美国脑血管病治疗指南解读 (Guideline )

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脑卒中的康复治疗

但是，由于在患者样本量、构架设计和转归评价方法等方面存在不一致性，因此难以确定适用于所有卒中患者的“最佳临床实践” 。证据没有提出治疗干预的具体类型或小组治疗方案的类型或哪种因素对患者转归的影响最大作出解释。卒中本身及多方面的影响使得需要采取灵活多样的治疗方案。
2.使用标准化的评价工具
否
患者是否准备好社医生话？是
否
处理治疗的依从性和阻碍病情改善的因素：一如果病情不稳定，转送至急性期治疗科室一如果存在心理健康因素，转送至精神科
重度卒中和/或生话完全依对患者/家属将来的
赖, 或功能恢复预后不良？计划进行教育
是患者回家或去护理之家
否
继续门诊康复治疗
再评价
图3
以下是社区康复医疗流程
卒中严重程度的评价
NIHSS用于指导急性卒中治疗的决策，其信度和效度均很高。可根据NIHSS严重程度和可能的转归对患者进行分层，评分＞16分预示死亡或严重残疾的可能性很大, 而＜6 分则预示恢复良好。
卒中和动脉粥样硬化性血管病的二级预防
卒中二级预防是康复治疗的重要组成部分。它包括：治疗高血压；心房纤颤患者应用华法林和脑缺血患者进行抗血小板治疗；对于缺血性卒中或有CHD等高危因素的非缺血性卒中患者，进行冠心病的二级预防也是重要的组成部分，临床资料确认有效的措施包括：抗血小板治疗、控制高血压、必要时考虑血管紧张素转化酶抑制剂、、即使低密度脂蛋白胆固醇醇正常也进行降脂治疗、体育锻炼和戒烟等。
-康复治疗 -预防远期并发症的措施 -减少复发性卒中可能性的长期治疗 -家庭支持 -治疗抑郁
病史的采集和体格检查
（1）建议最初阶段采用HIHSS评价卒中严重程度，将其作为死亡和远期转归的预测指标。

中美缺血性卒中门诊医疗质量改进项目进展

中美缺血性卒中门诊医疗质量改进项目进展陈盼;王拥军【摘要】美国指南优势（The Guideline Advantage，TGA）医疗质量改进项目为“跟着指南走”（Get With the Guideline，GWTG）项目的门诊延伸，其数据直接通过电子病历和卫生技术平台进行收集，以体现循证医学指南的依从性。

中国门诊医疗质量改进项目刚起步，其中中国金桥工程中的中国城市神经科门诊缺血性卒中登记研究拟对全国约100家医院门诊的1.5万例缺血性卒中患者进行调查和随访，评估缺血性卒中的医疗服务现状、二级预防的长期依从性、临床结局等，为进一步的医疗质量改进提供基础数据。

%The Guideline Advantage quality improvement program (TGA) is an extended program of Get With the Guideline (GWTG) in outpatient setting in USA. TGA utilizes data from electronic health records (EHRs) or health technology platforms to report on adherence to evidence-based guidelines. Outpatient medical care quality improvement program has just started in China. Registry of outpatients with ischemic stroke in urban China (ROOTS) study evaluates the secondary prevention status, adherence and long-term persistence to secondary prevention and clinical outcome of 15 000 outpatients with ischemic stroke in 100 hospitals in China. ROOTS provides basic data for further medical care quality improvement process.【期刊名称】《中国卒中杂志》【年(卷),期】2015(000)001【总页数】4页(P84-87)【关键词】缺血性卒中;二级预防;门诊;医疗质量改进;指南优势【作者】陈盼;王拥军【作者单位】100050北京首都医科大学附属北京天坛医院神经内科，国家神经系统疾病临床医学研究中心;100050北京首都医科大学附属北京天坛医院神经内科，国家神经系统疾病临床医学研究中心【正文语种】中文卒中具有发病率高、病死率高、致残率高以及复发率高等特点，是导致全球人类致残的首要病因[1]。

脑血管疾病的几个热点问题

2）静脉溶栓
• ㈠纳入标准 • 年龄18岁以上； • 临床明确诊断缺血性脑血管病，并且造成
明确的神经功能障碍（NIHSS>4分）； • 症状开始出现至临床干预时间<180分钟；
（对于3－6小时患者，在充分影像学信息支持下★，可考虑静脉溶栓） • 患者家属对静脉溶栓的收益/风险知情同意。
• 排除标准
表型
报道国家
CADASIL（伴有皮质下梗死和白质脑病的常染色体欧美和中国（宣武医院）
显性遗传性脑动脉病）
常染色体显性淀粉样血管病脑动脉粥样硬化与家族性缺血性脑血管病
欧美冰岛
海绵状血管瘤青年人缺血性卒中
土耳其人缺血性卒中缺血性卒中
欧美欧美
欧美欧美
缺血性卒中缺血性卒中缺血性卒中缺血性卒中缺血性卒中
男性，29岁，突发右侧肢体无力半小时，CT显示左侧半球缺血；MRI显示左侧底节区有腔梗，血管造影显示左MCA闭塞
尿激酶50万单位后血管部分再通，行支架成型术后，即刻及术后1 年随访管腔通畅
女性，67岁，房颤4年，二尖瓣置换术6月突发左侧肢体全瘫4小时行动脉溶栓术，溶栓后出血
（1）静脉溶栓
*Data from CAPRIE study (n=19,185) 1. Coccheri S. Eur Heart J 1998; 19(suppl): P1268.
国别西方
观念
把脑血管病、心血管病和周围血管病合为一体，称为血管事件
中国
血管事件的概念和范畴尚未引起关注和重视
防治
综合治疗
研究名称
The multicenter acute stroke trial-Europe (MAST-E)

美国卒中或短暂性脑缺血发作防治指南(中文版)

