Talking about stroke prevention and treatment from multiple angles, the secretary general of the Shanghai Stroke Society said...

Stroke, also known as acute cerebrovascular disease, is divided into hemorrhagic stroke and ischemic stroke, the most common of which is cerebral infarction
.
According to the results of the 2019 survey on the burden of stroke disease in China, ischemic stroke accounts for about 80% of the total number of stroke patients in China^[1].

October 29 of each year is World Stroke Day, so that the people know the basic knowledge of stroke, understand that stroke is a preventable and treatable disease, and also need more efforts of
medical and health science workers.
Professor Li Wei, Secretary General of Shanghai Stroke Society, introduced
the relevant knowledge of ischemic stroke from four aspects: early recognition of cerebral infarction, acute treatment, neuroprotective treatment and rehabilitation treatment.

Early recognition of the acute phase of cerebral infarction

Cerebral infarction and cerebral hemorrhage are both acute cerebrovascular diseases, both of which have the characteristics of
acute onset and sudden symptoms.
Patients with cerebral hemorrhage will immediately have corresponding symptoms of neurological deficits due to obvious hematoma mass effect at the onset of the disease, which is easy to be identified and treated
.
The essence of cerebral infarction is the blockage of blood vessels, which will take
a period of time from ischemia of brain tissue to the production of corresponding symptoms of neurological deficits.
Although it is also an acute onset, it is more insidious than the symptoms of cerebral hemorrhage and is easily overlooked
by patients or family members.
If the blood supply can be restored in the early stage of cerebral ischemia, the prognosis
of patients can be greatly improved.
Timely identification and timely delivery of cerebral infarction to patients with cerebral infarction is very important for improving the prognosis of cerebral infarction patients, the so-called "time is the brain"! Every year around World Stroke Day, we in the Shanghai Stroke Society will mobilize the majority of medical personnel, concentrate for a period of time, and publicize it with great fanfare through various channels to enable the people to grasp the recognition
of early symptoms of stroke 。 BE FAST is an English slogan that literally means "fast" (the faster the better)! where B (Balance): standing unstable balance difficult; E(Eyes): blurry vision and unclear vision; F(Face): facial paralysis/crooked mouth corners; A(Arm): limb weakness; S(Speech): Unclear speech; T(Time): Once a patient develops any of these symptoms, quickly dial 120 or try to get to the nearest doctor
in time.
This recognition ability needs to be mastered not only by emergency doctors, but also by ordinary people
.

Some patients present with early symptoms of stroke that last for a short period of time, resolve spontaneously within minutes and hours, and are often overlooked
.
This type of stroke is called a transient ischemic attack (TIA
).
At this time, the cause of cerebral ischemia is temporarily relieved, and the blood supply to the brain tissue is temporarily restored, so the symptoms are alleviated
.
However, if you do not seek medical attention in time, find and treat the cause of the disease, you can not prevent the TIA attack, and eventually lead to cerebral infarction
.
So the TIA should also be paid enough attention!

Treatment of acute phase of cerebral infarction

Timely recovery of perfusion of ischemic brain tissue after the onset of cerebral infarction is the key to the
treatment of acute cerebral infarction.
Around the core lesion of acute cerebral infarction, there is still a considerable part of the brain tissue that is in ischemic state, but has not yet been completely necrotic, which we call "ischemic semi-dark band"
.
Timely recovery of perfusion of ischemic brain tissue is to restore the blood supply
to the "semi-dark band" brain.
How to effectively save ischemic semi-dark zones is one of
the hottest topics in the current acute treatment of stroke.
Intravenous thrombolysis within 3 to 4.
5 hours of onset is the most convenient and effective treatment in the acute phase
.
The blood clot that occurs in the blood vessels of the cerebral artery is mainly composed of fibrin as a stent and is attached to tangible substances such as red blood cells and platelets
.
Intravenous thrombolysis is the introduction of drugs with lysed fibrin stents into the body
by means of intravenous infusion.
Under the action of the drug, the fibrin is deconstructed, and the other formed parts attached to it are "disassembled" to achieve the purpose of
"disintegrating" the blood clot and restoring blood flow.
This medication is also called tissue fibrinolytic enzyme.

Since the 1990s, many countries in the world have begun to conduct a series of studies
from urokinase to rt-PA.
Since 1998, several basic hospitals and a group of relatively experienced clinicians in Shanghai have begun to explore the clinical application
of rt-PA in China.
Later, intravenous thrombolysis technology was gradually promoted throughout the country
.
At present, the vast majority of areas in China, even in some remote and remote areas, can also carry out intravenous thrombolytic therapy
for patients with early cerebral infarction.

