Treatment
1.Western medical treatment.
(1) Thrombolytic therapy is recommended.
(1) Intravenous thrombolytic therapy should be actively used for strictly selected patients with acute ischemic stroke within 3h of onset. The first choice is rt-PA. If rt-PA is not available, urokinase can be used instead.
(ii) Intravenous urokinase thrombolysis can be applied to acute stroke patients with 3-6h onset, but the selection of patients should be more stringent.
(③For acute stroke patients with 3-6h onset, intra-arterial thrombolytic therapy study can be considered in experienced and qualified units. Chen Chao, Department of Emergency Medicine, Shanghai Hospital of Traditional Chinese Medicine Chen Chao, Department of Emergency Medicine, Shanghai Hospital of Traditional Chinese Medicine
④The time window and indications for thrombolytic therapy for basilar artery thrombosis can be relaxed appropriately.
⑤ Thrombolysis beyond the time window will mostly not increase the therapeutic effect and will increase reperfusion injury and bleeding complications, so it is not appropriate to thrombolysis, and thrombolysis should be disabled for patients in the recovery period.
(2) Fibre-lowering therapy
(1) Bactrim; (2) fibrin-lowering enzyme; (3) other fibrin-lowering agents: such as earthworm kinase, herbicase, etc.
Suggestions: ①Fiber-lowering therapy can be used in the early stage of cerebral infarction (especially within 12h); patients with hyperfibrinogenemia should be actively treated with fibrin-lowering therapy. (2) Indications and contraindications should be strictly mastered.
(3) Anticoagulation therapy is recommended.
(①General patients with acute cerebral infarction are not recommended to use anticoagulants routinely and immediately.
(②The use of anticoagulants within 24 hours is not recommended for patients treated with thrombolysis.
③Elective use of anticoagulants may be considered when there are no contraindications for the following conditions (e.g. bleeding tendency, severe liver or kidney disease, blood pressure >180/100 mmHg): a. Patients with cardiogenic infarction (e.g. prosthetic valve, atrial fibrillation, myocardial infarction with appendage thrombosis, left atrial thrombosis, etc.), prone to recurrent stroke. b. Ischemic stroke with protein C deficiency, protein S deficiency, active protein C resistance Patients with embolism-prone conditions such as protein C deficiency, protein S deficiency, active protein C resistance, etc.; patients with symptomatic extracranial entrapment aneurysm; patients with intracranial and extracranial arterial stenosis. c. Patients with bedridden cerebral infarction may use low-dose heparin or appropriate doses of LMW to prevent deep vein thrombosis and pulmonary embolism.
(4) Anti-platelet agglutination agents are recommended.
(1) Most patients without contraindications for non-thrombolysis should be started on aspirin as soon as possible after stroke (preferably within 48 hours).
(ii) Patients with thrombolysis should use aspirin or a combination of aspirin and pansentine extended-release agents 24 hours after thrombolysis.
(③Recommended dose of aspirin 150-300mg/d in 2 divided doses and change to prophylactic dose after 4 weeks.
(5) Neuroprotective agents
At present, the commonly used ones are cytarabine, Ducoxib, Cerebroflucan, calcium channel blockers, etc. There is still a lack of convincing clinical observation data in a large sample, and the exact efficacy needs to be studied.
2.TCM treatment
(1) Key points of TCM dialectic.
The difference between the two lies in the presence or absence of mental changes. In the case of meridians, the disease is superficial and mild, usually without any change in the mind, manifested as sudden onset of mouth and eyes? In the case of middle meridians, the disease is deeper and more serious, manifesting as sudden fainting, unconsciousness and paralysis. The disease is deeper and more serious, manifesting as sudden fainting, unconsciousness, and paralysis, mostly with sequelae.
②The internal organs can be identified as closed and decompensated. The internal organs are divided into closed and decompensated. The closed evidence is the evil is closed in the internal, to the teeth closed, mouth silent open, both hands clenched, limbs strong spasm, urinary and fecal closed as the main symptoms; off the evidence is the Yang Qi external off, to the eyes closed mouth open, snoring breath micro, hand spreading limbs soft, two urine from the shed, sweating limbs cold, pulse weak want to end as the main symptoms. The closed evidence is mostly seen in the middle storm, the disease nature is mainly solid, while the detached evidence is mostly transformed from the deterioration of the closed evidence, the disease nature is mainly deficiency, the disease is critical, the prognosis is dangerous.
