The following is a compilation of some of the interviews.
Cerebrovascular disease is defined as brain dysfunction caused by cerebrovascular lesions. Broadly speaking, cerebrovascular lesions include diseases caused by occlusion of blood vessel lumens due to embolism and thrombosis, rupture of blood vessels, damage to blood vessel walls or changes in permeability, abnormal coagulation mechanisms, abnormal blood viscosity or abnormal changes in blood composition. The morbidity, mortality and disability rates of cerebrovascular diseases are extremely high, and it is crucial for such patients to be diagnosed and treated quickly. In this micro-interview, Professor Xing Yan, Director of Department of Neurology, Aviation General Hospital, is invited to discuss the “green channel for emergency treatment of cerebrovascular diseases”.
Prof. Xing Yan, chief physician and master tutor, is the director of the Department of Neurology of Aviation General Hospital, as well as the secretary of the General Branch of the Department of Internal Medicine and the director of the Department of Teaching and Research. He is a member of the Standing Committee of the First Committee of the Neurodegenerative Diseases Committee of the Chinese Society of Microcirculation; a member of the First Committee of Neurology of the Chinese Association of Women Physicians; a member of the Committee of Neurology of the Beijing Branch of the Chinese Medical Association; the chief expert of the Beijing Cerebrovascular Disease Network; a member of the Cerebrovascular Disease Expert Committee of the Red Cross “Casting China’s Heart Together”; a member of the China Aviation Industry Health and Wellness Association; and a member of the Department of Neurology. Member of the Committee of the Red Cross “Casting Chinese Heart” Cerebrovascular Disease Expert Committee; Specially appointed expert of the Health Management Center of AVIC. He is also an expert reviewer for the Chinese Journal of Neurological Regeneration Research (NRR) and a special expert reviewer for the Chinese Journal of Brain Diseases and Rehabilitation. He is the editor of Modern Neurology, and the translator of DeJong Neurological Examination. He has published more than 20 professional papers.
In December 2013, he took the lead in setting up a multidisciplinary standardized stroke thrombolysis treatment program (MOST program) initiation center in the hospital, forming a cerebrovascular disease treatment team including neurology, neurosurgery and interventional medicine, and formulating a standardized cerebrovascular disease emergency green channel procedure. media reports.
Interview content (42 questions, 42 responses)
Clove Correspondent ：@Sunshine walks with a catwalk Ask @香香lv: May I ask Prof. Xing: What is the status of intracranial hematoma fragmentation in clinical practice now? There used to be frequent training courses, but now there seems to be little noise, is it worth promoting in county level primary hospitals?
Guests in this issue
Fragrant lv: The advantage of intracranial hematoma puncture and aspiration is that it is simple, easy to perform, less expensive, and suitable for primary hospitals, but the drainage is not complete, the puncture is easy to damage the blood vessels, intraoperative bleeding is difficult to stop, and the assistance of neurosurgery is required. With the advancement of imaging technology, new technologies such as stereotactic, small bone window, and endoscopy are maturing, and there are more options for cerebral hemorrhage, intracranial hematoma puncture and aspiration is gradually losing its original advantages, and its benefits are mixed.
This issue’s guests
Thank you for your attention and questions about the emergency green channel for cerebrovascular disease. I hope to take advantage of the excellent platform of Clove Garden to communicate with everyone and learn and improve together.
hxzzq ：给@香香lv提问：Please ask Prof. Yin: Do patients with subarachnoid hemorrhage need to routinely use anti-platelet aggregation drugs after aneurysm intervention?
Guest
Aromalv：If there is no stent assistance, it is not necessary.
滄海月明sm：A question for @香香lv: How to control blood pressure and blood volume in patients with stroke and heart failure?
Guests in this issue
AromaLV: There is a lack of reliable research evidence on whether blood pressure should be lowered immediately after stroke, the target value of blood pressure lowering, when to resume the use of antihypertensive drugs after stroke, and the choice of antihypertensive drugs. The Chinese Guidelines for the Management of Acute Ischemic Stroke 201 0 recommend that patients with elevated blood pressure within 24 h of an ischemic stroke should be managed with caution. Tension and anxiety, pain, nausea and vomiting, and increased intracranial pressure should be managed first. Persistently elevated blood pressure with systolic blood pressure >200 mm Hg or diastolic blood pressure ≥110 mm Hg, or with severe cardiac insufficiency, aortic coarctation, or hypertensive encephalopathy, may be treated with cautious antihypertensive therapy and closely monitored for blood pressure changes, with intravenous use of short-acting drugs (e.g. labetalol, nicardipine) if necessary, preferably with the application of a microinfusion pump to avoid dropping the blood pressure too low. Those with combined cardiac insufficiency should pay attention to the balance of intake and output, try to gastrointestinal intake, and control the amount and drip rate of intravenous fluids.
