中国脑出血诊治指南(2014)

2014中国急性缺血性脑卒中诊治指南一、背景急性缺血性脑卒中是一种常见的危急疾病，其症状快速发展，易导致残疾和死亡。

根据数据显示，我国每年新发脑卒中约270万例。

为了更好地指导临床实践，2014年中国脑卒中学会制定了《2014中国急性缺血性脑卒中诊治指南》。

二、诊断标准1.临床表现急性缺血性脑卒中的最常见症状是突发中枢性神经系统缺血症状，包括一侧肢体无力和感觉丧失、失语、视力障碍等。

此外，还可能出现头晕、意识障碍等非特异性症状。

2.神经影像学除了临床表现外，神经影像学检查也是诊断急性缺血性脑卒中的关键手段。

常用的检查方法包括CT和MRI。

CT检查可以在最短时间内确定是否出现缺血性病变，MRI检查则可以更准确地确定病变范围和病变类型。

三、治疗原则1.早期干预急性缺血性脑卒中的治疗应该早期干预，以尽早恢复梗死区域的血液流通。

在脑缺血的前6小时内进行血管溶栓治疗可以获得最好的效果，因此可以考虑对于符合溶栓治疗标准的患者，进行溶栓治疗。

2.综合治疗除了溶栓治疗外，还需要进行综合治疗。

例如，抗血小板治疗、抗凝治疗、血压控制、降低血脂、体温管理、血糖控制等措施。

3.康复治疗康复治疗是缺血性脑卒中的重要组成部分，包括运动康复、语言康复、认知康复和精神康复等。

康复治疗可以帮助患者尽早重返社会和家庭。

四、预防措施1.控制危险因素控制危险因素是预防缺血性脑卒中的重要措施之一，危险因素包括高血压、高脂血症、糖尿病、吸烟等。

对于已经出现危险因素的患者，应该积极治疗。

2.生活方式干预积极的生活方式干预也是预防缺血性脑卒中的重要措施之一，可以采取戒烟限酒、科学饮食、适当运动等方式。

3.药物治疗针对高血压、高血脂等危险因素，可以进行药物治疗。

例如，降压药、降脂药等。

五、《2014中国急性缺血性脑卒中诊治指南》提供了全面而又系统的诊断和治疗方案，为临床医生提供了很好的指导。

通过早期干预和综合治疗，可以在一定程度上减轻患者的痛苦，提高其康复率和生活质量。

万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据中国脑出血诊治指南(2014)作者：中华医学会神经病学分会， 中华医学会神经病学分会脑血管病学组作者单位：刊名：中华神经科杂志英文刊名：Chinese Journal of Neurology年，卷(期)：2015,48(6)被引用次数：1次1.Steiner T;Bosel J Options to restrict hematoma expansion after spontaneous intracerebral hemorrhage 2010(2)2.Mayer SA;Rincon F Treatment of intracerebral haemorrhage 2005(10)3.Liu M;Wu B;Wang WZ Stroke in China:epidemiology,prevention,and management strategies 2007(5)4.Zhao D;Liu J;Wang W Epidemiological transition of stroke in China:twenty-one-year observational study from the Sino-MONICA-Beijing Project 2008(6)5.杨期东,周艳宏,刘运海,许宏伟,田发发,谷文萍,张乐,夏健长沙社区人群脑卒中患者发病的监测研究[期刊论文]-中华医学杂志2003(4)6.Wang YL;Wu D;Liao X Burden of stroke in China 2007(3)7.Morgenstern LB;Hemphill JC 3rd;Anderson C Guidelines for the management of spontaneous intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart Association/American Stroke Association 2010(9)8.Steiner T;Kaste M;Forsting M Recommendations for the management of 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脑出血临床路径一、脑出血临床路径标准住院流程（一）适用对象。

第一诊断为脑出血( ICD-l0:161)。

（二）诊断依据。

根据《中国脑出血诊治指南(2014)》（中华医学会神经病学分会脑血管病学组制定，中华神经科杂志；2015,48(6):435-444.）。

1.急性起病；2.局灶神经功能缺损症状(少数为全面神经功能缺损)，常伴有头痛、呕吐、血压升高及不同程度意识障碍；3.头颅CT或MRI显示出血灶；4.排除非血管性脑部病因。