The disease is mainly deficient and the prognosis is critical and dangerous. In the case of yang closed, there is redness and heat, thick breath and bad breath, restlessness, yellow tongue coating and smooth pulse; in the case of yin closed, there is white lips and darkness, restlessness, lack of warmth in the extremities, congestion of phlegm and saliva, white tongue coating and smooth pulse.
The acute phase refers to within 2 weeks after the onset of the disease, and can last up to 1 month in the internal organs; the recovery phase refers to 2 weeks after the onset of the disease or within 1 month to 6 months; and the sequelae phase refers to more than 6 months after the onset of the disease.
⑤ Identify the disease potential smooth and adverse first in the internal organs, such as the will gradually turn clear, hemiplegia is not aggravated or recovery of the disease from the internal organs to the transformation of the meridians, the disease potential is smooth, the prognosis is more good. If the disease is serious in the internal organs, such as the symptoms of hemiplegia in the acute stage, it is still in the smooth state. If you see frequent erratic rebellion, or sudden dizziness, twitching of the limbs, or sudden burning of the back and abdomen with coldness of the limbs and coldness of the hands and feet, or if you see Dai Yang and vomiting blood, the disease is reversed. (6) Identification of evidence combined with clinical auxiliary examination Stroke is similar to acute cerebrovascular disease in Western medicine, clinical examination of cerebrospinal fluid, fundus and CT, MRI, etc. is needed to clarify the nature of the disease.
(2) Identification and typing
(1) Stroke in the meridians
a. Empty meridians and veins, wind evil into the medium-sized.
Symptoms: symptoms include distorted mouth and eyes, salivation at the corners of the mouth, unfavorable language, or even hemiplegia, usual skin insensitivity, numbness of the hands and feet, or vicious cold, fever, restrained limbs, aching joints, white moss, floating pulse
Treatment: Expel wind, nourish blood and promote circulation
Radix: Radix Gentiana Macrophyllae Tang plus reduction
Gentiana macrophylla 9, Chuanxiong rhizome 12, Dushuo 9, Angelica sinensis 15, Bai Shao 15
gypsum 30 licorice 6 qiangwu 12 fangfeng 12 dahurica 15
Scutellaria baicalensis 12 Atractylodes macrocephala 12 Poria cocos 30 Radix et Rhizoma rehmanniae 30 Radix rehmanniae 18
Hesperidin 3
b. Liver and kidney yin deficiency, wind and yang upward disturbance type.
Symptoms: symptoms include hemiplegia, distorted mouth and eyes, unfavorable language, numbness of the deviated body, or dizziness and headache, tinnitus and dizziness, little sleep and dreaminess, red tongue with yellowish greasy coating, thin or slippery pulse.
Treatment: Nourishing Yin and submerging Yang, quenching the wind and clearing the channels.
Treatment: Nourish Yin, submerge Yang, quench wind and clear the channels. Chinese medicine treatment: e.g. Salvia miltiorrhiza, Chuanxiongzin, Panax notoginseng, Gekisu, Ginkgo biloba preparation, etc.
Huai Niu Knee 15 Dai Ochre 30 Raw Dragon Bone 30 Raw Oyster 30
Tortoise Plate 18 Raw Hang Shao 15 Radix Ginseng 12 Asparagus 15
Neem 15 Raw wheat sprout 15 Yin Chen 9 Licorice 6
②Internal organs in stroke
a. Closed evidence.
Yang Closure
Symptoms: sudden fainting, unconsciousness, red face and body heat, silent mouth and constipation, restlessness, clenching of both hands, strong spasm of the limbs. The coating is yellow and greasy, and the pulse is stringent and slippery.
Treatment: Clearing the liver and quenching the wind, pungent and cooling to open the orifice.
Treatment: Infusion or intranasal administration of Bureau formula Zhibao Dan or Angong Niuhuang Wan, and addition and subtraction of Antelope Horn Tang to clear the liver and quench the wind and nurture Yin and submerge Yang. Combine with Chinese medicine to awaken the brain, phlegm-heat clear intravenous drip.
