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The prognosis of stroke is not only related to primary injury, but also to secondary brain injury that occurs over time.
Reducing primary injury and preventing secondary injury are the core of stroke treatment, and this core largely depends on For close monitoring of the condition.
The "Consensus of Chinese Multidisciplinary Experts on the Surveillance of Stroke Condition" puts forward consensus recommendations for the monitoring of stroke condition, aiming to provide an important reference for the monitoring of stroke condition and clinical diagnosis and treatment.
Hemorrhagic stroke (cerebral hemorrhage) 1.
Basic vital signs ➤ Intracerebral hemorrhage (ICH) patients should be continuously monitored for body temperature.
It is recommended to monitor the core body temperature (bladder, rectum, etc.
) closer to the brain temperature (level C evidence, category Ⅱa recommendation) ).
There is insufficient evidence for the benefit of mild hypothermia (34-35 ℃) in the treatment of cerebral hemorrhage (level C evidence, category IIb recommendation).
➤ Patients with ICH need blood oxygen control.
If necessary, establish artificial airway (or) mechanical ventilation as soon as possible.
The control target is blood oxygen saturation (SpO2) ≥94%, and blood oxygen partial pressure (PO2) ≥75 mmHg (level B evidence) , Class I recommendation).
But for stroke patients with normal SpO2, oxygen therapy does not significantly improve the prognosis (level A evidence, category IIa recommendation).
➤ Patients with ICH must undergo blood pressure control (level A evidence, type I recommendation).
Controlling SBP ≤140 mmHg can benefit patients (level A evidence, type I recommendation).
Antihypertensive drugs should choose drugs that have less impact on intracranial pressure.
2.
Monitoring of important laboratory indicators ➤ Severe stroke patients require comprehensive management of the functional status of the heart, lungs, liver, kidneys and other organs, including circulation, breathing, blood clotting, and urinary.
➤ The blood sodium control target for stroke patients is 135-155 mmol/L (C-level evidence, Class I recommendation), and daily blood sodium is controlled within 8-10 mmol/L to reduce the occurrence of osmotic encephalopathy (level C) Evidence, Class I recommendation).
➤ The blood glucose control target for stroke patients is 7.
8 to 10.
0 mmol/L (level B evidence, type I recommendation).
In the acute phase, short-acting insulin can be selected as an intravenous continuous pump, and blood glucose should be measured every 2 to 4 hours to avoid hypoglycemia (level A evidence, category I recommendation).
3.
Neuroimaging examination ➤ In the acute phase of cerebral hemorrhage, CT or MRI should be reviewed regularly, which is helpful for timely detection of changes in the condition such as hematoma enlargement, cerebral edema, and hydrocephalus (level B evidence, category I recommendation).
➤ The "mixed sign", "black hole sign", "island sign", etc.
seen on CT plain scans, and the "point sign" and "bird's beak sign" seen on CT enhanced scans are predictors of hematoma enlargement (level B evidence, category IIa recommendation).
4.
Intracranial pressure and cerebral perfusion pressure (CPP) monitoring ➤ When patients with ICH with GCS ≤ 8 points, and the patient’s symptoms, signs, CT results and other evidence suggest increased intracranial pressure, it is recommended to perform invasive intracranial pressure monitoring (Grade C) Evidence, category IIa recommendation).
➤ The priority order of invasive intracranial pressure monitoring is intraventricular, brain parenchyma, subdural, and epidural.
It is more accurate to choose ipsilateral intracranial pressure monitoring for cerebral hemorrhage (level C evidence, level IIb recommendation).
➤ Intervention is recommended when the intracranial pressure of ICH patients continues to be higher than 20 mmHg (level B evidence, level IIb recommendation).
In patients with intracranial pressure monitoring, it is reasonable to control CPP at 50-70 mmHg (level C evidence, category IIb recommendation).
5.
Neuroelectrophysiological monitoring ➤ The application of electroencephalogram (EEG) monitoring to stroke patients can help determine the degree of conscious coma and non-convulsive epileptic activities, and is used for the evaluation of brain damage (level B evidence, category IIa recommendation) .
➤ It is feasible to monitor evoked potentials to understand the sensory conduction pathways and the functional state of the brainstem, and to help dynamically evaluate the patient's clinical neurological recovery (level C evidence, category IIb recommendation).
