1 Cranial computed tomography (CT) cranial CT plain scan is the most commonly used examination. However, it is not sensitive to ultra-early ischemic lesions and small cortical or subcortical infarct foci, especially brainstem and cerebellar infarcts are more difficult to detect. However, hemorrhagic disease can be excluded, and infarct foci can be visualized at 24 to 48 hours. Du Quanyue, Department of Neurology, Baicheng Central Hospital In the ultra-early stage (within 6 hours of onset), CT can detect some minor changes: e.g., high-density sign of middle cerebral artery.
Head MRI can clearly show the infarct foci early, but critical patients are limited, and patients wearing pacemakers, dentures, aneurysm placement metal clips, etc. cannot be examined by MRI. Advantages: 1 High resolution can clearly show a 1mm lesion. 2 Sensitive to tissue water content, can show early lesions and edema. 3 Can measure blood flow velocity. 4 No cranial artifacts. Arbitrary cross-sectional images can be obtained.T2 The lesion is visible at 8 hours of onset TI like a 16-hour lesion. Advanced (field strength) NMR diffusion-weighted DWI can show ischemic lesions at 2 hours again PWI can show reversible injury lesions at 30 minutes. mrs spectral NMR can provide signal of lactate in the tissue of the lesion can detect the lesion at 4 hours.
2 Ultrasound examination
(1) Carotid ultrasonography: It should be used as a basic examination for patients and can often show atherosclerotic plaques. However, its clinical value for mild to moderate arterial stenosis is low, and it cannot discriminate between severe stenosis and complete carotid artery obstruction.
(2) Transcranial color Doppler ultrasound, i.e., brain color: It is a powerful means to detect intracranial large vessel stenosis. It can detect severe intracranial stenosis, determine collateral circulation, perform embolic monitoring, and assess the status of cerebral blood circulation before angiography. (3) Transesophageal echocardiography (TEE): Compared with conventional transthoracic cardiac ultrasound, it improves the visualization of the atria, atrial wall, atrial septum and ascending aorta, and can detect abnormalities of the atrial septum (aneurysm of the atrial septum, unclosed foramen ovale, atrial septal defect), atrial appendage thrombus, mitral valve redundancy, and a variety of cardiogenic sources of emboli such as atherosclerosis of the aortic arch.
3.Cerebral angiography
(1) Selective arterial catheter cerebral angiography (digital subtraction angiography, DSA): It is the most accurate diagnostic tool (gold standard) for assessing intracranial and extracranial arterial vascular lesions. However, cerebral angiography is more expensive and carries certain risks, and the incidence of serious complications is about 0.5% to 1.0%.
(2) CTA (computerized imaging angiography) and MRA (magnetic resonance imaging angiography): are new non-invasive vascular imaging techniques, but they are not as detailed as the vascular situation provided by DSA and can lead to over-judgment of the degree of arterial stenosis.
Nowadays, there are some misconceptions among some patients that they only care about the infarction but not the blood vessels, and simply dilute the blood or activate the blood vessels for treatment, in fact, most of the infarcts have lesions of the vessel walls, while some patients neglect the examination and treatment of the blood vessels. This is just like a blocked water pipe, no matter how clear the water is, it is useless. I suggest to do more assessment and treatment on blood vessels, in fact, a simple TCD is enough, which is good for early detection of arterial stenosis, and this examination is well carried out in our hospital.
32 Treatment principles of cerebral infarction: Acute ischemic stroke is an emergency in neurology. In recent years, tethering, antiplatelet aggregation, anticoagulation and surgical treatment have been applied to achieve better results. Early clinical diagnosis and ultra-early treatment can save the neurological function of the patient, and proper management during the acute phase can reduce the mortality, disability and complications of the patient and improve the survival rate. In this sense, time is brain.
Ultra-early treatment: First of all, we should raise the awareness of stroke as an emergency and seek medical attention immediately after the onset of stroke in order to obtain the best treatment.
2 Individualized principle: Any single therapy or drug has its limitation, and different treatment methods such as thrombolysis, fibrin-lowering, anticoagulation, antiplatelet aggregation and cerebral protection are adopted according to the degree of disease, the presence or absence of comorbidities, the presence or absence of underlying causes and age. And comprehensive drugs, surgery, rehabilitation and other therapies should be chosen according to the person and at the right time, which is still the best program for the treatment of cerebrovascular.
3 holistic treatment: over-promotion of a certain drug or therapy is one-sided, and over-emphasis on a certain therapy to the exclusion of other therapies is also undesirable and detrimental to the treatment of patients. We advocate that only under the premise of holistic concept and individualization principle, comprehensive treatment can achieve the best results.
I will talk about some misunderstandings after the infarction
Some patients have the perception that the blood pressure should be lowered immediately after the thrombosis, and the sooner the better. In fact, the AHA treatment guidelines point out that post-stroke blood pressure is elevated in many ways, such as stress response, urinary retention, pain, the body’s response to cerebral hypoxia and increased intracranial pressure. It may fall after debridement, and when systolic sub >220 cautiously give antihypertensive drugs. Excessive hypotension can lead to exacerbation of the disease.
