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*Only for medical professionals to read for reference.
October 29, 2021 is the 16th World Stroke Day.
The medical community will join hands with the "Huashan Hospital Neurology Department" to show you these things~ October 29, 2021 is the 16th "World Stroke Day" "Stroke Day", the National Health Commission’s Brain Defense Commission and the Chinese Stroke Society released this year’s theme as "Be alert to stroke symptoms, identify and treat as soon as possible!" In response to the call, the "medical community" joined hands with the "Huashan Hospital of Fudan University" to carry out the "Huashan Gods" "Take you to understand these things about stroke" series of activities, in this column, the deputy chief physician Cao Wenjie of Huashan Hospital Affiliated to Fudan University was specially invited to share his insights on "vascular interventional therapy"
.
How to conduct preoperative evaluation of neurological intervention patients? Interventional treatment of ischemic cerebrovascular disease is mainly divided into two types: the first type is emergency surgery, and the second type is elective surgery
.
1.
Preoperative evaluation of emergency surgery Emergency surgery is the endovascular thrombus removal treatment of acute cerebral infarction.
All preoperative evaluations for this type of patients must be completed within one hour, including medical history inquiry, neurological deficit assessment, and imaging Examination, among which imaging examination includes conventional head CT plain scan, multi-mode CT and so on
.
Conventional head CT scan is mainly to determine whether there is cerebral hemorrhage or whether there is an existing cerebral infarction or the size of the cerebral infarct area
.
Multi-mode CT includes CT angiography and CT perfusion imaging.
CT angiography can clarify the location of the occluded blood vessel.
CT perfusion imaging can assess the state of cerebral blood perfusion and whether there is rescued brain tissue.
Therefore, the brain within 24 hours of onset Infarctions can be determined through the above assessment to determine whether there is value for emergency intervention
.
2.
Preoperative evaluation of elective surgery.
Elective surgery is stenting for intracranial and extracranial artery stenosis.
In addition to some routine preoperative examinations, there is also a high-resolution MRI examination of the vessel wall to know whether there is plaque hemorrhage and The degree of calcification of the plaque, etc.
, is of certain value for reducing embolism during surgery and predicting the vagus reflex, heart rate and blood pressure drop caused by carotid sinus stimulation
.
In addition, it is recommended to measure the thromboelastogram before surgery to predict the effects of different antiplatelet drugs in patients.
If a certain drug is not sensitive, some adjustments can be made in time to reduce thrombosis during stent implantation and postoperative complications.
Stent restenosis rate
.
In recent years, new research progress or guideline evidence for intravascular interventional therapy 1.
Progress of emergency endovascular interventional therapy For endovascular interventional therapy in the anterior circulation, emergency endovascular thrombectomy has confirmed the onset of 6 hours from the five major clinical studies in 2015.
The internal use of stent-assisted mechanical thrombectomy is a significant benefit, and the subsequent DEFUSE 3 and DAWN studies have extended the time window of endovascular treatment to 16-24 hours
.
In 2020, the DIRECT-MT study led by Professor Liu Jianmin of the Naval General Hospital in our country proved that under the premise of appropriate and reasonable procedures, direct thrombus removal is not inferior to intravenous thrombolysis and bridging intravascular treatment
.
In the DIRECT-MT study, the material used for embolectomy is not only limited to embolectomy stents, but also suction catheters.
For suction catheters, there are also some studies that have proved its strengths in recanalization and remediation.
The recanalization time may be shorter than stent removal
.
In addition, some studies have shown that the final result of stent removal combined with aspiration is better than pure stent removal treatment.
Therefore, with the widespread use of intermediate catheters, the technology of stent removal combined with suction has been further developed
.
For endovascular interventional therapy in the posterior circulation, current evidence shows that endovascular therapy is not necessarily superior to intravenous thrombolysis or drug therapy.
The most important domestic BEST study and BASICS study compare the effects of intravascular interventional therapy, comparing standard drugs with emergency treatments.
Whether there is a difference between the two groups of interventional therapy, the results did not prove that our endovascular treatment is definitely better than standard drug treatment.
Therefore, the endovascular treatment of the posterior circulation needs further research to confirm
.
