ② For those who are not suitable for thrombolytic therapy, defibrase (clotrimamide, defibrase), anticoagulant (low molecular weight heparin) or antiplatelet preparation can be used as appropriate according to the etiology. ③ For those who don't thrombolysis or thrombolysis, according to the clinical and pathological conditions, treatment methods that affect blood pressure, reduce blood volume and improve blood circulation can be selected as appropriate, such as Danshen, Ligustrazine, Panax notoginseng or Ginkgo biloba preparation, calcium antagonists (nimodipine, flunarizine, cinnarizine) and low molecular dextran. ④ Drugs or brain protectants for improving brain nutrition metabolism, such as energy preparation (ATP, coenzyme A), vitamin preparation (C, E), coenzyme Q 10 magnesium sulfate, cytidine choline diphosphate, dexamethasone, mannitol, etc. ⑤ Anti-brain edema can reduce intracranial pressure. Mannitol, furosemide, glycerol fructose, dexamethasone, etc. Severe patients can be used early (24 hours), and those with cerebral hernia crisis should be decompressed by surgery. ⑥ Strengthen nursing, prevent and cure complications, and those who have conditions will be admitted to stroke ward or intensive care unit. ⑦ For those who need fluid infusion, glucose solution should not be used before 12 or within 24 hours, and 706 generation plasma and Ringer's solution can be used.
1.2. 1.2 The second stage (3 ~ 14 days) is mainly the treatment of anti-brain edema, reducing intracranial pressure, improving cerebral blood circulation and nutritional metabolism, which is basically the measures of reducing fiber, anticoagulation, improving blood circulation and brain nutrition, anti-brain edema and reducing intracranial pressure in the first stage. Those with stable vital signs should receive early rehabilitation treatment.
1.2. 1.3 The third stage (15 ~ 30 days) is mainly to improve cerebral blood circulation and nutritional metabolism. If there is no intracranial hypertension, the dehydrating agent can be stopped. In addition to the second-stage method, Chinese medicine and acupuncture can be added as appropriate.
1.2.2 During the recovery period (2-6 months), the measures to improve cerebral blood circulation and brain protective agents should be adjusted appropriately, and traditional Chinese medicine and acupuncture should be selected appropriately for standardized rehabilitation treatment, including the rehabilitation of cognition, language and limb functions. At the same time, prevent pathogenic factors and prevent recurrence.
1.2.3 sequelae (after 6 months) basically continued the rehabilitation plan, focusing on rehabilitation, and taking measures against the etiology and pathogenic factors to prevent recurrence.
Second cerebral hemorrhage
2. 1 Classification therapy is usually classified according to pathology, clinical signs, imaging and prognosis. Considering that CT technology has been widely used, and can diagnose and determine the location and scope of hematoma in early time, and the location and size of hematoma are closely related to prognosis, it is convenient, reliable and valuable to classify by CT, so it is widely used in clinic. According to the location of bleeding, the size of hematoma, whether it breaks into the ventricle, the degree of involvement of midline structure, and the signs of brain injury, the treatment method is selected.
2. 1. 1 putamen hemorrhage can be divided into five types according to the scope of hematoma and whether it breaks into the ventricle on CT: type ⅰ: hematoma extends to the external capsule. Type Ⅱ: Hematoma extends to the forelimb of internal capsule. Type Ⅲ A: Hematoma extends to the hind limb of internal capsule. Type Ⅲ B: Hematoma extends to the hind limb of the internal capsule and breaks into the ventricle. Type Ⅳ A: Hematoma extends to the anterior and posterior limbs of internal capsule. Type Ⅳ b: Hematoma extends to the anterior and posterior limbs of the internal capsule and breaks into the ventricle. Type ⅴ: Hematoma extends to internal capsule and thalamus.
The choice of treatment method, the amount of hematoma of the above type is less than or equal to ≤30mL, the shape of brainstem cistern is normal, and medical treatment is adopted. If the hematoma volume is greater than 30mL and the brainstem cistern is compressed, surgery is needed. Surgical methods can be classified according to CT. Craniotomy is mostly used in type ⅰ and type ⅱ, and craniotomy is needed to remove hematoma in type ⅲ, ⅳ and ⅴ. For those who break into the ventricle, some can also add ventricular drainage.
2. 1.2 Thalamic hemorrhage can be divided into three types according to the hematoma range and whether it has broken into the ventricle, and each type can be divided into two subtypes. Type I: Hematoma is confined to thalamus. Type Ⅱ: Hematoma extended to the internal capsule. Type ⅲ: Hematoma extends to hypothalamus or midbrain. It is subtype A that does not break into the ventricle, and subtype B that breaks into the ventricle.
Hematoma is small, especially within 10mL, with no obvious symptoms, and it is treated by internal medicine. Hematoma ≥ 15mL, and the symptoms get worse gradually. Craniotomy or craniotomy should be performed, and ventricular drainage is feasible for those who break into the ventricle. If the hematoma is ≥30mL and the brain stem compression is not serious, the hematoma must be removed by craniotomy.
