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*Only for medical professionals to read for reference.
The neurology channel of the medical circle and the Department of Neurology of Huashan Hospital have created a column "Huashan Big Coffee Stroke Talk".
Stroke is the number one cause of death and disability among Chinese residents.
One person in China occurs every 12 seconds.
Stroke, one person dies of stroke every 21 seconds, and more than 1.
9 million patients die from stroke each year.
Patients and their families will suffer huge pain and burden.
Therefore, effective prevention and treatment of stroke will reduce the harm of disease and realize "Healthy China".
The 2030" target is of great significance
.
October 29, 2021 is the 16th "World Stroke Day".
This year's theme is "Be alert to stroke symptoms, identify and treat as soon as possible".
In response to the call, the "medical community" and "Huashan Hospital Affiliated to Fudan University" launched a series of activities.
In this "Huashan Master Stroke Talk" column, we talked with Chief Physician Cheng Xin of the Department of Neurology, Huashan Hospital Affiliated to Fudan University, and made an in-depth discussion on the "intravenous thrombolytic treatment" of acute ischemic stroke
.
Exceeding the time window of thrombolysis, whether it can benefit or not requires the use of imaging examination to review the history of intravenous thrombolysis of ischemic stroke, and extending the treatment time window has always been the direction of neurologists' efforts
.
The thrombolysis time window ranges from 3 hours to 4.
5 hours, and then to 4.
5-9 hours.
The expansion of the thrombolysis time window is not a simple and blind expansion, but is based on objective imaging standards
.
Different imaging examinations provide different degrees of information related to thrombolysis for acute ischemic stroke
.
Through CT plain scan, we can screen out stroke patients with thrombolysis time window of only 4.
5 hours
.
Previous studies have shown that based on CT plain scans, patients who were included within 6 hours of onset for intravenous thrombolysis have not seen any benefit from thrombolysis
.
The amount of information provided by CT plain scans is very limited
.
If we want to further extend the time window of thrombolysis, we need to use multi-modal imaging examination to evaluate the patient's histology
.
We need to see the ischemic penumbra in patients with acute ischemic stroke, and the core of cerebral infarction is relatively small
.
In line with such objective evidence, patients may benefit from thrombolysis with a super-thrombolytic time window
.
Reduce the risk of hemorrhage transformation and strictly grasp the indications for thrombolysis.
For clinicians, the most important strategy for reducing the risk of thrombolysis and hemorrhage transformation is to strictly grasp the indications and contraindications of thrombolysis, which we call "intake and discharge criteria" for short.
.
These criteria for entry and exclusion established by the guidelines fully take into account the bleeding risk of patients
.
For example, the contraindication of thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) within 3 hours clearly mentions "history of intracranial hemorrhage", "head CT or MRI suggesting a large area of infarction (infarct area> 1/ 3 Middle cerebral artery blood supply area)" and other 17 contraindications [1]
.
These contraindications need to be firmly grasped.
If they are violated, they may bring vicious consequences
.
For patients who have strictly controlled the entry and discharge criteria, there are still 1%-2% of patients who will experience symptomatic intracranial hemorrhage.
At present, this part is determined by the treatment itself and cannot be avoided
.
There is really no better way to predict who will actually bleed.
This is also a worldwide problem
.
Therefore, for clinicians, the most important thing is to master the admission and discharge standards and strictly implement them in the clinic
.
Thrombolytic therapy can be vividly compared to walking a tightrope, which requires a balance between treatment and risk: the patient must not only obtain reperfusion, but also minimize bleeding
.
Effective thrombolytic therapy may cause reperfusion injury, damage to the blood-brain barrier, and cause bleeding.
However, not all hemorrhagic transformations need to be worried
.
Clinically, hemorrhagic transformation is usually divided into hemorrhagic infarction (HI) and parenchymal hemorrhage (PH)
.
HI1 type is punctate microhemorrhage in the infarct area; H12 type is fusion patch hemorrhage in the infarct area
.
PH1 type hematoma is less than 30% of the infarct area and has no mass effect; PH2 type hematoma is more than 30% of the infarct area, with obvious mass effect or hemorrhage outside the infarct [2]
.
