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*Only for medical professionals to read and reference "Stones from other mountains can attack jade" The 2022 International Stroke Conference (ISC 2022) officially kicked off on FebruaryIn the keynote report of the opening ceremony, Professor Shinichi Yoshimura of Japan announced The results of the RESCUE-Japan LIMIT study suggest that acute large vessel occlusion with large core infarction ischemic stroke, endovascular treatment may be effecti.
This research has made domestic scholars interested in related endovascular treatment guidelines in Jap.
At present, China has more interpretations of European and American stroke-related guidelines, and less translation and interpretation of Japanese and Korean guidelin.
Japan is a medical pow.
At the same time, due to its historical reasons, Japan and Germany have done more vivisections, so that they have accumulated rich experience in neurolo.
In order to enable domestic scholars to better understand the guidelines for endovascular interventional therapy in Japan, the author specially translated the key parts of the "Japanese Guidelines for Mechanical Thrombectomy (Fourth Edition)" for reference by peers, as follo.
Guidelines Screenshot Reading Notes: Recommendation 1 Devices for MT (Mechanical Thrombectomy) 1 An approved device should be used to provide MT [Class A] At the time of this guideline, the MT device approved and in use in Japan was the stent extractor Solitaire , Trevo, Tron FX and EmboTrap and suction catheters Sofia, AXS Catalyst, Penumbra and REACT, and Versi Retriever in clinical tria.
2 The use of medical devices should be in accordance with their approval conditio.
The above MT devices are approved to achieve recanalization within 8 hours of onset of acute ischemic stroke in patients who are not suitable for use with IV rt-PA or not achieved with IV rt-PA Reconne.
The indications for Trevo and Solitaire were expanded in 2019 to include use within 24 hours of onset or the last known time in patients who met certain imaging criter.
These devices reduce damage by clearing cerebral vascular thrombus to restore blood flow in acute ischemic stroke patients with relatively small infarcts that occlude proximal major cerebral arteries in the anterior circulation (the M1 segment of the ICA or MC.
These devices are approved on the condition that endovascular therapy should be initiated within 6-24 hours of the last known good time in patients who are unfit for or unresponsive to intravenous rt-.
This approval condition is not necessarily consistent with scientific evidence from clinical studies of .
Newly approved medical devices should be used in accordance with their approved conditions and specificatio.
2Eligibility for treatment Scientific evidence supports the effectiveness of MT for acute ischemic stroke caused by large vessel occlusi.
MT is recommended when the following conditions are m.
1) For early acute ischemic stroke, in addition to drug therapy including intravenous infusion of rt-PA (alteplase), it is recommended that patients who meet all of the following conditions use a stent extractor or suction within 6 hours of ons.
Suction catheter for endovascular therapy (including MT): ① Diagnosed with occlusion of major cerebral arteries in the anterior circulation (ICA or MCA M1 segment); ② Pre-morbid mRS score of 0 or 1; ③ Head CT or MRI diffusion-weighted imaging (DWI) ) Alberta Stroke Project Early CT or MRI Score (ASPECTS) ≥ 6; ④ National Institutes of Health Stroke Scale (NIHSS) score ≥ 6; ⑤ At least 18 years old [Grade .
2) For ischemic stroke, which appears to be caused by acute occlusion of the ICA or MCA M1 segment, more than 6 hours from the last known time, MT is strongly recommended within 16 hours from the last known time, the patient's disease Anterior mRS score of 0 or 1, NIHSS score of ≥10, and ASPECTS of ≥7 on MRI D.
In addition, in patients with ischemic core volume (CT perfusion or MRI DWI) not matching neurological dysfunction or with hypoperfused lesions on perfusion imaging, MT is recommended within 24 hours of the last known good time [Grade .
In Japan, however, it should be noted that, with the exception of Trevo and Solitaire, the intended use listed in the package insert of all thrombectomy devices should be labeled "Acute ischemic stroke within 8 hours of onset" u.
3) Although there is currently no substantial scientific evidence for MT, mild neurological deficits with ASPECTS <6, NIHSS score <6, MCA M2 segment or basilar artery (BA) in patients with a large ischemic core of acute occlusi.