Antelope’s horn 9 Chrysanthemum 12 Xia Ku Cao 15 Cicada 9
Gouban 15 Bai Shao 12 Shijiazhuang 30 Dan Pi 12
Radix Rehmanniae 15 Glycyrrhiza glabra 6
Yin Closure
Symptoms: Sudden fainting, unconsciousness, closed teeth, silent mouth, clenched hands, closed urine and stool, strong spasms of limbs, white face and dark lips, unheated extremities, and congestion of phlegm and saliva. The coating is white and greasy, and the pulse is sunken and slippery.
Treatment: Expelling phlegm and quenching wind, pungent and warm to open the orifice.
Prescription: Urgently use Suhexiang Pill to warm and open the orifices, and take a decoction of Phlegm Cleansing Soup.
Radix Panax Notoginseng 9, Radix Orange Red 12, Poria 9, Radix Bupleurum 15
Acorus calamus 15 Bile South Star 9 Citrus aurantium 9 Glycyrrhiza glabra 6
b. Discharge of evidence.
Symptoms: sudden fainting, unconsciousness, eyes closing and mouth opening, hand spilling urine, low respiration, sweating and limb syncope, limb weakness. The pulse is weak or weak and wants to die.
Treatment: To benefit qi and return yang, to save yin and consolidate detachment.
Treatment: Improve qi and return yang, save yin and consolidate detachment. Intravenous drip injection of ginseng and sperm injection, ginseng and wheat injection, and moxibustion of Shen Que, Guan Yuan and Qi Hai points for 20 minutes can help return yang and consolidate detachment.
c. Closure and dislodgement of each other.
Symptoms: sudden fainting, unconsciousness, squeaking phlegm, closed teeth, strong spasms in the limbs, incontinence of the two stools, sweating and syncope in the limbs, thick and greasy moss, slippery and weak pulse.
Treatment: Expelling phlegm and opening the orifice, returning Yang to fix the detachment.
Treatment: Cleansing phlegm and combining with Ginseng and Radix
Radix Panax notoginseng 12 Chen Pi 8 Poria 15 Bile South Star 15
Bamboo Roo15 Acorus calamus12 Gui Zhi10 Tian Ma12
Hooked vine 12 Ginseng 15 Radix et Rhizoma 6
③Aftereffects.
a. Qi deficiency, blood stasis, and stagnation of veins and ligaments type.
Symptoms: symptoms see hemiplegia, limb weakness, accompanied by swelling of the affected side of the hands and feet, unfavorable language, distorted mouth and eyes, withered face, or dull and colorless, thin white tongue coating, pale yellow tongue, thin and astringent pulse, etc.
Treatment: Tonifying Qi and invigorating Blood, invigorating the meridians
Remedy: Tonic Yang Returning Five Soup with addition and subtraction. Combined with acupuncture and massage treatment.
Astragalus membranaceus 30, peach kernel 12, safflower 12, angelica 15
Radix Paeoniae 15 Di Long 2
b. Wind-phlegm blocking the ligament type.
Symptoms: symptoms include strong tongue, numbness in the limbs, and slippery pulse.
Treatment: Dispel wind and phlegm, promote orifice and clear the ligaments.
Prescription: Decrease the dosage of Xieyue Dan. Combined with acupuncture and tui-na treatment.
Tianma 12, All Scorpion 3, Bile South Star 6, White Herba 6
Fuzhi6 Calamus9 Mu Xiang12
All of the above symptoms are treated on the basis of identification of disease and evidence by reusing the hair of activating blood circulation and resolving blood stasis, including proprietary Chinese medicines such as Danshen, Chuanxiongzin, Panax notoginseng, Gejiazu, and Ginkgo biloba preparations by intravenous drip or oral administration.
3.Management of complications
(1) Increased intracranial pressure
①General treatment
②Dehydration treatment
a. Mannitol: use 125-250ml of 20% mannitol for rapid intravenous infusion, once every 6-8 hours, and it is appropriate to apply it for 5-7 days in general. If the intracranial pressure increases significantly or there is brain hernia formation, the dose can be increased, rapid intravenous drip, the use of time can also be extended.
b. Furanilic acid (tachyphylaxis).
c. Glycerol fructose.
