"Today's Treatment Guideline 2017 (Japan)" p881Purchase

I wrote a section on "Treatment of Cerebral Hemorrhage" to be able to refer to the summary of the cerebral hemorrhage treatment for private practitioners and working doctors.

Treatment of intracerebral hemorrhagepoint of treatment
・Intracerebral hemorrhage often exacerbates in the acute phase, and appropriate management in the acute phase affects life and functional prognosis.
・If neurological symptoms worsen due to hematoma expansion, consider hematoma removal or decompressive craniotomy as a life-saving measure.・As a general rule, do not order DNR (discontinue resuscitation), which is directly linked to the patient's death, within 2 days of onset.
・Early initiation of rehabilitation, early rehabilitation hospital transfer, and early home discharge with adequate medical support improve functional prognosis.


Topics
A large-scale randomized controlled trial (INTERACT 2) showed that severe hypotension in the hyperacute phase is safe and improves functional prognosis after 90 days. I was advised to lower my systolic blood pressure to less than 140 mmHg (previously 180 mmHg).


pathology and diagnosis
The number of deaths in 2014 was 26 per 100,000, the in-hospital mortality rate was 15%, and the independence of daily living (mRS 0-2) at discharge was 33%.Risk factors for intracerebral hemorrhage include aging, hypertension, male gender, excessive alcohol consumption, and low total cholesterol. Pathological changes in arterioles due to hypertension (vascular necrosis, small aneurysms, etc.) are important causes of intracerebral hemorrhage, and subcortical hemorrhage in the elderly is often associated with amyloid angiopathy (2.2 times more women, rebleeding, multiple occurrences). Other causes include vascular malformations, cerebral aneurysms, clotting disorders, anticoagulant therapy, stroke, tumors, and substance abuse.CT is useful for early diagnosis of intracerebral hemorrhage. CT angiography, MRI/MRA are performed to differentiate vascular abnormalities other than hypertension, and DSA is also considered if necessary. A spot sign (punctate enhancement within the hematoma) on contrast-enhanced CT suggests increased bleeding.

Treatment policy
○A Conservative treatment
Blood pressure, blood sugar, body temperature, intracranial pressure (ICP) control, respiratory control, correction of abnormal coagulation, etc. are important. Hematoma enlargement within 20 hours of onset is observed in 40% of cases, and is strongly correlated with functional prognosis. The mortality rate is high when stroke occurs during anticoagulant therapy, and vitamin K and FFP are administered during oral warfarin to reduce the INR to 1.35 or less as soon as possible. If an increase in ICP is suspected (disturbance of consciousness, headache, vomiting, severe hypertension, amount of hematoma on head CT, etc.),treat with hyperventilation, 30-degree head elevation, administration of osmotic diuretics, etc.

prescription example
Perdipine injection 1 μg/kg/min Start with intravenous infusion and maintain at 1-10 μg/kg/min(when intracranial pressure rises)Glyceol injection 200 mL once, 2 to 4 times a day, intravenous drip infusion over 1 hour

○B Surgical treatment
Cerebellar hemorrhage of 3 cm or more and subcortical hemorrhage of less than 1 cm from the brain surface accompanied by neurological deterioration should be considered for craniotomy. Ventricular drainage should be considered for hydrocephalus associated with brain stem hemorrhage or thalamic hemorrhage. For putaminal hemorrhage, surgery should be considered if the neurological findings are moderate or higher and the amount of hematoma is 31 ml or more.Consider placing an ICP monitor if there is a GCS ≤8 and CT findings of cerebral herniation, intraventricular hemorrhage, or hydrocephalus, aiming for ICP <20 mmHg and cerebral perfusion pressure >70 mmHg.


❢Key Points of Nursing and Nursing Care
If paralysis is present, intermittent pneumatic compression prevents deep vein thrombosis and pulmonary embolism. Compression stockings alone are not considered to be protective.