虽然许多随机试验和汇总分析支持治疗高血压在预防原发性心血管病，尤其是卒中中的重要性，但只有少数试验直接针对降压治疗在卒中或ＴＩＡ患者二级预防中的作用进行过评价¨０’１５｜。还缺乏可靠的证据来指导急性缺血性卒中早期的高血压处理；目前推荐采用谨慎的方法进行降压治疗，但尚未确定开始治疗的最佳时机¨引。
【关键词】美国心脏协会科学声明；脑缺血；短暂性脑缺血发作；卒中；卒中预防
在美国，卒中是导致死亡和残疾的一个重要原因。短暂性脑缺血发作（ｔｒａｎｓｉｅｎｔｉｓｃｈｅｍｉｃａｔｔａｃｋ，ＴＩＡ）或卒中存活者代表着随后卒中风险增高的一个人群。在每年发生的７９５０００例卒中患者中，约１／４为复发性事件。ＴＩＡ的真实患病率很难估计，因为有相当多的ＴＩＡ患者并未到医疗机构就诊…。基于针对复发性卒中决定因素的流行病学资料和临床试验结果，我们能够提出循证推荐来降低卒中风险。值得注意的是，许多现有数据来自包含有限数量的老年人、女性和多种族人群的临床研究，还需要进一步研究，以证实这些研究结果的普遍适用性。
万方数据
国匣堕鱼簦近苤壶垫！！生！旦笙！！鲞筮！塑蜒』堡咝螋！Ｑ熊』ｇ婴！盟垫！！：地：１２：奠！：１
·３·
１ＴＩＡ和缺血性卒中亚型的定义ＴＩＡ是卒中的一个重要预测因素。据报道，
ＴＩＡ后９０ｄ内的卒中风险可高达１７％，其中以第１周内的风险最高口剖。由于许多预防方法同时适用于ＴＩＡ和缺血性卒中，因此近年来二者的区别已变得不太重要㈣。它们的病理生理学机制相同，但预后可能因严重程度和病因而异，而且定义有赖于诊断性检查的时机和范围。按照传统的临床定义，如果局灶性神经系统症状或体征持续不超过２４ｈ，就被定义为ＴＩＡ。随着现代影像学技术日益广泛应用于颅脑检查，已发现多达ｌ乃症状持续不足２４ｈ的患者存在脑梗死灶”引，从而催生出基于组织学的ＴＩＡ新定义：由局部脑、脊髓或视网膜缺血所致的一过性神经系统功能障碍，但无急性脑梗死的证据＂Ｊ。值得注意的是，本指南所引用的大多数研究采用的都是旧的ＴＩＡ定义。无论采用哪种ＴＩＡ定义，我们都认为本指南提供的推荐意见同时适用于ＴＩＡ和卒中。

美国神经重症监护学会《大面积脑梗死治疗指南(2015)》

美国神经重症监护学会《大面积脑梗死治疗指南(2015)》大面积脑梗死(large hemispheric infarction，LHI)也称恶性大脑中动脉梗死，是导致人类死亡或残疾的重要疾病。

此类患者具有较典型的临床症状，相对单一的进程，常常因小脑幕切迹疝而死亡。

为此，在美国心脏协会/美国卒中协会(American heartassociation/American stroke association，AHA/ASA)《大脑和小脑梗死伴水肿治疗指南(2014)》基础上[1]，美国神经重症监护学会(neurocritical care society,NCS)、德国神经重症监护和急诊医学学会(German society for neuro-intensive care and emergency medicine)汇集了来自北美和欧洲神经重症、神经外科、神经内科、神经介入和神经麻醉等多学科专家，为解决LHI治疗中遇到的诸多临床问题制定了2015年《大面积脑梗死治疗指南》[2]。

该指南对提高LHI临床诊疗水平具有重要的指导意义。

内科治疗相关问题1．体位：头部抬高可促进静脉回流并降低颅内压，同时也降低脑灌注压(cerebral perfusion pressure，CPP)。

平卧位颅压增高，但CPP也随之增加。

大多数LHI可取平卧位，但应注意预防误吸；对伴有高颅压者，可取头高30°位(弱推荐，极低质量)。

2．呼吸道相关问题：LHI常伴有意识障碍、呼吸运动减弱、保护性反射减弱以及吞咽困难，易出现呼吸衰竭。

机械通气是肺脏功能支持治疗的重要手段。

(1)气管插管：格拉斯哥昏迷评分(GCS)<10、呼吸衰竭、保护性反射减弱、颅内压增高、梗死面积>2/3大脑中动脉供血区域、中线移位、肺水肿、肺炎以及拟手术患者，都是气管插管的适应证。

对于伴有呼吸功能不全或神经功能恶化者，应行气管插管(强推荐，极低质量)。

ACCP美国胸科协会抗栓治疗指南治疗指南PPT课件

PCI后常规静脉肝素（证据1A）
UA/NSTEMI病人的LMWH治疗
UA/NSTEMI病人 LMWH治疗
距最后一次注射< 8 h
PCI 根据LMWH时间（证据1C）
距最后一次注射8–12 h
距最后一次注射>12 h
不再加用UFH/ LMWH （证据2C）
依诺肝素 0.3 mg/kg IV bolus
强烈推荐进行分组血栓预防
第七届ACCP血栓栓塞预防指南
Seventh ACCP Consensus Conference on Antithrombotic Therapy
W. Geerts, chair G. Pineo J. Heit D. Bergqvist M. Lassen C. Colwell J. Ray
VTE : 威胁生命的疾病
急性PE后的累积病死率 (%) * (不包括在尸检时首次发现的PE)
Ø 明确诊断的PE的病死率: 3个月17% Ø 75% PE死亡发生于首次住院期间
16 14 12 10
8 6 4 2 0
0
10 20 30 40 50 60 70 80 90 距离诊断的时间 (天)
Goldhaber SZ, et al. Lancet 1999; 353:1386–1389.
（证据2C）
传统抗凝治疗UFH （证据2C）
2C证据（来自于观察性研究）: 极不推荐，其他替代治疗方法同样有效
心房颤动/心房扑动抗栓治疗
危险因素
•卒中病史 •TIA或栓塞病史 •年龄>75岁 •中度或重度左室
功能受损和/或充血性心力衰竭
•高血压病史 •糖尿病
有危险因素
华法林（INR2.0-3.0） [证据级别：1A]

美国医院联合会人血白蛋白、非蛋白胶体及晶体溶液使用指南(中英对照)

Adapted from UHC Guidelines for the Use of Albumin, Nonprotein Colloid, and Crystalloid Solutions, May 2000.美国医院联合会人血白蛋白、非蛋白胶体及晶体溶液使用指南（2000年5月）Hemorrhagic Shock♦Crystalloids should be considered the initial resuscitation fluid of choice.♦Nonprotein colloids may be considered over crystalloids when crystalloids (4 L) have failed to produce a response within 2 hours for adult patients.♦When nonprotein colloids are contraindicated*, albumin 5 percent may be used.♦Patients who experience shock symptoms while under-going hemodialysis are included in this guideline.出血性休克♦晶体溶液可以作为首选药物用于扩张血容量。

