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Stroke, commonly known as "stroke", also known as cerebrovascular accident, including ischemic stroke and hemorrhagic stroke, is caused by the sudden blockage or rupture of the blood supply artery of the brain
.
Among them, ischemic stroke (cerebral infarction) accounts for 85%; hemorrhagic stroke is what people often call cerebral hemorrhage or cerebral hemorrhage, and subarachnoid hemorrhage also belongs to this category
.
In order to implement the macro strategy of “advance the gate and sink the center of gravity; improve literacy, and promote education first” in the prevention and treatment of stroke of the National Commission for Brain Defense, improve people’s understanding of stroke prevention and treatment, thereby reducing the incidence, disability and incidence of stroke.
According to the fatality rate, the Hubei Provincial Cerebrovascular Disease Prevention and Treatment Association organized provincial cerebrovascular disease experts to formulate a stroke prevention and treatment science education plan and plan, aiming to provide guidance for medical institutions to effectively carry out stroke science education and education work
.
01 Improve public awareness of first aid stroke The treatment effect of stroke is extremely time-dependent.
If patients with acute stroke can receive timely and effective treatment, the mortality and disability rate can be greatly reduced
.
For ischemic stroke, thrombolytic therapy can make 13% of patients heal quickly, and 20% of patients have a significant improvement; thrombolysis can improve 50% of patients’ condition, but thrombolysis and thrombolysis have a strict time window.
After a delay of 1 minute, 1.
9 million brain cells will die
.
The current thrombolysis rate of ischemic stroke in China is only 7%, and 93% of patients miss the prime time for treatment.
Therefore, it is very important to raise the public's awareness of stroke first aid
.
02 Standardizing prehospital first aid for stroke Strengthening professional training of first aid personnel in stroke first aid procedures is a necessary prerequisite for improving the ability of stroke prehospital first aid
.
Emergency personnel should quickly and effectively identify stroke patients, and the 120 emergency center should prioritize the dispatch of stroke patients
.
03 Early recognition of cerebrovascular disease symptoms (1) Stroke 1-2-0 three-step recognition method: "1" means "seeing a face (skewed mouth)", "2" means "checking two arms ( Cannot lift one side)", "0" means "listen (zero) listening to the language (unclear speaking, big tongue)"
.
If an abnormality is found, the emergency number 120 should be called immediately
.
(2) FAST quick assessment: "F" (Face) face: let the patient smile, if the face is not symmetrical when smiling, it will indicate facial paralysis; The falling of the side limbs indicates limb paralysis; "S" (Speech) language: Let the patient speak a long sentence, if they do not understand, have difficulty speaking, or cannot find a word, it indicates language barriers; "T" (Time) time: above The symptom is a suspected stroke, please call 120 immediately
.
(3) BEFAST fast identification: balance disturbance and visual disturbance are added on the basis of FAST, so as not to miss patients with posterior circulation infarction
.
"B"-Balance refers to balance: loss of balance or coordination, sudden instability in walking; "E"-Eyes refers to eyes: sudden changes in vision, difficulty seeing objects; "F", "A", "S "And "T" are the same as above
.
(4) Recognition of posterior circulation infarction: posterior circulation infarction may be life-threatening, but there are not many clinical assessment methods for the posterior circulation, especially when the patient presents with isolated vertigo (no symptoms and signs of neurological localization), the diagnosis is difficult
.
Through detailed consultation on dizziness, diplopia, dysphagia, balance disorders and auditory symptoms, as well as examinations such as Horner’s sign, nystagmus, head impulse test, eye deviation, etc.
, help early diagnosis
.
04 Rescue and treatment of ischemic stroke (1) Once a stroke is suspected, the green channel of stroke should be entered immediately: first treatment, then payment; inspection and medicine take priority
.
Immediately perform ECG, blood routine, blood sugar and head CT examination
.
For patients who meet the criteria for intravenous thrombolysis or thrombus removal, treat them after communicating with the patient and/or family members concisely and clearly
.
The National Brain Defense Commission requires that the time from the patient entering the hospital to the start of intravenous thrombolysis (Door to needle Time, DNT) within 60 minutes of the stroke center, and the time from entering the hospital to the successful puncture (DPT) of thrombectomy patients (Door to puncture time, DPT) It is required to be within 90min
.
Hospitals without thrombolysis or thrombectomy conditions need to transfer patients to qualified stroke centers as soon as possible
.