HI bleeding has not caused a significant aggravation of the patient's symptoms, which is acceptable, and there is no need to worry too much
.
And these small bleeding does not affect the follow-up antithrombotic treatment
.
What needs to be worried about is hemorrhage with a larger area, such as the above-mentioned PH2 hemorrhage, which may even cause cerebral edema
.
Once this type of bleeding occurs
.
The mortality rate is high, and the overall prognosis is poor.
If it is life-threatening, neurosurgery is required for surgical treatment
.
Intravenous thrombolysis, the future will focus on two key issues.
The first key question is whether there are better thrombolytic drugs? At present, the intravenous thrombolytic drug with the most evidence-based evidence and the most widely used clinically is rt-PA
.
rt-PA has received the highest level of evidence-based recommendation at home and abroad, and can increase the probability of a good prognosis for patients by 30%
.
However, rt-PA has two major drawbacks.
One is that the recanalization rate of large blood vessels is relatively low; the other is that the steps are not simple enough, and it needs to be injected by intravenous bolus first and then intravenous drip
.
Therefore, researchers have been exploring better thrombolytic drugs that can make the large blood vessel recanalization rate higher, lower the bleeding risk, and more convenient to use
.
In recent years, the third-generation thrombolytic drug, tenecteplase, has attracted increasing attention in clinical research and practice
.
There is increasing evidence that tenecteplase may be non-inferior to rt-PA, and that the recanalization rate of large vessels is better
.
So far, tenecteplase is only indicated for acute myocardial infarction, and there is no indication for acute ischemic stroke
.
The application of tenecteplase still needs to accumulate evidence-based evidence
.
There are also phase III clinical trials of some domestic and imported drugs in China
.
It is believed that in the next 2 to 3 years, we may see the market and clinical application of new thrombolytic drugs, which will change our clinical practice
.
The second key question is whether patients with acute ischemic stroke with large vessel occlusion can skip intravenous thrombolysis and directly undergo thrombectomy therapy
.
At present, in the Department of Cardiology, many centers directly perform percutaneous coronary intervention (PCI) for patients with acute myocardial infarction
.
In the field of cerebrovascular, is it not inferior to bridging therapy to skip intravenous thrombolysis and direct thrombus removal? However, the current results and conclusions are inconsistent.
Some studies show that direct thrombus removal is not inferior to bridging therapy, while some studies have the opposite conclusion
.
This is actually a very complicated issue
.
The conditions of each stroke center are different.
For example, some internal cardiovascular treatment teams respond very quickly and can get in place quickly, but rt-PA treatment requires bolus injection and then intravenous drip, waiting for the completion of intravenous thrombolysis before intravascular treatment can be done.
, It will delay the time of intravascular treatment
.
Intravenous bolus injection of tenecteplase followed by immediate acute endovascular treatment is also the focus of many studies
.
In view of the differences in stroke treatment centers, the treatment of patients with large vessel occlusion should be individualized and precise treatment, or treatment should be carried out according to local conditions according to the conditions of the local stroke center
.
Don't tell everyone arbitrarily that direct thrombus removal is not inferior to bridging therapy
.
We need a more precise judgment
.
Summary: Intravenous thrombolytic therapy is an effective treatment for acute ischemic stroke, and the expansion of the thrombolytic time window is based on histological evaluation
.
Strictly grasping the indications and contraindications of intravenous thrombolysis is the main means to reduce the risk of hemorrhagic transformation; thrombolytic treatment of hemorrhagic transformation, focusing on symptomatic intracranial hemorrhage
.
In the future, we hope to see intravenous thrombolytic drugs with a higher recanalization rate of large vessels and more convenient use; the treatment of patients with large vessel occlusion should be individualized and precise
.
Finally, Chief Physician Cheng Xin addressed the patients with acute ischemic stroke as follows: Stroke is the leading cause of death and disability among Chinese residents.
“Once a cerebral infarction occurs, it must be the first time to have the conditions for thrombolysis and thrombus removal.
the hospital, to avoid missing the optimal therapeutic time window
.
everyday life have to do primary prevention, better control of risk factors of disease, reduce the incidence of stroke from the root
.
