แนวทางเวชปฏิบัติโรคหลอดเลือดสมองแตก 2556

ET

1999
T HA
IS
TROKE SOCI
Clinical Practice Guidelines for Hemorrhagic Stroke
T HA
ET
Y
1999
IS
TROKE SOCI
(Clinical Practice Guidelines for Hemorrhagic Stroke)
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ISBN
: 978974422702-7
1 : 2556
: .
..
.

:

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9 64 14 10310
. 0-2530-4114 () 0-2108-8950-51
E-mail : tanapress@gmail.com, tana@tanapress.com
8/15/13 1:21:05 PM

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2550
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iv
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(i)

(ii)

(iii)

(iv)

(vi)

(vii)

1
1
3
(Guidelines for the Management of Hemorrhagic Stroke)

2
8
(Surgical Management of Hemorrhagic Stroke)

3
21
(Medical Management in Acute Phase of Hemorrhagic Stroke)
4
22
(Guidelines for the Rehabilitation of Hemorrhagic Stroke)

1. (Calculation of of Hematoma volume)
34
2
35
3. CT scan of Normal Brain
37
4. Hydrocephalus CT Brain (Diagnosis of Hydrocephalus by CT brain)
39
5. CT brain of Hemorrhagic Stroke
40
6. (Factors affect outcome)
44
7. CT scan
46
(Risk of hematoma expansion after initial CT Scan)
8. (case study)
47

53
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1

2

3

4

5

6

7

8

9

vi
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(Initial management and Diagnosis of stroke)

(Classification of Hemorrhagic Stroke by Location)
Lobar Hemorrhage
(Management of Lobar Hemorrhage)
Basal Ganglia
(Management of Basal Ganglia Hemorrhage)
Thalamus
(Management of Thalamic Hemorrhage)

(Management of Cerebellar Hemorrhage)
brainstem
(Management of Brainstem Hemorrhage)
Subarachnoid Space
(Management of Subarachnoid Hemorrhage)

4
6
12
14
16
17
19
23
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1 (Strength of Recommendation)
2 (Quality of Evidence: QE)
3 (Strength of recommendation)

(Strength of Recommendation)
4

5

(Treatment of Increased Intracranial Pressure)
6

(Guidelines for Neurosurgical Consultation in Hemorrhagic Stroke)

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26
28
29
30
31
32
33
vii
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1

2
3
4

5
6
7
8

viii
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(Calculation of Volume of Hematoma)

CT Scan of Normal Brain
Hydrocephalus CT Brain
(Diagnosis of Hydrocephalus by CT brain)
CT Brain of Hemorrhagic Stroke
(Factors affect outcome)
(Case study)

34
35
37
39
40
44
46
47
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(stroke, cerebrovascular disease)
1 ..2553
(Public Health Statistics A.D.2010)2 3
(20.6 )

1 2
(Disability Adjusted Life Year) 2 3

Stroke means rapidly developed clinical signs of focal (global) disturbance of cerebral
function lasting more than 24 hours or leading to death, with no apparent cause other than a
vascular origin.4

5

2551

- CT brain (computerized tomography brain)
CT scan
Siriraj Stroke Score

- Cerebellar hemorrhage

- Subarachnoid hemorrhage

-

-

-

-
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(Quality of Evidence: QE) 2 A, B, C I,II,III IV
(strength of recommendation) 5 ++, +, +/-, - --
( 1 - 3)

3

1.

2.

3.

4.

2
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(Guidelines for the management of hemorrhagic stroke)

(hemorrhagic stroke)
10-15 35-52 30 6,7
1 508
2553 39,948
63 100,000 9
10
11,12
24 23-38 13

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(Initial management and Diagnosis of stroke)

Sudden onset of neurological deficit with suspicious of stroke
Clinical assessment & grading*

Advanced life support & emergency lab.