6.
Brain tissue oxygen monitoring ➤ Brain tissue oxygen partial pressure (PbtO2) is an indicator of local brain tissue oxygen levels, and jugular venous blood oxygen saturation (SjvO2) is an indicator of total brain oxygenation.
PbtO2 and SjvO2 can provide complementary information and are more comprehensive Reflect the relationship between oxygen supply and demand in the brain (C-level evidence, IIb recommendation). ➤ It is recommended to use it in combination with other monitoring methods such as intracranial pressure/CPP to obtain more accurate disease assessment and prognosis prediction (level B evidence, category IIa recommendation).
7.
Non-invasive brain edema monitor monitoring ➤ The non-invasive brain edema dynamic monitor can provide patients with a non-invasive, bedside, dynamic craniocerebral disease monitoring, which has a good early warning value for hematoma expansion and hemorrhage transformation after thrombectomy/removal.
, But further research is needed (level B evidence, IIb recommendation).
8.
Transcranial ultrasound monitoring ➤ Transcranial ultrasound can provide real-time information on cranial structures and hemodynamics, and its dynamic changes can provide a basis for the evaluation of stroke patients (level B evidence, category IIa recommendation).
➤ Optic nerve sheath diameter (ONSD) has high accuracy in the diagnosis of intracranial hypertension.
When ONSD>5 mm indicates that intracranial pressure may be greater than 20 mmHg, it is recommended to use the average longitudinal and transverse ONSD (level B evidence, IIb) Class recommendation).
Cerebral infarction (AIS) 1.
Basic vital signs ➤ Body temperature is related to the condition and prognosis of AIS patients and should be closely monitored.
Patients with elevated body temperature should look for and deal with the cause of fever, and those with infection should be given anti-infection treatment in time.
Preventive use of antibiotics is not recommended.
Patients with body temperature >38 ℃ should be given antipyretic measures (level B evidence, category IIa recommendation).
➤ It is recommended that AIS patients undergo respiratory monitoring, and critically ill patients should be monitored at least once an hour to maintain oxygen saturation >94% (level A evidence, category IIa recommendation).
Respiratory frequency, breathing pattern, and respiratory movement monitoring are helpful for finding brain herniation, predicting the location of brain injury, finding pulmonary embolism, Guillain Barre syndrome and other complications (level B evidence, category IIa recommendation).
➤ For stroke patients with normal SpO2, oxygen therapy does not significantly improve the prognosis, and over-oxygen therapy (PaO2≥300 mmHg) is associated with poor prognosis (level A evidence, category IIa recommendation).
After extubation of mechanical ventilation, noninvasive ventilation combined with high-flow nasal oxygen can reduce the risk of reintubation (level A evidence, category IIa recommendation).
➤ Two-thirds of AIS patients have heart rate and ECG abnormalities.
It is recommended that heart rate and ECG monitoring be routinely performed.
A 12-lead ECG examination was performed within 24 hours of the onset, and a 24-hour ECG monitoring and echocardiography were performed within 7 days of the onset (level A evidence, category I recommendation).
➤ Elevated blood pressure in AIS patients is a common phenomenon and should be monitored closely.
Patients undergoing thrombolysis and/or mechanical thrombectomy should strengthen preoperative and postoperative blood pressure monitoring to avoid excessive and rapid blood pressure fluctuations (level A evidence, category IIa recommendation).
The evidence for the benefit of early antihypertensive therapy is not yet sufficient.
2.
Monitoring of important laboratory indicators ➤ For recommendations, please refer to the monitoring content of ICH important laboratory indicators.
3.
Neuroimaging examination ➤ It is recommended to use head CT plain scan or MRI for rapid neuroimaging examination to distinguish between ischemic stroke and hemorrhagic stroke in order to determine the follow-up treatment strategy (level A evidence, type I recommendation).
➤ Before performing endovascular treatment for AIS patients, it is recommended to use non-invasive imaging examination to determine whether there is intracranial or extracranial large vessel occlusion; for patients with suspected large vessel occlusion, it is recommended to use a one-stop CTA+CTP imaging examination program to quickly implement preoperative image evaluation and guidance Endovascular treatment (level A evidence, type I recommendation).
