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*Only for medical professionals to read and refer to these points to master! A large number of cerebral hemorrhage and tentorium hernia is one of the clinical emergency situations, and the time available for clinicians to treat is very short.
The efficient process is conducive to increasing the patient's hope of survival and improving the subsequent quality of life
.
At the 7th Annual Conference of the Chinese Stroke Society (CSA&TISC 2021), Professor Wu Guofeng from the Affiliated Hospital of Guizhou Medical University gave us the title "Large Cerebral Hemorrhage and Cerebral Hernia: Pre-hospital First Aid Key Points and Interpretation of the Latest Guidelines "Let’s learn about it together~ First of all, start with a case! Clinical case The eighty-year-old lady was suddenly unconscious at home for 2 hours.
The family members called 96999, and the ambulance went to the clinic
.
When the patient was sent to the Emergency Medicine Department of the Affiliated Hospital of your hospital, the pupils on both sides were already unequal.
The diameter of the pupil in the right eye was about 4.
0mm, and the diameter of the pupil in the left eye was 2.
5mm.
Based on experience, it is judged that the patient has had a brain herniation
.
The patient was treated for dehydration and lowering intracranial pressure immediately, and the green channel was opened for emergency head CT scan.
The results suggested that the elderly female patient had a severe cerebral hemorrhage, with a bleeding volume of 120ml, and her life was at stake
.
Emergency head CT revealed that there was a large amount of supratentorial cerebral hemorrhage and brain herniation, the midline structure was severely displaced, and the space-occupying effect was obvious (see Figure 1)
.
Figure 1: According to the traditional model of emergency head CT, it must be a neurosurgery consultation for transfer treatment.
However, considering that the patient's condition is serious, transfer to the department will delay the rescue treatment time, so it is decided to carry out the treatment on the spot in the rescue room and implement it urgently.
Aspiration of hematoma at bedside to reduce intracranial pressure; 2 hours after operation, the patient's pupils returned to normal level, and 3 days after operation, the head CT was rechecked (see Figure 2), the hematoma was basically cleared, and the patient was in danger of being out of danger.
Clear
.
Figure 2: Re-examination of the head CT.
From this case, we have some enlightenment.
Spontaneous intracerebral hemorrhage is a type of stroke that seriously threatens the patient's life.
Not only the mortality rate is high, but the disability rate is also high: massive supratentorial intracerebral hemorrhage often complicates the temporal lobe.
Groove hernia, also known as canopy hernia, the treatment time window is very short, what is robbed is time, what is robbed is the process, and the rescue links are reduced as much as possible! Overview of Spontaneous Cerebral Hemorrhage Hemorrhagic stroke refers to the spontaneous rupture of cerebrovascular vessels, and blood flows into the brain tissue or subarachnoid space, thereby compressing or destroying the brain tissue and affecting nerve function
.
The patient may manifest as unconsciousness, hemiplegia, speech disorder, and even death in a short period of time; intracranial pressure increases with the increase of hematoma volume, and the patient may show vomiting at first, then quickly enter a coma and further develop.
The pupils appear to be unequal in size, which immediately compresses the brainstem, resulting in the final death of the patient.
Therefore, patients with large amounts of cerebral hemorrhage require urgent surgical treatment; for large amounts of supratentorial cerebral hemorrhage with cerebral herniation, surgical treatment is the only option
.
Clinical study on the treatment of massive supratentorial intracerebral hemorrhage and herniation-a multi-center non-randomized controlled study (1) Research purpose To study the effect and feasibility of emergency stereotactic minimally invasive surgery in the treatment of massive intracerebral hemorrhage complicated by herniation; to study targeted minimally invasive surgery As the observation group, routine craniotomy and decompression with bone removal and hematoma removal were used as the control group; the primary endpoint was survival at three months and neurological score or quality of life
.
(2) Methods and technical main observation indicators: patient mortality; ability of daily living (ADL) score; Glasgow coma score (GCS); National Institutes of Health Stroke Scale (NIHSS)
.
Secondary indicators: the incidence of postoperative rebleeding; the incidence of other postoperative complications (such as: secondary epilepsy, severe cardiopulmonary complications, etc.
)
.
(3) Enrollment criteria 1) Patients with hypertensive cerebral hemorrhage over 18 years old who were diagnosed with cerebral parenchymal hemorrhage by head CT; 2) Hemorrhage location supratentorial: thalamus, basal ganglia or brain lobe; 3) Hippocampal sulcus hernia The clinical symptoms and signs of the patient, CT of the head showed that the midline structure was shifted, and the space-occupying effect was serious; 4) There was no contraindication to surgery, and the family members signed an informed consent
.