（三）选择治疗方案的依据。

根据《中国脑出血诊治指南(2014)》（中华医学会神经病学分会脑血管病学组制定，中华神经科杂志；2015,48(6):435-444.）；以及《中国脑血管病临床管理指南》（中国卒中学会编写，北京：人民卫生出版社，2019）1.内科治疗:(1)尽量卧床休息，维持生命体征和内环境稳定，保持情绪稳定及大便通畅。

(2)控制血压：收缩压在150mmHg以上时，控制收缩压在140mmHg以下。

(3)血糖管理：控制血糖值在7.7-10mmol/L的范围内。

(4)控制体温。

2.药物治疗：神经保护治疗、传统医药治疗3.并发症及其他情况的预防与处理(1)控制脑水肿，必要时降低颅内压治疗；(2)控制癫痫发展、肺部感染，防治深静脉血栓。

4.必要时外科手术。

5.早期康复治疗。

（四）临床路径标准住院日为14-21天。

（五）进入路径标准。

1.第一诊断必须符合ICD-10: 161脑出血疾病编码。

2.当患者同时具有其他疾病诊断，但在住院期间不需要特殊处理也不影响第一诊断的临床路径流程实施时，可以进入路径。

（六）住院后检查的项目。

1.必需的检查项目:( 1 )血常规、尿常规;( 2 )肝功能、肾功能、电解质、血糖、凝血功能、心肌酶谱；( 3 )头颅CT、胸片、心电图。

2.根据患者具体情况，可选择的检查项目: CTA、MRA。

（七）选择用药。

1.脱水药物：甘露醇、呋塞米等。

2.降压药物：可选用卡托普利、依那普利、尼群地平、硝苯地平等。

中国脑出血诊疗指导规范一、概述脑出血(ICH)是神经内外科最常见的难治性疾病之一，亚洲国家ICH占脑卒中患者的25%〜55%,而欧美国家ICH仅占脑卒中患者的10%〜15%。

ICH 1个月死亡率高达35〜52%,6个月末仍有80%左右的存活患者遗留残疾，是中国居民死亡和残疾的主要原因之一。

规范ICH的诊断标准和治疗技术，有利于降低其死亡率和致残率。

二、脑出血的分类脑出血的危险因素及病因以高血压、脑淀粉样血管变性(CAA)、脑动静脉畸形、脑动脉瘤、肿瘤卒中、凝血功能障碍等多见。

目前国际上尚无公认的分类，欧洲将ICH分为原发性脑出血、继发性脑出血和原因不明性脑出血；美国有学者将ICH命名为非动脉瘤性、非AVM性、非肿瘤性自发性脑出血。

原发性脑出血与继发性脑出血的分类，目前得到较多认可。

继发性脑出血一般指有明确病因的脑出血，多由脑动静脉畸形、脑动脉瘤、使用抗凝药物、溶栓治疗、抗血小板治疗、凝血功能障碍、脑肿瘤、脑血管炎、硬脑膜动静脉痿、烟雾病(Moyamoya病)、静脉窦血栓形成等引起”气占ICH的15%~20%。

原发性脑出血指无明确病因的脑出血，多数合并有高血压。

在我国，虽未进行大样本流行病学调査，但就现有文献资料分析，原发性脑出血合并高血压者可高达70%〜80%",所以我国一直沿用“高血压脑出血”命名。

而在国外医学文献中，多将该病统称为脑出血或自发性脑出血，约占所有ICH的80%〜85%。

本指导规范仅限于原发性脑出血的诊断及治疗。

三、辅助检查1.影像学检查影像学检查是诊断ICH的重要方法，主要包括：脑CT、MRI和脑血管造影等。

CT及MRI能够反映出血的部位、出血量、波及范围及血肿周围脑组织情况。

1.1 CT扫描：使用广泛，ICH在CT上表现为高密度影，是诊断脑卒中首选的影像学检査方法冋。

可根据多田公式粗略计算血肿体积：血肿体积T(ml)=it/6*L*S*Slice,式中L为血肿的长轴，S为短轴，Slice为所含血肿层面的厚度(cm)；目前有相关软件可根据CT图像精确计算血肿体积。