每日一题_2022.4.19

A 59-year-old, active man with a medical history of atrial fibrillation, diabetes mellitus, systolic heart failure, and hypertension is brought to the emergency department by his wife for sudden onset of aphasia, left hemiparesis, and dysarthria eight hours ago. He takes aspirin and pravastatin for stroke prevention. Vital signs are: blood pressure 188/98 mm Hg, heart rate 108 beats/min, respiratory rate 26 breaths/min, oxygen saturation 86%, and temperature 38.2°C (100.8°F). On examination, he is hard to arouse, has a left-sided gaze palsy with symmetric and reactive pupils, and a dense right-sided hemiplegia. Glasgow Coma Scale score is 7; National Institutes of Health Stroke Scale score is 23. He is intubated for mechanical ventilation, an infusion of 25% mannitol is started, his head is elevated at a 30° angle, and he is transferred to the ICU. White blood cell count is 12,500/μL, INR 1.4, partial thromboplastin time is 28 sec, and platelets are 150,000/μL. CT is shown below.

Which of the following is the best next intervention?

A. Adjust the ventilator to immediately hyperventilate.

B. Administer IV tissue plasminogen activator (tPA).

C. Request emergent consult for endovascular intra-arterial tPA.

D. Request emergent neurosurgical consult for decompressive hemicraniectomy.

答案解析：

该患者有较大的左半球梗死(LHI)，如CT所示。他不是IV或动脉内组织型纤溶酶原激活物(tPA)的适应症，因为自症状发作后分别超过4.5小时和6小时。两种血运重建替代方案（IV和动脉内）均取决于在合理窗口内的给药。他似乎没有脑疝，因此在这种情况下，禁忌过度通气，因为它可以减少已经受损的脑血流量。肝素在他的治疗中没有直接作用。有证据表明，在房颤相关栓塞性卒中背景下使用肝素对卒中复发无获益，实际上可能增加LHI的出血风险。在60岁以下的患者中，去骨瓣减压术与LHI后死亡率和功能结局改善相关。继续进行去骨瓣减压的决定取决于患者和家属。

正确答案：D