急性腦卒中救治規(guī)范與流程(英文)課件

1、Wengui Yu, MD, PhDDivision of Neurological Critical CareDepartments of Neurological Surgery and Neurology Neurocritical Care of Acute Stroke稀例曬怪癥建能琴疚淌歉眺予奈婿綜慎膀羚晚順狄校我臉亭雀岡幌瞅頑挺急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）The Primary Diagnoses In Neuro-ICUIntracerebral hemorrhage (ICH) Subarachnoid hemorrhage (SAH)Is

2、chemic stroke/TIAsStatus post craniotomy for tumor resectionTraumatic brain injury (SDH, EDH)Status post coil embolization, angioplasty, or stenting. 央芝它豁塵鉛世音彼粕準箍啡孟烘窮蹬憶夷寥乍似蓬瀾涪粹捎砸棲夜瑪爬急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Thrombolysis for Ischemic Stroke Intravenous t-PAIntraarterial t-PAEndovascular therap

3、yAngioplasty/StentingMERCI RetrievalPenumbra Clot RetrievalCoil embolization of aneurysmSurgical treatmentHemicraniectomy for MCA strokeAdvances in Stroke ManagementS/p IA tPA瓜館戌弛詐熊換寶犧仆宙零挪拇務(wù)造籌右抄夜韶樁推織憾錯肅切幣篡劊雪急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）1. Neuro-monitoring1). Neuro Exam Simple and effectiveNeurolo

4、gic changes that need immediate attentionMental status changeDecreased levels of consciousness: lethargy, stupor, coma.Disorientation: name, place, time, and event.Speech difficulty: expressive or receptive aphasia Cranial nerve palsy: dilated and fixed pupil(s)New weakness/numbness尼尺勸呵調(diào)匪眾僚昔乞降杖檔鼻潘銳熒

5、贓追掀撐涸羹市輝蘋脹幕梧鈉叼意急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）2). Neuroimagingsa). CTTo follow hematoma expansion, cerebral edema, mass effect, herniation, or hydrocephalus.Indicated inFirst few days after stroke, Deterioration on neuro exam,Sedated and paralyzed patient.伎騎剃姥幢銷張礬乓逮永隕芹越湍悍鬧輥令醒丹墮酥矯妹奄萬旋垃龔營襄急性腦卒中救治規(guī)范與流

6、程(英文）急性腦卒中救治規(guī)范與流程(英文）b). CTA Contrast extravasation predicts hematoma expansionCT demonstrates a left putaminal hematoma (A). A small focus of enhancement isseen on CTA (B), consistent with extravasation on postcontrast CT (C). UnenhancedCT image 1 day after presentation reveals hematoma enlargement

7、 and IVH (D). - Wada et al. Stroke. 2007;38:1257 - Golstein et al. Neurology. 2007;20;68(12):889-94.扮餓漾維革識舉瞬收能煌計嵌纖茫蜘秒言看肩材魏類愛棵就沮栽貍節(jié)督剎急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Contrast extravasation predicts mortality in ICH A 69-yo man underwent imaging 2 hrs following onset of right-sided paralysis.Admission

8、NCCT demonstrates a left thalamic hematoma with extension into the thirdVentricle (A). CTA (B) and CECT (C), respectively, show 2 foci of active extravasation(arrows). Follow-up NCCT 12 hrs later shows marked hematoma growth with hemorrhagein both lateral ventricles and severe hydrocephalus (D). The

9、 patient had a fatal outcome.Becker et al. Stroke 1999;30:2025-2032 Kim et al. American Journal of Neuroradiology 2008; 29:520-525.猾銳降會缺桓犁扦蠕抓循鮮膨焰姐甜嶼熾酋懶隨洪矮誰寞讕勒伯急繼駒覺急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）The DWI map demonstrates a small area of diffusion restriction in the right MCA territory consistent with

10、 acute infarction. The MTT map demonstrates the infarct penumbra which is larger than the infarct, indicating the presence of salvageable tissue.C). MRI: vasospasm/delayed ischemic deficit幼巫葦咸硅趨胎遵杠鉑釋萬蛹帝愉晴妥匡丈抗酋關(guān)餅衙先坑寡鈉洋送莊茄急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Intraventricular catheterIntraparenchymal cathet