Or patients with pre-morbid mRS score ≥ 2, if the individual patient's situation is carefully considered, and the benefit of efficacy is considered to be greater than the risk of safety, MT can be considered [Grade C
4) When perfusion imaging is not time-consuming, automated image analysis software capable of rapidly measuring ischemic core volume and detecting hypoperfused lesions can be used for decision-making in MT [Class C
3 Treatment considerations 1 Eligible patients should be given priority to intravenous rt-PA [Grade .
Based on accumulated scientific evidence, intravenous infusion of rt-PA is strongly recommended for eligible patients with acute ischemic stroke within 5 hours of onset, who are eligible and have no contraindicatio.
For example, the "Guidelines for Intravenous Thrombolysis (Recombinant Tissue-Type Plasma Protein Activator) Third Edition" formulated by the Japanese Stroke Society, rt-PA should be administered intravenously after careful selection of eligible patients, in a non-experimental setting MT in eligible patients must be avoided; and in non-experimental settings, the use of IV rt-PA in eligible patients must be avoided because the efficacy and safety of this approach have not been established at the time of this guideline .
Even if the time of onset is unknown, IV rt-PA within 5 hours of symptom recognition may be considered in the presence of a DWI/fluid-enhanced inversion recovery (FLAIR) mismat.
However, the efficacy and safety of intravenous rt-PA followed by thrombectomy in these patients with large vessel occlusion has not been established [Grade C
2 Early initiation of treatment and shorter recanalization time were associated with better outcom.
Therefore, endovascular therapy (MT) should be performed as soon as possible after patient arrival [Level .
When rt-PA is administered intravenously, the onset of MT should not be delayed for evaluation of thrombolytic effects [Grade .
3 As first-line devices for MT, stent extractors and suction catheters have been shown to have comparable efficacy [Grade .
While a combined technique using a stent and suction catheter can be considered, it must be recognized that this technique has not been proven to produce good results, involves complex techniques, and is costly [Grade C
4 MT is usually performed under local anesthes.
If needed, or without delaying treatment, general anesthesia may be considered [Grade C
5 The benefits and risks of MT should be explained to eligible patients or their legal representatives and their informed consent should be obtain.
4 Essential elements of a medical institution 1 The medical institution should have an environment that allows intravenous injection of rt-PA, and should be equipped with an operating room that can perform MT at any time [Class .
Medical institutions that perform rt-PA should be able to perform head CT or MRI, general hematology, coagulation, and electrocardiography; have acute stroke care specialists who can start treatment as soon as the patient arrives; provide neurological assistance quickly if necessa.
system of surgical intervention
In addition, each point of care should have an MT-enabled environment,.
an angiography room or vascular suite in the operating room, an acute stroke care specialist who can start treatment as soon as possible upon arrival, and continuous monitoring and improvement of the environment at their si.
2 MT must be performed by a neurovascular therapist or a certified MT operator with considerable experien.
To ensure safe MT operation, the procedure must be performed by a JSNET-certified neurological therapist or a certified MT operator with considerable experien.
The term "certified MT operator" refers to a member of JSNET who is a specialist in one of the four core disciplines .
neurosurgery, internal medicine, radiology and emergency department) who performed diagnostic cerebral angiography on 200 patients , 100 patients underwent neurovascular therapy (including 20 as first operators and 15 as MT providers) and were registered by JSN.
What are the similarities and differences between the Chinese and Japanese guidelines for endovascular interventional treatment of acute large vessel occlusion stroke patients? After reading the entire Japanese guidelines for endovascular interventional therapy, the author is deeply touch.
First of all, Japan's certification for endovascular interventional therapy is very stri.
It requires that operators who can perform surgery must have experience in at least 200 cases of whole-brain angiography, and have performed at least 100 cases of interventional thera.
The number of surgeons must be greater than 20, and emergency endovascular thrombectomy must be greater than 1At present, there are such neurointerventional training centers in China to continuously improve the clinical level of the overall neurointerventional physicians, but its implementation is currently slower than that in Jap.
The second point is that the author mentioned in the previous interpretation of the Japanese and Korean guidelines that the Japanese and Korean Stroke Associations believe that intravenous thrombolysis should be given priority to patients with acute stroke 5 hours after onset, but intravenous thrombolysis should be given priori.