➤ Within 3 hours of onset, NIHSS score ≥9 points, or within 6 hours of onset, and NIHSS score ≥7 points, it indicates that there is a large blood vessel occlusion; when non-invasive imaging evaluation is performed unconditionally, CT is used to exclude bleeding, and then the whole cerebral vascular DSA is quickly evaluated.
For occlusion and collateral circulation compensation, suitable patients are selected for endovascular treatment, and the prognosis of patients can be predicted based on the mTICI score (level A evidence, type I recommendation).
4.
Intracranial pressure monitoring ➤ Patients with large area of supratentorial cerebral infarction and cerebellar infarction are at higher risk of brain herniation due to increased intracranial pressure.
Intracranial pressure monitoring is recommended for such patients (level B evidence, category IIa recommendation) .
➤ Patients with AIS after decompressive craniectomy within 48 hours of onset are recommended to undergo invasive intracranial pressure monitoring, and to guide clinical treatment based on the monitoring results.
The intervention threshold refers to the aforementioned recommendations (level B evidence, category IIa recommendation). 5.
Transcranial Doppler (TCD) cerebral blood flow monitoring ➤ TCD-related parameters have certain value in finding large vessel stenosis, embolus signals in the blood, predicting the risk of AIS recurrence, hemorrhagic transformation after stroke, and prognostic judgment.
It is recommended that qualified units use TCD technology for bedside cerebral blood flow monitoring for AIS patients (level B evidence, category IIa recommendation).
6.
Electroneurophysiological monitoring ➤ EEG can reflect the location and degree of brain injury.
The larger the infarction area, the more superficial the location, and the more obvious EEG abnormalities.
It is recommended that patients with severe AIS undergo EEG monitoring, and use Synek and other grading standards to judge the severity and prognosis of the disease (level B evidence, category IIa recommendation).
7.
Other monitoring For details, please refer to the aforementioned "Intracerebral Hemorrhage" section.
The above content is extracted from: Neurosurgery Committee of Chinese Medical Doctor Association, Shanghai Stroke Society, Chongqing Stroke Society.
Chinese Multidisciplinary Expert Consensus on Stroke Surveillance[J].
Chinese Medical Journal,2021,101 (05): 317 -326.
Reducing primary injury and preventing secondary injury are the core of stroke treatment, and this core largely depends on For close monitoring of the condition.
The "Consensus of Chinese Multidisciplinary Experts on the Surveillance of Stroke Condition" puts forward consensus recommendations for the monitoring of stroke condition, aiming to provide an important reference for the monitoring of stroke condition and clinical diagnosis and treatment.
Hemorrhagic stroke (cerebral hemorrhage) 1.
Basic vital signs ➤ Intracerebral hemorrhage (ICH) patients should be continuously monitored for body temperature.
It is recommended to monitor the core body temperature (bladder, rectum, etc.
) closer to the brain temperature (level C evidence, category Ⅱa recommendation) ).
There is insufficient evidence for the benefit of mild hypothermia (34-35 ℃) in the treatment of cerebral hemorrhage (level C evidence, category IIb recommendation).
➤ Patients with ICH need blood oxygen control.
If necessary, establish artificial airway (or) mechanical ventilation as soon as possible.
The control target is blood oxygen saturation (SpO2) ≥94%, and blood oxygen partial pressure (PO2) ≥75 mmHg (level B evidence) , Class I recommendation).
But for stroke patients with normal SpO2, oxygen therapy does not significantly improve the prognosis (level A evidence, category IIa recommendation).
➤ Patients with ICH must undergo blood pressure control (level A evidence, type I recommendation).
Controlling SBP ≤140 mmHg can benefit patients (level A evidence, type I recommendation).
Antihypertensive drugs should choose drugs that have less impact on intracranial pressure.
2.
Monitoring of important laboratory indicators ➤ Severe stroke patients require comprehensive management of the functional status of the heart, lungs, liver, kidneys and other organs, including circulation, breathing, blood clotting, and urinary.
➤ The blood sodium control target for stroke patients is 135-155 mmol/L (C-level evidence, Class I recommendation), and daily blood sodium is controlled within 8-10 mmol/L to reduce the occurrence of osmotic encephalopathy (level C) Evidence, Class I recommendation).
➤ The blood glucose control target for stroke patients is 7.