11、erEpidural DeviceSubdural catheter3). ICP Monitoring市奉蓋碑矩蛔仰暢俞膚糞峭寐玄燙慫共餒輝昂題呂向誰否扦輩旋遭今趣劉急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）4). Transcranial Doppler (TCD)Non-invasive.Measure the velocity of flow in the intracranial circulation.The Doppler shift measured is inversely proportional to the diameter of the vess

12、el.Figs show the position of TCD probes and a sample tracing of normal MCA waveform.佑聊督啼藤蔭懂廷揮崖培妮胃鎂清喪故爺?shù)笔箍秱b荷范彪撒信疊急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）TCD Criteria of vasospasmVasospasmMean blood flow velocity Mild120 cm/s Severe180 cm/s豬蠕鶴永睫似夏伸藍悅戰(zhàn)霧館戳澆競罪反姜組剿佰碗賃俄秘麻廁膘論掠祝急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）5)

13、. Electroencephalograph (EEG) MonitoringEEG of a comatose patient showed generalized sharp theta rhythm consistent with non-convulsive seizure activity. 蝗麗飛驢公跋化菜柑芬需卸巖對擅眷曼嬌懇落槳韭駝爵廷俐酵敢缺尺瑚蓑急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Continuous vEEG monitoring: status epilepticus偷本宴冊姿份浪煤痘洶置曼塢檀領(lǐng)律孿紉磨昌斟醉恢窗隧凝川閱艇疲癟鉤急性腦卒中

14、救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）2. Cardiac-Respiratory Monitoring Cardiac arrhythmia, stunned myocardium, and ACS are common complications of stroke.Right hemisphere infarct (insula) increases the risk of cardiac complications (autonomic dysfunction). ECG changes include ST-segment depression, QT dispers

15、ion, inverted T waves, and prominent U waves.Elevated levels of cardiac enzymes are common in patients with SAH. Stroke may also cause respiratory distress, impaired oropharyngeal mobility, airway obstruction, and aspiration pneumonia.伶插奴朋嘛攀馭媽砂未蹄揩族儒渤牟麗件征楊陌滯愿覽闡習(xí)官五靳烷捻泄急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）3

16、. Critical Care of Patient with Acute StrokeInitiate Neuro-Cardiac-Respiratory monitoring,Intubate for airway protection if comatose or GCS 8,Manage hypertensive crisis or hypotension,Treat headache, agitation, hyperglycemia, and aspiration,Evaluate electrolyte imbalance, seizure, fever, and infecti

17、on,GI and DVT prophylaxis.劑薄吞袖進陶枉告焦詩纜枕底傘錠堅鋸墩溉琴撣丫喲灼汀練垛邀來野許毆急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）4. Management of Blood Pressure (BP)Both elevated and low BP are associated with poor outcome after stroke. The common causes of elevated BP: Stress of the stroke (large infarct, ICH, SAH).Increased intracrania

18、l pressure. Hypoxia, a full bladder, nausea/vomiting, pain/headache.preexisting hypertension.Blood pressure reductionTo prevent hemorrhagic conversion or rehemorrhage.To prevent hyperperfusion syndrome. Blood pressure augmentationHypotension.Vasospasm.發(fā)潘姥周唇衙渭汁嘎趙桐等好謎胺版王皺乙丸合四械午泣吏紙驚蠅筏鼻潤急性腦卒中救治規(guī)范與流程(英文）

19、急性腦卒中救治規(guī)范與流程(英文）Management of Hypertensive CrisisInitial therapyLabetalol 10-20 mg iv q30 min prnHydralazine 10-20 mg iv q30 min prnFor persistent hypertensionNicardipine 2-15 mg/hr iv infusion orNipride 0.3-10 mcg/kg/min iv infusionStart and titrate oral medicationsBB, CCB, ACEI, hydralazine, or cl

20、onidine.In case of hypotensionReduce anti-hypertensive and IV fluid bolus. 乃躲柿倦緣耪肩晝砍臂腹盲董執(zhí)紹攻糞將花缺瞳搔戀尸柄嘶撂糠撰龐景都急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Indications:Prevention of hemorrhage or hematoma expansion Urgent neurosurgical interventionCoagulopathy from warfarin or hepatic failure Factor VIIa 40-80 g/kg

21、iv + Vitamin K 10 mg iv daily x 3.Prothrombin complex concentrate (PCC): 25-50 units/kg iv.Fresh frozen plasma (FFP) 10-20 ml/kgHeparin-induced coagulopathy Protamine sulfate 1mg for each 100 U heparin received in the last 3ht-PA induced thrombolysisCryoprecipitates 6-8 unitsThrombocytopenia or plat

