Maintain stable vital signs: closely monitor changes in vital signs and neurological signs; keep the airway open, paying special attention to the prevention and treatment of pneumonia, atelectasis, pulmonary embolism, aspiration and pneumonia. Maintain stable circulatory system function and renal function.
Blood pressure and blood glucose: Blood pressure regulation needs to be individualized to achieve a more ideal blood pressure level, which will benefit the overall treatment and rehabilitation of cerebrovascular disease. When blood glucose increases more than 11.1 mmol/L, insulin therapy should be given to control it below 8.3 mmol/L.
Third, correct water and electrolyte balance disorders: pay attention to the balance of in and out, the crystal colloid ratio of rehydration and the adjustment of diet, which can effectively prevent water and electrolyte disorders. Among them, hyponatremia and hypokalemia are more common (especially anterior communicating aneurysm).
Corticosteroids: Although they can reduce cerebral edema, they are prone to cause infection, elevate blood sugar and induce stress ulcers, so they are mostly not advocated to be used excessively. However, patients with anterior communicating artery aneurysm should be used as appropriate, especially patients with clamping surgery.
V. Dehydration therapy: Dehydration therapy is not recommended for all stroke patients, unless there is an increase in intracranial pressure (ICP).
VI. Increased ICP: Most often seen in patients with high bleeding, bleeding into the ventricles, hydrocephalus, or large cerebral infarction. Methods to reduce ICP include
1. General treatment.
(1) Lie in bed and avoid excessive head and neck distortion.
(2) Avoid factors associated with increased ICP, such as agitation, exertion, fever, epilepsy, respiratory insufficiency, cough, constipation, etc.
(3) Appropriate restriction of fluid intake, prevention and control of hyponatremia, hyperventilation, etc. can help reduce ICP.
(4) Dehydration treatment: mannitol, tachypnea and glycerol fructose are commonly used, and albumin can also be used as appropriate. Tachyphylaxis and mannitol can be used alternately to reduce the adverse effects of both. Glycerol fructose has a mild effect, generally without rebound, and has a certain amount of heat, and can also be used in renal insufficiency. In addition, sodium hesperidin has anti-inflammatory, anti-exudative and eliminating swelling effects.
(5) Etiological treatment.
(①For large cerebral infarction in the cerebral hemisphere, debridement decompression and/or partial brain tissue resection should be performed as early as possible.
(2) Intracerebral hematoma: large volume (≥30 ml) with midline shift (≥1 cm) should be surgically removed as early as possible to lower intracranial pressure to save life. For moderate volume hemorrhage, minimally invasive surgery such as craniotomy through small bone windows, minimally invasive puncture or cone skull can be performed. Minimally invasive surgery is suitable for subcortical, nucleus accumbens and cerebellar hemorrhage, and can also be used for deep hemorrhage extending to the superficial area; it can be performed locally in county hospitals, shortening the rescue time; if available, CT guidance, stereotactic, endoscopic or navigation techniques can be used to achieve better results. Fibrinolytic agents (such as UK, rtPA, recombinant streptokinase, etc.) can be injected into the hematoma cavity to dissolve the residual hematoma and facilitate drainage.
3.Larger cerebellar infarction or cerebellar hemorrhage (≥10 ml), especially if it affects brainstem function or causes cerebrospinal fluid circulation obstruction, posterior cranial fossa craniotomy for decompression or (and) direct resection of part of cerebellar infarction is feasible to release brainstem compression.
4. Ventricular hemorrhage.
(1) Bilateral lateral ventricular hemorrhage cast: use bilateral lateral ventricular frontal horn puncture, both put thicker external drainage tube and drain bilaterally; if the drainage is poor, one side can be flushed with saline + fibrinolytic solution and one side can be drained. After 7 days, all external drains should be removed to prevent intracranial infection. If there is still a small amount of blood in the ventricle, the Ommaya tube is placed in the ventricle and the CSF drainage is performed by puncturing the subscalp Ommaya reservoir capsule, which can be used repeatedly and for a long time and can effectively prevent intracranial infection.
(2) One side ventricular hemorrhage cast, one side ventricular hemorrhage more: put thicker external drainage tube on the cast side, put thinner external drainage tube on the other side, the rest as A.
(3) More bleeding in one ventricle and less bleeding in one ventricle (deposited in the posterior horn): put a thin external drainage tube in the side with more bleeding, and put an Ommaya tube in the side with less bleeding; the Ommaya tube will not drain externally for the time being, and then connect to external drainage after the thin external drainage tube is removed.
(4) Less hemorrhage in one ventricle and no hemorrhage in one ventricle: place an Ommaya tube for external drainage on the side without hemorrhage.
(5) Four-ventricle hemorrhage: lateral ventricular hemorrhage can occur in cases C and D. Treat accordingly according to C and D. However, the external drainage height should not be low to prevent supraventricular herniation.
(6) Unless it is determined that there is no intracranial hypertension, external drainage of CSF by lumbar puncture should not be done to prevent herniation of the foramen magnum.
VII. Prevention and treatment of cerebral artery spasm and cerebral ischemia
1.Maintain normal blood pressure, blood volume and blood viscosity (3N treatment).
2. Early and adequate use of nimodipine: the usual dose is 10-20 mg/d and 1 mg/h intravenously for 10-14 days.
3.Lumbar puncture with continuous CSF external drainage or CSF replacement: if it is determined that there is no intracranial hypertension, its use will be beneficial to prevent cerebral vasospasm and reduce sequelae symptoms, especially for patients with severe headache, irritability and other severe meningeal irritation signs.
4. If the above treatment is ineffective, intra-arterial injection of nimodipine or poppy bases (300 mg in 15-60 mins) and balloon angioplasty (PTA) are feasible. Both can be used alone or in combination.
VIII. Prevention and treatment of hydrocephalus
1, drug treatment: mild to moderate hydrocephalus can be preceded by drug treatment, giving drugs such as acetazolamide to reduce CSF secretion, mannitol, tachyzoites, etc. as appropriate.
2, ventricular puncture CSF external drainage: moderate to severe hydrocephalus in people with impaired consciousness, Ommaya can be placed in the ventricle to perform CSF external drainage. Because CSF cells and proteins are high in the acute stage, it is not advisable to do permanent internal shunt directly (unless CSF cells and proteins are normal).
3. CSF shunt: some hydrocephalus can be reversed by treatment, if it is ineffective, and CSF laboratory tests are normal, ventricular-atrial or ventricular-abdominal shunt is feasible.
9. Symptomatic treatment.
Sedatives are given for irritability, analgesics for headache, and drugs that may affect respiratory function, such as morphine and dulcolax, are used with caution. In case of seizures, short-term anti-epileptic drugs such as sodium valproate, carbamazepine or Valium are available. Also, prevent and control stress ulcers.
X. Intensify care.
Give high-fiber, high-energy diet. Nasogastric tube can be given to those with impaired consciousness, and prevent asphyxia and aspiration pneumonia carefully. Keep the urine and stool unobstructed, keep urinary retention with catheterization, and pay attention to the prevention of urinary tract infection. Prevent complications such as decubitus ulcers, pulmonary atelectasis and deep vein thrombosis by regular turning, limb movement and air mattress.
XI. Rehabilitation
It should be carried out as early as possible and can be started 10 to 14 days after the disease. Pay attention to the patient’s depression and anxiety status.