Stroke disease monitoring, see what the latest Chinese expert consensus says?

*It is only for medical professionals to read and refer to what kind of advice the guide based on a large number of evidence-based evidence gives, let's learn together! The 2021 version of the "Chinese Multidisciplinary Expert Consensus on Stroke Surveillance" (hereinafter referred to as the "Consensus") was published in the Chinese Medical Journal on February 2, 2021 [1].

According to the 2019 systemic national overall disease burden study, stroke has become the first cause of death in my country [2], and the death toll accounts for almost one-third of the global death toll from stroke [3].

Figure 1: Screenshot of the consensus title As a disease with a very high disability and fatality rate, it is necessary to improve the prognosis of patients.
The prognosis of stroke is not only related to the primary injury, but also closely related to the secondary injury that occurs over time.
Strict monitoring of the condition helps patients adjust the treatment plan before irreversible damage occurs, and the use of various tools for monitoring brain metabolism, perfusion and oxygenation provides information on brain structure, physiology, biochemistry, and function to obtain advanced clinical observations The multi-modal monitoring (MMM) of the changes in the craniocerebral disease is the future development trend.
Comprehensive evaluation of various parameters can achieve personalized treatment.

The consensus is divided into 4 categories to elaborate on important issues related to stroke surveillance, 37 recommendations are provided, covering various common clinical situations, and the quality of evidence is attached [A (multiple randomized clinical trials or meta-analysis), B ( Single randomized trial or non-randomized study), C (expert consensus, case study or medical standard)] and recommendation strength [Class I (should be implemented), Class IIa (implementation is appropriate), Class IIb (can be considered), Class III (Unhelpful or harmful)], next, let us learn together! 1.
Condition assessment on admission 1.
After admission, stroke patients need to assess their vital signs first.
The preliminary medical history and neurological examination are helpful for condition judgment and preliminary diagnosis (level A evidence, category I recommendation).

2.
The Glasgow Coma Score (GCS), the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow-Pittsburgh Coma Scale are commonly used to score the level of consciousness and illness (level A evidence, category I recommendation).2.
Differential diagnosis of stroke types 3.
CT is the first choice for the differential diagnosis of acute stroke.
The sensitivity of the diagnosis of cerebral hemorrhage is very high.
For patients with acute ischemic stroke, CT scan is performed to rule out cerebral hemorrhage (A-level evidence , Class I recommendation).

4.
MRI is more sensitive than CT in diagnosing cerebral infarction, and DWI is more sensitive and specific than other sequences in diagnosing cerebral infarction, which is helpful for the early diagnosis of acute ischemic stroke (level A evidence, class Ⅰ recommendation) .

5.
DSA is the "gold standard" for diagnosing cerebral infarction.
CTA and MRA can also help to understand the location of vascular occlusion, the presence or absence of plaque and its nature when time is urgent or conditions are not available (level A evidence, category Ⅰ recommendation) ).

6.
Mobile stroke units (including mobile CT and mobile MRI units) provide important support for the rapid prehospital diagnosis and treatment of acute stroke (level B evidence, type I recommendation).

3.
Hemorrhagic stroke (ICH) ▌ Basic vital signs 7.
Patients with ICH should be continuously monitored for body temperature.
It is recommended to monitor the core body temperature (bladder, rectum, etc.
) closer to the brain temperature (level C evidence, category IIa recommendation).

8.
There is insufficient evidence for the benefit of mild hypothermia (34℃~35℃) in the treatment of cerebral hemorrhage (level C evidence, IIb recommendation).

9.
ICH patients need blood oxygen control, and if necessary, establish artificial airway (or) mechanical ventilation as soon as possible.
The control target is blood oxygen saturation (SpO2) ≥94%, blood oxygen partial pressure (PO2) ≥75mmHg (level B evidence) , Class I recommendation).

But for stroke patients with normal SpO2, oxygen therapy does not significantly improve the prognosis (level A evidence, category IIa recommendation).

10.
Patients with ICH must undergo blood pressure control (level A evidence, type I recommendation).
Controlling systolic blood pressure (SBP) ≤140 mmHg can benefit patients (level A evidence, type I recommendation).

Antihypertensive drugs should choose drugs that have less impact on intracranial pressure.

▌ Monitoring of important laboratory indicators 11.
Severe stroke patients require comprehensive management of the functional status of the heart, lungs, liver, kidneys and other organs, including circulation, breathing, blood clotting, and urinary. 12.
The blood sodium control target of stroke patients is 135~155 mmol/L (C-level evidence, Class I recommendation), and the daily blood sodium should be controlled within 8~10 mmol/L fluctuations to reduce the occurrence of osmotic encephalopathy (C Level of evidence, type I recommendation).

13.
The blood glucose control target for stroke patients is 7.
8-10.
0 mmol/L (level B evidence, type I recommendation).

In the acute phase, short-acting insulin can be selected as an intravenous continuous pump, and blood glucose should be measured every 2 to 4 hours to avoid hypoglycemia (level A evidence, category I recommendation).