In addition, whether or not to perform anesthesia during the perioperative period of emergency thrombus removal is also a hot topic.
It is still inconclusive.
Some stroke centers recommend anesthesia, and some stroke centers recommend sedation.
Both of these are ok, and both are available at your own hospital.
Conditions to implement
.
Most of the causes of thrombectomy and aspiration are cardiogenic embolism, or the occlusion of this blood vessel caused by the embolism, and in patients with intracranial artery stenosis and stenosis acute occlusion, mechanical thrombectomy is often not very good.
For the recanalization effect, tirofiban can be injected or combined with a balloon stent implantation at this time.
It is currently in the process of exploration
.
2.
Progress in selective endovascular interventional treatment For extracranial vascular stenosis, such as carotid artery stenosis, there are currently two options, one is carotid endarterectomy, and the other is carotid stenting, for people at high risk of surgery It can benefit from carotid artery stenting.
Among the non-surgical high-risk groups, which is better or worse than carotid endarterectomy is still a hot topic of research.
There is still no conclusion.
.
For patients with stenosis or occlusion of large intracranial vessels, foreign SAMMPRIS trials and VISSIST studies have failed to prove that intracranial artery stenosis is inferior to drug treatment by stent implantation.
This means that for intracranial artery stenosis, the current interventional stent There is no clear evidence for implantation, which is the direction we will explore and research in the future
.
Common complications and prevention and treatment for emergency thrombus removal, including intraoperative and postoperative complications
.
Intraoperative complications, including vascular dissection, distal vascular embolization, vascular perforation and bleeding, etc.
.
The most important method of prevention and treatment is accurate assessment.
There is a clear understanding of the state and shape of the blood vessel before the operation.
A complete and detailed surgical plan is required.
The appropriate materials and surgical methods are used during the operation.
In addition, it depends on personal experience and The materials used determine the surgical plan
.
Postoperative perioperative complications include hemorrhagic transformation of cerebral infarction and reperfusion injury
.
If the area of cerebral infarction or core infarction is relatively large when the patient is admitted to the hospital, the risk of bleeding after recanalization will increase
.
In addition, high perfusion performance, that is, high perfusion caused by reperfusion injury, also needs attention.
The main prevention method is to control blood pressure more strictly.
Postoperative systolic blood pressure must be controlled below 130mmHg, which is to control blood pressure more stable, and Relatively lower, in addition, be cautious about the medication of patients after surgery
.
If the patient has a higher risk of bleeding, postoperative use of tirofiban should be relatively cautious.
In addition, dehydration drugs or drugs to reduce cerebral edema can be used
.
If the patient has high perfusion performance, the sedation time of anesthesia can be appropriately extended to pass the high-risk period
.
In addition, the rate of in-stent restenosis is also a thorny issue.
The incidence is about 15%-20%.
The preventive measures are mainly the management of postoperative risk factors, including hypertension or diabetes.
At the same time, it should be based on the elasticity of the thrombus.
The picture shows whether the use of antiplatelet drugs is reasonable
.
The intracranial drug-coated stents and intracranial drug-coated balloons currently in clinical use are expected to provide more possibilities in reducing the incidence of intra-stent restenosis
.
Expert profile Cao Wenjie, Deputy Chief Physician, Doctor of Medicine, Department of Neurology, Huashan Hospital, Fudan University
.
Good at cerebrovascular interventional therapy, ultrasound diagnosis and evaluation of carotid artery stenosis, TCD monitoring and imaging evaluation of cerebral blood perfusion
.
Visited and studied at the Brain Research Center of Royal Melbourne Hospital in Australia (2012-2013) and the Department of Neurology, Johns Hopkins Hospital in the United States (2019)
.
Published more than 20 SCI articles as the first author or corresponding author
.
He is currently a young director of the Chinese Stroke Society, a standing member of the Neurology Branch of the Shanghai Stroke Society, a member of the Neurovascular Monitoring Group of the Chinese Research Hospital Association, a member of the Neural Intervention Collaboration Group of the Chinese Medical Association, and an editorial board member of the Journal of Stroke and Vascular Neurology
.