2 Blood glucose levels should be 6 to 9 mmol/L greater than 10 mmol/L should be given insulin therapy. Some people talk about insulin. High blood sugar can aggravate the condition and should be brought down to the normal range immediately.
Let me talk about the pharmacological treatment after infarction
Drug therapy: cerebral infarction occurs when cerebral artery blood flow is interrupted for more than 5 minutes, and the central part of the lesion is already irreversibly damaged, but timely restoration of blood flow and improvement of tissue metabolism can salvage only functionally altered tissues around the infarct and avoid the formation of necrosis. Those tissues are the semidark zone. Most cerebral infarcts are occlusions of intracranial arteries caused by thromboembolism; therefore, revascularization and restoration of flow is the most reasonable treatment. If effective treatment is administered, the degree of brain damage can be reduced and functional recovery promoted, but these measures must be administered within a limited time period, called the treatment time window. It is usually 3-6 hours. Thrombolytic therapy is to salvage the ischemic semidark zone by dissolving the thrombus, recanalizing the occluded cerebral artery, restoring the blood supply to the infarcted area, and preventing irreversible damage to the ischemic brain tissue from occurring. The timing of thrombolytic therapy is the key to the efficacy.
(1) A intravenous thrombolytic drugs usually used in clinical practice include: recombinant human tissue-type fibrinogen activator (rt-PA), urokinase (UK) Indications
1 Age not more than 75 years.
2 within 6h of onset, with progressive stroke time extended to 12h.
Blood pressure below 24.0/14.7 kPa (180/110 mmHg).
absence of impaired consciousness, which may also be considered in the presence of impaired consciousness due to the poor prognosis of thrombosis of the vertebrobasilar system
muscle strength of the hemiplegic limb below grade 3.
Exclusion of cerebral hemorrhage by head CT and absence of hypodense infarct foci corresponding to the present symptoms.
Patient or family consent.
Contraindications to thrombolytic therapy include.
(i) bleeding tendency or bleeding quality; (ii) history of stroke or traumatic brain injury within the last 3 months; (iii) blood pressure higher than 24.0/14.7 kPa (180/110 mmHg); (iv) rapid improvement of neurological symptoms or only mild neurological deficits, such as sensory loss, dysarthria and mild muscle weakness; (v) large hypodense responsible lesions visible on head CT; (vi) severe heart, liver and renal dysfunction.
Complications of thrombolytic therapy: mainly 1 secondary bleeding from cerebral infarction lesions or bleeding from other parts of the body. 2 fatal reperfusion injury and cerebral edema. 3 re-occlusion. Our hospital is one of the early hospitals to carry out this procedure. (discontinuation, review of CT, fresh frozen plasma, 1 unit of platelets)
B arterial tethering
Super-selective tethering under direct DSA digital subtraction arteriography. Features small dose of intra-arterial thrombolysis, high local drug concentration, precise thrombolytic effect, short recanalization time, low impact on fibrinolytic system, long time window, more suitable for embolization of single thrombus or small amount of clot in large vessels and patients who are not suitable for intravenous thrombolysis for the time being after surgery
2) Anticoagulation therapy Heparin, low molecular heparin, warfarin
3) Fibrin-lowering enzyme therapy degrades fibrinogen in blood to inhibit thrombus formation. Commonly used are fibrin-lowering enzyme and bactrim.
(4) Anti-platelet aggregation therapy Cyclooxygenase inhibitors: Aspirin inhibits cyclooxygenase, inhibits the synthesis of arachidonic acid in platelets, and inhibits the synthesis of thromboxane A2. Ceclopidine inhibits ADP-induced platelet aggregation with better efficacy than aspirin, but it is expensive and not widely used. Aspirin dipyridamole tablets (Tianji)
5) Cerebral protection therapy
Calcium antagonists Nimodipine, flunarizine hydrochloride. Free radical scavengers Free radicals: unpaired atoms, ions, molecules present in the electron orbitals. Vitamin E, vitamin C, edaravone, phenolic compounds have strong scavenging effect of free radicals, and the study of ketenol interconversion isomers found that edaravone has strong anti-free radical effect. Now it has been used in a large number of clinical applications.
6) Dehydration and lowering of cranial pressure
7) Chinese medicine preparations Chuanxiong and Danshen
8) Vascular interventional treatment
(2) It is an effective treatment for stenosis of carotid and internal carotid arteries in the extracranial segment.1 PTA intracranial arterioplasty was started in 1992.2 Intracerebral artery stenting. Started 1999. Indication is low-flow TIA with cerebral artery stenosis that is difficult to control by drugs. Now it is one of the effective methods .