8 to 10.
0 mmol/L (level B evidence, type I recommendation).
In the acute phase, short-acting insulin can be selected as an intravenous continuous pump, and blood glucose should be measured every 2 to 4 hours to avoid hypoglycemia (level A evidence, category I recommendation).
3.
Neuroimaging examination ➤ In the acute phase of cerebral hemorrhage, CT or MRI should be reviewed regularly, which is helpful for timely detection of changes in the condition such as hematoma enlargement, cerebral edema, and hydrocephalus (level B evidence, category I recommendation).
➤ The "mixed sign", "black hole sign", "island sign", etc.
seen on CT plain scans, and the "point sign" and "bird's beak sign" seen on CT enhanced scans are predictors of hematoma enlargement (level B evidence, category IIa recommendation).
4.
Intracranial pressure and cerebral perfusion pressure (CPP) monitoring ➤ When patients with ICH with GCS ≤ 8 points, and the patient’s symptoms, signs, CT results and other evidence suggest increased intracranial pressure, it is recommended to perform invasive intracranial pressure monitoring (Grade C) Evidence, category IIa recommendation).
➤ The priority order of invasive intracranial pressure monitoring is intraventricular, brain parenchyma, subdural, and epidural.
It is more accurate to choose ipsilateral intracranial pressure monitoring for cerebral hemorrhage (level C evidence, level IIb recommendation).
➤ Intervention is recommended when the intracranial pressure of ICH patients continues to be higher than 20 mmHg (level B evidence, level IIb recommendation).
In patients with intracranial pressure monitoring, it is reasonable to control CPP at 50-70 mmHg (level C evidence, category IIb recommendation).
5.
Neuroelectrophysiological monitoring ➤ The application of electroencephalogram (EEG) monitoring to stroke patients can help determine the degree of conscious coma and non-convulsive epileptic activities, and is used for the evaluation of brain damage (level B evidence, category IIa recommendation) .
➤ It is feasible to monitor evoked potentials to understand the sensory conduction pathways and the functional state of the brainstem, and to help dynamically evaluate the patient's clinical neurological recovery (level C evidence, category IIb recommendation).
6.
Brain tissue oxygen monitoring ➤ Brain tissue oxygen partial pressure (PbtO2) is an indicator of local brain tissue oxygen levels, and jugular venous blood oxygen saturation (SjvO2) is an indicator of total brain oxygenation.
PbtO2 and SjvO2 can provide complementary information and are more comprehensive Reflect the relationship between oxygen supply and demand in the brain (C-level evidence, IIb recommendation). ➤ It is recommended to use it in combination with other monitoring methods such as intracranial pressure/CPP to obtain more accurate disease assessment and prognosis prediction (level B evidence, category IIa recommendation).
7.
Non-invasive brain edema monitor monitoring ➤ The non-invasive brain edema dynamic monitor can provide patients with a non-invasive, bedside, dynamic craniocerebral disease monitoring, which has a good early warning value for hematoma expansion and hemorrhage transformation after thrombectomy/removal.
, But further research is needed (level B evidence, IIb recommendation).
8.
Transcranial ultrasound monitoring ➤ Transcranial ultrasound can provide real-time information on cranial structures and hemodynamics, and its dynamic changes can provide a basis for the evaluation of stroke patients (level B evidence, category IIa recommendation).
➤ Optic nerve sheath diameter (ONSD) has high accuracy in the diagnosis of intracranial hypertension.
When ONSD>5 mm indicates that intracranial pressure may be greater than 20 mmHg, it is recommended to use the average longitudinal and transverse ONSD (level B evidence, IIb) Class recommendation).
Cerebral infarction (AIS) 1.
Basic vital signs ➤ Body temperature is related to the condition and prognosis of AIS patients and should be closely monitored.
Patients with elevated body temperature should look for and deal with the cause of fever, and those with infection should be given anti-infection treatment in time.
Preventive use of antibiotics is not recommended.
Patients with body temperature >38 ℃ should be given antipyretic measures (level B evidence, category IIa recommendation).
➤ It is recommended that AIS patients undergo respiratory monitoring, and critically ill patients should be monitored at least once an hour to maintain oxygen saturation >94% (level A evidence, category IIa recommendation).