October 29, 2021 is the 16th World Stroke Day.
The medical community will join hands with the "Huashan Hospital Neurology Department" to show you these things~ October 29, 2021 is the 16th "World Stroke Day" "Stroke Day", the National Health Commission’s Brain Defense Commission and the Chinese Stroke Society released this year’s theme as "Be alert to stroke symptoms, identify and treat as soon as possible!" In response to the call, the "medical community" joined hands with the "Huashan Hospital of Fudan University" to carry out the "Huashan Gods" "Take you to understand these things about stroke" series of activities, in this column, the deputy chief physician Cao Wenjie of Huashan Hospital Affiliated to Fudan University was specially invited to share his insights on "vascular interventional therapy"
.
How to conduct preoperative evaluation of neurological intervention patients? Interventional treatment of ischemic cerebrovascular disease is mainly divided into two types: the first type is emergency surgery, and the second type is elective surgery
.
1.
Preoperative evaluation of emergency surgery Emergency surgery is the endovascular thrombus removal treatment of acute cerebral infarction.
All preoperative evaluations for this type of patients must be completed within one hour, including medical history inquiry, neurological deficit assessment, and imaging Examination, among which imaging examination includes conventional head CT plain scan, multi-mode CT and so on
.
Conventional head CT scan is mainly to determine whether there is cerebral hemorrhage or whether there is an existing cerebral infarction or the size of the cerebral infarct area
.
Multi-mode CT includes CT angiography and CT perfusion imaging.
CT angiography can clarify the location of the occluded blood vessel.
CT perfusion imaging can assess the state of cerebral blood perfusion and whether there is rescued brain tissue.
Therefore, the brain within 24 hours of onset Infarctions can be determined through the above assessment to determine whether there is value for emergency intervention
.
2.
Preoperative evaluation of elective surgery.
Elective surgery is stenting for intracranial and extracranial artery stenosis.
In addition to some routine preoperative examinations, there is also a high-resolution MRI examination of the vessel wall to know whether there is plaque hemorrhage and The degree of calcification of the plaque, etc.
, is of certain value for reducing embolism during surgery and predicting the vagus reflex, heart rate and blood pressure drop caused by carotid sinus stimulation
.
In addition, it is recommended to measure the thromboelastogram before surgery to predict the effects of different antiplatelet drugs in patients.
If a certain drug is not sensitive, some adjustments can be made in time to reduce thrombosis during stent implantation and postoperative complications.
Stent restenosis rate
.
In recent years, new research progress or guideline evidence for intravascular interventional therapy 1.
Progress of emergency endovascular interventional therapy For endovascular interventional therapy in the anterior circulation, emergency endovascular thrombectomy has confirmed the onset of 6 hours from the five major clinical studies in 2015.
The internal use of stent-assisted mechanical thrombectomy is a significant benefit, and the subsequent DEFUSE 3 and DAWN studies have extended the time window of endovascular treatment to 16-24 hours
.
In 2020, the DIRECT-MT study led by Professor Liu Jianmin of the Naval General Hospital in our country proved that under the premise of appropriate and reasonable procedures, direct thrombus removal is not inferior to intravenous thrombolysis and bridging intravascular treatment
.
In the DIRECT-MT study, the material used for embolectomy is not only limited to embolectomy stents, but also suction catheters.
For suction catheters, there are also some studies that have proved its strengths in recanalization and remediation.
The recanalization time may be shorter than stent removal
.
In addition, some studies have shown that the final result of stent removal combined with aspiration is better than pure stent removal treatment.
Therefore, with the widespread use of intermediate catheters, the technology of stent removal combined with suction has been further developed
.
For endovascular interventional therapy in the posterior circulation, current evidence shows that endovascular therapy is not necessarily superior to intravenous thrombolysis or drug therapy.
The most important domestic BEST study and BASICS study compare the effects of intravascular interventional therapy, comparing standard drugs with emergency treatments.
Whether there is a difference between the two groups of interventional therapy, the results did not prove that our endovascular treatment is definitely better than standard drug treatment.
Therefore, the endovascular treatment of the posterior circulation needs further research to confirm
.