According to global clinical practice, although patients in the early stages of cerebral infarction receive intravenous thrombolytic therapy, less than 50% of patients have finally completely resolved symptoms, some patients have no or only partial remission of symptoms, and about 6% of patients face life risk
due to postthrombolytic cerebral hemorrhage.
In the past ten years, on the basis of intravenous thrombolysis, the way of "intravascular therapy" has gradually developed, which is what we now call "mechanical thrombosis"
.
In layman's terms, it is through the catheter device to destroy the blood clot and remove it from the body in
a minimally invasive way.
There are direct arterial vascular thrombosis in patients in the acute stage, and there is also mechanical thrombectomy for patients who fail to thrombolysis after intravenous thrombolysis therapy, which is called "bridging therapy"
.
Some high-quality clinical studies have shown that bridging therapy is more effective than vein thrombolysis alone or direct arterial thromboplasty, but does not reduce the adverse outcomes
of bleeding and death.
Mechanical thrombectomy alone sometimes increases the risk of poor prognosis, and intravenous thrombolysis remains the most reliable treatment modality in the acute phase
.

In 2021, the National Health Commission proposed a three-year plan for stroke treatment to hospitals at all levels, the first of which is to expand the proportion of intravenous thrombolysis as much as possible and increase the proportion of venous thrombolysis to more than
80% within three years.
All stroke centers that are qualified for intravenous thrombolysis must carry out intravenous thrombolysis, and as an important indicator
of stroke medical quality assessment.
As a supplement to intravenous thrombolysis, intravascular arterial therapy is also actively being explored
.

In addition to RT-PA, a new type of thrombolytic drug is on the rise
.
Tenecteplase, also known as TNK, is a multipoint variant of rt-PA
.
TNK is the third generation fibrinolytic solvent and the sixth fibrinolytic solvent approved by the FDA to be produced and marketed
.
Multiple completed and ongoing clinical studies have confirmed that TNK's efficacy is not inferior to RT-PA within a reasonable dosage range, but whether it is better than RT-PA still needs to be confirmed
by further research.

"New Wave" – neuroprotective therapy

In addition to thrombolysis and thrombotic therapy in the acute phase, neuroprotective therapy is also a hot topic
in the acute phase of stroke.
Many patients have not been able to get timely treatment within the "time window" or there are contraindications to thrombolysis therapy, or even if thrombolysis, thrombotomy and other measures have been applied, the blocked blood vessels have been opened, and drugs such as butylphthalide and edaraven dacterol have been applied to promote the recovery of cell function by repairing and improving the metabolism of organelles, and to achieve the effect of improving the patient's
prognosis.
The results have also been preliminarily verified
by clinical studies.
Edalafen dacterol injection with a concentrated solution of inflammation inhibitor dacterol and edala Bong scientific compatibility, through the two components of multiple mechanisms of action - scavenging free radicals, anti-inflammatory and protection of the blood-brain barrier, etc.
, can reduce the brain nerve damage
caused by acute cerebral infarction.
The drug has been approved for marketing
in China.

Large clinical studies
of neuroprotective agents are currently underway in various regions.
Overall, the widespread use of neuroprotective agents is still expected to be further confirmed
by more large clinical studies.

"The sooner the better" rehabilitation

In addition, the role of rehabilitation in the management of stroke patients has long been proven, and the concept of "early rehabilitation" has been widely supported
by the industry.
In China, whether it is early stroke treatment or "secondary prevention", the status of rehabilitation treatment is gradually improving
.
What is early rehabilitation? It is from the moment the patient "falls" to start preparing for rehabilitation, the sooner the better
.
The concept of rehabilitation treatment is very broad, but in fact, it is very professional, and the patient's posture, position, training plan, etc.
are all components
of rehabilitation treatment.
It is worth mentioning that rehabilitation treatment must be operated under the guidance of qualified rehabilitation professional doctors and technicians to achieve maximum results
.

Li Wei

Professor, chief physician, graduate supervisor

Former Director of the Department of Neurology, Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

He was a member of the cerebrovascular disease group of the Neurology Branch of the Chinese Medical Association

He is a member of the Neurology Committee, the Stroke Committee, and the Behavioral Committee of the Shanghai Medical Association

Director of Shanghai Branch of Chinese Neuroscience

He is a member of the Neurology Branch of the Chinese Association of Integrative Traditional and Western Medicine

Member of the Standing Committee of the Neurology Branch of the Shanghai Association of Traditional Chinese Medicine

He is currently the Secretary General of the Shanghai Stroke Society

References:

[1] Writing team of "China Stroke Prevention and Control Report 2019".
Summary of "China Stroke Prevention and Control Report 2019".
Chinese Journal of Cerebrovascular Diseases, 2020, 17: 272.

*This article is for the sole purpose of providing scientific information to healthcare professionals and does not represent the views of the Platform