CT Brain non contrast

No**

Normal/Hypodensity
CT brain scan

Hyperdensity/Mass

Ischemic
stroke/Others

Yes

Hemorrhagic
Stroke
* (GCS < 8, signs of brain herniation, hypoxia,
) advanced life support

** 3, 5

4
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sudden neurological deficit vital signs,
neurological signs emergency advanced life support airway,
ventilation Glasgow Coma Scale (GCS) score < 8
aspiration emergency laboratory tests
(CBC, BS, BUN, Cr, electrolytes)

anticoagulants
(extracranial cause)
Sudden onset of persistent focal neurological deficit and no history of head trauma
probability of stroke 80%14

acute stroke CT brain 15 ischemic
hemorrhagic stroke

(systolic blood pressure) 220 .. 170 ../. (
) anticoagulant antipaltlate warfarin aspirin
hemorrhagic stroke ischemic stroke16

ischemic hemorrhagic stroke CT brain

CT brain ischemic stroke
hemorrhagic stroke
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SAH & IVH*

SAH & ICH*

Primary IVH

IVH

ICH & IVH*
= Intracerebral hemorrhage
ICH
ICH

IVH
= Intraventricular hemorrhage
ICH & IVH

Lobar
= ICH in cortical or subcortical area
Primary SAH

Non-lobar = ICH in basal ganglia, thalamus, brain stem, cerebellum Primary IVH
SAH
= Subarachnoid hemorrhage
SAH & ICH

Primary IVH = IVH
SAH & IVH
* primary hemorrhage

Primary SAH

SAH

Hemorrhagic stroke

ICH
Lobar
3-7 ( 8,11,13,15,17)
3-7 ( 8,11,13,15,17)

3-7

Non-lobar
(Classification of Hemorrhagic Stroke by Location)

CT
brain CT brain
hemorrhagic stroke 3 subarachnoid hemorrhage (SAH),
intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH)
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(Surgical Management of Hemorrhagic Stroke)

/ arteriovenous malformation (AVM), aneurysm

8
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Lobar Hemorrhage
(Management of Lobar Hemorrhage)

HCP**
or
IVH with HCP
or
SAH
or
Temporal lobe
hematoma
Lobar hemorrhage
Criteria for neurosurgical consultation

1. GCS < 13
2. Volume of hematoma > 30 ml.
3. Midline shift > 0.5 cm.

Criteria > 2

Criteria < 2

Medical treatment

Worse*

Improved ( 9)
Lobar hemorrhage
1. CT brain abnormal vessels
2. < 45
3.
Discharge

= 0.524 X Y Z
(X,Y,Z = X,Y,Z )17

* (extracranial cause)
2

** 4

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GCS = Glasgow Coma Scale

HCP = Hydrocephalus

IVH = Intraventricular hemorrhage

SAH = Subarachnoid hemorrhage

Hematoma CT brain CT brain
24 onset15 ( 7)

Lobar hemorrhage intracerebral hemorrhage (ICH) cortical
subcortical frontal, temporal, parietal, occipital lobes
cerebral amyloid angiopathy, aneurysm, AVM
> 2 GCS < 1319,20, volume > 30 ml.21, midline shift > 0.5 cm.22
1
(medical treatment)
< 45 CT brain abnormal blood vessels
enlarged vessels calcification hematoma hyperdensity dura venous sinus

cortical vein venous drainage hematoma
cerebral angiography23 - 25

temporal lobe early brain herniation 21
10
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Non-Lobar Hemorrhage
(Management of Non-Lobar Hemorrhage)

Non-lobar hemorrhage intracerebral hemorrhage basal ganglia (
putamen), thalamus, cerebellum, brainstem ( pons)
stroke 45 hypertensive hemorrhage23,24
45 CT brain
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Basal Ganglia
(Management of Basal Ganglia Hemorrhage)

Basal ganglia hemorrhage*

1. GCS < 13
HCP***
or
IVH with HCP
or
SAH

Criteria > 2

Criteria < 2

Medical treatment

Worse*

Improved ( 9)

Discharge

= 0.524 X Y Z

(X,Y,Z = X,Y,Z )17

* Basal ganglia hemorrhage putamen, globus pallidus

caudate nucleus ( 5 40)