(4) Patient grouping A total of 149 patients were enrolled.
The directional puncture group was subjected to negative pressure aspiration of hematoma (MIS group, n=75), and the control group was subjected to conventional decompressive craniectomy (CDC group, n=74)
.
(5) Research results ① Comparison of the number of patients alive/death at 12 weeks of follow-up (see Figure 3) At 3 months of follow-up, 38 cases (51.
38%) survived in the conventional craniotomy group, 64 cases (85.
33%) in the minimally invasive group survived
.
Figure 3: Comparison of the number of survivors/deaths in the 12-week follow-up ②Death and survival in the vegetative state The mortality and survival in the vegetative state of patients in the minimally invasive treatment group were significantly lower than those in the conventional craniotomy group
.
③Glasgow coma scores The scores of patients in the minimally invasive treatment group were significantly higher than those in the conventional craniotomy group
.
④Comparing the survival status of the two groups at 3 months of follow-up, the severe disability rate of the minimally invasive treatment group was significantly lower than that of the conventional craniotomy group
.
⑤Comparison of neurological function scores (By NIHSS) at 3 months of follow-up, the scores of patients in the minimally invasive treatment group were significantly higher than those in the conventional craniotomy and decompression group
.
⑥Comparison of postoperative complications The incidence of postoperative rebleeding, secondary epilepsy, and severe cardiopulmonary complications in the minimally invasive treatment group was significantly lower than that in the conventional craniotomy group
.
(6) Research conclusions 1.
Emergency surgical treatment is an important way to save the lives of patients with massive supratentorial cerebral hemorrhage and cerebral herniation; 2.
In terms of reducing mortality and vegetative survival rate, emergency minimally invasive surgery is significantly better than conventional treatment of cerebral hemorrhage Craniotomy
.
Interpretation of the relevant content of the multidisciplinary guidelines for the diagnosis and treatment of cerebral hemorrhage 1.
Recommendation level and evidence level description: Recommendation level: I (should be implemented); IIa (implementation is appropriate); IIb (can be considered); level III (unintentional or harmful)
.
Evidence level: A (multi-center or multiple randomized controlled trials); B (single-center single randomized controlled trial or multiple randomized controlled trials); C level (expert opinion, case study)
.
2.
Pre-hospital first aid points 1.
Clean up respiratory tract vomit or secretions, if necessary, tracheal intubation, balloon assisted breathing; 2.
Establish venous channels, monitor blood pressure, heart rate, breathing and other vital signs; 3.
Quickly and briefly inquire about the disease , Rapid initial diagnosis; 4.
Adjust blood pressure and intracranial pressure, and quickly inject 20% mannitol intravenously to reduce intracranial pressure, which will win precious time for emergency treatment in the hospital; 5.
Quickly transfer the patient to a nearby qualified hospital for follow-up Processing; 6.
Notify the emergency department of relevant hospitals in advance to prepare, start the green channel, and shorten the waiting time in the hospital
.
3.
The main points of emergency in the hospital (1) General treatment 1.
Closely observe vital signs, consciousness, pupils, and physical activities; 2.
2.
Continuous ECG monitoring, blood oxygen monitoring, etc.
; 3.
3.
Perform a physical examination and assessment of the nervous system quickly; 4.
For clinical seizures, antiepileptic drugs should be used therapeutically; 5.
Quickly perform CT scan to confirm the diagnosis; 6.
Those with conditions can monitor intracranial pressure; 7.
Monitor the blood sugar of ICH patients and control the body temperature of ICH patients
.
Figure 4: Guideline recommendations (2) Emergency surgical treatment 1.
Indications for surgery include: ① Temporal sulcus hernia; ②CT, MRI and other imaging examinations found that the midline structure shifted more than 5mm, or the ipsilateral cistern, and the sulcus was blurred Or disappear; ③The actual measurement of intracranial pressure (ICP)>25mmHg
.
The goal of surgery is to quickly relieve intracranial hypertension or brain herniation and save lives
.
2.
Surgical methods: common surgical methods include bone flap craniotomy, bone window craniotomy, endoscopic surgery, and stereotactic puncture hematoma aspiration
.
Figure 5: Recommendations for surgical treatment.
Attachment: Admission emergency flow chart.
Figure 6: Admission emergency flow chart.
Source of this article: Medical Neurology Channel.
This article is organized by Saber.
Expert: Wu Guofeng, Affiliated Hospital of Guizhou Medical University.
This article is reviewed by Li Tuming, deputy chief physician.
Editor: Mr.
