Understand the scale strategy of ischemic cerebrovascular disease in seconds

*Only for medical professionals to read and remember, but also to be able to use it! As a neurology novice who is new to the workplace, the scoring scale taught by the teacher when he was studying was complicated and numerous, and he was “lost” when he thought of it.
Now that he is on duty, how can I use these scales? Next, the scale will present his own clinical practice experience through 4 scenarios of 3 patients, hoping to bring some help to everyone
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Scenario One: Male, 50 years old, with a history of hypertension and diabetes for 10 years.
He did not take medication regularly.
He suffered repeated speech problems and weakness of the right limbs within 3 days, and the relief lasted about 5 minutes each time, so he came to the hospital for treatment
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The preliminary consideration is: transient ischemic attack (TIA)
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Double antibody or monoclonal antibody? At this time, the scale can come into play.
The most commonly used TIA risk stratification tool is the ABCD2 score
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Table 1: ABCD2 score ABCD2 score can determine whether TIA patients are at high risk of stroke
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Therefore, all patients suspected of TIA should use the ABCD2 scoring tool to assess the risk coefficient of stroke at the beginning of treatment
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The ABCD2 score 0-3 is determined as low-risk group, 4-5 is divided into middle-risk group, and 6-7 is divided into high-risk group
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The therapeutic significance of this score is that [1] patients with acute non-cardiogenic TIA (defined according to the 24 h time) with a high risk of stroke recurrence (ABCD2 score ≥ 4) should be given as soon as possible in the acute phase (within 24 h of onset) Clopidogrel combined with aspirin was treated for 21 days (the first daily loading dose of clopidogrel was 300 mg), followed by clopidogrel monotherapy (75 mg/d), the total course of treatment was 90 days
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Since then, clopidogrel and aspirin can be used as first-line drugs for long-term secondary prevention (Class I, Class A evidence)
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Is it a very simple and easy-to-use scale? Scenario Two Li Si, 60 years old this year, has a history of high blood pressure and diabetes for 10 years, and has not taken medication regularly.
He suddenly had speech problems with weakness of the right limbs one hour ago, so he came to the hospital for treatment
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The patient’s symptoms persisted and he was initially considered to be an ischemic stroke
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According to the 2018 version of the ischemic stroke diagnosis and treatment guidelines, there are three main steps.
The first step is to determine whether it is a stroke, the second step is to determine whether it is an ischemic stroke, and the third step is to determine the severity of stroke.
The most commonly used scale is The National Institutes of Health Stroke Scale (NIHSS)
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The content includes 11 assessment items, namely the level of consciousness, the ability to answer questions, the ability to follow instructions, eye movement, visual field, facial muscle strength, upper limb motor function, lower limb motor function, limb coordination, sensory function, language, structure The sound and feeling are ignored
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The scoring method is as follows: each item is scored on 3 to 5 levels, with a scoring range of 0-42 points.
The higher the score, the more severe the nerve damage
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A score of 0-1 indicates normal or close to normal, a score of 1-4 indicates a mild stroke, a score of 5-15 indicates a moderate stroke, a score of 15-20 indicates a severe stroke, and a score of 20 or more indicates a severe stroke.
A higher score indicates a condition The more serious the scale, the more commonly used, the table shows "How to use the stroke risk assessment scale? Just read this article" (click to jump)
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In addition to assessing the severity, the significance of the NIHSS score is that within 24 hours of onset, patients with mild ischemic stroke (NIHSS ≤ 3 points) should be treated with aspirin combined with clopidogrel for 21 days as soon as possible [1]
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A list includes 11 items, and it will explode when you think about it.