(2) Intravenous thrombolytic therapy is the most effective measure to restore cerebral blood flow
.
Patients with ischemic stroke with indications within 4.
5 hours of onset can be treated with recombinant tissue-type plasminogen activator (rt-PA) (alteplase) and intravenous thrombolysis with urokinase within 6 hours
.
The European Stroke Organization (ESO) 2021 Acute Ischemic Stroke Intravenous Thrombolysis Guidelines recommend that the rt-PA intravenous thrombolysis time window be extended to 4.
5-9h after the onset, but CT or magnetic resonance imaging is required to confirm the core/perfusion area mismatch
.
Outcome after rt-PA thrombolysis: 13% returned to normal, 20% improved significantly, 65% remained unchanged, 2% worsened, 1% severely disabled or died
.
(3) Emergency endovascular surgical treatment includes bridging, mechanical thrombectomy, angioplasty, and stents.
It is used for patients with large vessel disease to achieve vascular recanalization through thrombus aspiration and stent thrombectomy
.
It can be used in combination with thrombolytic therapy.
For patients within 6 hours of onset, bridging (thrombolysis followed by endovascular treatment)/intravascular thrombectomy is feasible; patients within 6-24 hours of onset, after multimodal imaging evaluation, meet the indications Patients can be treated intravascularly
.
(4) Patients with thrombolysis and thrombectomy in other acute phases of ischemic stroke should be closely monitored for changes in their condition, and the National Institutes of Health Stroke Scale (NIHSS) score should be performed according to the time node.
Assess for re-infarction or bleeding
.
Regardless of whether thrombolysis or thrombus removal, patients should be closely monitored for changes in symptoms and signs to prevent and manage possible progressive strokes
.
In addition to blood pressure and blood sugar management, antiplatelet and lipid-lowering therapy, critically ill patients need to be admitted to the Neurological Intensive Care Unit (NICU) to monitor vital signs, reduce intracranial pressure, and prevent complications
.
Butylphthalide (injection and capsule) can open collateral circulation and protect mitochondria; edaravone can scavenge free radicals and resist excitatory amino acid toxicity, both of which have been proven to improve the neurological function of patients with ischemic stroke.
Prognosis
.
(5) Antiplatelet aggregation therapy for patients with non-cardiac ischemic stroke ➤Aspirin (50-325mg/d) or clopidogrel (75mg/d) single-agent antiplatelet therapy can be used
.
Patients with high risk of bleeding can choose indobufen or cilostazol; ➤Patients with mild ischemic stroke should start dual antiplatelet therapy (Dual antiplatelet therapy, DAPT) (aspirin 100mg/d combined Clopidogrel 75mg/d), which can be changed to a single agent after 21 days; ➤ischemic stroke or transient cerebral deficiencies with symptomatic severe intracranial artery stenosis (stenosis rate 70%-99%) within 30 days of onset Transient ischemic attack (TIA) patients should be treated with aspirin combined with clopidogrel for 90 days as soon as possible, and then switched to monoclonal antibody therapy; ➤ For patients with intermediate and high-risk recurrent strokes, DAPT should be initiated within 24 hours of onset and lasted for 21 days.
Afterwards, it can be changed to clopidogrel 75mg/d as a single agent, and the total course of treatment is 90d; then aspirin (100mg/d) or clopidogrel (75mg/d) monoclonal antibody long-term medication
.
(6) Antithrombotic therapy for patients with cardiogenic stroke.
For patients with ischemic stroke or TIA with atrial fibrillation, warfarin or new oral anticoagulants (dabigatran, rivaroxaban, a Pixaban, etc.
) to prevent recurrence of thromboembolism
.
Patients who are not suitable for anticoagulation therapy can choose antiplatelet therapy with aspirin (100mg/d) or clopidogrel (75mg/d)
.
(7) Acute treatment of hemorrhagic stroke After the head CT is diagnosed as cerebral hemorrhage or subarachnoid hemorrhage, it should be transferred to a neurosurgery or neurology department with treatment conditions as soon as possible
.
In the acute phase, control blood pressure and stabilize vital signs, identify the cause as soon as possible, and adopt conservative or surgical treatment according to the condition: minimally invasive puncture drainage or craniotomy for cerebral hemorrhage; endovascular treatment or clip for aneurysm and other causes of subarachnoid hemorrhage Close surgery to prevent rebleeding, and actively control related complications
.