Clove correspondent ：@yjsrc to @香香lv Question: Please ask Prof. Xing, how to use anticoagulation in patients with cerebral hemorrhage or traumatic intracranial hematoma with hypercoagulable state? Thank you!
Guests in this issue
香香lv ：Guidelines recommend the use of low-dose heparin for the prevention of venous thrombosis at 24h (ACCP guidelines) or 72h (AHA) for cerebral hemorrhage; there are also patients with atrial fibrillation anticoagulation-related cerebral hemorrhage, and anticoagulation therapy can be restarted at 7-10 days for cerebral hemorrhage, and low-molecular heparin anticoagulation therapy should be started immediately for cerebral hemorrhage caused by intracranial venous sinus thrombosis.
Clove correspondent ：@lsjdoc asked @香香lv: May I ask Prof. Yin, when to start oral anticoagulation after the onset of cerebral infarction with atrial fibrillation without oral anticoagulation before the onset?
Guest
Xiang Xiang lv ：It is unclear when to anticoagulate for cardiogenic cerebral embolism, that is, what is the timing of anticoagulation. Generally speaking, if it is a large cerebral infarction in the acute phase of anticoagulation will increase the chance of bleeding events, we do not recommend the use of anticoagulants in the acute phase, and it is generally considered that giving anticoagulation after 2 weeks is an option.
qinguoren ：Queue to @香香lv：There are a lot of arterial thrombolysis (urokinase) done within the time window, but not many of them have a good final outcome, all the patients were completely lysed during the operation, but the symptoms were aggravated the next day when they returned to the ward, and all of them had large cerebral edema on the rechecked head CT, and the final result was high mortality and very poor results. So beautiful? Why I have not seen his beauty?
This issue’s guests
Aroma lv : The key to the treatment of acute ischemic stroke (AIS) is to open the occluded vessels and restore blood flow as early as possible to save the ischemic semidark zone tissue. At present, both domestic and international guidelines recommend intravenous thrombolysis as the main treatment for AIS, but intra-arterial thrombolysis is an option for patients with large arterial occlusions where thrombolysis is contraindicated or has failed. A good clinical prognosis after arterial thrombolysis is highly dependent on the time of treatment initiation, and for patients suitable for arterial thrombolysis, the key to treatment is the rapid initiation of patient screening, transport, and a multidisciplinary “green channel” or clinical pathway. As with intravenous thrombolysis, the shorter the time from symptom onset to reperfusion, the better the clinical outcome. Delays before drug administration should be minimized (Class I, Level of Evidence B). Beyond a certain time even if the vessel is revascularized, but the neurons are irreversibly necrotic, the perfusion is ineffective and does not result in a good prognosis.
xiao79bing ：Ask @XiangXianglv: Ask Prof. Xing: For patients with acute cerebral infarction and MR showing ischemic semidark zone, how many hours can the time window for thrombolysis be delayed?
Guest
Xiang Xiang lv ：Intravenous: 3-4.5 hours, arterial: 6 hours for anterior circulation, and posterior circulation can be extended to 24 hours depending on the condition. Others are limited to clinical exploration or individual experience.
ksyhyg ：Question for @香香lv：Female, 48 years old, new infarct foci in temporo-occipital region, consider embolic lesions, no risk factors for cerebrovascular disease on ancillary examination, no atherosclerosis and plaque on vascular ultrasound, no abnormalities on cardiac ultrasound. What should be done for secondary prevention in this patient
Guests in this issue
Aroma lv: For ischemic stroke with no clear cause, secondary prevention should be based on antiplatelet + statin + risk factor control. Of course, in long-term prevention and follow-up, we should still actively search for the cause, such as long-time cardiac Holter, transesophageal cardiac ultrasound or foam test to exclude cardiogenic, head and neck CTA or DSA to exclude entrapment, etc., after the cause is clear, we can target secondary prevention.
wangna2011：A question for @香香lv: Is intravenous rtPA thrombolysis contraindicated in menstruating women?