♦成人患者输入4L晶体液后2小时无效，可考虑非蛋白胶体液。

♦当对非蛋白胶体液有禁忌，可以考虑使用5％白蛋白。

♦在进行血液透析过程中出现休克表现，也符合如上处理原则。

Nonhemorrhagic (Maldistributive) Shock♦Crystalloids should be considered first-line therapy for nonhemorrhagic shock. Clinical trials have not shown colloids to be more effective in treating sepsis.♦In the presence of capillary leak with pulmonary and/or severe peripheral edema, the administration of up to 4 L of crystalloids in adults before using colloids is appropriate.♦If nonprotein colloids are contraindicated*, albumin may be given.♦Nonprotein colloids and albumin should be used with caution in patients with systemic sepsis.非出血性（分布异常性）休克♦对于非出血性休克，晶体溶液可作为一线治疗药物。

美国脑囊虫病治疗指南 2013年

Ruth Ann Baird,MD Sam Wiebe,MD Joseph R.Zunt,MD, MPHJohn J.Halperin,MD, FAANGary Gronseth,MD, FAANKaren L.Roos,MD, FAAN Correspondence toAmerican Academy of Neurology: guidelines@ Supplemental data at ABSTRACTObjective:To review the evidence base for different treatment strategies in intraparenchymal neurocysticercosis in adults and children.Method:A literature search of Medline,EMBASE,LILACS,and the Cochrane Database from1980 to2008,updated in2012,resulted in the identification of10Class I or Class II trials of cysticidal drugs administered with or without corticosteroids in the treatment of neurocysticercosis. Results:The available data demonstrate that albendazole therapy,administered with or without corticosteroids,is probably effective in decreasing both long-term seizure frequency and the number of cysts demonstrable radiologically in adults and children with neurocysticercosis,and is well-tolerated.There is insufficient information to assess the efficacy of praziquantel. Recommendations:Albendazole plus either dexamethasone or prednisolone should be considered for adults and children with neurocysticercosis,both to decrease the number of active lesions on brain imaging studies(Level B)and to reduce long-term seizure frequency(Level B).The evidence is insufficient to support or refute the use of steroid treatment alone in patients with intraparen-chymal neurocysticercosis(Level U).Neurologyâ2013;80:1424–1429GLOSSARYAED5antiepileptic drug;CI5confidence interval;RCT5randomized controlled trial.Cysticercosis,infection with the larval form of Taeniasolium,is widely prevalent in developing countries ofAfrica,Asia,and Latin America.It is considered by theWHO to be the most common preventable cause ofepilepsy in the developing world,with an estimated2million people having epilepsy caused by T soliuminfection.1Humans can acquire2different forms ofinfection—by eating raw or undercooked pork contain-ing T solium cysts or by eating food contaminated withT solium eggs.Cysts consumed in undercooked meatmature into adult parasites in the human intestine,atwhich time they release eggs and gravid proglottids inthe stool.This form of intestinal infection is called tae-niasis.When T solium eggs are consumed,throughfecal–oral transmission from another human with tae-niasis or through autoinfection,they release onco-spheres into the host’s digestive tract and can thenmigrate throughout the host’s body,becoming encystedin end organs.This systemic infection is called cysticer-cosis.Seeding of larvae in the CNS results in neuro-cysticercosis.Neurocysticercosis,in turn,may affect theCNS parenchyma or the CSF space.In this guideline,we focus solely on parenchymal infections.Cysticercal cysts evolve through4stages,with differ-ent appearances on neuroimaging—the vesicular stage,where the cyst contains a living larva;a colloidal stage asthe larva degenerates;a“granulo-nodular”stage as themembrane of the cyst thickens;and the final stage ofcalcification.Only cysts in the vesicular and colloidalstages contain live larvae2and are amenable to anticy-sticercal treatment.Encysted larvae can remain asymp-tomatic for years.When the larvae do elicit a hostimmune response,patients can develop brain edemaand,more often,seizures.Optimal treatment of thisFrom the Departments of Clinical Neurology(R.A.B.)and Neurology and Neurological Surgery(K.L.R.),Indiana University School of Medicine, Indianapolis;Division of Neurology(S.W.),University of Calgary,Calgary,Canada;Department of Neurology(J.R.Z.),University of Washington, Seattle;Department of Neurosciences(J.J.H.),Overlook Medical Center,Summit,NJ;Department of Neurology and Medicine(J.J.H.),Mount Sinai School of Medicine,New York,NY;and Department of Neurology(G.G.),University of Kansas,Kansas City,KS.Appendices e-1through e-8and the e-tables are available as data supplements on the Neurology®website at .Accepted for publication by the Guideline Development Subcommittee on July14,2012;by the Practice Committee on July24,2012;and by the AAN Board of Directors on December26,2012.Go to for full disclosures.Funding information and disclosures deemed relevant by the authors,if any,are provided at the end of the article.1424©2013American Academy of Neurologyinfection has been the subject of considerable debate, with controversy regarding the appropriate role of both corticosteroids and cysticidal drugs such as praziquantel or albendazole for active infections.To address this controversy,we performed a sys-tematic review of the literature regarding the follow-ing specific clinical questions:1.In patients with symptomatic intraparenchymalneurocysticercosis,is cysticidal therapy more effec-tive than no therapy,and does it affect long-term seizure outcome?2.In patients with symptomatic intraparenchymal neu-rocysticercosis,is treatment with corticosteroids more effective than no treatment?3.When during the course of antiparasitic treatment should steroids be started?4.What is the efficacy of antiepileptic drugs(AEDs)in treating or decreasing occurrence of subsequent seiz-ures secondary to intraparenchymal neurocysticerco-sis,and what is the optimal time course of AED treatment for seizures secondary to intraparenchymal neurocysticercosis?DESCRIPTION OF THE ANALYTIC PROCESS Because cysticercosis is quite prevalent in Latin America,a number of relevant studies have been published in the Spanish-language literature.Therefore,a com-prehensive search was performed of both English-and Spanish-language articles(with the latter reviewed by2 panel members,J.R.Z.and S.W.,who are fluent in Span-ish)in Medline,EMBASE,LILACS,and Cochrane Database of Systematic Reviews from1980to2008, using the search terms“neurocysticercosis,”“cerebral cys-ticercosis,”“brain cysticercosis,”“antiparasitic agents,”“antihelmintics,”“cysticidal,”“clinical trials,”“research design,”“antiseizure,”“anticonvulsant,”“antiepileptic,”“albendazole,”“praziquantel,”“steroid,”“corticosteroid,”“anti-inflammatory agents,”“hydrocortisone,”“predni-sone,”“prednisolone,”“dexamethasone,”and“neurosur-gery”(see appendix e-1on the Neurology®Web site at for complete search strategy).The search identified590citations.An updated search of Medline and the Cochrane Database of Systematic Re-views was performed