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大脳半球梗塞の管理 ガイドライン - JSEPTIC

Large hemispheric infarc/on LHI Large hemispheric infarc/on LHI . =malignant middle cerebral infarc/on LHI . LHI Stroke. 2010 ;41(9):2108- 29 Stroke. 2013;44(3):870- 947 Stroke. 2014;45(4):1222- 38 Neurocri/cal Care Society the German Society for Neuro- Intensive Care and Emergency Medicine LHI . Neurocri/cal Care Society NCS 22 Recommenda/on . BMJ. 2004;328(7454):1490. Grading of Recommenda/on Assessment Development and Evalua/on GRADE system Evidence very low, low, moderate, high 2012 10 NCS annual mee/ng.

AHAガイドライン ! 脳浮腫がある脳梗塞の管理について述べており、! 特に集中治療医が日々対応する臨床上の問題点に!

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Transcription of 大脳半球梗塞の管理 ガイドライン - JSEPTIC

1 Large hemispheric infarc/on LHI Large hemispheric infarc/on LHI . =malignant middle cerebral infarc/on LHI . LHI Stroke. 2010 ;41(9):2108- 29 Stroke. 2013;44(3):870- 947 Stroke. 2014;45(4):1222- 38 Neurocri/cal Care Society the German Society for Neuro- Intensive Care and Emergency Medicine LHI . Neurocri/cal Care Society NCS 22 Recommenda/on . BMJ. 2004;328(7454):1490. Grading of Recommenda/on Assessment Development and Evalua/on GRADE system Evidence very low, low, moderate, high 2012 10 NCS annual mee/ng.

2 Recommenda/ons 2013 1 the German Society for Neuro- Intensive Care and Emergency Medicine annual mee/ng LHI ACA PCA. 1. Airway management LHI 10 J Stroke Cerebrovasc Dis. 2004 ;13(4):183- 8 LHI GCS<10 2 ICP MCA 2/3 midline shi[ Mayo Clin Proc. 1997;72(3):210- 3 Crit Care Med. 2000;28(8):2956- 61 GCS 8 eye4 . Am J Respir Crit Care Med. 1997;156(2 Pt 1):459- 65 LHI evidence Cerebrovasc Dis. 2006;21(3):159- 65 Neurocrit Care. 2010;13(1):40- 6 7 14 weaning Recommenda/ons LHI strong recommenda/on, very low quality of evidence LHI strong recommenda/on, very low quality of evidence breathing trials 7 14 strong recommenda/on, low quality of evidence 2 Hyperven/la/on ICP LHI LHI Am J Neuroradiol.]

3 1993;14(2):475- 84 Crit Care Clin. 1997;13(1):163- 84 Crit Care Med. 2002;30(12):2619- 25 ICP Stroke. 1998;29(7):1281- 92 J Neurosurg. 1991;75(5):731- 9 Trans Am Neurol Assoc. 1973;98:309- 10 Stroke. 1973;4(4):568- 631 Recommenda/ons LHI strong recommenda/on, very low quality of evidence weak recommenda/on, very low quality of evidence 3. Analgesia and Seda/on wake- up trial Recommenda/ons strong recommenda/on, very low quality of evidence strong recommenda/on, very low quality of evidence wake- up trial ICP ICP CCP wake- up trial strong recommenda/on, very low quality of evidence 4.

4 Gastrointes/nal Tract LHI PEG Recommenda/ons LHI weaning weak recommenda/on, very low quality of evidence LHI weak recommenda/on, very low quality of evidence ICU 1 3 NIHSS PEG weak recommenda/on, very low quality of evidence 5. Glucose Control LHI LHI . Neurocrit Care. 2010;13(3):307- 12 Crit Care. 2012;16(5):R203. Recommenda/ons LHI 140- 180mg/dl strong recommenda/on, very low quality of evidence strong recommenda/on, very low quality of evidence 6. Hemoglobin Control LHI Hb LHI Hb Hb7g/dl Recommenda/ons LHI strong recommenda/on, very low quality of evidence.