"Expert profile Cheng Xin, chief physician of the Department of Neurology, Huashan Hospital Affiliated to Fudan University, Associate Professor, Master's Tutor, Shanghai Youth Science and Technology Star, Young Top Talent, Member of Cerebrovascular Disease Group of Chinese Medical Association Neurology Branch, Chinese Stroke Society Cerebrovascular Disease Branch Deputy Chairman, Standing Committee, Cerebral Blood Flow and Metabolism Branch, Chinese Stroke Society, Standing Committee, Cerebral Small Vascular Disease Committee, National Health Commission, Cerebrovascular Diseases Committee, Standing Committee, National Health Commission, Cerebral Defense Committee, Youth Committee, Standing Committee, Shanghai Medical Association, Science Popularization Branch, Youth Committee, Deputy Chairman, Shanghai The young committee member of the Neurology Specialist Branch of the Medical Association mainly focuses on the imaging and treatment of acute stroke, clinical and basic research of cerebrovascular disease, and presides over 6 projects above the provincial and ministerial level such as the National Natural Science Foundation of China, the Ministry of Education, and the Shanghai Science and Technology Commission.
As the backbone of the project Participated in 2 key R&D programs of the Ministry of Science and Technology, invited to publish reviews in Lancet Neurology, published more than 30 articles in domestic and foreign journals such as Annals of Neurology, Neurology as the first or corresponding author, edited 1 monograph, and wrote industry associations in this field Consensus/standard 4 references: [1] Chinese Medical Association Neurology Branch, Chinese Medical Association Neurology Branch Cerebrovascular Disease Group.
Chinese Acute Ischemic Stroke Diagnosis and Treatment Guide 2018[J].
Chinese Journal of Neurology,2018 ,51(9):666-682.
Link: https://d.
wanfangdata.
com.
cn/periodical/ChlQZXJpb2RpY2FsQ0hJTmV3UzIwMjExMDI2Eg56aHNqazIwMTgwOTAwNRoIeDVsdHFvNnU%3D
The neurology channel of the medical circle and the Department of Neurology of Huashan Hospital have created a column "Huashan Big Coffee Stroke Talk".
Stroke is the number one cause of death and disability among Chinese residents.
One person in China occurs every 12 seconds.
Stroke, one person dies of stroke every 21 seconds, and more than 1.
9 million patients die from stroke each year.
Patients and their families will suffer huge pain and burden.
Therefore, effective prevention and treatment of stroke will reduce the harm of disease and realize "Healthy China".
The 2030" target is of great significance
.
October 29, 2021 is the 16th "World Stroke Day".
This year's theme is "Be alert to stroke symptoms, identify and treat as soon as possible".
In response to the call, the "medical community" and "Huashan Hospital Affiliated to Fudan University" launched a series of activities.
In this "Huashan Master Stroke Talk" column, we talked with Chief Physician Cheng Xin of the Department of Neurology, Huashan Hospital Affiliated to Fudan University, and made an in-depth discussion on the "intravenous thrombolytic treatment" of acute ischemic stroke
.
Exceeding the time window of thrombolysis, whether it can benefit or not requires the use of imaging examination to review the history of intravenous thrombolysis of ischemic stroke, and extending the treatment time window has always been the direction of neurologists' efforts
.
The thrombolysis time window ranges from 3 hours to 4.
5 hours, and then to 4.
5-9 hours.
The expansion of the thrombolysis time window is not a simple and blind expansion, but is based on objective imaging standards
.
Different imaging examinations provide different degrees of information related to thrombolysis for acute ischemic stroke
.
Through CT plain scan, we can screen out stroke patients with thrombolysis time window of only 4.
5 hours
.
Previous studies have shown that based on CT plain scans, patients who were included within 6 hours of onset for intravenous thrombolysis have not seen any benefit from thrombolysis
.
The amount of information provided by CT plain scans is very limited
.
If we want to further extend the time window of thrombolysis, we need to use multi-modal imaging examination to evaluate the patient's histology
.