in January2012and identified an additional20citations.Each abstract was reviewed by at least2reviewers.Review articles without primary data, case reports,and small case series were discarded.The remaining pertinent123articles were reviewed in detail, and data regarding cohort size,patient characteristics, inclusion and exclusion criteria,completion rate, treatment and dosage,study design,study length, primary and secondary outcomes,efficacy,and effect size were extracted from each article and tabulated using a data extraction form.Each article was classified according to the American Academy of Neurology therapeutic clas-sification of evidence scheme(see appendix e-4).Risk differences with95%confidence intervals(CIs) were used as the preferred measure of effect and statisti-cal precision.When necessary to increase statistical pre-cision,studies with the lowest risk of bias were pooled in a fixed-effects meta-analysis.Class II studies were included in the meta-analysis only when precision was insufficient after Class I studies were pooled. ANALYSIS OF EVIDENCE In patients with symptomatic intraparenchymal neurocysticercosis,is cysticidal therapy more effective than no therapy,and does it affect long-term seizure outcome?Treatment efficacy can be judged by a radiologic surrogate marker—the numbers of remain-ing active and inactive cysts—and clinically by the num-ber of patients experiencing seizures after treatment.Of note in these studies,patients received anticonvulsants initially,most often phenytoin,but this was not explicitly controlled as part of the treatment protocols.Also of note,although some of the cited studies were limited to patients with active cysts,some included individuals with transitional cysts,in which the parasite is already dead or dying.Because cysticidal therapy would not be expected to affect the disease course if the organism were already dead,this may actually have led to an underesti-mation of treatment efficacy.Three Class I325(1Class I for imaging only5and Class IV for clinical measures,including seizure fre-quency)and6Class II studies6–11(1Class II for imag-ing studies only6)addressed cysticidal therapy (administered with or without steroids)in the initial treatment of neurocysticercosis.One11of the Class II studies compared albendazole alone with albendazole with praziquantel without a control group and therefore was not informative regarding whether antihelminthic therapy is useful.(There was no difference in any out-come measure between the2regimens.)Five of the remaining Class II studies were restricted to the pedi-atric population.7–11One of these studies was Class II for imaging studies only.9One Class I study3included adults only.Two Class I studies3,4and all5pediatric Class II studies7–11combined corticosteroid treatment with cysticidal therapy.One randomized controlled trial(RCT)(Class I) evaluated120patients with viable parenchymal cysts and seizures who were assigned to receive either albenda-zole(800mg/day)plus dexamethasone(6mg/day,both for10days)or2placebos.3During months2–30 following treatment,there was a nonsignificant 46%reduction in the number of total seizures (95%CI74%to83%)in the albendazole/dexa-methasone group as compared with placebo and a significant67%reduction in number of seizures with generalization(95%CI20%to86%,p5 0.01).At6-month follow-up the number of patients Neurology80April9,20131425with active cysts on imaging studies was significantly lower in patients receiving active treatment than in those receiving placebo (p ,0.007).Therapy was well-tolerated with the exception of abdominal pain and nausea,which were reported more commonly in the treatment group.The studies do not state whether gastrointestinal prophylaxis was used.An RCT (Class II)in 29patients with multiple cystic lesions on CT (cysts of all types,excluding only calcified cysts)6who received either albendazole (15mg/kg/day for 7days)or placebo showed no signifi-cant difference in total number of lesions or resolu-tion of cysts on head CT at 1week,1month,and 3months.Seizure outcomes were not reported.A third RCT,in which all patients had active or tran-sitional (i.e.,vesicular evolving into colloidal)cysts,4as-signed 88patients to receive albendazole (800mg/day,or weight based,for 8days)and oral prednisone (75mg/day or weight based)and 90patients to receive prednisone and placebo.At 1month,cysts had disappeared in 31%of those receiving albendazole and in 7%of those receiv-ing prednisone alone (p ,0.001).When Kaplan-Meyer projections were applied,at 12months 62%of patients receiving albendazole were seizure-free vs 52%of con-trols (not significant).In a fourth RCT,5in which all patients had contrast-enhancing cysts,33patients received 3days of albenda-zole (15mg/kg for 3days,without corticosteroids),and 34patients received placebo.At 6months,cysts had resolved completely in 85%of those receiving albenda-zole and in 41%of those receiving placebo (p ,0.001).Seizure frequency was low in both groups at 6-month follow-up,with no significant difference in frequency.In the pediatric population,4Class II studies pro-vide conflicting results for radiologic outcomes but used differing criteria.Two studies 7,9(63patients and 93patients,respectively)found a decrease in active le-sions in patients receiving albendazole (15mg/kg/day for 28days in both,prednisolone 1–2mg/kg/day for the first 5days in the first,dexamethasone 0.15mg/kg/day for 5days in the second).In the first study,CT scans performed 3months after treatment showed disappear-ance of active lesions in 64.5%of patients treated with albendazole and in 37.5%of controls.In the second study,CT scans performed at 3months demonstrated complete or partial resolution of cysts in 79%of patients given treatment vs in 57%of controls.Two 8,10studies (with 53patients and 110patients,respectively)found no difference in the number of patients in whom lesions disappeared (treatment albendazole 15mg/kg/day for 28days,with prednisolone 2mg/kg/day for 3days before albendazole in the first;albendazole 15mg/kg/day for 4weeks,prednisolone 2mg/kg/day for 21days,and then a 1-week taper in the second).In the first,cysts disap-peared on 6-month follow-up CT scan in 54%of pa-tients receiving treatment and in 55%of those receiving placebo.In the second,single cysts disappeared on 3-month follow-up CT in 53%of patients receiving steroids,in 60%of those receiving albendazole,and in 63%of those receiving both treatments.One Class II study 7showed a decrease in late recurrent seizures among treated patients,although the numbers were small in both groups,and the difference was not significant.One Class II study 10showed cysticidal therapy was ben-eficial in reducing seizure recurrence.To increase the precision of the estimate of the effec-tiveness of albendazole regarding seizure frequency,we performed a meta-analysis combining the 2Class I 3,4and 4Class II studies 5,7,8,10with comparable