2. 1.3 Cerebral lobe (subcortical) hemorrhage depends on hematoma size and ventricular pressure, and the amount of hemorrhage is less than 30mL, so it is treated by internal medicine; 3 1 ~ 50 ml, skull drilling and puncture can be used; Most patients with more than 50mL need craniotomy to remove hematoma, especially when the ventricle is obviously compressed.
2. 1.4 cerebellar hemorrhage, because the lesion is close to the brain stem, there is no obvious warning before it worsens. In order to prevent sudden cerebral hernia, most people think that surgery is the only effective treatment. Unless the clinical symptoms are mild and the amount of bleeding is less than < 10mL, temporary medical treatment may be considered. Patients with severe hematocele due to rupture into the ventricle need ventricular drainage at the same time.
2. 1.5 Brain stem hemorrhage is mostly treated by internal medicine, and ventricular drainage is feasible for patients with secondary ventricular hemorrhage. With the improvement of technical level, there are many successful cases of surgical treatment, and hematoma > 5 ml is appropriate.
Hematoma plays a leading role in the clinical and pathological changes in the acute stage of cerebral hemorrhage, especially in the early stage. The location and size of hematoma and the degree of cerebrospinal fluid circulation are important factors to determine the prognosis. So typing is an important basis for finding early treatment.
2.2 Phased treatment
After cerebral hemorrhage, the damage quickly reaches the peak, and then goes through the process of stability, relief and gradual recovery. There are corresponding changes in clinical symptoms and signs, which is the theoretical basis for staged treatment. Therefore, it is necessary to adopt the best treatment according to different clinical and pathological stages. However, drug therapy to ensure the stability of intracranial environment, such as regulating blood pressure, maintaining good visceral function and improving brain nutrition metabolism, is an important basic treatment for every patient.
2.2. 1 acute phase (1 ~ 1.5 months) The main treatment measures are different due to the location, size and secondary brain injury of hematoma. Intracranial pressure has no obvious increase in small hematoma, which is basically the basic treatment of internal medicine. Patients with brain edema and intracranial hypertension need active and reasonable dehydration treatment. For patients with large hematoma and obvious displacement of midline structure, most of them must be operated in time. In fact, for severe cerebral hemorrhage, the core of treatment and rescue is edema area, mainly to reduce the damage of ischemia and edema and restore brain function as much as possible. According to the location, scope, past history, general situation, age, secondary damage, technical conditions, etc. of the hematoma, the most favorable surgical methods are selected, such as skull drilling and drainage, intracranial hematoma puncture and aspiration, straight incision small bone window intracranial hematoma removal or large bone window craniotomy. Sometimes in order to save critically ill patients, emergency surgery is needed. Early operation within 6 hours of onset can greatly reduce the secondary injury, improve the success rate of rescue and reduce the disability rate, thus obtaining better curative effect.
2.2.2 In the recovery period (1.5 or 2-6 months), the brain lesions were basically stable, the clinical signs such as brain edema and intracranial hypertension subsided, and the damaged brain function recovered. In this period, in addition to the original drug treatment, the focus should be on improving cerebral blood circulation and promoting nutritional metabolism. The former should pay attention to the choice of drugs that dilate blood vessels lightly, have little effect on blood volume and have moderate effect, starting from low dose and gradually increasing to therapeutic dose. Another important measure is rehabilitation treatment, especially for patients with severe neurological deficits such as hemiplegia and aphasia, which should be started as soon as possible and carried out step by step in order to achieve better results and significantly reduce disability.
2.2.3 Severe patients in sequela period (6 months later) mostly left serious neurological deficits such as limb movement and language, and functional exercise was the main rehabilitation treatment. As long as the method is correct and persistent, most of them can be improved considerably. In addition, we must pay attention to the treatment of the cause to prevent recurrence.
Three times subarachnoid hemorrhage
3. 1 typing therapy
3. 1. 1 CT classification 1.980 Fisher classified subarachnoid hemorrhage into 5 types according to the high absorption area of hemorrhage revealed by CT examination within 5 days: type I: no bleeding. Type Ⅱ: Diffuse thin-layer hemorrhage in subarachnoid space (65438±0mm). Type ⅲ: subarachnoid space with thick (more than 65438±0mm) hemorrhage or localized hematoma. Type ⅳ: accompanied by cerebral parenchyma or intraventricular hemorrhage.
Cerebral vasospasm after subarachnoid hemorrhage is closely related to the location and severity of hemorrhage. According to Fisher's classification, about half of the patients are type ⅲ, and most of them can see cerebral vasospasm. However, there are not many patients with type ⅰ, ⅱ and ⅲ cerebral vasospasm. Therefore, in addition to general treatment, prevention and treatment of type ⅲ cerebral vasospasm should be emphasized. The prevention and treatment of hydrocephalus should be paid attention to in type ⅳ ventricular hemorrhage, and the treatment of cerebral parenchymal hemorrhage is basically the same as that of cerebral hemorrhage.