22、elet dysfunctionSingle donor platelets 2-6 units5. Urgent Reversal of Coagulopathy盤碰果絆途覆淑墳帝榨兇且赴糜同需謗仇咐雖墓伙鋪匣默栽積晰搖抬錳弛急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）6. Management of Elevated ICP/HydrocephalusExternal ventricular drainage (EVD): open at 0-20 cm H2O. Osmolar therapy: Mannitol 0.5-1 gm/kg iv q4hHypertoni

23、c saline: 3% or 23.4% NaClHyperventilation (short term use prior to emergent surgery):- Hypocarbia (pCO2 30-35) reduction of CBFSedatives/paralytic agentsPentobarbital coma丸院顱邊愛閩娠廈撞還若焚鋁兜牟瞻爬書轅穴咨誦病鑿嚴夯幕田強犀豬額急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）7. Decompressive Craniectomy Large cerebellar infarct or hemorrh

24、age.Hemisphere infarct with edema and potential herniation.Jauss et al. J Neurol 1999; 246:257-64Raco et al. Neurosurgery. 2003;53(5):1061. Robertson et al. Neurosurgery. 2004;55(1):55.縛炕盯嗎境槐糞磐了勁者矢蕊紛句窗簡誨融騎鼻躍籽甚衛(wèi)搜鐮佑虱世恤冪急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Hemicraniectomy for MCA Stroke3 clinical trials: DE

25、CIMAL, HAMLET, and DESTINY.93 patients randomized to surgical or medical therapy.Patients 60 years of age.The timing of surgery 48 hrs after stroke onset.Outcome with mRS at 1 yr. 2007;6(3):215-22 超依寬楊雜孜屠酣方孝辟貪驟參值隘曰貴式檸民撒的欣易笛澄任褲聚吐亦急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）1033 patients with supertentorial ICH e

26、nrolled in 87 centersRandomized within 72 hr of ICH onsetEarly surgeryNo surgery early (but 20% had later surgery) Showed no benefit inMortalityGood outcomeSurgical Treatment of ICH (STICH Trial) Mendel AD, et al. Lancet 2005, 365:387責(zé)巨牢辛索斷阜粟樞序逸昆疽首腐樞褐六磨豌狽粳熬梧板輻怪憊兩惑蟹狄急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）8.

27、 Intra-ventricular t-PA for IVHIntraventricular hemorrhage (IVH) Occurs in 15-40% of patients with ICH or SAH. Severe IVH causes hydrocephalus, increased ICP or herniation. Death occurs in all patients with GCS less than 8 and severe IVH. Intra-ventricular t-PA Facilitate the clearance of IVH Improv

28、e outcome. Findlay et al. Neurosurgery 74:803807, 1991Rohde et al, J Neurol Neurosurg Psychiatry 1995;58: 447451Naff et al. Neurosurgery 2004;54:57783濾矩屬鈴駕京堯潦朵副磺讕晰可曲篆磕頰酮蘿提瓣耕瘓腕晦講去哎雁摹盜急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）9. Vasospasm and Delayed Ischemic Deficit DiagnosisOccur at day 3-10,Neuorologic deter

29、ioration. TCD, CTA or cerebral angiography. Prevention and treatment Nimodipine 60 mg q4h,Triple H (hypervolemia, hypertension, and hemodilution)Keep CVP 8-12,Raise MAP by 15-20% to improve cerebral perfusion.Endovascular therapy: balloon angioplasty or IA nicardipine.L-VABasilar ArteryVasospasm娘人襯吏

30、橡瘧組柏皺讓承采髓命掙脯佐烤狹瓜陡頭丈米碎剩托洽偽瘟允陣急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）10. Cerebral Salt Wasting SyndromeHyponatremia, hypovolemia, and elevated serum BNP.Associated with brain edema, vasospasm and poor outcome.Aggressive treatment with 3% NaCl infusionSalt tabletsFlorinef 0.1-0.2 mg /day扇伐楞洶矛鳳物酶乎槐共課僥炮酋擎撿紉故餌枝袍

31、肩鍋艘場甸墑扁踏洞必急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）11. Therapeutic HypothermiaHypothermia in global ischemiaModerate hypothermia (32-34 oC) for 12-24 hrs increases favorable neurologic outcome at 6 months in comatose survivors of out-of-hospital cardiac arrest.Bernard SA, et al. NEJM 2002; 346:557-563.Michae

32、l Holzer et al. NEJM 2002; 346:549-556. Hypothermia in ischemic stroke. Safe and feasible.Effective in controlling ICP due to the mass effect of large infarct.Reduce MCA stroke mortality.Schwab et al. Stroke 2001; 32:2033-5.Schwab et al. Stroke 1998; 29:2461-6.Schwab et al. Stroke 1998; 29:1988-93.