Lu Li's copyright declaration This article is organized and welcome to forward to Moments of Friends-End-Contribution/Reprint/Business Cooperation: yxjsjbx@yxj.
org.
cn
The efficient process is conducive to increasing the patient's hope of survival and improving the subsequent quality of life
.
At the 7th Annual Conference of the Chinese Stroke Society (CSA&TISC 2021), Professor Wu Guofeng from the Affiliated Hospital of Guizhou Medical University gave us the title "Large Cerebral Hemorrhage and Cerebral Hernia: Pre-hospital First Aid Key Points and Interpretation of the Latest Guidelines "Let’s learn about it together~ First of all, start with a case! Clinical case The eighty-year-old lady was suddenly unconscious at home for 2 hours.
The family members called 96999, and the ambulance went to the clinic
.
When the patient was sent to the Emergency Medicine Department of the Affiliated Hospital of your hospital, the pupils on both sides were already unequal.
The diameter of the pupil in the right eye was about 4.
0mm, and the diameter of the pupil in the left eye was 2.
5mm.
Based on experience, it is judged that the patient has had a brain herniation
.
The patient was treated for dehydration and lowering intracranial pressure immediately, and the green channel was opened for emergency head CT scan.
The results suggested that the elderly female patient had a severe cerebral hemorrhage, with a bleeding volume of 120ml, and her life was at stake
.
Emergency head CT revealed that there was a large amount of supratentorial cerebral hemorrhage and brain herniation, the midline structure was severely displaced, and the space-occupying effect was obvious (see Figure 1)
.
Figure 1: According to the traditional model of emergency head CT, it must be a neurosurgery consultation for transfer treatment.
However, considering that the patient's condition is serious, transfer to the department will delay the rescue treatment time, so it is decided to carry out the treatment on the spot in the rescue room and implement it urgently.
Aspiration of hematoma at bedside to reduce intracranial pressure; 2 hours after operation, the patient's pupils returned to normal level, and 3 days after operation, the head CT was rechecked (see Figure 2), the hematoma was basically cleared, and the patient was in danger of being out of danger.
Clear
.
Figure 2: Re-examination of the head CT.
From this case, we have some enlightenment.
Spontaneous intracerebral hemorrhage is a type of stroke that seriously threatens the patient's life.
Not only the mortality rate is high, but the disability rate is also high: massive supratentorial intracerebral hemorrhage often complicates the temporal lobe.
Groove hernia, also known as canopy hernia, the treatment time window is very short, what is robbed is time, what is robbed is the process, and the rescue links are reduced as much as possible! Overview of Spontaneous Cerebral Hemorrhage Hemorrhagic stroke refers to the spontaneous rupture of cerebrovascular vessels, and blood flows into the brain tissue or subarachnoid space, thereby compressing or destroying the brain tissue and affecting nerve function
.
The patient may manifest as unconsciousness, hemiplegia, speech disorder, and even death in a short period of time; intracranial pressure increases with the increase of hematoma volume, and the patient may show vomiting at first, then quickly enter a coma and further develop.
The pupils appear to be unequal in size, which immediately compresses the brainstem, resulting in the final death of the patient.
Therefore, patients with large amounts of cerebral hemorrhage require urgent surgical treatment; for large amounts of supratentorial cerebral hemorrhage with cerebral herniation, surgical treatment is the only option
.
Clinical study on the treatment of massive supratentorial intracerebral hemorrhage and herniation-a multi-center non-randomized controlled study (1) Research purpose To study the effect and feasibility of emergency stereotactic minimally invasive surgery in the treatment of massive intracerebral hemorrhage complicated by herniation; to study targeted minimally invasive surgery As the observation group, routine craniotomy and decompression with bone removal and hematoma removal were used as the control group; the primary endpoint was survival at three months and neurological score or quality of life
.
(2) Methods and technical main observation indicators: patient mortality; ability of daily living (ADL) score; Glasgow coma score (GCS); National Institutes of Health Stroke Scale (NIHSS)
.
Secondary indicators: the incidence of postoperative rebleeding; the incidence of other postoperative complications (such as: secondary epilepsy, severe cardiopulmonary complications, etc.
)
.
(3) Enrollment criteria 1) Patients with hypertensive cerebral hemorrhage over 18 years old who were diagnosed with cerebral parenchymal hemorrhage by head CT; 2) Hemorrhage location supratentorial: thalamus, basal ganglia or brain lobe; 3) Hippocampal sulcus hernia The clinical symptoms and signs of the patient, CT of the head showed that the midline structure was shifted, and the space-occupying effect was serious; 4) There was no contraindication to surgery, and the family members signed an informed consent
.
(4) Patient grouping A total of 149 patients were enrolled.