(8) Rehabilitation treatment of stroke ➤Rehabilitation training for motor function includes traditional muscle strengthening training, joint mobility training, neurophysiological methods, proprioceptive neuromuscular stimulation, etc.
, as well as compulsory exercise therapy, weight loss walking training, Exercise re-learning program, etc.
.
➤ Sensory disturbances: specific sensory training and sensory-related training can be performed, or transcutaneous electrical stimulation combined with conventional treatment can be used to improve the patient's sensory abilities such as touch and muscle motor perception
.
➤Language function: As soon as possible, a speech therapist will evaluate stroke patients with communication barriers in terms of listening, speaking, reading, writing, and retelling, and provide rehabilitation treatment for speech and semantic barriers
.
➤Cognitive and emotional disorders: First, use the Mini Mental State Examination Scale (MMSE), Montreal Cognitive Assessment Scale (MoCA), etc.
to evaluate cognitive function; post-stroke anxiety and depression can be assessed by the Hamilton Anxiety Scale (HAMA), depression Scale (HAMD) for screening
.
Cholinesterase inhibitors can be used to improve post-stroke cognitive function; post-stroke mood disorders can choose classic antidepressants such as selective serotonin reuptake inhibitor citalopram or Shugan Jieyu capsules, Jieyu pills, etc.
Chinese patent medicine and psychotherapy
.
➤Swallowing disorders: "Shaker" therapy, thermal tactile stimulation, neuromuscular electrical stimulation and other methods can be used for swallowing function training.
For those who cannot maintain adequate nutrition and water through the mouth, enteral nutrition (through nasogastric tube, nasointestinal tube) Or gastrostomy under percutaneous endoscopy)
.
➤Urine and stool disorders: Using the catheter for more than 48 hours will increase the risk of urinary tract infection, it is recommended to remove it as soon as possible; if you need to continue to use it, it is recommended to use an antibacterial catheter such as a silver alloy coated catheter; it also needs to be urinary and stool disorder.
Of patients develop and implement bladder and bowel training plans
.
Yimaitong is compiled from: Chang Liying, He Xiaoming, Cao Xuebing, Zhang Zhaohui, Peng Xiaoxiang, Mei Bin.
Expert consensus on popularization and education of stroke prevention and treatment[J].
Stroke and Neurological Diseases,2021,28(06):713-718.
.
Among them, ischemic stroke (cerebral infarction) accounts for 85%; hemorrhagic stroke is what people often call cerebral hemorrhage or cerebral hemorrhage, and subarachnoid hemorrhage also belongs to this category
.
In order to implement the macro strategy of “advance the gate and sink the center of gravity; improve literacy, and promote education first” in the prevention and treatment of stroke of the National Commission for Brain Defense, improve people’s understanding of stroke prevention and treatment, thereby reducing the incidence, disability and incidence of stroke.
According to the fatality rate, the Hubei Provincial Cerebrovascular Disease Prevention and Treatment Association organized provincial cerebrovascular disease experts to formulate a stroke prevention and treatment science education plan and plan, aiming to provide guidance for medical institutions to effectively carry out stroke science education and education work
.
01 Improve public awareness of first aid stroke The treatment effect of stroke is extremely time-dependent.
If patients with acute stroke can receive timely and effective treatment, the mortality and disability rate can be greatly reduced
.
For ischemic stroke, thrombolytic therapy can make 13% of patients heal quickly, and 20% of patients have a significant improvement; thrombolysis can improve 50% of patients’ condition, but thrombolysis and thrombolysis have a strict time window.
After a delay of 1 minute, 1.
9 million brain cells will die
.
The current thrombolysis rate of ischemic stroke in China is only 7%, and 93% of patients miss the prime time for treatment.
Therefore, it is very important to raise the public's awareness of stroke first aid
.
02 Standardizing prehospital first aid for stroke Strengthening professional training of first aid personnel in stroke first aid procedures is a necessary prerequisite for improving the ability of stroke prehospital first aid
.
Emergency personnel should quickly and effectively identify stroke patients, and the 120 emergency center should prioritize the dispatch of stroke patients
.
03 Early recognition of cerebrovascular disease symptoms (1) Stroke 1-2-0 three-step recognition method: "1" means "seeing a face (skewed mouth)", "2" means "checking two arms ( Cannot lift one side)", "0" means "listen (zero) listening to the language (unclear speaking, big tongue)"
.
If an abnormality is found, the emergency number 120 should be called immediately
.