** 2

GCS = Glasgow Coma Scale HCP = Hydrocephalus

IVH = Intraventricular hemorrhage SAH = Subarachnoid hemorrhage

*** 4

12
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Basal ganglia hemorrhage > 2 GCS < 13,
volume > 30 ml. 26, midline shift > 0.5 cm. 22 < 2
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Thalamus
(Management of Thalamic Hemorrhage)

HCP
or
IVH with HCP
Thalamic hemorrhage

1. GCS < 13

Criteria > 2

Criteria < 2

Medical treatment

Worse*

Improved ( 9)

Discharge

= 0.524 X Y Z

(X,Y,Z = X,Y,Z )12

* 2


HCP = Hydrocephalus


** 4

14
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Thalamic hemorrhage > 2 GCS < 13, volume > 10 ml.27,28,
midline shift > 0.5 cm. / hydrocephalus (HCP)
< 2 hydrocephalus
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(Management of Cerebellar Hemorrhage)

Cerebellar hemorrhage

* (refer case)
6

Cerebellar hemorrhage hemorrhagic stroke

hemorrhagic stroke
hydrocephalus

16
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brainstem
(Management of Brainstem Hemorrhage)

Criteria

Brainstem hemorrhage*
for neurosurgical consultation
1. GCS < 13
2. HCP ***
3. IVH with HCP

Criteria > 1

Criteria = 0

Medical treatment

Worse*

Improved ( 9)

Discharge


HCP = Hydrocephalus


* signs brainstem dysfunction 2

** Repeated episodes Brainstem hemorrhage

*** 4

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7

Brainstem hemorrhage pons GCS < 13
hydrocephalus (HCP) intraventricular hemorrhage with HCP
(repeated episodes) cavernous
angioma GCS > 13
hydrocephalus
18
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Subarachnoid Space
(Management of Subarachnoid Hemorrhage)

Clinical suspicion of SAH
CT brain non contrast

Other diagnosis

Negative for SAH

Positive
for SAH
+ ICH / IVH

LP for CSF analysis

Normal or Other diagnosis
(persistent RBC
SAH
+/- xanthochromia)

Appropriate management

CSF =

CT brain =

ICH =

IVH =
Cerebrospinal fluid LP = Lumbar puncture

Computer tomography brain RBC = Red blood cell
Intracerebral hemorrhage SAH = Subarachnoid hemorrhage
Intraventricular hemorrhage
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8
Subarachnoid hemorrhage (SAH) subarachnoid space

SAH ruptured aneurysm, ruptured AVM, blood dyscrasia,
head injury, parasite

SAH CT brain CT brain SAH
SAH parasite

SAH 2
CT brain
20
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(Blood pressure management)

ICH
SAH 4
(Management of body temperature)

brain
metabolism 29 4
(Management of Blood Glucose)

stress 30
> 140 ./.
(Prevention of Seizure)

ICH (grade C)

(grade A)

isotonic solution normal saline
4
(Management of increased intracranial pressure)

pulse pressure
5
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22
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(1)
(2)
(2)

2 (3)
1 (3)
2 .. (4)
1/2 .. (4)

(7)/

(8)

(5)

(6)

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9

(1) 31

48

(2)
2.1

- (motor function assessment)

- (sensory assessment)

- (coordination)

- (range of motion)

- (muscle tone)
2.2

-

-
2.3
2.4
2.5 (cognitive and perception assessment)
2.6 (Bowel and bladder function)
2.7
2.8

*

(3) 2

1

24

(4)

24
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(5) 31

2 3

(6)

1 2
2-3

(7)

7.1

7.2

7.3

7.4

7.5

(8)
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++
1.
(QE = I) 32 - 34
2.
++
2.1 (QE = III) 35
+/-
+/-
2.4 (resting or antispastic splint)