Guest
aromalv ：Menstruation is a contraindication to intravenous thrombolysis
DingXiangYuan correspondent: @fuaijun1 asked @香香lv: How can the prognosis of patients with acute basilar artery occlusion, which has a high success rate of mechanical opening, be improved?
Guests in this issue
Xiang Xianglv: Endovascular treatment of acute occlusion of the basilar artery can be delayed until 24 hours after the onset (2014 Chinese Expert Consensus on Endovascular Treatment of Acute Ischemic Stroke). However, the opening time should not be delayed because of this. Time is brain. If the ischemic brain tissue is not perfused, it will apoptosis at a rate of approximately 1.9 million neurons per minute, and often mechanical opening is followed by failure to restore function because too much brain tissue is already necrotic. Improvements: reduce in-hospital delays, reduce interventional preparation time, if within the time window of intravenous thrombolysis can be given partially before endovascular treatment (catheterization room preparation phase) (give a dose of 0.6 mg/kg body weight, this part needs to be fully communicated with the patient’s family to obtain informed consent)
Clove Correspondent ：@Dinosaur Country Ask @xiangxianglv: Hypertensive cerebral hemorrhage whose pathological basis is atherosclerosis, why not initiate statin therapy and when to initiate antiplatelet therapy?
Guests in this issue
AromaLV: Studies of statin therapy after cerebral hemorrhage have yielded inconsistent results. Recent studies suggest that statin use during the acute phase of cerebral hemorrhage can be neuroprotective, but it has not yet been recommended by guidelines and needs to be chosen based on patient-specific circumstances. For example, if the bleeding is small and combined with severe stenosis, statin therapy can be initiated in the acute phase. Whether and when to initiate antiplatelet therapy for the prevention of ischemic stroke after cerebral hemorrhage is also unanimous and is a direction for future research. Current experience is that antiplatelet can be initiated after 1-2 weeks of stabilization in patients with more severe stenosis. Small experience: the guidelines for cerebral hemorrhage specify that anticoagulation can be initiated 1-4 days after cerebral hemorrhage to prevent CVT, so antiplatelet therapy can be considered to be initiated after anticoagulation has stopped
Clove correspondent ：@asd1998 asked @香香lv: For young people with cerebral infarction, no relevant risk factors were found, and after the condition is stabilized by treatment, how to do secondary prevention. How to do secondary prevention for patients who have had stressful peptic ulcer bleeding after the onset of the disease
Guests in this issue
Aroma lv ： For ischemic stroke with no clear cause, follow the antiplatelet + statin + risk factor control program for secondary prevention. Of course, the cause should still be actively sought in long-term prevention and follow-up, such as long-range HOLTER, transesophageal ultrasound or foam test, head and neck CTA or DSA, etc. The cause can be targeted for secondary prevention after clarification. In patients with stress ulcers after the onset, aspirin is prohibited and clopidogrel + statin can be used, along with acid suppression and gastric mucosal protection agents
Clove correspondent ：@xwzhou to @xiangxianglv Q: 3 For interventional treatment of cerebrovascular disease, can you briefly summarize the indications for intracranial and extracranial vessels? Especially for vertebrobasilar stenosis, can you summarize the indications for intervention? Thanks!
Guests in this issue
Aroma lv: The 2014 US Stroke Secondary Prevention Guidelines have a lot of new content on interventional treatment of cerebrovascular disease. Briefly, optimal medical drug therapy is recommended, and there is still no evidence to support stent intervention for intracranial vessels even with severe stenosis and recurrent stroke or TIA. For carotid stenosis: carotid artery stenting (CAS) may be an alternative to carotid endarterectomy (CEA) for symptomatic patients with an average or low risk of complications associated with vascular intervention when >70% reduction in lumen diameter of the internal carotid artery is demonstrated by noninvasive imaging or >50% by transcatheter imaging/noninvasive imaging, with an expected rate of <6% risk of perioperative stroke or death. (Class iia, Level b); There is a reason to consider patient age when selecting cas or cea, and in the elderly (patients >70 years of age),… View Details>>http://dxy.me/ZreQVb
丁香园通讯员 ：@xwzhou asked @香香lv a question: 2 about dual antibodies: Recent guidelines suggest that dual antibodies should be used for TIA and mild stroke. Is it better to use mono- or dual antibodies for larger infarcts? If dual antibodies are used, how long should they be used? For post-stenting, is it better to use dual antibodies for 3 months, 6 months or 1 year?