5 Hb weak recommenda/on, very low quality of evidence . weak recommenda/on, very low quality of evidence 7. Deep Venous Thrombosis Prophylaxis LHI DVT DVT 3 J Stroke Cerebrovasc Dis. 2012 CLOT1 trial 7 10 DVT 25 30 4 J Thromb Haemost. 2011;9(11):2193- 200 DVT, PE . Lancet. 2009;373(9679):1958- 65 CLOT3 trial intermibent pneuma/c compression IPC DVT Lancet. 2013;382(9891):516- 24 LMWH LHI Acta Neurol Scand. 2002;106(2):84- 92 Stroke. 2006;37(1):139- 44 Recommenda/ons LHI ICP DVT strong recommenda/on, very low quality of evidence ICU DVT strong recommenda/on, very low quality of evidence IPC strong recommenda/on, moderate quality of evidence strong recommenda/on, moderate quality of evidence 8.

6 An/coagula/on LHI LHI Recommenda/ons LHI 2 4 weak recommenda/on, very low quality of evidence . DVT PE TEE weak recommenda/on, very low quality of evidence LHI . weak recommenda/on, very low quality of evidence 9. Blood Pressure Management LHI mean85mmHg SBP220mmHg anterior, posterior . LHI Neurology. 2006;66(12):1878- 81 Stroke. 2013;44(3):870- 947 Neurology. 2008;71(8):552- 8 Recommenda/ons mean85mmHg . SBP220mmHg strong recommenda/on, low quality of evidence LHI weak recommenda/on, low quality of evidence 10.

7 Steroid Therapy LHI 1 Cohrane Database Syst Rev. 2011(9):CD000064 10 112 2 placebo vs dexamethasone 21 Brit Med J. 1986;292(6512):21- 3 Recommenda/on LHI strong recommenda/on, low quality of evidence 11. Barbiturate Therapy LHI LHI RCT LHI . ICP Neurology. 1997;48(6):1608- 13 Recommenda/on LHI strong recommenda/on, low quality of evidence 12. Temperature Control LHI LHI ICP Stroke. 2002;33(6):1584- 8 ICP Stroke. 2001;32(12):2833- 5 Recommenda/ons LHI . weak recommenda/on, low quality of evidence 33- 36 24- 72 weak recommenda/on, low quality of evidence weak recommenda/on, very low quality of evidence 13.

8 Head Posi/on LHI ICP 45 CPP J Neurosurg. 1986;65(5):636- 41 Neurol Res. 1997;19(3):249- 53 30 ICP MAP CPP CPP . ICP Stroke. 2002;33(2):497- 501 Recommenda/on LHI ICP 30 weak recommenda/on, very low quality of evidence 14. Osmo/c Therapy Recommenda/ons strong recommenda/on, moderate quality of evidence weak recommenda/on, low quality of evidence strong recommenda/on, moderate quality of evidence AKI strong recommenda/on, moderate quality of evidence strong recommenda/on, high quality of evidence 15. Neuroimaging by CT and MRI CT MRI LHI MCA 50 hypodensity 85 Stroke.

9 2001;32(9):2117- 23 220ml Acta Neurochir (Wien). 2012;154(1):79- 85 Stroke. 2010;41(11):2539- 44 145 Midline shi[ Cerebrovasc Dis. 2003;16(3):230- 5 Recommenda/on CT MRI LHI strong recommenda/on, low quality of evidence 16. Ultrasound Transcranial Doppler TCD transcranial color- coded duplex TCCS LHI LHI TCCS midline shi[ midline shi[4 4 Neurology. 1999;52(1):45- 9 Recommenda/on TCCS . weak recommenda/on, low quality of evidence 17. Evoked Poten/als Brainstem auditory evoked poten/als BAEPs 24 Neurocrit ;9(1):13- 6 Recommenda/on MCA.]]]

10 24 BAEP weak recommenda/on, very low quality of evidence 18. EEG EEG EEG EEG LHI Recommenda/ons 24 EEG weak recommenda/on, very low quality of evidence EEG . weak recommenda/on, very low quality of evidence 19. Invasive Mul/modal Monitoring ICP, microdialysis, p/O2 Recommenda/on . weak recommenda/on, low quality of evidence 20. Surgical Management Decompressive hemicraniectomy: DHC DHC DHC DHC DHC Decompressive hemicraniectomy: DHC DHC LHI DHC 60 NIHSS16 48 DHC 2 29 78 Lancet ;8(4):326- 33 Stroke. 2007;38(9):2506- 17 DHC DHC DHC midline shi[ DHC.]