(QE = III)35
+/-
2.5 Diazepam
(QE = II-2)41
2.2

Tizanidine Baclofen

Tizanidine (QE = II-1)36
2.3 Botulinum toxin A (QE = I)37 - 40

phenol alcohol
3.
++
3.1
++
3.2
3.3
3.4 (overhead pulleys)42

4.
++
4.1
++
4.2
+/-
4.3 (QE = III-2)43
++
5.
(QE = III)44 - 46

26
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- 38 C

- > 100 < 60 /

- SBP >180 < 90 DBP > 110 < 60

-

-

-

-

-

-

-

-

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1 (Strength of Recommendation)
Grade
Recommendation
supported by data from randomized controlled trials with low false-positive

and low false-negative errors
supported by data from randomized controlled trials with high false-positive

and high false-negative errors
supported by data from non-randomized cohort studies, case series,

case report, expert opinion or consensus
28
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2 (Quality of Evidence: QE)

I
I-1
I-2
II
II-1
II-2
II-3
II-4

(systemic review) -
(randomized-controlled clinical trials)
-
(a well-designed, randomized-controlled, clinical trial)

(non-randomized,
controlled, clinical trial)
(well-designed, non-randomized,
controlled clinical trial)
(cohort)
(case control analytic studies)
/
(multiple time series)

..
III
III-1
III-2

(descriptive studies)
(fair-designed, controlled clinical trial)
IV
IV-1
(consensus)

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3 (Strength of recommendation)
(Strength of Recommendation)
++

(cost effective) /
(strongly recommend)

/ (recommend)
+/-

(neither recommend nor against)

(against)
--

(strongly against)
30
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1. Respiration
blood gas

2. Blood Pressure6
hypotension
mean arterial pressure (MAP) < 110 mmHg BP 160/90
(grade C)
MAP = Diastolic BP + 1/3 (Systolic BP - Diastolic BP)
2.1 systolic BP > 200 mmHg MAP > 150 mmHg
- Nitroprusside 0.25-10 g/kg/min 3
- Nitroglycerine 5 mg 1-4 mg/hr
- 2.2
2.2 systolic BP = 180-200 mmHg DBP = 105-140 mmHg MAP > 130 mmHg
- Captopril 6.25-12.5 mg 15-30 4-6 ..
- Small patch of nitroglycerine
- Hydralazine 5-10 mg 1-2 1-2 ..
- Nicardepine 0.1-0.2 mg/ml 5 mg/hr.
- nifedipine

2.3 Systolic BP = 180-200 mmHg MAP > 130 mmHg

cerebral perfusion pressure 60 mmHg
3. Temperature
cooling blanket
4. (Management of Blood Glucose)
> 140 ./.
5. (Prevention of Seizure)

6. Fluid & Electrolyte*
- dehydration overhydration isotonic solution
normal saline = urine output + 500 ml (insensible
loss) 300 ml/1oC (37oC)
- electrolyte *

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(Treatment of Increased Intracranial Pressure)
1. Clear airway Foleys catheter

2. 20-30
3. (jugular vein)
4. Hyperventilation PaCO2 = 30-35 mmHg
5. *
- 20% mannitol : loading dose 1 gm/kg 20
0.25-0.5 gm/kg 6 serum osmolarity
serum osmolarity < 320 mOsm/l (grade C)
- 10% glycerol 250 ml 30 6
- 50% glycerol 50 ml 4
- Furosemide 1 mg/kg (grade C)
6. hypotonic solution
7. steroid 47,48 (grade A)
32
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(Guidelines for Neurosurgical Consultation in Hemorrhagic Stroke)
Lobar
Temporal lobe
Basal ganglia
Thalamus
Cerebellum
Pons
Subarachnoid
hemorrhage (SAH)
Primary intraventicular
hemorrhage (IVH)
Hydrocephalus (HC)
(criteria)
1. GCS < 13
2. Volume > 30 ml
1. GCS < 13
2. Volume > 30 ml
1. GCS < 13
2. Volume > 10 ml
1. GCS < 13
2. HC
3. IVH
4. Repeated episodes
-
Criteria < 2
Criteria > 2
Criteria < 2
Criteria > 2
Criteria < 2
Criteria > 2
Criteria = 0
Criteria > 1
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(Calculation of Volume of Hematoma)17

(volume of hematoma) = 0.524 * X * Y * Z
(X, Y, Z X, Y, Z)

1. slice (slice thickness) .