3. 1.2 Etiology Classification Aneurysm is the most common cause of subarachnoid hemorrhage, followed by vascular malformation. Other causes include abnormal vascular network at the bottom of the brain, hypertension atherosclerosis, hematological diseases, intracranial tumors, anticoagulation therapy and so on. Once subarachnoid hemorrhage is diagnosed, cerebral angiography should be performed as soon as possible to determine whether there is an aneurysm or vascular malformation and its location. ① Aneurysms: In 1956, Botterell divided these patients into five grades according to the severity of bleeding: Grade I: less bleeding, conscious, no neurological dysfunction. Grade II: less bleeding, conscious, mild nervous system dysfunction, such as oculomotor nerve paralysis, neck rigidity, etc. Ⅲ a: moderate bleeding, drowsiness or confusion, stiff neck, with or without nervous system dysfunction. Ⅲ B: moderate or massive hemorrhage, obvious nervous system dysfunction and progressive aggravation. Grade Ⅳ: Elderly patients with less bleeding and mild nervous system dysfunction, but with severe cerebrovascular diseases. Grade ⅴ: Critical patients with central nervous system failure or denervated rigidity.
The American Aneurysm Collaborative Research Group proposed the following criteria, with slight modifications: Class I: asymptomatic. He recovered completely after the last bleeding. Grade II: mild. Conscious, headache, no major nervous system dysfunction. Level 3: moderate. Sleepiness, headache and stiff neck, no cerebral hemisphere dysfunction; Awake, basically recovered after bleeding, cerebral hemisphere dysfunction. Level 4: severe. Unconscious, but without major nervous system dysfunction; Insomnia or slow response, accompanied by cerebral hemisphere dysfunction (such as hemiplegia, aphasia, mental symptoms). Grade ⅴ: The brain rigidity was relieved and the response to stimulation disappeared. At present, it is generally believed that Botterell ⅰ and ⅱ patients have good tolerance to surgery and good surgical effect, so they should be operated early. Most patients in stage Ⅲ and Ⅳ have obvious cerebral edema and vasospasm, and they will be operated after the situation improves. If the patient has intracranial hematoma, the condition is critical and progressive deterioration, and emergency surgery should be performed. ⅴ patients are not suitable for surgery. ② Cerebral arteriovenous malformation: The sites involved in compression veins are classified into superficial types: mainly involving pia mater and cortex; Deep type: mainly invading subcortical white matter; Medullary type: mainly involving medullary arteries and veins. Paracentral type: mainly invading basal ganglia, ventricle, corpus callosum, brain stem and cerebellum. Multiple or broad types: involving a wide range of parts.
According to the volume measured by enhanced CT scanning, it can be divided into: ① small: diameter less than 2cm, volume less than 4.2mL, medium: diameter 2 ~ 4 cm or volume 4.3 ~ 33.5 ml. ③ Large: the diameter is greater than 4cm and the volume is greater than 33.5mL.
Without surgical treatment, cerebral arteriovenous malformation will eventually lead to permanent neurological dysfunction and death due to intracranial hemorrhage. Most of them have to fight for surgical treatment. For patients with lesions located in deep brain and important functional areas of brain or with huge lesions and multiple arterial systems, conditions should be created for intravascular interventional therapy.
3.2 Phased treatment
3.2. 1 acute phase (1 month), while maintaining vital signs and symptomatic treatment, it is important to prevent rebleeding and manage intracranial pressure. Absolute bed rest time is not less than 3 ~ 4 weeks. Hypertensive patients can slowly lower their blood pressure, maintaining it at 2/3 of normal blood pressure, but not too fast or too low. Acute obstructive hydrocephalus caused by massive hemorrhage or blood entering ventricle should be treated with osmotic dehydrating agent or diuretic. If acute obstructive hydrocephalus occurs, ventricular drainage should be performed immediately. Cerebrospinal fluid drainage can discharge some blood, reduce intracranial pressure and relieve hydrocephalus. At the same time, preventive medication should be taken as soon as possible to prevent cerebral vasospasm. Under the condition of maintaining sufficient sedation and blood pressure management, cerebral angiography should be performed as soon as possible to clarify the cause of bleeding. If elective surgery, it is best to give fibrin inhibitor within 3 days, which can prevent thrombolysis and prevent or reduce rebleeding. Treating complicated cerebral hemorrhage and cerebral infarction at the same time. At present, microsurgery is the best surgical method. With the rapid update of embolization materials and techniques, endovascular embolization can replace microsurgery to treat many patients with aneurysms.
3.2.2 During the recovery period (2 ~ 3 months), blood pressure management and symptomatic treatment will continue. Some patients who are not suitable for surgery in the early stage can be operated at this stage. Temporary or permanent cerebrospinal fluid shunt is feasible for patients with chronic hydrocephalus. Paralyzed limbs can recover.
3.2.3 In the sequela period (3 months later), a few patients can leave hemiplegia and mental disorder. In addition to paying attention to the prevention and treatment of etiology, rehabilitation is the main treatment.