(2) FAST quick assessment: "F" (Face) face: let the patient smile, if the face is not symmetrical when smiling, it will indicate facial paralysis; The falling of the side limbs indicates limb paralysis; "S" (Speech) language: Let the patient speak a long sentence, if they do not understand, have difficulty speaking, or cannot find a word, it indicates language barriers; "T" (Time) time: above The symptom is a suspected stroke, please call 120 immediately
.
(3) BEFAST fast identification: balance disturbance and visual disturbance are added on the basis of FAST, so as not to miss patients with posterior circulation infarction
.
"B"-Balance refers to balance: loss of balance or coordination, sudden instability in walking; "E"-Eyes refers to eyes: sudden changes in vision, difficulty seeing objects; "F", "A", "S "And "T" are the same as above
.
(4) Recognition of posterior circulation infarction: posterior circulation infarction may be life-threatening, but there are not many clinical assessment methods for the posterior circulation, especially when the patient presents with isolated vertigo (no symptoms and signs of neurological localization), the diagnosis is difficult
.
Through detailed consultation on dizziness, diplopia, dysphagia, balance disorders and auditory symptoms, as well as examinations such as Horner’s sign, nystagmus, head impulse test, eye deviation, etc.
, help early diagnosis
.
04 Rescue and treatment of ischemic stroke (1) Once a stroke is suspected, the green channel of stroke should be entered immediately: first treatment, then payment; inspection and medicine take priority
.
Immediately perform ECG, blood routine, blood sugar and head CT examination
.
For patients who meet the criteria for intravenous thrombolysis or thrombus removal, treat them after communicating with the patient and/or family members concisely and clearly
.
The National Brain Defense Commission requires that the time from the patient entering the hospital to the start of intravenous thrombolysis (Door to needle Time, DNT) within 60 minutes of the stroke center, and the time from entering the hospital to the successful puncture (DPT) of thrombectomy patients (Door to puncture time, DPT) It is required to be within 90min
.
Hospitals without thrombolysis or thrombectomy conditions need to transfer patients to qualified stroke centers as soon as possible
.
(2) Intravenous thrombolytic therapy is the most effective measure to restore cerebral blood flow
.
Patients with ischemic stroke with indications within 4.
5 hours of onset can be treated with recombinant tissue-type plasminogen activator (rt-PA) (alteplase) and intravenous thrombolysis with urokinase within 6 hours
.
The European Stroke Organization (ESO) 2021 Acute Ischemic Stroke Intravenous Thrombolysis Guidelines recommend that the rt-PA intravenous thrombolysis time window be extended to 4.
5-9h after the onset, but CT or magnetic resonance imaging is required to confirm the core/perfusion area mismatch
.
Outcome after rt-PA thrombolysis: 13% returned to normal, 20% improved significantly, 65% remained unchanged, 2% worsened, 1% severely disabled or died
.
(3) Emergency endovascular surgical treatment includes bridging, mechanical thrombectomy, angioplasty, and stents.
It is used for patients with large vessel disease to achieve vascular recanalization through thrombus aspiration and stent thrombectomy
.
It can be used in combination with thrombolytic therapy.
For patients within 6 hours of onset, bridging (thrombolysis followed by endovascular treatment)/intravascular thrombectomy is feasible; patients within 6-24 hours of onset, after multimodal imaging evaluation, meet the indications Patients can be treated intravascularly
.
(4) Patients with thrombolysis and thrombectomy in other acute phases of ischemic stroke should be closely monitored for changes in their condition, and the National Institutes of Health Stroke Scale (NIHSS) score should be performed according to the time node.
Assess for re-infarction or bleeding
.
Regardless of whether thrombolysis or thrombus removal, patients should be closely monitored for changes in symptoms and signs to prevent and manage possible progressive strokes
.
In addition to blood pressure and blood sugar management, antiplatelet and lipid-lowering therapy, critically ill patients need to be admitted to the Neurological Intensive Care Unit (NICU) to monitor vital signs, reduce intracranial pressure, and prevent complications
.
Butylphthalide (injection and capsule) can open collateral circulation and protect mitochondria; edaravone can scavenge free radicals and resist excitatory amino acid toxicity, both of which have been proven to improve the neurological function of patients with ischemic stroke.
Prognosis
.
(5) Antiplatelet aggregation therapy for patients with non-cardiac ischemic stroke ➤Aspirin (50-325mg/d) or clopidogrel (75mg/d) single-agent antiplatelet therapy can be used
.