At the same time, he emphasized that endovascular interventional therapy should not be delayed because of intravenous thrombolys.
Koreans directly pointed out that for patients with large vessel occlusion, intravenous thrombolysis can be performed at the same time as direct endovascular interventi.
The third point is the current Japanese guidelin.
Because the overall cost may be considered, the stent combined suction technique is not recommend.
In fact, according to the author's experience, unless there are special circumstances, generally speaking, stent thrombectomy or direct suction is not recommended for stent remov.
The vast majority of patients can achieve good results, and the combination of the two or the dual-stent thrombectomy technique is only a minority, and the stent thrombectomy combined with suction technique is not recommended as a routine choice in Chi.
To sum up, China and Japan have similar concepts of endovascular interventional therapy for stroke caused by acute large vessel occlusion, but Japan itself has clear requirements for the number of surgical cases and experience of operators, which is worthy of domestic reference and learni.
How to get more free guides? There are "Clinical Guides" on the doctor's station👇 Scan the QR code below the codeClick "Download Now"Open the Doctor's Station App and click the columnFind the "corresponding department" in the guide interpretation, follow the column and subscribe to the column, read it every day A new guide!Click on the guide on the homepage and search for the desired guideClick on the email to send/share WeChat friends, you can get the original text, download the Doctor Station App, and get the new guide for free~ Reference source: [1]Yamagami H, Hayakawa M, Inoue M , et .
Guidelines for mechanical thrombectomy in Japan, the fourth edition, March 2020: a guideline from the Japan stroke society, the Japan neurosurgical society, and the Japanese society for neuroendovascular therapy[.
Neurologia medico-chirurgica, 2021: nmc .
2020-035 First release of the text: Neurology Channel of the Medical Community Author of this article: Liu Peihui Review of this article: Deputy Chief Physician Li Tuming Editor in charge: .
Lu Li The timeliness of the content, and the accuracy and completeness of the cited data (if any), e.
make any commitments and guarantees, and do not assume any responsibility for the outdated content, the possible inaccuracy or incompleteness of the cited da.
any liabili.
Relevant parties are requested to check separately when adopting or using it as a basis for decision-maki.
Contribution/reprint/business cooperation: yxjsjbx@y.
o.
cn
This research has made domestic scholars interested in related endovascular treatment guidelines in Jap.
At present, China has more interpretations of European and American stroke-related guidelines, and less translation and interpretation of Japanese and Korean guidelin.
Japan is a medical pow.
At the same time, due to its historical reasons, Japan and Germany have done more vivisections, so that they have accumulated rich experience in neurolo.
In order to enable domestic scholars to better understand the guidelines for endovascular interventional therapy in Japan, the author specially translated the key parts of the "Japanese Guidelines for Mechanical Thrombectomy (Fourth Edition)" for reference by peers, as follo.
Guidelines Screenshot Reading Notes: Recommendation 1 Devices for MT (Mechanical Thrombectomy) 1 An approved device should be used to provide MT [Class A] At the time of this guideline, the MT device approved and in use in Japan was the stent extractor Solitaire , Trevo, Tron FX and EmboTrap and suction catheters Sofia, AXS Catalyst, Penumbra and REACT, and Versi Retriever in clinical tria.
2 The use of medical devices should be in accordance with their approval conditio.
The above MT devices are approved to achieve recanalization within 8 hours of onset of acute ischemic stroke in patients who are not suitable for use with IV rt-PA or not achieved with IV rt-PA Reconne.
The indications for Trevo and Solitaire were expanded in 2019 to include use within 24 hours of onset or the last known time in patients who met certain imaging criter.
These devices reduce damage by clearing cerebral vascular thrombus to restore blood flow in acute ischemic stroke patients with relatively small infarcts that occlude proximal major cerebral arteries in the anterior circulation (the M1 segment of the ICA or MC.
These devices are approved on the condition that endovascular therapy should be initiated within 6-24 hours of the last known good time in patients who are unfit for or unresponsive to intravenous rt-.
This approval condition is not necessarily consistent with scientific evidence from clinical studies of .
Newly approved medical devices should be used in accordance with their approved conditions and specificatio.