We need to see the ischemic penumbra in patients with acute ischemic stroke, and the core of cerebral infarction is relatively small
.
In line with such objective evidence, patients may benefit from thrombolysis with a super-thrombolytic time window
.
Reduce the risk of hemorrhage transformation and strictly grasp the indications for thrombolysis.
For clinicians, the most important strategy for reducing the risk of thrombolysis and hemorrhage transformation is to strictly grasp the indications and contraindications of thrombolysis, which we call "intake and discharge criteria" for short.
.
These criteria for entry and exclusion established by the guidelines fully take into account the bleeding risk of patients
.
For example, the contraindication of thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) within 3 hours clearly mentions "history of intracranial hemorrhage", "head CT or MRI suggesting a large area of infarction (infarct area> 1/ 3 Middle cerebral artery blood supply area)" and other 17 contraindications [1]
.
These contraindications need to be firmly grasped.
If they are violated, they may bring vicious consequences
.
For patients who have strictly controlled the entry and discharge criteria, there are still 1%-2% of patients who will experience symptomatic intracranial hemorrhage.
At present, this part is determined by the treatment itself and cannot be avoided
.
There is really no better way to predict who will actually bleed.
This is also a worldwide problem
.
Therefore, for clinicians, the most important thing is to master the admission and discharge standards and strictly implement them in the clinic
.
Thrombolytic therapy can be vividly compared to walking a tightrope, which requires a balance between treatment and risk: the patient must not only obtain reperfusion, but also minimize bleeding
.
Effective thrombolytic therapy may cause reperfusion injury, damage to the blood-brain barrier, and cause bleeding.
However, not all hemorrhagic transformations need to be worried
.
Clinically, hemorrhagic transformation is usually divided into hemorrhagic infarction (HI) and parenchymal hemorrhage (PH)
.
HI1 type is punctate microhemorrhage in the infarct area; H12 type is fusion patch hemorrhage in the infarct area
.
PH1 type hematoma is less than 30% of the infarct area and has no mass effect; PH2 type hematoma is more than 30% of the infarct area, with obvious mass effect or hemorrhage outside the infarct [2]
.
HI bleeding has not caused a significant aggravation of the patient's symptoms, which is acceptable, and there is no need to worry too much
.
And these small bleeding does not affect the follow-up antithrombotic treatment
.
What needs to be worried about is hemorrhage with a larger area, such as the above-mentioned PH2 hemorrhage, which may even cause cerebral edema
.
Once this type of bleeding occurs
.
The mortality rate is high, and the overall prognosis is poor.
If it is life-threatening, neurosurgery is required for surgical treatment
.
Intravenous thrombolysis, the future will focus on two key issues.
The first key question is whether there are better thrombolytic drugs? At present, the intravenous thrombolytic drug with the most evidence-based evidence and the most widely used clinically is rt-PA
.
rt-PA has received the highest level of evidence-based recommendation at home and abroad, and can increase the probability of a good prognosis for patients by 30%
.
However, rt-PA has two major drawbacks.
One is that the recanalization rate of large blood vessels is relatively low; the other is that the steps are not simple enough, and it needs to be injected by intravenous bolus first and then intravenous drip
.
Therefore, researchers have been exploring better thrombolytic drugs that can make the large blood vessel recanalization rate higher, lower the bleeding risk, and more convenient to use
.
In recent years, the third-generation thrombolytic drug, tenecteplase, has attracted increasing attention in clinical research and practice
.
There is increasing evidence that tenecteplase may be non-inferior to rt-PA, and that the recanalization rate of large vessels is better
.
So far, tenecteplase is only indicated for acute myocardial infarction, and there is no indication for acute ischemic stroke
.
The application of tenecteplase still needs to accumulate evidence-based evidence
.
There are also phase III clinical trials of some domestic and imported drugs in China
.
It is believed that in the next 2 to 3 years, we may see the market and clinical application of new thrombolytic drugs, which will change our clinical practice
.
The second key question is whether patients with acute ischemic stroke with large vessel occlusion can skip intravenous thrombolysis and directly undergo thrombectomy therapy
.