1 . slice thickness = t
2. (hematoma) (location)
3. slice slices = n slices
4. Z = t * n c
5. slice slice
6. X = a Y = b
( a b )
7. (volume of hematoma) = 0.524 * a * b *c
(c = t * n)
34
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1. Vital signs:
a. Blood pressure (BP): Cushings reflex BP
Pulse pressure
b. Heart rate (HR): Cushings reflex HR
c. Respitatory rate (RR): (worse)
RR Apnea
2. Glasgow Coma Scale (GCS) : GCS score 2

3. Pupil:
a. Size: pupil Brain herniation (uncal herniation)
b. Equality: pupil 1 mm
c. Reaction to light: pupil Brain herniation (uncal
herniation)
pupil (
)
4. Motor power: motor power 1 grade
5. increased intracranial pressure hydrocephalus (vomiting, sixth

nerve palsy), brain herniation
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GCS (Glasglow Coma Scale)

Level of response

Scale value
1. Eye opening
Spontaneously
4
To speech
3
To pain
2
None
1
2. Motor response
Obeys commands
6
Localizes to pain
5
Withdraws to pain
4
Abnormal flexion
3
Abnormal extension
2
None
1
3. Verbal response
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible
2
None
1
Brainstem dysfunction
Hemorrhagic stroke Brainstem dysfunction
1 Vital signs: RR
2. Level of consciousness: Brainstem Reticular activating system

3. Brainstem
a. Brainstem function: Cranial nerve (CN. III, IV, VI)
(CN. VII) (CN.IX, X)
b. Brainstem reflexes: Corneals reflex (CN. V & VII), Dolls eye (CN. III & VI & VIII),
Caloric test (CN.III & VI & VIII), Nystagmus (CN.III & VI & VIII), Gag reflex (CN.IX)
36
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CT Scan of Normal Brain62
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37
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38
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Hydrocephalus CT Brain
(Diagnosis of Hydrocephalus by CT brain)
Hydrocephalus was defined as the presence of
1. The presence of a dilated contralateral temporal horn.
2. Unilateral dilated frontal and posterior horn of the lateral ventricle from deep cerebral
hemorrhage.
3. Bilateral dilated lateral ventricles with or without a dilated third ventricle resulting from
obstruction by a clot in the ventricle or the mass effect of deep cerebral hemorrhage.
4. The frontal horn is considered to have enlarged if there is an increased radius, decreased
ventricular angle, and sulcal effacement of the frontal lobe.
5. The posterior horn is considered to have enlarged if there is rounding of the posterior horn
with sulcal effacement of the parieto-occipital lobe.
6. The third ventricle is enlarged if the width is increased (> 7 mm.) and if there is ballooning
of the anterior recess.
7. The fourth ventricle is considered enlarged if there is bulging.
8. The bicaudate index : > 0.15 = ventricular enlargement
9. Evans ratio (index)is the ratio of maximum with of the frontal horns to the maximum with
of the inner table of the cranium = A/B > 0.3 in hydrocephalus
Hydrocephalus by CT brain A and B : Evans ratio = 0.34

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CT Brain of Hemorrhagic Stroke

Lobar hemorrhage
3
Frontal lobe
4
Temporal lobe
5
Parieto-occipital lobe
Basal ganglia hemorrhage
6
Small hemorrhage
at putamen
7
8
Classical hemorrhage Large basal ganglia hemorrhage
at globus pallidus
with secondary IVH
40
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Thalamic hemorrhage
9
Small thalamic hemorrhage
10
Large thalamic hemorrhage
with secondary IVH
11
12
Small pontine hemorrhage
13
Large Pontine hemorrhage
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14
Diffuse subarachnoid hemorrhage
15
Intraventricular hemorrhage in bilateral
ventricles and small amount of subarachnoid
hemorrhage along bilateral sylvian fissures
16
in the 3rd ventricle and lateral ventricle
17
in the 4th ventricle
42
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18 Rupture anterior communicating artery aneurysm (not shown)

with subarachnoid hemorrhage at the inferior anterior interhemispheric fissure
19 Rupture right middle cerebral artery aneurysm (not shown)

with diffuse subarachnoid hemorrhage and a localized hematoma
at the lateral right sylvian fissure
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(Factors affect outcome)