Here is another simple memorization formula, a message from a doctor at the bottom of the article "A formula teaches you to quickly remember NIHSS scores!": Figure 1: Wang Wu, a patient with three memory formula scenarios, male, 76 years old, with a history of hypertension and diabetes for 15 years, and found persistent atrial fibrillation when the 24-hour electrocardiogram was completed during physical examination
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The patient is getting older and has many chronic diseases, and is worried that he will have a stroke
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A family member who knows a little about pediatric medicine asks me whether I need anticoagulation, how should I evaluate it? The CHA2DS2-VASc score came to mind
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Table 2: The score used to assess the risk of stroke in patients with atrial fibrillation is: CHA2DS2-VASc score [2] According to the CHA2DS2-VASc scoring system [2], if the male score is ≥2 points, and the female score is ≥3 points, anticoagulation therapy is recommended
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For those with a score of 1 (excluding the female gender score), oral anticoagulants may be considered based on the benefits and risks
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If the score is 0, no anticoagulant and antiplatelet drugs are required
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After evaluating Wang Wu with a score of 4, he needs anticoagulation, but he is worried about the risk of bleeding while giving anticoagulation treatment.
How can this be good? Don't worry, HAS-BLED score is here to help
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HAS-BLED[3] score bleeding risk assessment criteria are as follows: Table 3: HAS-BLED score cumulative score ≥3 points to indicate a high risk of bleeding, patients with high bleeding risk should be cautious regardless of whether they receive warfarin or aspirin treatment, and should be cautious when starting anti-inflammatory drugs.
After suppository treatment, re-examination should be strengthened
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Particular attention should be paid to patients with high scores who cannot give up anticoagulation directly, and patients with high bleeding are usually associated with high ischemic risk.
The 2019 ACC/AHA/HRS atrial fibrillation guidelines recommend that the risk of stroke and bleeding should be regularly assessed in order to reassess the need for anticoagulation therapy Sex and drug choice
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Scenario 4 patients Zhang San and Li Si (non-cardiac stroke) were in stable condition under my "superb medical skills" treatment.
In order to assess the risk of recurrence of stroke, Esssen (Essen Stroke Risk Score, ESRS) was given
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Table 4: Esssen score Essen score is a predictive tool for assessing the long-term recurrence risk of patients with ischemic stroke; low risk: 0-2 points; high risk: 3-6 points; very high risk: 7-9 points
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It is reported that [4] the annual incidence rate of high-risk population is 6%-9%, and the annual incidence rate of very high-risk population is 11%; low-risk population can use aspirin, and it is recommended to use clopidogrel for secondary prevention for patients above high-risk; two The patient improved after treatment and was scheduled to be discharged.
The national single-disease reporting system required me to complete the mRS score to evaluate the stroke recovery outcome
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Don't worry, the mRS score is very simple, as follows: Table 5: mRS score In addition, there are scales such as Barthel index and ADL score that can assess the impact of stroke on daily life through different aspects
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In short, scales play an extremely important role in the prevention and rehabilitation of ischemic stroke, but at the same time there are certain limitations.
Only by weighing the pros and cons, making specific analysis, and flexibly mastering the relevant scales can be used for better guidance.
Treat diseases and improve prognosis
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References: [1] Chinese Expert Consensus Group on Transient Ischemic Attack.
Chinese Expert Consensus on Antiplatelet Therapy for Transient Ischemic Attack and Mild Stroke (2014).
Chinese Medical Journal, 2014, Volume 94, Issue 27, 2092 -2096.
[2] Atrial Fibrillation Stroke Prevention and Treatment Committee of the National Health Committee of Experts on Stroke Prevention, Chinese Medical Association Electrophysiology and Pacing Branch, Chinese Medical Doctor Association Cardiology Committee.
Chinese Cardiogenic Stroke Prevention and Treatment Guidelines (2019) )[J].
Chinese Journal of Arrhythmia, 2019,23(6):463-484.
[3] Chinese Medical Association, Expert Group for Compiling Guidelines for Primary Diagnosis and Treatment of Cardiovascular Diseases
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Guidelines for Primary Diagnosis and Treatment of Atrial Fibrillation (2019); Chinese Journal of General Practitioners, 2020.
19 (6) 465-473.
[4] Wang Yilong, Wang Chunxue, Zhao Xingquan, etc.
; Prediction model for stroke recurrence in patients with ischemic stroke without atrial fibrillation-Essen stroke Risk score scale
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Chinese Journal of Stroke; 2009.
4 (5); 440-442