At present, in the Department of Cardiology, many centers directly perform percutaneous coronary intervention (PCI) for patients with acute myocardial infarction
.
In the field of cerebrovascular, is it not inferior to bridging therapy to skip intravenous thrombolysis and direct thrombus removal? However, the current results and conclusions are inconsistent.
Some studies show that direct thrombus removal is not inferior to bridging therapy, while some studies have the opposite conclusion
.
This is actually a very complicated issue
.
The conditions of each stroke center are different.
For example, some internal cardiovascular treatment teams respond very quickly and can get in place quickly, but rt-PA treatment requires bolus injection and then intravenous drip, waiting for the completion of intravenous thrombolysis before intravascular treatment can be done.
, It will delay the time of intravascular treatment
.
Intravenous bolus injection of tenecteplase followed by immediate acute endovascular treatment is also the focus of many studies
.
In view of the differences in stroke treatment centers, the treatment of patients with large vessel occlusion should be individualized and precise treatment, or treatment should be carried out according to local conditions according to the conditions of the local stroke center
.
Don't tell everyone arbitrarily that direct thrombus removal is not inferior to bridging therapy
.
We need a more precise judgment
.
Summary: Intravenous thrombolytic therapy is an effective treatment for acute ischemic stroke, and the expansion of the thrombolytic time window is based on histological evaluation
.
Strictly grasping the indications and contraindications of intravenous thrombolysis is the main means to reduce the risk of hemorrhagic transformation; thrombolytic treatment of hemorrhagic transformation, focusing on symptomatic intracranial hemorrhage
.
In the future, we hope to see intravenous thrombolytic drugs with a higher recanalization rate of large vessels and more convenient use; the treatment of patients with large vessel occlusion should be individualized and precise
.
Finally, Chief Physician Cheng Xin addressed the patients with acute ischemic stroke as follows: Stroke is the leading cause of death and disability among Chinese residents.
“Once a cerebral infarction occurs, it must be the first time to have the conditions for thrombolysis and thrombus removal.
the hospital, to avoid missing the optimal therapeutic time window
.
everyday life have to do primary prevention, better control of risk factors of disease, reduce the incidence of stroke from the root
.
"Expert profile Cheng Xin, chief physician of the Department of Neurology, Huashan Hospital Affiliated to Fudan University, Associate Professor, Master's Tutor, Shanghai Youth Science and Technology Star, Young Top Talent, Member of Cerebrovascular Disease Group of Chinese Medical Association Neurology Branch, Chinese Stroke Society Cerebrovascular Disease Branch Deputy Chairman, Standing Committee, Cerebral Blood Flow and Metabolism Branch, Chinese Stroke Society, Standing Committee, Cerebral Small Vascular Disease Committee, National Health Commission, Cerebrovascular Diseases Committee, Standing Committee, National Health Commission, Cerebral Defense Committee, Youth Committee, Standing Committee, Shanghai Medical Association, Science Popularization Branch, Youth Committee, Deputy Chairman, Shanghai The young committee member of the Neurology Specialist Branch of the Medical Association mainly focuses on the imaging and treatment of acute stroke, clinical and basic research of cerebrovascular disease, and presides over 6 projects above the provincial and ministerial level such as the National Natural Science Foundation of China, the Ministry of Education, and the Shanghai Science and Technology Commission.
As the backbone of the project Participated in 2 key R&D programs of the Ministry of Science and Technology, invited to publish reviews in Lancet Neurology, published more than 30 articles in domestic and foreign journals such as Annals of Neurology, Neurology as the first or corresponding author, edited 1 monograph, and wrote industry associations in this field Consensus/standard 4 references: [1] Chinese Medical Association Neurology Branch, Chinese Medical Association Neurology Branch Cerebrovascular Disease Group.
Chinese Acute Ischemic Stroke Diagnosis and Treatment Guide 2018[J].
Chinese Journal of Neurology,2018 ,51(9):666-682.
Link: https://d.
wanfangdata.
com.
cn/periodical/ChlQZXJpb2RpY2FsQ0hJTmV3UzIwMjExMDI2Eg56aHNqazIwMTgwOTAwNRoIeDVsdHFvNnU%3D