Patients with high risk of bleeding can choose indobufen or cilostazol; ➤Patients with mild ischemic stroke should start dual antiplatelet therapy (Dual antiplatelet therapy, DAPT) (aspirin 100mg/d combined Clopidogrel 75mg/d), which can be changed to a single agent after 21 days; ➤ischemic stroke or transient cerebral deficiencies with symptomatic severe intracranial artery stenosis (stenosis rate 70%-99%) within 30 days of onset Transient ischemic attack (TIA) patients should be treated with aspirin combined with clopidogrel for 90 days as soon as possible, and then switched to monoclonal antibody therapy; ➤ For patients with intermediate and high-risk recurrent strokes, DAPT should be initiated within 24 hours of onset and lasted for 21 days.
Afterwards, it can be changed to clopidogrel 75mg/d as a single agent, and the total course of treatment is 90d; then aspirin (100mg/d) or clopidogrel (75mg/d) monoclonal antibody long-term medication
.
(6) Antithrombotic therapy for patients with cardiogenic stroke.
For patients with ischemic stroke or TIA with atrial fibrillation, warfarin or new oral anticoagulants (dabigatran, rivaroxaban, a Pixaban, etc.
) to prevent recurrence of thromboembolism
.
Patients who are not suitable for anticoagulation therapy can choose antiplatelet therapy with aspirin (100mg/d) or clopidogrel (75mg/d)
.
(7) Acute treatment of hemorrhagic stroke After the head CT is diagnosed as cerebral hemorrhage or subarachnoid hemorrhage, it should be transferred to a neurosurgery or neurology department with treatment conditions as soon as possible
.
In the acute phase, control blood pressure and stabilize vital signs, identify the cause as soon as possible, and adopt conservative or surgical treatment according to the condition: minimally invasive puncture drainage or craniotomy for cerebral hemorrhage; endovascular treatment or clip for aneurysm and other causes of subarachnoid hemorrhage Close surgery to prevent rebleeding, and actively control related complications
.
(8) Rehabilitation treatment of stroke ➤Rehabilitation training for motor function includes traditional muscle strengthening training, joint mobility training, neurophysiological methods, proprioceptive neuromuscular stimulation, etc.
, as well as compulsory exercise therapy, weight loss walking training, Exercise re-learning program, etc.
.
➤ Sensory disturbances: specific sensory training and sensory-related training can be performed, or transcutaneous electrical stimulation combined with conventional treatment can be used to improve the patient's sensory abilities such as touch and muscle motor perception
.
➤Language function: As soon as possible, a speech therapist will evaluate stroke patients with communication barriers in terms of listening, speaking, reading, writing, and retelling, and provide rehabilitation treatment for speech and semantic barriers
.
➤Cognitive and emotional disorders: First, use the Mini Mental State Examination Scale (MMSE), Montreal Cognitive Assessment Scale (MoCA), etc.
to evaluate cognitive function; post-stroke anxiety and depression can be assessed by the Hamilton Anxiety Scale (HAMA), depression Scale (HAMD) for screening
.
Cholinesterase inhibitors can be used to improve post-stroke cognitive function; post-stroke mood disorders can choose classic antidepressants such as selective serotonin reuptake inhibitor citalopram or Shugan Jieyu capsules, Jieyu pills, etc.
Chinese patent medicine and psychotherapy
.
➤Swallowing disorders: "Shaker" therapy, thermal tactile stimulation, neuromuscular electrical stimulation and other methods can be used for swallowing function training.
For those who cannot maintain adequate nutrition and water through the mouth, enteral nutrition (through nasogastric tube, nasointestinal tube) Or gastrostomy under percutaneous endoscopy)
.
➤Urine and stool disorders: Using the catheter for more than 48 hours will increase the risk of urinary tract infection, it is recommended to remove it as soon as possible; if you need to continue to use it, it is recommended to use an antibacterial catheter such as a silver alloy coated catheter; it also needs to be urinary and stool disorder.
Of patients develop and implement bladder and bowel training plans
.
Yimaitong is compiled from: Chang Liying, He Xiaoming, Cao Xuebing, Zhang Zhaohui, Peng Xiaoxiang, Mei Bin.
Expert consensus on popularization and education of stroke prevention and treatment[J].
Stroke and Neurological Diseases,2021,28(06):713-718.