2Eligibility for treatment Scientific evidence supports the effectiveness of MT for acute ischemic stroke caused by large vessel occlusi.
MT is recommended when the following conditions are m.
1) For early acute ischemic stroke, in addition to drug therapy including intravenous infusion of rt-PA (alteplase), it is recommended that patients who meet all of the following conditions use a stent extractor or suction within 6 hours of ons.
Suction catheter for endovascular therapy (including MT): ① Diagnosed with occlusion of major cerebral arteries in the anterior circulation (ICA or MCA M1 segment); ② Pre-morbid mRS score of 0 or 1; ③ Head CT or MRI diffusion-weighted imaging (DWI) ) Alberta Stroke Project Early CT or MRI Score (ASPECTS) ≥ 6; ④ National Institutes of Health Stroke Scale (NIHSS) score ≥ 6; ⑤ At least 18 years old [Grade .
2) For ischemic stroke, which appears to be caused by acute occlusion of the ICA or MCA M1 segment, more than 6 hours from the last known time, MT is strongly recommended within 16 hours from the last known time, the patient's disease Anterior mRS score of 0 or 1, NIHSS score of ≥10, and ASPECTS of ≥7 on MRI D.
In addition, in patients with ischemic core volume (CT perfusion or MRI DWI) not matching neurological dysfunction or with hypoperfused lesions on perfusion imaging, MT is recommended within 24 hours of the last known good time [Grade .
In Japan, however, it should be noted that, with the exception of Trevo and Solitaire, the intended use listed in the package insert of all thrombectomy devices should be labeled "Acute ischemic stroke within 8 hours of onset" u.
3) Although there is currently no substantial scientific evidence for MT, mild neurological deficits with ASPECTS <6, NIHSS score <6, MCA M2 segment or basilar artery (BA) in patients with a large ischemic core of acute occlusi.
Or patients with pre-morbid mRS score ≥ 2, if the individual patient's situation is carefully considered, and the benefit of efficacy is considered to be greater than the risk of safety, MT can be considered [Grade C
4) When perfusion imaging is not time-consuming, automated image analysis software capable of rapidly measuring ischemic core volume and detecting hypoperfused lesions can be used for decision-making in MT [Class C
3 Treatment considerations 1 Eligible patients should be given priority to intravenous rt-PA [Grade .
Based on accumulated scientific evidence, intravenous infusion of rt-PA is strongly recommended for eligible patients with acute ischemic stroke within 5 hours of onset, who are eligible and have no contraindicatio.
For example, the "Guidelines for Intravenous Thrombolysis (Recombinant Tissue-Type Plasma Protein Activator) Third Edition" formulated by the Japanese Stroke Society, rt-PA should be administered intravenously after careful selection of eligible patients, in a non-experimental setting MT in eligible patients must be avoided; and in non-experimental settings, the use of IV rt-PA in eligible patients must be avoided because the efficacy and safety of this approach have not been established at the time of this guideline .
Even if the time of onset is unknown, IV rt-PA within 5 hours of symptom recognition may be considered in the presence of a DWI/fluid-enhanced inversion recovery (FLAIR) mismat.
However, the efficacy and safety of intravenous rt-PA followed by thrombectomy in these patients with large vessel occlusion has not been established [Grade C
2 Early initiation of treatment and shorter recanalization time were associated with better outcom.
Therefore, endovascular therapy (MT) should be performed as soon as possible after patient arrival [Level .
When rt-PA is administered intravenously, the onset of MT should not be delayed for evaluation of thrombolytic effects [Grade .
3 As first-line devices for MT, stent extractors and suction catheters have been shown to have comparable efficacy [Grade .
While a combined technique using a stent and suction catheter can be considered, it must be recognized that this technique has not been proven to produce good results, involves complex techniques, and is costly [Grade C
4 MT is usually performed under local anesthes.
If needed, or without delaying treatment, general anesthesia may be considered [Grade C
5 The benefits and risks of MT should be explained to eligible patients or their legal representatives and their informed consent should be obtain.
4 Essential elements of a medical institution 1 The medical institution should have an environment that allows intravenous injection of rt-PA, and should be equipped with an operating room that can perform MT at any time [Class .