data (figure).Overall,there was a 6.1%decrease in the risk of having seizures (95%CI 0.3%to 11.9%,number needed to treat 516).Conclusion.Based on imaging findings in 4Class I studies (3concordant,1underpowered study failing to show an effect)and a meta-analysis of 2Class I and 4Class II studies,albendazole (400mg BID for adults or weight-based dosing for either adults or children)is probably safe and effective in reducing both the number of cysts and long-term seizure frequency in adults and children with neurocysticercosis.In most studies,cortico-steroids were coadministered,in varying dosages,and this combination appears effective.Data are insufficient to indicate whether corticosteroids are necessary in this setting.Clinical context.The available studies have used different stratification methods for seizure analysis and different criteria for judging improvementinMeta-analysis,combining data from the 2Class I and 4Class II studies with outcome data regarding seizure risk (proportion of treated patients with seizures relative to proportion of untreated patients with seizures).1426Neurology 80April 9,2013imaging.On the basis of the3Class I studies it ap-pears albendazole plus corticosteroids decreases the number of active brain lesions relative to placebo and,on the basis of a meta-analysis of available data,de-creases the number of patients with seizures,at modest cost.These findings appear to be consistent in adults and children.Side effects of treatment appear minimal.Of greatest concern has been the potential—emphasized in a single large study12—for increased seizures and encephalopa-thy as a result of treatment-induced parasite death. This study,in which all patients had multiple cysts (with5or more cysts in over25%of patients)and in which neither allocation nor treatment was con-cealed,was considered to be Class IV and therefore not considered contributory.Of the3Class I or II studies that reported seizure frequency during treat-ment,3,4,7none showed an increase in seizure fre-quency with treatment(pooled risk difference vs placebo20.1%,95%CI26.2%to5.9%).Only 2studies3,4detailed other side effects.In the first study3headaches occurred in32of60patients given treatment vs in31of60controls;dizziness occurred in9patients vs in4,and abdominal com-plaints occurred in8vs in0.Only the last finding was significant;however,patients given treatment in this study all received corticosteroids,whereas con-trols did not.In the second study,headaches occurred in59of88patients given treatment vs in 53of90controls;abdominal complaints occurred in 38vs in40(neither side-effect finding being significant).Recommendations often emphasize the danger of antihelminthic treatment in patients with a very large lesion burden.The cited studies all excluded patients with massive cerebral edema or innumerable lesions but were otherwise inconsistent.Three studies5,7,10 were limited to patients with single lesions.In one study,patients had1or2cysts.9In another study, 84%of patients had1or2;the remainder had fewer than100.In the remaining3studies,the number of cysts was described as“multiple,”6“less than20,”3and “less than36.”4Recommendation.Albendazole plus either dexametha-sone or prednisolone should be considered for adults and children with neurocysticercosis,both to decrease the number of active lesions on brain imaging studies (Level B)and to reduce long-term seizure frequency (Level B).In patients with symptomatic intraparenchymal neurocysticercosis,is treatment with corticosteroids more effective than no treatment?One Class I study13and one Class II/Class IV study14assessed steroid treatment without administration of cysticidal therapy.In the Class I study,148patients with solitary cysts were randomized to receive prednisolone(40–60mg/day on the basis of weight for2weeks,followed by a4-day taper)or pla-cebo.At3months there were no differences in imaging findings or in overall seizure frequency between the2 groups.Frequency of generalized seizures at follow-up was16%in patients receiving corticosteroids and60% in controls;frequency of focal seizures was63%among those receiving methylprednisolone and25%among controls(both differences significant).The second study14included97patients with new-onset seizures and a single enhancing CT lesion, randomized to receive AEDs plus prednisolone(pred-nisolone1mg/kg/day for10days,followed by a4-day taper)or AED monotherapy alone.At6-month follow-up,the CT lesions had disappeared in88%of patients in the prednisolone group vs in52%of those in the antiepileptic group(p50.003).The Kaplan-Meier esti-mated risk of seizure recurrence was significantly less in the prednisolone group(8.38;df1;p,0.01).Although the study showed benefit,the strength of evidence is Class II for CT resolution of lesions outcome and Class IV for seizure outcome.Conclusion.On the basis of one Class I study showing no benefit radiologically and ambiguous benefit clinically and one Class II/IV study showing benefit,there is insuf-ficient evidence to recommend steroid treatment alone for patients with solitary intraparenchymal neurocysticer-cosis granulomata.Clinical context.The effect of corticosteroid treatment alone in neurocysticercosis has not been widely studied. Most trials include a combination of cysticidal therapy and steroid treatment.Recommendation.The evidence is insufficient to support or refute the use of steroid treatment alone in patients with intraparenchymal neurocysticercosis(Level U). When during the course of antiparasitic treatment should steroids be started?We found no studies to answer this question.What is the efficacy of AEDs in treating or decreasing occurrence of subsequent seizures secondary to intraparenchymal neurocysticercosis,and what is the optimal time course of AED treatment for seizures secondary to intraparenchymal neurocysticercosis?We found no studies to answer this question.Clinical context.Given the well-established efficacy and safety of a broad range of AEDs and the frequency with which neurocysticercosis causes seizures,it is reasonable to treat these patients with AEDs at least until the active lesions have subsided.RECOMMENDATIONS FOR FUTURE RESEARCH Several aspects of treatment require further study.1.Cysticercal cysts evolve through4stages:the livinglarva,the degenerating larva,a reactive thickening of the cyst membrane,and calcification.Only cysts in the first2stages contain live cysts.2A study that Neurology80April9,20131427evaluates the response to therapy on the basis of the stage of the cyst would be useful.2.The successful treatment trials cited all used cystici-dal therapy administered with or without cortico-steroids.Studies are needed to determine the appropriate use and timing of administration of adjuvant corticosteroids and the potential benefit of combination cysticidal therapy.3.Neurocysticercosis can be intraventricular or intraoc-ular or can involve the subarachnoid space.Studies