Respiratory frequency, breathing pattern, and respiratory movement monitoring are helpful for finding brain herniation, predicting the location of brain injury, finding pulmonary embolism, Guillain Barre syndrome and other complications (level B evidence, category IIa recommendation).
➤ For stroke patients with normal SpO2, oxygen therapy does not significantly improve the prognosis, and over-oxygen therapy (PaO2≥300 mmHg) is associated with poor prognosis (level A evidence, category IIa recommendation).
After extubation of mechanical ventilation, noninvasive ventilation combined with high-flow nasal oxygen can reduce the risk of reintubation (level A evidence, category IIa recommendation).
➤ Two-thirds of AIS patients have heart rate and ECG abnormalities.
It is recommended that heart rate and ECG monitoring be routinely performed.
A 12-lead ECG examination was performed within 24 hours of the onset, and a 24-hour ECG monitoring and echocardiography were performed within 7 days of the onset (level A evidence, category I recommendation).
➤ Elevated blood pressure in AIS patients is a common phenomenon and should be monitored closely.
Patients undergoing thrombolysis and/or mechanical thrombectomy should strengthen preoperative and postoperative blood pressure monitoring to avoid excessive and rapid blood pressure fluctuations (level A evidence, category IIa recommendation).
The evidence for the benefit of early antihypertensive therapy is not yet sufficient.
2.
Monitoring of important laboratory indicators ➤ For recommendations, please refer to the monitoring content of ICH important laboratory indicators.
3.
Neuroimaging examination ➤ It is recommended to use head CT plain scan or MRI for rapid neuroimaging examination to distinguish between ischemic stroke and hemorrhagic stroke in order to determine the follow-up treatment strategy (level A evidence, type I recommendation).
➤ Before performing endovascular treatment for AIS patients, it is recommended to use non-invasive imaging examination to determine whether there is intracranial or extracranial large vessel occlusion; for patients with suspected large vessel occlusion, it is recommended to use a one-stop CTA+CTP imaging examination program to quickly implement preoperative image evaluation and guidance Endovascular treatment (level A evidence, type I recommendation).
➤ Within 3 hours of onset, NIHSS score ≥9 points, or within 6 hours of onset, and NIHSS score ≥7 points, it indicates that there is a large blood vessel occlusion; when non-invasive imaging evaluation is performed unconditionally, CT is used to exclude bleeding, and then the whole cerebral vascular DSA is quickly evaluated.
For occlusion and collateral circulation compensation, suitable patients are selected for endovascular treatment, and the prognosis of patients can be predicted based on the mTICI score (level A evidence, type I recommendation).
4.
Intracranial pressure monitoring ➤ Patients with large area of supratentorial cerebral infarction and cerebellar infarction are at higher risk of brain herniation due to increased intracranial pressure.
Intracranial pressure monitoring is recommended for such patients (level B evidence, category IIa recommendation) .
➤ Patients with AIS after decompressive craniectomy within 48 hours of onset are recommended to undergo invasive intracranial pressure monitoring, and to guide clinical treatment based on the monitoring results.
The intervention threshold refers to the aforementioned recommendations (level B evidence, category IIa recommendation). 5.
Transcranial Doppler (TCD) cerebral blood flow monitoring ➤ TCD-related parameters have certain value in finding large vessel stenosis, embolus signals in the blood, predicting the risk of AIS recurrence, hemorrhagic transformation after stroke, and prognostic judgment.
It is recommended that qualified units use TCD technology for bedside cerebral blood flow monitoring for AIS patients (level B evidence, category IIa recommendation).
6.
Electroneurophysiological monitoring ➤ EEG can reflect the location and degree of brain injury.
The larger the infarction area, the more superficial the location, and the more obvious EEG abnormalities.
It is recommended that patients with severe AIS undergo EEG monitoring, and use Synek and other grading standards to judge the severity and prognosis of the disease (level B evidence, category IIa recommendation).
7.
Other monitoring For details, please refer to the aforementioned "Intracerebral Hemorrhage" section.
The above content is extracted from: Neurosurgery Committee of Chinese Medical Doctor Association, Shanghai Stroke Society, Chongqing Stroke Society.
Chinese Multidisciplinary Expert Consensus on Stroke Surveillance[J].
Chinese Medical Journal,2021,101 (05): 317 -326.