Medical institutions that perform rt-PA should be able to perform head CT or MRI, general hematology, coagulation, and electrocardiography; have acute stroke care specialists who can start treatment as soon as the patient arrives; provide neurological assistance quickly if necessa.
system of surgical intervention
In addition, each point of care should have an MT-enabled environment,.
an angiography room or vascular suite in the operating room, an acute stroke care specialist who can start treatment as soon as possible upon arrival, and continuous monitoring and improvement of the environment at their si.
2 MT must be performed by a neurovascular therapist or a certified MT operator with considerable experien.
To ensure safe MT operation, the procedure must be performed by a JSNET-certified neurological therapist or a certified MT operator with considerable experien.
The term "certified MT operator" refers to a member of JSNET who is a specialist in one of the four core disciplines .
neurosurgery, internal medicine, radiology and emergency department) who performed diagnostic cerebral angiography on 200 patients , 100 patients underwent neurovascular therapy (including 20 as first operators and 15 as MT providers) and were registered by JSN.
What are the similarities and differences between the Chinese and Japanese guidelines for endovascular interventional treatment of acute large vessel occlusion stroke patients? After reading the entire Japanese guidelines for endovascular interventional therapy, the author is deeply touch.
First of all, Japan's certification for endovascular interventional therapy is very stri.
It requires that operators who can perform surgery must have experience in at least 200 cases of whole-brain angiography, and have performed at least 100 cases of interventional thera.
The number of surgeons must be greater than 20, and emergency endovascular thrombectomy must be greater than 1At present, there are such neurointerventional training centers in China to continuously improve the clinical level of the overall neurointerventional physicians, but its implementation is currently slower than that in Jap.
The second point is that the author mentioned in the previous interpretation of the Japanese and Korean guidelines that the Japanese and Korean Stroke Associations believe that intravenous thrombolysis should be given priority to patients with acute stroke 5 hours after onset, but intravenous thrombolysis should be given priori.
At the same time, he emphasized that endovascular interventional therapy should not be delayed because of intravenous thrombolys.
Koreans directly pointed out that for patients with large vessel occlusion, intravenous thrombolysis can be performed at the same time as direct endovascular interventi.
The third point is the current Japanese guidelin.
Because the overall cost may be considered, the stent combined suction technique is not recommend.
In fact, according to the author's experience, unless there are special circumstances, generally speaking, stent thrombectomy or direct suction is not recommended for stent remov.
The vast majority of patients can achieve good results, and the combination of the two or the dual-stent thrombectomy technique is only a minority, and the stent thrombectomy combined with suction technique is not recommended as a routine choice in Chi.
To sum up, China and Japan have similar concepts of endovascular interventional therapy for stroke caused by acute large vessel occlusion, but Japan itself has clear requirements for the number of surgical cases and experience of operators, which is worthy of domestic reference and learni.
How to get more free guides? There are "Clinical Guides" on the doctor's station👇 Scan the QR code below the codeClick "Download Now"Open the Doctor's Station App and click the columnFind the "corresponding department" in the guide interpretation, follow the column and subscribe to the column, read it every day A new guide!Click on the guide on the homepage and search for the desired guideClick on the email to send/share WeChat friends, you can get the original text, download the Doctor Station App, and get the new guide for free~ Reference source: [1]Yamagami H, Hayakawa M, Inoue M , et .
Guidelines for mechanical thrombectomy in Japan, the fourth edition, March 2020: a guideline from the Japan stroke society, the Japan neurosurgical society, and the Japanese society for neuroendovascular therapy[.
Neurologia medico-chirurgica, 2021: nmc .
2020-035 First release of the text: Neurology Channel of the Medical Community Author of this article: Liu Peihui Review of this article: Deputy Chief Physician Li Tuming Editor in charge: .
Lu Li The timeliness of the content, and the accuracy and completeness of the cited data (if any), e.
make any commitments and guarantees, and do not assume any responsibility for the outdated content, the possible inaccuracy or incompleteness of the cited da.
any liabili.
Relevant parties are requested to check separately when adopting or using it as a basis for decision-maki.
Contribution/reprint/business cooperation: yxjsjbx@y.
o.
cn