have not addressed these forms of the infection. Assessment of different treatment strategies,medical or surgical,for such patients would be helpful.4.HIV coinfection may alter efficacy of antihelminthic treatment or produce important drug–drug interac-tions;determination of best treatment for neurocysti-cercosis in such patients is needed.5.Additional studies should focus on clinical outcomes rather than surrogate CT outcomes,as the two do not always correlate.Patients may experience seizure recurrence despite resolution of lesions on CT. AUTHOR CONTRIBUTIONSRuth Ann Baird:drafting/revising the manuscript,study concept or design,anal-ysis or interpretation of data.Samuel Wiebe:drafting/revising the manuscript, study concept or design,analysis or interpretation of data.Joseph Raymond Zunt:drafting/revising the manuscript,study concept or design,analysis or inter-pretation of data.John Halperin:drafting/revising the manuscript,study concept or design,analysis or interpretation of data,statistical analysis,study supervision. Gary Gronseth:drafting/revising the manuscript,analysis or interpretation of data,statistical analysis.Karen L.Roos:drafting/revising the manuscript,study concept or design,analysis or interpretation of data,study supervision.STUDY FUNDINGThis guideline was developed with financial support from the American Acad-emy of Neurology.None of the authors received reimbursement,honoraria,or stipends for their participation in development of this guideline.DISCLOSURER.A.Baird has no disclosures to report.S.Wiebe has received honoraria from UCB Pharma Inc.and has received research funding from Alberta Heritage Medical Research Foundation,Canadian Institute for Health Research,MSI Foundation of Alberta,and the Hotchkiss Brain Institute of the University of Calgary.J.R.Zunt has received honoraria from the American Academy of Neu-rology and has received funding from the NIH on retroviral infections.J.Hal-perin has testified in several physician medical malpractice cases and aided the Connecticut Department of Health in proceedings regarding Lyme disease.G.Gronseth has served on a speakers’bureau for Boehringer Ingelheim (resigned December2011),and receives honoraria from the American Acad-emy of Neurology.K.Roos has received funding for travel from the American Academy of Neurology as a member of its Board of Directors.Go to for full disclosures.DISCLAIMERThis statement is provided as an educational service of the American Academy of Neurology.It is based on an assessment of current scientific and clinical information.It is not intended to include all possible proper methods of care for a particular neurologic problem or all legitimate criteria for choosing to use a specific procedure.Neither is it intended to exclude any reasonable alter-native methodologies.The AAN recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient,based on all of the circumstances involved.The clinical context section is made avail-able in order to place the evidence-based guideline(s)into perspective with cur-rent practice habits and challenges.Formal practice recommendations are not intended to replace clinical judgment.CONFLICT OF INTERESTThe American Academy of Neurology is committed to producing independent, critical,and truthful clinical practice guidelines(CPGs).Significant efforts are made to minimize the potential for conflicts of interest to influence the recom-mendations of this CPG.To the extent possible,the AAN keeps separate those who have a financial stake in the success or failure of the products appraised in the CPGs and the developers of the guidelines.Conflict of interest forms were obtained from all authors and reviewed by an oversight committee before pro-ject initiation.AAN limits the participation of authors with substantial conflicts of interest.The AAN forbids commercial participation in,or funding of,guide-line projects.Drafts of the guideline have been reviewed by at least3AAN committees,a network of neurologists,Neurology peer reviewers,and represen-tatives from related fields.The AAN Guideline Author Conflict of Interest Policy can be viewed at .Received August3,2012.Accepted in final form December14,2012.REFERENCES1.Coyle CM,Mahanty S,Zunt JR,et al.Neurocysticercosis:neglected but not forgotten.PLoS Negl Trop Dis2012;6: e1500.2.Murthy JMK,Reddy YVS.Prognosis of epilepsy associ-ated with single CT enhancing lesion:a long term follow-up study.J Neurol Sci1998;159:151–155.3.Garcia HH,Pretell EJ,Gilman RH,et al.A trial of anti-parasitic treatment to reduce the rate of seizures due to cerebral cysticercosis.N Engl J Med2004;350:249–258.4.Carpio A,Kelvin EA,Bagiella E,et al.Effects of albenda-zole treatment on neurocysticercosis:a randomised con-trolled trial.J Neurol Neurosurg Psychiatry2008;79: 1050–1055.5.Chaurasia RN,Garg RK,Agarwal A,et al.Three day alben-dazole therapy in patients with a solitary cysticercus granuloma:a randomized double blind placebo controlled study.SoutheastAsian J Trop Med Public Health2010;41:517–525.6.Padma MV,Behari M,Misra NK,Ahuja GK.Alben-dazole in neurocysticercosis.Natl Med J India1995;8: 255–258.7.Baranwal AK,Singhi PD,Khandelwal N,Singhi SC.Alben-dazole therapy in children with focal seizures and single small enhancing computerized tomographic lesions:a randomized, placebo-controlled,double blind trial.Pediatr Infect Dis J 1998;17:696–700.8.Gogia S,Talukdar B,Choudhury V,Arora BS.Neuro-cysticercosis in children:clinical findings and response to albendazole therapy in a randomized,double-blind,pla-cebo-controlled trial in newly diagnosed cases.Trans R Soc Trop Med Hyg2003;97:416–421.9.Kalra VK,Dua T,Kumar V.Efficacy of albendazole andshort-course dexamethasone treatment in children with1or 2ring-enhancing lesions of neurocysticercosis:a randomized controlled trial.J Pediatr2003;143:111–114.10.Singhi P,Jain V,Khandelwal N.Corticosteroids versusalbendazole for treatment of single small enhancing com-puted tomographic lesions in children with neurocysticer-cosis.J Child Neurol2004;19:323–327.11.Kaur S,Singhi P,Singhi S,Khandelwal binationtherapy with albendazole and praziquantel versus alben-dazole alone in children with seizures and single lesion neurocysticercosis:a randomized,placebo-controlled double blind trial.Pediatr Infect Dis J2009;28: 403–406.12.Das K,Mondal GP,Banerjee M,Mukherjee BB,Singh OP.Role of antiparasitic therapy for seizures and resolution of lesions in neurocysticercosis patients:an8year randomised study.J Clin Neurosci2007;14:1172–1177.1428Neurology80April9,201313.Singla M,Prabhakar S,Modi M,Medhi B,Khandelwal N,Lal V.Short-course of prednisolone in solitary cysticercus granuloma:a randomized,double-blind,placebo-controlled trial.Epilepsia2011;52:1914–1917.14.Mall RK,Agarwal A,Garg RK,Kar AM,Skukla R.Shortcourse of prednisolone in Indian patients with solitary cysticer-cus granuloma and new-onset seizures.Epilepsia2003;44: 1397–1401.Neurology80April9,20131429。

