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1、精品文档，仅供学习与交流，如有侵权请联系网站删除大连医科大学硕士研究生试卷 2010年级专业外语试卷学号 姓名 考生须知1、检查所发试卷是否和自己所报科目一致，试卷有无缺页、漏印、字迹模糊，如有可举手请求换卷。2、必须将自己的学号、姓名、专业班级写在试卷指定位置上。3、在试卷密封线以外填写姓名、学号或写有与答题内容无关的语句和作其它标记的试卷一律作废，后果自负。命题单位：大医二院 教研室：急诊医学 教研室主任审核签字： 阅卷人 ： 一二三四五总分分数英译汉：Emergency Diagnosis and Assessment of ICH and Its CausesRapid recogni
2、tion and diagnosis of ICH are essential because of its frequently rapid progression during the first several hours. The classic clinical presentation includes the onset of a sudden focal neurological deficit while the patient is active,which progresses over minutes to hours. This smooth symptomatic
3、progression of a focal deficit over a few hours is uncommon in ischemic stroke and rare in subarachnoid hemorrhage. Headache is more common with ICH than with ischemic stroke, although less common than in subarachnoid hemorrhage.Vomiting is more common with ICH than with either ischemic stroke or su
4、barachnoid hemorrhage. Increased blood pressure and impaired level of consciousness are common. However, clinical presentation alone, although helpful, is insufficient to reliably differentiate ICH from other stroke subtypes.The early risk of neurological deterioration and cardiopulmonary instabilit
5、y in ICH is high. Identification of prognostic indicators during the first several hours is very important for planning the level of care in patients with ICH. The volume of ICH and grade on the Glasgow Coma Scale (GCS) on admission are the most powerful predictors of death by 30 days. Hydrocephalus
6、 was an independent indicator of 30-day death in another study. Conversely, cortical location,mild neurological dysfunction, and low fibrinogen levels have been associated with good outcomes in medium to large ICH. Because of the difficulty in differentiating ICH from ischemic stroke by clinical mea
7、sures, emergency medicine personnel triage and transport patients with ICH and ischemic stroke to hospitals similarly. As described below, patients with ICH often have greater neurological instability and risk of very early neurological deterioration than do patients with ischemic stroke and will ha
8、ve a greater need for neurocritical care, monitoring of increased intracranial pressure (ICP), and even neurosurgical intervention. This level of care may exceed that available at some hospitals, even those that meet the criteria for primary stroke centers. Thus, each hospital that evaluates and tre
9、ats stroke patients should determine whether the institution has the infrastructure and physician support to manage patients with moderate-sized or large ICHs or has a plan to transfer these patients to a tertiary hospital with the appropriate resources.Initial clinical diagnostic evaluation of ICH
10、at the hospital involves assessment of the patients presenting symptoms and associated activities at onset, time of stroke onset, age, and other risk factors. The patient or witnesses are questioned about trauma; hypertension; prior ischemic stroke, diabetes mellitus, smoking, use of alcohol and pre
11、scription, over-thecounter, or recreational drugs such as cocaine; use of warfarin and aspirin or other antithrombotic therapy; and hematologic disorders or other medical disorders that predispose to bleeding, such as severe liver disease.The physical examination focuses on level of consciousness an
12、d degree of neurological deficit after assessment of airway, breathing, circulation, and vital signs. In several retrospective studies, elevated systolic blood pressure _160 mm Hg on admission has been associated with growth of the hematoma, but this has not been demonstrated in prospective studies
13、of ICH growth. Fever _37.5C that persists for _24 hours is found in 83% of patients with poor outcomes and correlates with ventricular extension of the hemorrhage.Brain imaging is a crucial part of the emergent evaluation. Computed tomography (CT) and magnetic resonance scans show equal ability to i
14、dentify the presence of acute ICH, its size and location, and hematoma enlargement. Deep hemorrhages in hypertensive patients are often due to hypertension, whereas lobar hemorrhages in nonhypertensive elderly patients are often due to cerebral amyloid angiopathy; however, a substantial number of lo
15、bar hemorrhages in hypertensivepatients may be due to hypertension, and both deep and superficial hemorrhages may be caused by vascular abnormalities and other nonhypertensive causes.CT may be superior at demonstrating associated ventricular extension, whereas magnetic resonance imaging (MRI) is sup