33 Role of early somatic rehabilitation in cerebrovascular disease
Rehabilitation has a unique place in the treatment of acute cerebrovascular disease. Research results have proved that early systematic, standardized and individualized rehabilitation treatment can help early functional recovery and reduce the rate of disability, and has received obvious results in recent years. Hospitals with conditions have special rehabilitation rooms and rehabilitation doctors, and the importance of rehabilitation, because there are still many patients who do not pay enough attention to it, and as a result, they miss the best rehabilitation time, delay treatment and leave undesirable sequelae.
Our hospital was the first to carry out rehabilitation in Baishengdi. The concept of stroke unit has also been introduced in recent years.
The stroke unit is an emerging ward management model. Its most important feature is that it combines drug-based treatment with physical rehabilitation, psychological rehabilitation, language training, health education and life care to create a holistic and integrated treatment model. Therefore, the core staff of the stroke unit includes not only neurologists and nurses, but also physiotherapists, psychotherapists, and speech trainers. Early rehabilitation of cerebrovascular disease
1） Maintain a good functional position: The finger joints of the paralyzed limbs should be extended and slightly flexed, a sponge roll can be placed in the hand; the elbow joint is slightly flexed, the shoulder joint of the upper limb is slightly abducted, a soft pillow is placed under the shoulder, the thigh and calf are at right angles, a hard pillow can be placed on the bottom of the foot in order to prevent the foot from sagging, and a support can be placed in the lateral part in order to prevent the lower limb from external rotation.
(2) massage: massage order should be distal to proximal end. Grasp the principle of light first, then heavy, from shallow to deep, from slow to fast, the patient’s upper limbs from the fingers to the forearm, around the shoulder joint, a gentle massage.
3） Passive movement: After the vital signs are stable, whether the patient is conscious or comatose, he should perform early passive movement of the limbs, including flexion, extension and lifting activities of the shoulder, elbow, finger, hip, knee and ankle joints.
(4) Active exercise When the patient’s consciousness is clear and vital signs are stable, active training in bed can be carried out to facilitate the recovery of limb function, from simple to complex training, with emphasis on training paralyzed limbs and weak muscle groups, including the lumbar and abdominal muscle groups.
(5) Off-bed training guidance: should be a process from lying on the bed to semi-sitting position → sitting position → sitting position with legs on the side of the bed → standing position → walking with hips and knees extended and flexed.
6) Daily life movement training: patients can be instructed to brush teeth, eat, put on and take off clothes, pluck beads, pick up beans and other self-care activities to exercise fine movements.
34 Some misconceptions about rehabilitation
1 The “misuse syndrome” of inappropriate exercise.
Some patients are anxious to walk with the help of their family members in the early stage of the disease; some patients put a band on the affected foot and walk with the affected leg pulled by the healthy hand; some patients attach a rope to the bed and repeatedly practice arm strength and sitting up by pulling the rope with their hands, and practice grip strength with rubber bands, etc. In fact, these practices are all wrong. This is because premature walking or excessive practice of upper limb pulling will cause the hemiplegic patient to develop a unique spastic posture, which is very difficult to correct once an abnormal pattern is formed. Exercises after hemiplegia should be done gradually, starting with bed exercises, to sitting exercises, to standing, and then to walking and going up and down steps. The functional training after hemiplegia is a process of learning motor function, not just muscle strength training, and the process of exercise should focus on the learning of muscle coordination.
In addition, there are some patients who are bedridden for a long time because they are worried about getting up too early to aggravate their condition. This long-term lack of movement and sensory stimulation state, easy to cause multi-system organ function decompensation, medical called “wasting syndrome”. The hypofunction of the motor system is manifested by joint contracture, muscle atrophy, osteoporosis, etc., which may cause or aggravate pain and limitation of movement. Cardiopulmonary hypofunction is manifested by disuse hypofunction, postural hypotension, impaired peripheral circulation, pulmonary infection and pulmonary embolism. Other system hypofunction manifests as: loss of appetite, constipation, urinary tract infection, skin and nail atrophy, as well as melancholy, mental retardation, and pseudo-dementia.
3 Rehabilitation is not only acupuncture, massage Beijing Zhongkang Hospital recently surveyed tens of thousands of stroke rehabilitation patients: 85.6% of patients already know the importance of early rehabilitation, which is a big improvement over 5 years ago when only less than 30% of people understood this. However, the survey also found that the number of patients who trained at home without formal rehabilitation, leading to misuse syndrome, was also much higher than five years ago. Less than 5% of urban patients received formal rehabilitation, and the vast majority of the rest missed the best time to rehabilitate due to misconceptions about rehabilitation. Among the patients who know about rehabilitation, only 13% know that they should go to professional rehabilitation institutions for rehabilitation evaluation before taking community rehabilitation or home rehabilitation; as many as 60% think that acupuncture and massage are rehabilitation; 10% think that physical therapy is rehabilitation. This indicates that people’s understanding of rehabilitation is still at the primary stage, and medical personnel need to go deep into the community to popularize and educate about rehabilitation in order to reduce the occurrence of “misuse syndrome” and “disuse syndrome”.