美国脑血管病治疗指南解读-Guideline-

• CEA后1个月、6个月和每年的颅外段颈动脉无创性成像检查是必要的，用以评估手术血管的通畅程度，并排除新的或对侧病变。如果在较长时间内仍较稳定，也可以间隔较长时间再去检查（C 级证据）。
CAS相关危险性
• 压力反射反应包括心动过缓、低血压和血管迷走神经反应， MI 危险性一般报道大约为1%， 3500例患者的CAPTURE登记研究中只有0.9%。但是在ARCHeR（使用ACCULINK的高危患者颈动脉血管重建术）试验中达到了2.4% 。
• 症状性颈动脉狭窄，无创性成像发现同侧颈内动脉直径狭窄超过70%（A级证据）或通过导管血管造影发现狭窄超过50%（B 级证据），血管内介入治疗可能具有低中危并发症，提示CAS 可以作为CEA的替代治疗方法，预期围手术期卒中或死亡率小于6%（B级证据）。
等级Ⅱ • 等级Ⅱa
• 颈内动脉狭窄程度大于70%的无症状患者，如果围手术期卒中、MI和死亡的危险性很低，施行CEA是合理的（A级证据）。
• 几个研究发现，颈部放射后也能成功行CEA。在这种情况下，行 CAS更加安全，但是CAS后的再狭窄率较高，3年以上的再狭窄率达到18%-80%。
CEA围手术期处理建议
• Ⅰ级
• 在CEA前推荐给予阿斯匹林（81-325mg/d），并且术后无限期持续服用（A级证据）。
• CEA术后一个月，应该使用阿斯匹林（75-3255mg/d），或低剂量阿斯匹林加双嘧达莫缓释片（分别25mg和200mg，bid）联合用药来预防缺血性心血管事件（B级证据）。
• 女性患者比男性有更高的手术危险性（分别为10.4% vs 5.8%）。ACAS和 NASCET研究中，女性患者在手术死亡率、神经系统发病率和颈动脉再狭窄率等方面，相比于男性很少出现有利结果，且几乎很少或根本不会从手术中获益。几个研究已经发现，对女性患者行补片修补会明显改善术后结果。

美国大面积脑梗死治疗指南解读

美国大面积脑梗死治疗指南解读导读大面积脑梗死（LHI）也称恶性大脑中动脉梗死，是导致人类死亡或残疾的重要疾病。

此类患者具有较典型的临床症状，相对单一的进程，常常因小脑幕切迹疝而死亡。

为此，来自北美和欧洲的多学科专家，制定了《大面积脑梗死治疗指南》，该指南对提高LHI临床诊疗水平具有重要的指导意义。

现结合国内外新近发表的相关文献解读如下。

证据来源级别和推荐力度证据来源：指南以循证医学为依据，采用“推荐分级的评估、制定与评价（GRADE）”体系，将证据来源分为：极低质量、低质量、中等质量、高质量。

推荐力度：综合证据来源级别、风险效益比、患者价值观以及费用等多种因素将推荐力度分为“强推荐”和“弱推荐”2级。

内科治疗相关问题体位头部抬高可促进静脉回流并降低颅内压，同时也降低脑灌注压（CPP）。

平卧位颅压增高，但CPP也随之增加。

大多数LHI可取平卧位，但应注意预防误吸；对伴有高颅压者，可取头高30°位（弱推荐，极低质量）。

呼吸道相关问题LHI常伴有意识障碍、呼吸运动减弱、保护性反射减弱以及吞咽困难，易出现呼吸衰竭。

机械通气是肺脏功能支持治疗的重要手段。

➤ (1) 气管插管：格拉斯哥昏迷评分（GCS）<10、呼吸衰竭、保护性反射减弱、颅内压增高、梗死面积>2/3大脑中动脉供血区域、中线移位、肺水肿、肺炎以及拟手术患者，都是气管插管的适应证。

对于伴有呼吸功能不全或神经功能恶化者，应行气管插管（强推荐，极低质量）。

➤ (2) 气管插管拔除：意识障碍和吞咽困难都可导致拔管困难，而再次插管却可增加ICU患者的致残率和致死率。

对于不能交流和配合动作的LHI患者，满足如下条件就可以尝试拔管：自主呼吸实验成功、无流涎、无频繁的吮吸动作、存在咳嗽反射且不耐受气管插管、未使用镇静和镇痛药物（强推荐，极低质量）。

➤ (3) 气管切开：一项针对ICU患者的回顾性研究表明，气管切开可以改善预后并减少机械通气时间、ICU治疗时间和治疗费用。

美国最新高血压治疗指南

美国最新高血压治疗指南美国高血压预防、监测、评估和治疗委员会（ JNC ）于 2003 年第 7 次报告时公布了美国的高血压治疗指南（以下简称 JNC 7 ）这一指南是世界最权威的有关高血压的指导性文件，下面介绍一下有关此指南的情况。

背景JNC 7 指南为美国高血压预防、检测、评估和治疗联合委员会第七份报告 ( 简要版本 ),2003 年 5 月在美国《 Journal of AmericanMedical Association 》第 289 卷 2560 至 2572 页上发表。

自从 1997 年JNC 6 公布以来的 6 年间 , 全球已经有 30 多个大规模高血压治疗临床试验获得结果。

这些研究结果几乎一致地证实 , 不论年龄、性别、种族与社会经济状况如何 , 降低血压具有决定意义的重要性 , 这些研究结果为制定新的较简易的治疗方案提供了更充分的依据。

美国高血压的知晓率、治疗率和控制率在近年来略有改善 , 分别从 10 年前的 68% 、 54% 、 27% 增长到目前的70% 、 59% 、 34% 。

虽然有所改善 , 但是治疗率和控制率仍然较低 , 控制率与 2010 年预定达到的 50% 目标相差还较大 , 其中一个重要原因是患者未得到有效的治疗 , 过去较复杂的评估与治疗方案相当程度上妨碍了临床医师对人数众多高血压患者实施治疗。

