今年美國心臟協會及腦中風會協會共同發表了一篇新的臨床指引~~處理自發性腦出血~~
距離上一次的指引是在2007年，過了3年終於有新的指引出現，那就看看有啥不同處吧!!一樣是依照證據等級及推薦等級來說明。證據等級 LEVEL A (多項隨機控制實驗或綜合分析)，LEVEL B(單一隨機控制實驗或非隨機研究)，LEVEL C(只有專家意見，個案研究，標準照護); 推薦等級 Class I (好處>>>害處),Class IIa(好處>>害處)，Class IIb(好處>=害處)，ClassIII(害處>=好處)。
1. Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke from ICH (Class I; Level of Evidence: A). (Unchanged from the previous guideline)(電腦斷層或核磁共振被推薦來區別腦出血或缺血腦中風)。
2. CT angiography and contrast-enhanced CT may be considered to help identify patients at risk for hematoma expansion (Class IIb; Level of Evidence: B), and CT angiography, CT venography, contrast-enhanced CT, contrast-enhanced MRI, magnetic resonance angiography,and magnetic resonance venography can be useful to evaluate for underlying structural lesions,including vascular malformations and tumors when there is clinical or radiological suspicion (Class IIa;Level of Evidence: B). (New recommendation)。 3.Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively.(Class I, Level C)(New recommendation)(病患有嚴重凝血因子缺乏或嚴重血小板缺乏應接受適當地凝血因子或血小板補充充)。 4.Patients with ICH whose INR is elevated due to OAC should have their warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K.(Class I, Level C)(Revised from the previous guideline)(因口服抗凝血劑導致INR延長應停止warfarin及接受Vitamin k 制劑) 5.PCCs have not shown improved outcome compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP (Class IIa; Level of Evidence:B).(Prothrombin complex concentrate對比新鮮冷凍血將有較少的併發症) 6.Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence.Current suggested recommendations for target BP in various situations are listed in Table 6 and may beconsidered (Class IIb; Level of Evidence: C). (Unchanged from the previous guideline)
7. In patients presenting with a systolic BP of 150 to 220 mm Hg, acute lowering of systolic BP to 140 mm Hg is probably safe (Class IIa; Level of Evidence: B). (New recommendation)(早期將血壓控制140mmHg可能是安全的)
8. Glucose should be monitored and normoglycemia is recommended (Class I: Level of Evidence: C). (New recommendation) (監測血糖及維持血糖在正常範圍)
9.Clinical seizures should be treated with antiepileptic drugs (Class I; Level of Evidence: A).(臨床癲癇發生應用抗癲癇藥物治療) (Revised from the previous guideline) Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of
brain injury (Class IIa; Level of Evidence: B). Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs (Class I; Level of Evidence: C).(意識改變伴隨腦波有癲癇波時應使用藥物治療) Prophylactic anticonvulsant medication should not be used (Class III; Level of Evidence:B). (New recommendation)(預防性抗癲癇藥物不應被使用)。 10.Patients with a GCS score of <8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A cerebral perfusion pressure of 50 to 70 mm Hg may be reasonable to maintain depending on the status of cerebral autoregulation (Class IIb; Level of Evidence:C). (New recommendation)(病患昏迷指數小於八且有經天幕腦疝脫的臨床證據或明顯腦室內出血或水腦，可考慮顱內壓監測及治療;根據腦部自我調節機轉，將腦灌注壓維持50~70mmHg是合理的)。(但證據強度似乎不強喔!!)
11.Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness (Class IIa; Level of Evidence: B). (New recommendation)(腦室引流治療對於意識下降的水腦病患是合理的)。 12.Although intraventricular administration of recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational (Class IIb; Level of Evidence: B). (New recommendation)(雖然腦室內導管給予rTPA似乎有低的併發症比率，但治療的效益及安全性仍不確定，需進一步地研究)(說明: 因為在腦室內插入導管可引流出腦室內血液，但血液會凝結，故造成導管引流不順，故需使用血栓溶解藥物，使得導管易於引流)。(目前證據力仍顯不足)
13.Patients with cerebellar hemorrhage who are deterioratingneurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence: B).(小腦出血併神經功能惡化或腦幹壓迫或/及阻塞性水腦，應盡可能接收外科手術移除出血)。(Revised from the previous guideline) 14.Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended (Class III; Level of Evidence: C). (New recommendation)。 15.For patients presenting with lobar clots >30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered (Class IIb; Level of Evidence: B). (Revised from the previous guideline)(位於距大腦表面1公分以內的腦葉出血（lobar hemorrhage）大於30ml，可考慮做傳統式的開顱手術)。
16.The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational (Class IIb;Level of Evidence: B). (New recommendation)
17.Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding (Class III; Level of Evidence: B). (Revised from the previous guideline)(無清楚證據顯示早期開刀移出天幕上出血可改善功能或死亡率，也許是有害的)。 18.In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions,it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E 2 or 4 alleles, and greater number of microbleeds on MRI (Class IIa; Level of Evidence: B). (New recommendation)(自出血危險因子為早期出血是在腦葉，年紀大，使用抗凝血劑，存在脂蛋白基因型及較多數目的微小出血)。 19.After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy (Class I; Level of Evidence: A).(New recommendation) 20.After the acute ICH period, a goal target of a normal BP of <140/90 (<130/80 if diabetes or chronic kidney disease) is reasonable (Class IIa; Level of Evidence: B). (New recommendation)(血壓控制在急性腦出血後期很重要) 21.Avoidance of heavy alcohol use can be beneficial (Class IIa; Level of Evidence: B). There is insufficient data to recommend restrictions on use of statin agents or physical or sexual activity (Class IIb; Level of Evidence: C). (New recommendation) 22.Given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation (Class IIa; Level of Evidence: B). Where possible, rehabilitation can be beneficial when begun as early as possible and continued in the community as part of a well-coordinated (seamless) program of accelerated
hospital discharge and home-based resettlement to promote ongoing recovery (Class IIa; Level of
Evidence: B). (New recommendation)(早期接受復健計畫可能是有益的，並且在社區持續進行)
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