In addition, whether or not to perform anesthesia during the perioperative period of emergency thrombus removal is also a hot topic.
It is still inconclusive.
Some stroke centers recommend anesthesia, and some stroke centers recommend sedation.
Both of these are ok, and both are available at your own hospital.
Conditions to implement
.
Most of the causes of thrombectomy and aspiration are cardiogenic embolism, or the occlusion of this blood vessel caused by the embolism, and in patients with intracranial artery stenosis and stenosis acute occlusion, mechanical thrombectomy is often not very good.
For the recanalization effect, tirofiban can be injected or combined with a balloon stent implantation at this time.
It is currently in the process of exploration
.
2.
Progress in selective endovascular interventional treatment For extracranial vascular stenosis, such as carotid artery stenosis, there are currently two options, one is carotid endarterectomy, and the other is carotid stenting, for people at high risk of surgery It can benefit from carotid artery stenting.
Among the non-surgical high-risk groups, which is better or worse than carotid endarterectomy is still a hot topic of research.
There is still no conclusion.
.
For patients with stenosis or occlusion of large intracranial vessels, foreign SAMMPRIS trials and VISSIST studies have failed to prove that intracranial artery stenosis is inferior to drug treatment by stent implantation.
This means that for intracranial artery stenosis, the current interventional stent There is no clear evidence for implantation, which is the direction we will explore and research in the future
.
Common complications and prevention and treatment for emergency thrombus removal, including intraoperative and postoperative complications
.
Intraoperative complications, including vascular dissection, distal vascular embolization, vascular perforation and bleeding, etc.
.
The most important method of prevention and treatment is accurate assessment.
There is a clear understanding of the state and shape of the blood vessel before the operation.
A complete and detailed surgical plan is required.
The appropriate materials and surgical methods are used during the operation.
In addition, it depends on personal experience and The materials used determine the surgical plan
.
Postoperative perioperative complications include hemorrhagic transformation of cerebral infarction and reperfusion injury
.
If the area of cerebral infarction or core infarction is relatively large when the patient is admitted to the hospital, the risk of bleeding after recanalization will increase
.
In addition, high perfusion performance, that is, high perfusion caused by reperfusion injury, also needs attention.
The main prevention method is to control blood pressure more strictly.
Postoperative systolic blood pressure must be controlled below 130mmHg, which is to control blood pressure more stable, and Relatively lower, in addition, be cautious about the medication of patients after surgery
.
If the patient has a higher risk of bleeding, postoperative use of tirofiban should be relatively cautious.
In addition, dehydration drugs or drugs to reduce cerebral edema can be used
.
If the patient has high perfusion performance, the sedation time of anesthesia can be appropriately extended to pass the high-risk period
.
In addition, the rate of in-stent restenosis is also a thorny issue.
The incidence is about 15%-20%.
The preventive measures are mainly the management of postoperative risk factors, including hypertension or diabetes.
At the same time, it should be based on the elasticity of the thrombus.
The picture shows whether the use of antiplatelet drugs is reasonable
.
The intracranial drug-coated stents and intracranial drug-coated balloons currently in clinical use are expected to provide more possibilities in reducing the incidence of intra-stent restenosis
.
Expert profile Cao Wenjie, Deputy Chief Physician, Doctor of Medicine, Department of Neurology, Huashan Hospital, Fudan University
.
Good at cerebrovascular interventional therapy, ultrasound diagnosis and evaluation of carotid artery stenosis, TCD monitoring and imaging evaluation of cerebral blood perfusion
.
Visited and studied at the Brain Research Center of Royal Melbourne Hospital in Australia (2012-2013) and the Department of Neurology, Johns Hopkins Hospital in the United States (2019)
.
Published more than 20 SCI articles as the first author or corresponding author
.
He is currently a young director of the Chinese Stroke Society, a standing member of the Neurology Branch of the Shanghai Stroke Society, a member of the Neurovascular Monitoring Group of the Chinese Research Hospital Association, a member of the Neural Intervention Collaboration Group of the Chinese Medical Association, and an editorial board member of the Journal of Stroke and Vascular Neurology
.