▌ Neuroimaging examination 14.
CT or MRI should be reviewed regularly in the acute phase of cerebral hemorrhage, which is helpful for timely detection of hematoma enlargement, cerebral edema, hydrocephalus and other disease changes (level B evidence, category I recommendation).

15.
"Mixed sign", "black hole sign", "island sign", etc.
seen on CT plain scan, "point sign" and "bird's beak sign" seen on CT enhanced scan are predictors of hematoma enlargement (level B evidence, class IIa recommendation) .

▌ Intracranial pressure and cerebral perfusion pressure (CPP) monitoring 16.
When patients with ICH have GCS ≤ 8 and the patient’s symptoms, signs, CT results and other evidence suggest increased intracranial pressure, invasive intracranial pressure monitoring is recommended (Grade C) Evidence, category IIa recommendation).

17.
The priority of invasive intracranial pressure monitoring is intraventricular, brain parenchyma, subdural, and epidural.
It is more accurate for ICH to monitor intracranial pressure in the ipsilateral ventricle (level C evidence, level IIb recommendation).

18.
Intervention is recommended when the intracranial pressure of ICH patients continues to be higher than 20mmHg (level B evidence, level IIb recommendation).

In patients with intracranial pressure monitoring, it is reasonable to control CPP at 50-70 mmHg (level C evidence, category IIb recommendation).

▌ Neuroelectrophysiological monitoring 19.
The application of electroencephalogram (EEG) monitoring to stroke patients can help determine the degree of consciousness coma and non-convulsive epileptic activities, and is used for the evaluation of brain damage (level B evidence, class IIa recommendation) .

20.
It is feasible to monitor evoked potentials to understand the sensory conduction pathways and the functional state of the brainstem, and to help dynamically evaluate the patient's clinical neurological function recovery (level C evidence, category IIb recommendation). ▌ Brain tissue oxygen monitoring 21.
PbtO2 is an indicator of local brain tissue oxygen level, SjvO2 is an indicator of whole brain oxygenation, PbtO2 and SjvO2 can provide complementary information, which more comprehensively reflects the relationship between oxygen supply and demand in the brain (level C evidence, category IIb recommendation) .

22.
It is recommended to use it in combination with other monitoring methods such as intracranial pressure/CPP to obtain more accurate disease assessment and prognosis prediction (level B evidence, class IIa recommendation).

▌ Non-invasive brain edema monitor monitoring 23.
The non-invasive brain edema dynamic monitor can provide patients with a non-invasive, bedside, dynamic craniocerebral disease monitoring, which has a good early warning value for hematoma expansion and hemorrhage transformation after thrombus dissolution/removal.
, But further research is needed (level B evidence, IIb recommendation).

▌ Transcranial Doppler (TCD) monitoring 24.
TCD can provide real-time certain craniocerebral structure and hemodynamic information, and its dynamic changes can provide a basis for the evaluation of stroke patients (level B evidence, class IIa recommendation).

25.
Optic nerve sheath diameter (ONSD) has high accuracy in the diagnosis of intracranial hypertension.
When ONSD>5mm indicates that intracranial pressure may be greater than 20mmHg, it is recommended to use longitudinal and transverse ONSD average values ​​(level B evidence, category IIb) recommend).

4.
Cerebral infarction (AIS) ▌ Basic vital signs 26.
Body temperature is related to the condition and prognosis of AIS patients and should be closely monitored.

Patients with elevated body temperature should look for and deal with the cause of fever, and those with infection should be given anti-infective treatment in time.

Preventive use of antibiotics is not recommended.

Patients with body temperature >38 ℃ should be given antipyretic measures (level B evidence, category IIa recommendation).

27.
It is recommended that AIS patients undergo respiratory monitoring, and critically ill patients should be monitored at least once an hour to maintain oxygen saturation >94% (level A evidence, category IIa recommendation).

Respiratory frequency, breathing pattern, and respiratory movement monitoring are helpful for finding brain herniation, predicting the location of brain injury, finding pulmonary embolism, Guillain-Barré syndrome and other complications (level B evidence, category IIa recommendation).

28.
In stroke patients with normal SpO2, oxygen therapy does not significantly improve the prognosis, and over-oxygen therapy (PaO2≥300 mmHg) is associated with poor prognosis (level A evidence, category IIa recommendation).

After extubation of mechanical ventilation, noninvasive ventilation combined with high-flow nasal oxygen can reduce the risk of reintubation (level A evidence, category IIa recommendation).

29.
2/3 of AIS patients have abnormal heart rate and electrocardiogram (ECG), and routine heart rate and ECG monitoring is recommended.

A 12-lead ECG examination was performed within 24 hours of the onset, and a 24-hour ECG monitoring and echocardiography were performed within 7 days of the onset (level A evidence, category I recommendation).