The directional puncture group was subjected to negative pressure aspiration of hematoma (MIS group, n=75), and the control group was subjected to conventional decompressive craniectomy (CDC group, n=74)
.
(5) Research results ① Comparison of the number of patients alive/death at 12 weeks of follow-up (see Figure 3) At 3 months of follow-up, 38 cases (51.
38%) survived in the conventional craniotomy group, 64 cases (85.
33%) in the minimally invasive group survived
.
Figure 3: Comparison of the number of survivors/deaths in the 12-week follow-up ②Death and survival in the vegetative state The mortality and survival in the vegetative state of patients in the minimally invasive treatment group were significantly lower than those in the conventional craniotomy group
.
③Glasgow coma scores The scores of patients in the minimally invasive treatment group were significantly higher than those in the conventional craniotomy group
.
④Comparing the survival status of the two groups at 3 months of follow-up, the severe disability rate of the minimally invasive treatment group was significantly lower than that of the conventional craniotomy group
.
⑤Comparison of neurological function scores (By NIHSS) at 3 months of follow-up, the scores of patients in the minimally invasive treatment group were significantly higher than those in the conventional craniotomy and decompression group
.
⑥Comparison of postoperative complications The incidence of postoperative rebleeding, secondary epilepsy, and severe cardiopulmonary complications in the minimally invasive treatment group was significantly lower than that in the conventional craniotomy group
.
(6) Research conclusions 1.
Emergency surgical treatment is an important way to save the lives of patients with massive supratentorial cerebral hemorrhage and cerebral herniation; 2.
In terms of reducing mortality and vegetative survival rate, emergency minimally invasive surgery is significantly better than conventional treatment of cerebral hemorrhage Craniotomy
.
Interpretation of the relevant content of the multidisciplinary guidelines for the diagnosis and treatment of cerebral hemorrhage 1.
Recommendation level and evidence level description: Recommendation level: I (should be implemented); IIa (implementation is appropriate); IIb (can be considered); level III (unintentional or harmful)
.
Evidence level: A (multi-center or multiple randomized controlled trials); B (single-center single randomized controlled trial or multiple randomized controlled trials); C level (expert opinion, case study)
.
2.
Pre-hospital first aid points 1.
Clean up respiratory tract vomit or secretions, if necessary, tracheal intubation, balloon assisted breathing; 2.
Establish venous channels, monitor blood pressure, heart rate, breathing and other vital signs; 3.
Quickly and briefly inquire about the disease , Rapid initial diagnosis; 4.
Adjust blood pressure and intracranial pressure, and quickly inject 20% mannitol intravenously to reduce intracranial pressure, which will win precious time for emergency treatment in the hospital; 5.
Quickly transfer the patient to a nearby qualified hospital for follow-up Processing; 6.
Notify the emergency department of relevant hospitals in advance to prepare, start the green channel, and shorten the waiting time in the hospital
.
3.
The main points of emergency in the hospital (1) General treatment 1.
Closely observe vital signs, consciousness, pupils, and physical activities; 2.
2.
Continuous ECG monitoring, blood oxygen monitoring, etc.
; 3.
3.
Perform a physical examination and assessment of the nervous system quickly; 4.
For clinical seizures, antiepileptic drugs should be used therapeutically; 5.
Quickly perform CT scan to confirm the diagnosis; 6.
Those with conditions can monitor intracranial pressure; 7.
Monitor the blood sugar of ICH patients and control the body temperature of ICH patients
.
Figure 4: Guideline recommendations (2) Emergency surgical treatment 1.
Indications for surgery include: ① Temporal sulcus hernia; ②CT, MRI and other imaging examinations found that the midline structure shifted more than 5mm, or the ipsilateral cistern, and the sulcus was blurred Or disappear; ③The actual measurement of intracranial pressure (ICP)>25mmHg
.
The goal of surgery is to quickly relieve intracranial hypertension or brain herniation and save lives
.
2.
Surgical methods: common surgical methods include bone flap craniotomy, bone window craniotomy, endoscopic surgery, and stereotactic puncture hematoma aspiration
.
Figure 5: Recommendations for surgical treatment.
Attachment: Admission emergency flow chart.
Figure 6: Admission emergency flow chart.
Source of this article: Medical Neurology Channel.
This article is organized by Saber.
Expert: Wu Guofeng, Affiliated Hospital of Guizhou Medical University.
This article is reviewed by Li Tuming, deputy chief physician.
Editor: Mr.
Lu Li's copyright declaration This article is organized and welcome to forward to Moments of Friends-End-Contribution/Reprint/Business Cooperation: yxjsjbx@yxj.
org.
cn