16、erior at detecting underlying structural lesions and delineating the amount of perihematomal edema and herniation. A CT scan with contrast may identify an associated aneurysm, arteriovenous malformation, or tumor. CT angiography may provide additional detail in patients with suspected aneurysm or ar
17、teriovenous malformation.CT has also clarified the natural history of ICH. One prospective study of spontaneous ICH in the mid-1990s demonstrated that an increase in volume of _33% is detectable on repeated CT examination in 38% of patients initially scanned within 3 hours after onset. In two thirds
18、 of cases with growth in volume of ICH, this increase was evident within 1 hour. Growth of the volume of ICH was associated with early neurological deterioration. Hematoma growth is associated with a nearly 5-fold increase in clinical deterioration, poor outcome, and death. The lobar location of ICH
19、 increases the risk of long-term recurrence by a factor of 3.8. MRI performs as well as CT in identifying ICH. In one multicenter study of acute stroke with in 6 hours of onset, gradient-echo MRI was as accurate as CT for the identification of acute hemorrhage and more accurate for identification of
20、 chronic hemorrhage. In another under-6-hour multicenter diagnostic trial, MRI showed equivalent performance to CT in ICH identification. MRI is also superior to CT for the identification of associated vascular malformations, especially cavernoma. MRI, however, is not as practical as CT for all pres
21、enting patients. One study found that MRI was not feasible in 20% of acute stroke patients because of contraindications to MRI or impaired consciousness, hemodynamic compromise, vomiting, or agitation. Of the patients with acute stroke ineligible for MRI, 73% had an ICH. Indications for catheter ang
22、iography include subarachnoid hemorrhage, abnormal calcifications, obvious vascular abnormalities, and blood in unusual locations, such as the sylvian fissure. Angiography may also be indicated in patients with no obvious cause of bleeding, such as those subjects with isolated IVH. The yield of angi
23、ography declines in elderly patients with hypertension and a deep hematoma. The timing of the angiogram balances the need for a diagnosis with the condition of the patient and the potential timing of any surgical intervention. A critically ill patient with hemorrhage and herniation may require urgen
24、t surgery before angiography, whereas the stable patient with imaging features of an aneurysm or arteriovenous malformation should undergo angiography before any intervention. Routine laboratory tests performed in patients with ICH include complete blood count; electrolytes; blood urea nitrogen and
25、creatinine; glucose; electrocardiogram; chest radiography; prothrombin time or international normalized ratio (INR); and activated partial thromboplastin time. A toxicology screen in young or middle-aged persons to rule out cocaine use and a pregnancy test in a woman of childbearing age should also
26、be obtained. Elevated serum glucose is likely a response to the stress and severity of ICH and is a marker for death, with an odds ratio (OR) of 1.2. Warfarin use, reflected in an elevated prothrombin time or INR, is a risk factor for hematoma expansion (OR 6.2), with expansion continuing longer tha
27、n in patients not taking warfarin. Recent studies have identified serum markers that add to the prognostic evaluation of ICH and may provide clues to its pathophysiology. Early neurological deterioration in one study was associated with a temperature _37.5C, elevated neutrophil count, and serum fibr
28、inogen. Matrix metalloproteinases are matrix-degrading enzymes activated by proinflammatory factors after stroke. Matrix metalloproteinase-9 levels at 24 hours after onset of bleeding correlate with edema, whereas matrix metalloproteinase-3 levels at 24 to 48 hours after bleeding correlate with risk
29、 of death. The levels of both enzymes correlate with residual cavity volume. c-Fibronectin is a glycoprotein that is important for platelet adhesion to fibrin and is a marker of vascular damage. Levels of c-fibronectin _6 _g/mL and levels of interleukin-6 (a marker of inflammation) _24 pg/mL were in
30、dependently associated with ICH enlargement in one study.18 In another study, levels of tumor necrosis factor-_ correlated with perihematomal edema, whereas levels of glutamate correlated with the size of the residual hematoma cavity. The clinical usefulness of these serum markers requires further testing.【精品文档】第 3 页