1. GCS score/stroke score
2. Location of hematoma
3. Size of hematoma
4. Coagulopathy
5. Hydrocephalus
Prospective Castellanos et al. 49
higher Canadian stroke score; lower blood pressure; higher
fibrinogen concentrations, CT findings smaller volume of ICH; more peripheral location of
hematoma; less intraventricular spread of bleeding; less midline shift.
prognosis & outcome
Intracerebral Hemorrhage (ICH) Score =

ICH score
Glasgow Coma Score*
3-4
5-12
13-15
(, cc.)**
>30
<30
tentorium
()
>80
<80
*Glasgow Coma Scale
** (A X B X C) / 2
2
1
0
1
0
1
0
1
0
1
0
44
_13-0689(001)P3.indd 44
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Intracerebral Hemorrhage
50
Glasgow coma score, 80 , ,
(intraventricular extension) tentorium
cerebellum (infra-or supra-tentorial location) ICH score
51 A x B x C / 2
A B C
slides 3 ICH score
52 - 54 ICH score functional
outcomes 1 7 55
Spot sign CT angiogram 24
spot sign score
spot sign score 54
spot sign score 9
1 45% 51% 51, 57- 59
meta-analysis 1 40.4%
1980 2008 60 2 56%
61%58 2.7% 16% 1 61
_13-0689(001)P3.indd 45
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The cutpoint for hematoma enlargement was determined as
V2-V1 = 12.5 cm3 or V2/V1 = 1.4 (sensitivity = 94.4%, specificity = 95.8%).
Kazui et al18 CT scan
Initial CT scan at 3 hours after onset of stroke 36%
Initial CT scan at 3 to 6 hours after onset of stroke 16%
( V1 = initial CT scan, V2 = second CT scan)

CT scan brian hematoma expansion

CT scan
alcoholic abuse; an irregularly shaped hematoma, and a low level of fibrinogen.50
46
_13-0689(001)P3.indd 46
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(Case study)
Case 1
- 41 .
- 8 ..
- BP 160/90 PR 80/min Temp 36.4 RR 17/min Blood Sugar 87 mg/dl PT, PTT normal
- GCS = 10, right hemiplegia
CT brain (at 8 hrs after onset):
- left putaminal hemorrhage, 3*4.3*2.1 cm., midline shift 3.3 mm.
Dx Left putaminal hemorrhage

Management
1. Volume of hematoma = 3*4.3*2.1*0.524 = 14.19 cc.
2. basal ganglia hemorrhage CPG criteria 1
(GCS = 10)
medical Rx
3. BP 160/90 mmHg criteria anti-hypertensive
conservative & supportive Rx
_13-0689(001)P3.indd 47
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4. CT brain 8 . onset expanding hematoma

15% observe ( 7) refer

5. Dx, management, risk
Case 2
- 71 . .
- 8 .
-
- 9 thalamus
- BP 200/100 mmHG PR 80/min Temp 37.4 RR 16/min

- GCS = 14, pupil 3 mm. RTL.BE., dysarthia, Gag reflex present, No facial palsy,
No nystagmus, Finger - Nose - Finger test impaired right side
- Left hemiparesis
CT brain (at 8 hrs after onset) :
- Right cerebellar hemorrhage 2.2*2.6*2.5 cm. with mild surrounding edema and mild
pressure effect upon fourth ventricle
Dx Right cerebellar hemorrhage

Management
1. Volume of hematoma = 2.2*2.6*2.5*0.524 = 7.49 cc.