30.
Elevated blood pressure in AIS patients is a common phenomenon and should be closely monitored.

Patients undergoing thrombolysis and/or mechanical thrombectomy should strengthen preoperative and postoperative blood pressure monitoring to avoid excessive and rapid blood pressure fluctuations (level A evidence, category IIa recommendation).
The evidence for the benefit of early antihypertensive therapy is not yet sufficient.

▌ The monitoring of important laboratory indicators is the same as the monitoring of important laboratory indicators in Part III.

▌ Neuroimaging examination 31.
It is recommended to use head CT plain scan or MRI for rapid neuroimaging examination to distinguish between ischemic stroke and hemorrhagic stroke in order to determine the follow-up treatment strategy (level A evidence, type I recommendation).

32.
Before AIS patients undergo endovascular treatment, it is recommended to use non-invasive imaging examination to determine whether there is intracranial or extracranial large vessel occlusion; for patients with suspected large vessel occlusion, it is recommended to use a one-stop CTA+CTP imaging examination program to quickly implement preoperative imaging evaluation.
Guide endovascular treatment (level A evidence, type I recommendation).

33.
Within 3 hours of onset, NIHSS score ≥9 points, or within 6 hours of onset, NIHSS score ≥7 points, it indicates the presence of large blood vessel occlusion; when non-invasive imaging evaluation is performed unconditionally, CT is used to exclude bleeding, and the whole cerebral vascular DSA is quickly evaluated for vascular occlusion.
Conditions and collateral circulation compensation, select suitable patients for endovascular treatment, and predict the prognosis of patients based on the modified cerebral infarction thrombolysis (mTICI) score (level A evidence, type I recommendation). ▌ Intracranial pressure monitoring 34.
Patients with large area of ​​supratentorial cerebral infarction and cerebellar infarction are at higher risk of brain herniation due to increased intracranial pressure.
Intracranial pressure monitoring is recommended for such patients (level B evidence, category IIa recommendation) .

35.
Patients with AIS after decompressive craniectomy within 48 hours of onset are recommended to undergo invasive intracranial pressure monitoring, and to guide clinical treatment based on the monitoring results.
The intervention threshold refers to the aforementioned recommendations (level B evidence, category IIa recommendation).

▌ TCD cerebral blood flow monitoring 36.
TCD related parameters have certain value in finding large vessel stenosis, embolus signals in the blood, predicting the risk of AIS recurrence, hemorrhagic transformation after stroke, and prognostic judgment.

It is recommended that qualified units use TCD technology for bedside cerebral blood flow monitoring for AIS patients (level B evidence, category IIa recommendation).

▌ Electroneurophysiological monitoring 37.
EEG can reflect the location and degree of brain injury.
The larger the infarction area, the more superficial the location, and the more obvious EEG abnormalities.

It is recommended that patients with severe AIS undergo EEG monitoring, and use Synek and other grading standards to determine the severity and prognosis of the disease (level B evidence, category IIa recommendation).

▌ Other brain tissue oxygen monitoring and non-invasive brain edema monitors also have certain applications in AIS.
For details, please refer to the ICH part.

Note: The evidence-based literature was searched in comprehensive databases such as MEDLINE, EMBASE, Cochrane Library, CNKI, and Wanfang database from January 1993 to May 2019.

This consensus only represents the opinions of experts involved in the compilation and discussion.

The consensus content is only used to guide the practice of clinicians and is not legally binding.

The consensus content is the staged understanding of this field, which will be updated at any time based on new clinical evidence in the future.

References: [1] Neurosurgery Committee of the Chinese Medical Doctor Association Neurosurgery Branch, Shanghai Stroke Society, Chongqing Stroke Society.
Chinese Multidisciplinary Expert Consensus on Stroke Surveillance[J].
Chinese Medical Journal,2021,101 (05) : 317-326.
DOI: 10.
3760/cma.
j.
cn112137-20201026-02927[2]Zhou M, Wang H, Zeng X, et al.
Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017[J].
Lancet, 2019, 394(10204): 1145‑1158.
DOI: 10.
1016/S0140‑6736(19)30427‑1.
[3]Feigin VL, Krishnamurthi RV , Parmar P, et al.
Update on the Global Burden of ischemic and hemorrhagic stroke in 1990—2013: the GBD 2013 study[J].
Neuroepidemiology, 2015, 45(3):161‑176.
DOI: 10.
1159/000441085.
This article Arranged from Chinese Medical Journal, 2021,101 (05): 317-326 Arrangement of this article: Chen Wuyi This article review: Li Tuming Deputy Chief Physician Editor: Mr.
Lu Li Email: yxjsjbx@yxj.
org.
cn Please specify: [Submission] Hospital + Department + Name Contributions are in the form of word documents, and the remuneration is favorable.
Edit WeChat: chenaFF0911