醫(yī)學(xué)資料 2017127腦出血的血壓管理

腦出血的血壓管理腦出血患者高血壓的發(fā)生率QureshiAI,EzzeddineMA,NasarA,etal.:Prevalenceofelevatedbloodpressurein563,704adultpatientswithstrokepresentingtotheEDintheUnitedStates.AmJEmergMed.2007;25(1):32–8.在最初的24小時(shí)內(nèi)，ICH患者的血壓較腦梗塞患者升高得更快，同時(shí)下降得也更快。FischerU,CooneyMT,BullLM,etal.:Acutepost-strokebloodpressurerelativetopremorbidlevelsinintracerebral

haemorrhageversusmajorischaemicstroke:apopulation-basedstudy.LancetNeurol.2014;13(4):374–84.矛盾OhwakiK,YanoE,NagashimaH,etal.:Bloodpressuremanagementinacuteintracerebralhemorrhage:relationshipbetweenelevatedbloodpressureandhematomaenlargement.Stroke.2004;35(6):1364–7.JauchEC,LindsellCJ,AdeoyeO,etal.:Lackofevidenceforanassociationbetweenhemodynamicvariablesandhematomagrowthinspontaneousintracerebralhemorrhage.Stroke.2006;37(8):2061–5.高血壓與卒中、尤其是ICH的死亡率及致殘率有明確的相關(guān)性。VemmosKN,TsivgoulisG,SpengosK,etal.:U-shapedrelationshipbetweenmortalityandadmissionbloodpressureinpatientswithacutestroke.JInternMed.2004;255(2):257–65.TerayamaY,TanahashiN,FukuuchiY,etal.:Prognosticvalueofadmissionbloodpressureinpatientswithintracerebralhemorrhage.KeioCooperativeStrokeStudy.Stroke.1997;28(6):1185–8.矛盾降低流體靜力學(xué)壓力；降低血腫體積；降低血腫周?chē)哪X水腫；灌注壓下降；血腫周?chē)娜毖又?；腎損傷；降低血壓可增加死亡率。QureshiAI,BliwiseDL,BliwiseNG,etal.:Rateof24-hourbloodpressuredeclineandmortalityafterspontaneousintracerebralhemorrhage:aretrospectiveanalysiswitharandomeffectsregressionmodel.CritCareMed.1999;27(3):480–5.MRI彌散顯示缺血灶增加，預(yù)示其預(yù)后不良；KidwellCS,SaverJL,MattielloJ,etal.:Diffusion-perfusionMRevaluationofperihematomalinjuryinhyperacute

intracerebralhemorrhage.Neurology.2001;57(9):1611–7.降低血壓并不影響腦血流及顱內(nèi)壓。QureshiAI,WilsonDA,HanleyDF,etal.:Pharmacologicreductionofmeanarterialpressuredoesnotadverselyaffectregionalcerebralbloodflowandintracranialpressureinexperimentalintracerebralhemorrhage.CritCareMed1999;27(5):965–71.2007AHA指南推薦建議對(duì)收縮壓超過(guò)200mmhg或MAP超過(guò)150mmhg進(jìn)行降壓處理；酌情處理收縮壓超過(guò)180mmhg或MAP超過(guò)130mmhg的情況；對(duì)于顱內(nèi)壓升高患者，建議目標(biāo)為灌注壓60-80mmhg；對(duì)于顱內(nèi)壓未升高患者，建議目標(biāo)血壓160/90mmhg或MAP110mmhg；BroderickJ,ConnollyS,FeldmannE,etal.:Guidelinesforthemanagementofspontaneousintracerebralhemorrhageinadults:2007update:aguidelinefromtheAmericanHeartAssociation/AmericanStrokeAssociationStrokeCouncil,HighBloodPressureResearchCouncil,andtheQualityofCareandOutcomesinResearchInterdisciplinaryWorkingGroup.Stroke.2007;38(6):2001–23.KochS,RomanoJG,FortezaAM,etal.:Rapidbloodpressurereductioninacuteintracerebralhemorrhage:feasibilityandsafety.NeurocritCare.2008;8(3):316–21.AndersonCS,HuangY,WangJG,etal.:Intensivebloodpressurereductioninacutecerebralhaemorrhagetrial(INTERACT):arandomisedpilottrial.LancetNeurol.2008;7(5):391–9.AntihypertensiveTreatmentofAcuteCerebralHemorrhage(ATACH)investigators:Antihypertensivetreatmentofacutecerebralhemorrhage.CritCareMed.2010;38(2):637–48.QureshiAI,PaleschYY,MartinR,etal.:Effectofsystolicbloodpressurereductiononhematomaexpansion,perihematomaledema,and3-monthoutcomeamongpatientswithintracerebralhemorrhage:resultsfromtheantihypertensivetreatmentofacutecerebralhemorrhagestudy.ArchNeurol.2010;67(5):570–6.2010AHA指南推薦收縮壓在150-220mmhg之間的病人，將其血壓降至140mmhg是安全的，但其有效性仍需進(jìn)一步的大型研究證實(shí)；MorgensternLB,HemphillJC3rd,AndersonC,etal.:Guidelinesforthemanagementofspontaneousintracerebralhemorrhage:aguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociation/AmericanStrokeAssociation.Stroke.2010;41(9):2108–29.AndersonCS,HeeleyE,HuangY,etal.:Rapidblood-pressureloweringinpatientswithacuteintracerebralhemorrhage.NEnglJMed.2013;368(25):2355–65.CarcelC,WangX,SatoS,etal.:DegreeandTimingofIntensiveBloodPressureLoweringonHematomaGrowthinIntracerebral

Hemorrhage:IntensiveBloodPressureReductioninAcuteCerebralHemorrhageTrial-2Results.Stroke.2016;47(6):1651–32015年AHA指南推薦對(duì)于血壓在150-220mmhg的自發(fā)性腦出血患者，快速降低收縮壓至140mmhg是安全的（IA）;可以有效地改善功能預(yù)后（IIaB）；HemphillJC3rd,GreenbergSM,AndersonCS,etal.:GuidelinesfortheManagementofSpontaneousIntracerebralHemorrhage:AGuidelineforHealthcareProfessionalsFromtheAmericanHeartAssociation/AmericanStrokeAssociation.