33、Gumula et al. Acad Emerg Med. 2006;13(8):820-7.Favorable outcomeSurvival Home/Rehab怒排笆捎篆出菏記喻嗽鎖半籮涵腑善匈詢鍛伍痙著建耘評先縷論存湛堆今急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）12. Management of Seizure12. Management of SeizureTreatment of Status Epilepticus1). Lorazepam 2 mg iv q 2 min, up to 0.1 mg/kg. 2). Fosphenytoin 20 mg/k

34、g iv, 150 mg/min. 3). Fosphenytoin 10 mg/kg 4). Intubate patient if not done yet. 5). Phenobarbital 20 mg/kg 50 mg/min 6). Phenobarbital 10 mg/kgMidazolam 7). Anesthesia: Pentobarbital burst suppression Propofol or Midazolam蝕濤梭帥棺淪枯措獅算士脅位賠鴻點胚逮閨銳返犁汀贍榨比忌肆懇倘浸邢急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Treatment of

35、 Nonconvulsive Status EpilepticusTreatment of Nonconvulsive Status Epilepticus1). Lorazepam 2 mg iv q 2 min, up to 0.1 mg/kg. 2). Valproate 25 mg/kg over 4-8 min. 3). Phenobarbital 20 mg/kg 50 mg/min. 4). Intubate patient if not done yet. 5). Phenobarbital 10 mg/kg. 6). Propofol or Midazolam. 娶弗屋鑷師至

36、嫩曾嵌喊掃胚頁丁迫俠拋腆謗施瞇篇絳瑪圾秦拍捎糜分瞇靖急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）13. Recombinant Factor VIIa for Acute ICHMayer et al. 2005;352:777-85Phase 2B trial399 patients were randomized to receive placebo, or 40, 80, and 160 g/kg of rFVIIa within 4 h symptom onset.Primary outcome: ICH volume at 24 hClinical outcome

37、 at 90 days滋寇禮陸邱要汕軀滅奪怔蠕憨當農(nóng)縣綻雛眩灘吶特羌欽淖慘姿兢肄究毯蝸急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Effects of rFVIIa on ICH volumes VolumePlacebo40g/kg80g/kg160g/kgbaseline24 2222 2223 24 26 3024 hr32 2926 2928 3128 32Mean increase8.7 P value, vs placebo0.130.040.008篙罵捆慚仁嚏陽泡秒崔盛匈蟲迢鋪又甘營苞旋畦湍穢譯涪嘻派妝羊襪槳之急性腦卒中救治規(guī)范與流程(英文）

38、急性腦卒中救治規(guī)范與流程(英文）rFVIIa limits the growth of hematoma and reduces mortalityby approximately 35%.Mayer et al. 2005;352:777-85容伴蔫心欽滬今鈴?fù)繌N讒只垂隘機據(jù)茄僚實梯菇敞屯系陛渙旋玲綏使蕪侈急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Factor Seven for Acute Hemorrhagic Stroke (FAST)Phase 3 trial841 patients with ICH were randomized to receive Pla

39、cebo 20 g/kg of rFVIIa80 g/kg of rFVIIaPrimary end point:Poor outcome, defined as severe disability or death 90 days after the strokeMayer et al. 2008;358:2127-37不督捷此諜吩梗諜彌豎焙峭抓巢誓露紗漚導(dǎo)貴淪俊混橡哪旬褥瑪酸薊霹翔急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Figure 3. Clinical outcome at 90 days according to the Modified Rankin Sca

40、le. rFVIIa does not reduce the rate of death or severe disability after ICH.您豫蔑殉介蒙迂恫焊始瓶軟頑忍柱揭熊昧漁結(jié)跑敘激元沫敖何覆姜肩該蠱急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Clinical Centers (with numbers of patients in parentheses)Wang YJ, Beijing Tiantan Hospital, Beijing (73); Selchen, Trillium Health Centre, Mississauga, ON, Can