Guests
Aroma lv: The dual antibodies are based on the CHANCE trial in China, only for TIA and light strokes, there is no RCT evidence for larger strokes and dual antibodies are not recommended. According to the CHANCE trial, theoretically, dual antibodies can be used for 3 months, but in practice, if there is no severe intracranial and extracranial stenosis, we usually only use it until discharge, and after going home, we usually switch to monoclonal antibodies. Post-stenting dual antibodies are recommended for 9 months to 1 year
Clove Correspondent ：@xwzhou asked @xiangxianglv: Ask Prof. Xing: 1 Question about statin use in primary prevention of cerebrovascular disease: If a patient is asymptomatic and screened for carotid plaque (multiple or single) when performing a physical examination, is it necessary to use statin lipid-lowering drugs if the patient has no other risk factors? When to start the application?
Guests in this issue
Aroma lv ：According to the 2013 ACC/AHA guidelines for ASCVD risk reduction, carotid plaque, as a type of peripheral vascular lesion, is an indication for statin intervention. However, in practice, if it is just an isolated stable small plaque with no other risk factors, close follow-up observation can be considered before deciding whether to use statin. After all, this guideline is still somewhat controversial and is considered to be an expansion of statin use
DingXiangYuan correspondent ：@GF2006 asked @XiangXianglv: Please ask Prof. Xing: How many hours can the thrombolytic time window be relaxed for infarcts considered to be in the posterior circulation? Also how to control the dose of urokinase intravenous thrombolysis? Thank you!
Guest
Fragrant lv: According to the guidelines, the time window for intravenous thrombolysis of rtPA in posterior circulation infarction is also within 3-4.5 hours, and the time window for endovascular treatment (arterial thrombolysis and intravascular mechanical thrombolysis, etc.) can be relaxed to within 24 hours. In the absence of conditions for rtPA, urokinase can be applied for thrombolysis, and the intravenous time window is within 6 h. The 2010 Chinese guidelines for the diagnosis and treatment of acute ischemic cerebrovascular disease recommend that patients with ischemic stroke within 6 h who cannot be treated with rtPA can be considered for intravenous administration of urokinase, and patients should be strictly selected according to the indications. Usage: Urokinase 1 million to 1.5 million IU, dissolved in saline 100-200 ml, continuous intravenous infusion for 30 min, patients should be closely monitored during administration (Class II recommendation, Level B evidence)
Ding Xiang Yuan correspondent ：@zzy888899 asked @香香lv: Please ask Prof. Xing: How to treat cerebral hemorrhage combined with extensive anterior wall myocardial rupture?
Guests in this issue
Xiang Xianglv: Take life saving as the premise. If brain hemorrhage is massive and life-threatening, surgical treatment of brain hemorrhage is the main concern, and cardiology is the main concern. If the cerebral hemorrhage is stable and the infarction is dangerous, the treatment of the infarction is the main concern, and antiplatelet (monoclonal antibody) and anticoagulation can be used.
丁香园通讯员 ：@cygplhcr asked @香香lv: What is the success rate of thrombolysis with urokinase? What is the bleeding rate?
Guest
Fragrant lv：Because of the non-selective nature of urokinase, the chance of bleeding is high. The guidelines state that rtPA is generally preferred for intravenous thrombolysis within 3-4.5 hours. Our hospital is applying rtPA for thrombolysis, and we have no experience in applying urokinase.
Clove Correspondent ：@Starry Moon Day asked @XiangXianglv: Please ask Prof. Xing: Is there sufficient evidence that hyperhomocysteinemia is a risk factor for cerebrovascular disease?
Guests in this issue
Fragrant lv: Homocysteinemia as a risk factor for cardiovascular and cerebrovascular diseases is included in the 2010 edition of the Chinese Guidelines for the Prevention and Treatment of Hypertension and the 2005 Chinese Guidelines for the Prevention and Treatment of Cerebrovascular Diseases, and is now considered to have endothelial toxic effects, stimulation of vascular smooth muscle proliferation, thrombosis, and disorders of glucose, lipid and protein metabolism. In the 2014 AHA/ASA guidelines for primary stroke prevention, hyperhomocysteinemia is listed as a Less Well-Documented or Potentially Modifiable Risk Factors (LDR). A large number of studies have confirmed the association of hyperhomocysteinemia with increased stroke risk, but trials of homocysteine treatment with B-vitamins have been used to reduce stroke risk.