为了加速血压控制率提高的步伐 , 治疗指南应该与时俱进 , 汲取科学研究的新成果 , 因此美国心、肺、血液研究院 (NHLBI) 的全国高血压教育项目 (NHBPEP) 协调委员会组织了专门的 JNC 7 起草组 , 制定一份简明、可操作性强的新指南。

要点1 调整血压分类新分类将血压水平分为正常、高血压前期、高血压 1 级、高血压 2 级。

而过去的 JNC 6 将血压分为理想、正常、正常高值、高血压 1 级、高血压 2 级和高血压 3 级。

JNC 7 的正常血压等同于过去的理想血压[ 收缩压 <120mmHg(1mmHg=0.133kPa) 和舒张压 <80mmHg]; 将过去的正常血压 ( 收缩压 <130mmHg 和舒张压 <85mmHg) 和正常高值 ( 收缩压 130 ～ 139mmHg 或舒张压 85 ～ 89mmHg) 合并为现在的“ 高血压前期”, 即 : 收缩压 120 ～ 139mmHg 或舒张压 80 ～ 89mmHg 。

2020AHA心肺复苏指南(成人基础及高级生命支持)

2020 AHA
心肺复苏指南解读
成人基础及高级生命支持
AHA：美国心脏协会
YIJIEWENKU PPT版权@医界指南演变1700年
法国溺水者口对口呼吸救治
1891年
报道了最早的人体胸部按压
1903年
首例胸外按压成功 CPR出现
1966年
美国出版CPR 指南
2000年
AHA出版基于循证医学全面 CPR指南
最近的一项试验性 RCT 表明，通过重新放置电极片来改变除颤电流的方向可能与双重连续除颤效用相当，同时避免因能量增加造成伤害以及除颤器受损的风险。根据目前的证据，尚不清楚双重连续除颤是否有益。 2020CPR&ECC guidelines 7272 Greenville Avenue Dallas.Texas 75231-4596，USA
2020CPR&ECC guidelines 7272 Greenville Avenue Dallas.Texas 75231-4596，USA
康复期间的治疗和支持
2010 我们建议心脏骤停存活者在出院前进行生理、神经、心肺和认知障碍方面的多模式
康复评估和治疗
2020
我们建议心无变脏化/再骤次确认停存活者在出院前进行生理、神经、心肺和认知障碍方面的多模式康复评估和治疗。
孕妇心脏骤停
2010 空白
2020
由于可能干无变扰化/再孕次确认产妇复苏，在孕妇心脏骤停期间不应进行胎儿监测。
在孕产妇心脏骤停期间对胎儿进行心脏评估并无帮助，还可能会分散对必要复苏操作的注意力 2020CPR&ECC guidelines 7272 Greenville Avenue Dallas.Texas 75231-4596，USA

美国高血压指南(中文版)

JAMA杂志今天发布了2014年成人高血压治疗指南（2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults），新指南包含9条推荐和一种治疗流JNC8高血压管理流程图：图1. JNC8推荐管理流程图新指南回答了三个常见问题：•何时开始降压治疗专家组对需要开始治疗的血压水平进行明确。

指南推荐，60岁以上老年人，血压达到150/90即应开始降压治疗；治疗目标值如上述。

但是，专家组强调，新指南规定的这一血压界值并不是重新定义高血压，此前由Joint National Committee 7定义的高血压水平（>=140/90 mm Hg ）仍然有效。

血压处于这一范围的人群，均应通过生活方式进行干预。

•血压治疗目标值新指南对以上三个问题的回答总体概括如下：60岁以上老年高血压患者的高血压治疗目标值应为150/90 mm Hg；30-59岁高血压患者舒张压应低于90mmHg。

但是这一年龄段高血压患者收缩压的推荐治疗目标值目前没有充足的证据支持，30岁以下高血压患者舒张压的治疗目标值也没有证据支持。

因此专家组推荐，这类人群的高血压治疗目标应低于140/90 mm Hg。

此外，对于60岁以下罹患高血压合并糖尿病，或高血压合并非糖尿病性慢性肾脏疾病(CKD)患者，指南推荐的治疗目标值和60岁以下普通高血压人群一致。

•高血压治疗起始用药专家点评：•Harold C. Sox, M.D.：新指南证据级别更有说服力Harold C. Sox, M.D.，达特茅斯学院教授Harold C. Sox, M.D.指出，新版指南以及撰写指南的专家小组权威性更高。

他指出，评价指南是否权威，可以从以下四个方面进行考察：1，指南中最可信的部分是什么？2，指南是如何撰写制定的？3，撰写指南的专家小组成员扮演何种角色？4，指南获取公众信任的途径是什么？Harold博士认为，从这四个角度来看，新版指南权威性更高。

JNC8美国高血压治疗指南推荐

JNC8美国高血压治疗指南推荐高血压是最常见的心血管病，是全球范围内的重大公共卫生问题。

高血压是多种心脑血管疾病的导火索，可促使冠心病、心力衰竭、脑卒中、脑出血及肾脏疾患等疾病的发病风险大大增高。

因此高血压被称为人类健康的“无形杀手”。

美国预防、检测、评估与治疗高血压联合委员会第八次报告（简称JNC 8）于近日在JAMA杂志发表，正式颁布了美国成人高血压治疗指南（Evidence-Based Guideline for the Management of High Blood Pressure in Adults），新指南建立了高血压治疗的临床证据条款和推荐，包含九条新推荐和一项高血压患者治疗流程图来帮助医师治疗高血压患者，以满足更多高血压医务工作者的需要，强调使用最佳的临床证据资料与改善患者临床预后为目标。

与JNC7相比，新指南的证据级别更高。

JNC8新指南的证据均来自于随机对照（RCT）研究，所有证据级别和推荐均根据临床研究对于人体健康的影响程度进行了评估。

美国JNC8新指南的制定对于提高高血压医师诊疗效果、改善高血压患者健康具有极其重要意义。

美国JNC8新指南主要有九条新推荐和三个常见临床问题解答。

临床问题解答如下：（1）、高血压患者开始治疗的时间点。

专家组对需要开始治疗的血压水平进行明确。

指南推荐，60岁以上老年人，血压达到150/90 mm Hg即应开始降压治疗。

但新指南规定的这一血压界值并不是重新定义高血压。