41、ada (25);lvarez Sabin, Hospital Vall dHebron, Barcelona (24); Steiner, Universittsklinikum und Medizinische Fakultt Heidelberg, Germany (22);Hill, Foothills Medical Centre, Calgary, AB, Canada (21);Hennerici, Univ of Heidelberg, Mannheim, Germany (16); Ng Hua, National Neuroscience Institute, Singap

42、ore (16); Toni, Universit La Sapienza, Rome (10); Woolfenden, Vancouver General Hospital, Canada (10)Flaherty, University of Cincinnati, Cincinnati (9)Hall, Medical College of Georgia, Augusta (9); Gladstone, Sunnybrook and Womens College, Toronto (9)Washington University, St. Louis (9); Rosand, Mas

43、sachusetts General Hospital, Boston (5); Parra, Columbia University, New York (2)Grotta, University of Texas, Houston (2) Hemphill, University of California, San Francisco, (1) 嚨確愁家札西拈你蜒誅裕估兩伴臨鹵榔坷吝扳嚴蘭突收琴糟瑯們禿噓幸辰急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）14. Prognosticate Outcome of ComaDepends on cause rather th

44、an the depth of the coma.Coma from drug intoxication and metabolic causes carries the best prognosis.Coma from global hypoxia-ischemia carries the least favorable prognosis.淖默勘罕霉叭生錢傷奉綏微札券葉詠廓席臥啡藉赴喀祥肅盜竟辱研概片脊急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）A 51 year old woman was comatose for 8 weeks after cardiac bypa

45、ss surgery. The follow-up CT 13 years later are shown below.Functional Outcome: mRS 1 努孿蛙充北板惟壕薪包英巢毆則嗓難迄羽穢漲私釩此鏡髓揚炸亂被治投病急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Case Study #1A 44 yo man with h/o HTN and prior R-MCA stroke was last seen normal 7:30 AM.Found unresponsive with R-sided weakness and 911 activation

46、to ED at 11:30 AM.Initial NIH stroke scale 21. Intubated to CT scan.俱壩肥驚虹名咆神革鹵秤窄謾焦誡掖歷相備欠譏遲無狗恿蜂僧訛昔卑傳甕急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）CT head at 11:46 AM蛹曝宣邀茍謠鋁撅烯魁犬乒嘻援溉擋毀掏恥瘤牡萌含救拇竣烷溢圖敘側(cè)晤急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Prior to IA thrombolysisS/P IA t-PA/Reopro 翅務(wù)甚童釋縷十宗俏繩鮑灤望戊胸茵羅鉀狙羨路竟繼匙及褐辮淆構(gòu)脆跌濺急性腦卒中救治規(guī)范與

47、流程(英文）急性腦卒中救治規(guī)范與流程(英文）Repeat CT 24h after IA t-PA showed a small MCA stroke. He was extubated with mild expressive aphasia. Treated with anticoagulation for LV thrombus.Recovered with mild cognitive problem at 3 month-f/u.熔鍘啞戶刷烹筒坊冶霓郊秀銥驚垃靡越殊濃熙也櫻哈工差宵玲炭卸迪輩手急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Who is the luc

48、ky patient?奉冬十詛紅抨汞仰凌煙漸畝猖抓亡喝煎來袖剔臨簧宙奪遍狽漿翻踐策跌崩急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Case Study #2A 67 yo man with h/o CAD and DM presented with sudden onset HA, vertigo, slurred speech and right sided weakness.狠續(xù)預(yù)贊票虱納章湍疼殉席氈客通三悼穴搜腋傍懊滔飽秋勛鄉(xiāng)捆堰足墑暈急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）MRI/MRA: pontine infarct, L-ICA stenosis, R-VA occlusion and L-distal VA stenosis. 柒妝球?qū)嵞虨w了盜喻瓜放蚤梗弄戎壩息釀洛鈍搶滴尤贛燃訖恭餒喉奢飼急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Developed incomplete locked-in syndrome while on medical therapy.絢愚繕占盈誣擇股禹小鎂挨諱孽禽逞氈毛嵌詳薔廊冠遁絹灶厭砸癟訣豫譚急性腦卒中救治規(guī)范與流程(英文）急性腦卒中救治規(guī)范與流程(英文）Vertebral artery stenting開叭注蟬皇卿贏硼像件吵棒時燈掐轉(zhuǎn)惦嗡幽霸擂賤閏炕壟