48
_13-0689(001)P3.indd 48
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2. cerebellar hemorrhage CPG

conservative & supportive Px
Case 3
- 58 .
- 8 .
: DM, HT
- BP 140/90 mmHg PR 80/min Temp 37.2 RR 18/min

- GCS = 14, pupils 3 mm. RTL.BE., No facial palsy
- Right hemiparesis gr. III
CT brain (at 8 hrs. after onset) :
- Left thalamic hemorrhage 2.1*1.0*0.5 cm.
Dx Left thalamic hemorrhage without midline shift or hydrocephalus.

Management
2. thalamic hemorrhage CPG criteria 1
(GCS = 10 )
medical Px
conservative & supportive Px

_13-0689(001)P3.indd 49
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4. CT brain 8 . onset expanding hematoma 15%

observe ( 7) refer

Case 4
- 74
- 3 .
- Hyperthyroidism hypothyroidism
- Bradycardia, Heart AF
BP 170/100 mm.Hg PR 80/min Temp 36.8 RR 15/min.
- GCS = 9, Left hemiparesis Grade I
- Pupils Rt. 3 mm. RTL, Lt. 2 mm. sluggish RTL.
CT brain (3 hrs. after onset): right basal ganglia hematoma size = 6.9*4.6*7.0 cm. effacement of
right ventricle
Dx Lobar hemorrhage at right temporal lobe

Management
3. lobar hemorrhage CPG criteria 2 (GCS = 9,
volume > 30 cc.

50
_13-0689(001)P3.indd 50
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Case 5
- 72 .
- 2
: Old CVD, HT, Aspirin
: BP 140/ 90 mm.Hg PR 98/min Temp 36.8 RR 15/min.
- GCS = 15, pupils 3 mm. RTL. BE.
- Left hemianopia
CT brain (48 hrs. after onset) : right occipital lobe hematoma, size = 1.7*2.8*3.0 cm.
Dx - Lobar hemorrhage right occipital lobe

Management
2. lobar hemorrhage CPG criteria 0
medical Rx
conservative & supportive Rx
( 7)

_13-0689(001)P3.indd 51
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Case 6
- 44 .
- 3
: 8 1 20
: BP 138/77 mmHg PR 90/min Temp 36 RR 15/min.
- GCS = 15 pupils 2 mm. RTL., no weakness
CT brain (72 hrs. after onset) : Left parietal lobe hematoma, size = 3.0*1.3*2.1 cm.
Dx. Lobar hemorrhage at left parietal lobe
Management
2. lobar hemorrhage CPG criteria 0
medical Rx
3. BP 138/77 mmHg criteria anti-hypertensive conservative &
supportive Rx
( 7)
6. 45
intracranial vascular study vascular abnormality
52
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Clinical Practice Guidelines for Hemorrhagic Stroke

Clinical Practice Guidelines for Hemorrhagic Stroke

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Guidelines for the Management of Hemorrhagic Stroke)

(Surgical Management of Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Initial management and Diagnosis of stroke)

Clinical assessment & grading*

* (GCS < 8, signs of brain herniation, hypoxia,

) advanced life support

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(CBC, BS, BUN, Cr, electrolytes)

hemorrhagic stroke ischemic stroke16

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Classification of Hemorrhagic Stroke by Location)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

IVH with HCP

Criteria for neurosurgical consultation

(Clinical Practice Guidelines for Hemorrhagic Stroke)

enlarged vessels calcification hematoma hyperdensity dura venous sinus

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Management of Non-Lobar Hemorrhage)

stroke 45 hypertensive hemorrhage23,24

(Clinical Practice Guidelines for Hemorrhagic Stroke)

Basal ganglia hemorrhage*

Criteria for neurosurgical consultation

IVH with HCP

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

IVH with HCP

Criteria for neurosurgical consultation

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Management of Cerebellar Hemorrhage)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

Clinical suspicion of SAH

CT brain non contrast

Cerebrospinal fluid LP = Lumbar puncture

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

(Clinical Practice Guidelines for Hemorrhagic Stroke)

2.1 (QE = III) 35

2.4 (resting or antispastic splint)

2.3 Botulinum toxin A (QE = I)37 - 40

3.4 (overhead pulleys)42