③Surgical treatment recommendations: Those with confirmed high cranial pressure should be treated with dehydration, with mannitol preferred. Dehydration is not recommended for all stroke patients. Those without increased intracranial pressure, such as lacunar infarction, should not be treated with dehydration. If dehydration therapy is ineffective or early brain herniation occurs, surgical treatment may be considered.
(2) Regulation of blood pressure
The principles of management of cerebrovascular disease combined with hypertension include: ① Actively control excessive blood pressure. ②Prevent lowering the blood pressure too low or too fast. (3) Close monitoring of blood pressure changes, especially in the process of anti-blood pressure treatment. ④Lowering blood pressure should be carried out slowly, because the blood pressure of such patients has poor autoregulation, and rapid and drastic lowering of blood pressure can easily lead to cerebral ischemia. (5) Blood pressure lowering should be individualized because each patient has different basal blood pressure, different sensitivity to the original blood pressure lowering drugs, and the combination of other different diseases, etc. ⑥Maintain the smoothness of the blood pressure lowering effect, and generally advocate the use of long-acting blood pressure lowering drugs. (7) In the process of lowering blood pressure, attention should be paid to the protection of target organs, especially the brain, heart and kidney.
(3) Pneumonia and pulmonary edema
About 5.6% of stroke patients have pneumonia. Aspiration is the main cause of stroke combined with pneumonia. Bacterial pneumonia is responsible for 15%-25% of deaths in stroke patients. Acute stroke can be complicated by acute pulmonary edema. Neurogenic pulmonary edema is seen in 30%-70% of patients with severe subarachnoid hemorrhage and cerebral hemorrhage, and occasionally in patients with cerebral infarction. Early recognition and management of swallowing problems and misaspiration in stroke patients can have a significant role in preventing aspiration pneumonia. Treatment of pneumonia consists mainly of respiratory support (e.g., oxygen therapy) and antibiotic therapy. Neurogenic pulmonary edema should be treated etiologically for the primary stroke, with lowering intracranial pressure and protecting brain cells as the primary means.
(4) Altered blood glucose
More than half of the patients with acute cerebrovascular disease have increased blood glucose, which can be a manifestation of pre-existing diabetes or a stress response. Hyperglycemia can be seen in all types of acute cerebrovascular disease, and its prognosis is worse than that of those with normal blood glucose.
Recommendations.
(1) Patients with acute stroke should be routinely tested for blood glucose, and those with increased blood glucose should be monitored.
(2) Acute stroke patients with increased blood glucose should use insulin to control blood glucose to less than 8.3 mmol/L.
(3) Acute stroke patients with hypoglycemia should be corrected promptly.
(5) Difficulty in swallowing
About 45% (30%-65%) of stroke patients have dysphagia on admission, and about half of them have not regained normal swallowing function by 6 months after onset. 43%-54% of acute stroke patients with dysphagia develop aspiration; 37% of these patients develop further pneumonia and 4% die of pneumonia.
The goals of dysphagia treatment are to prevent aspiration pneumonia, to avoid fluid deficiency and malnutrition due to inadequate dietary intake, and to re-establish swallowing function.
(6) Upper gastrointestinal bleeding
The incidence of upper gastrointestinal bleeding is as high as 30%, and the more severe the disease, the higher the incidence of upper gastrointestinal bleeding.
The management of upper gastrointestinal bleeding includes.
① Intragastric lavage: 100-200ml of iced saline, 50-100ml of which is added to 1-2mg of norepinephrine orally; if the bleeding still cannot be stopped, another 50-100ml is added to 1000-2000U of thrombin orally. Also use Lithopodium, Yunnan Baiyao, hemostatic minerals, hemostatic aromatic acid, growth inhibitors, etc.
②Use acid-control hemostatic drugs: metformin, loxacid.
③Prevent and control shock.
④Stop bleeding by gastroscopy.
(⑤) Surgical treatment.
(7) Post-stroke depression and anxiety states are recommended.
(1) Pay attention to the monitoring of mental and emotional changes in stroke patients and raise awareness of depression and anxiety states; (2) Pay attention to the psychological care of patients. In addition to active treatment of the primary disease, rehabilitation and management of risk factors, family members, psychologists, clinicians and charge nurses can provide psychological treatment (explanation, comfort, encouragement, reassurance) to patients in different situations, try to eliminate the existence of concerns and enhance (3) Once depression and anxiety are diagnosed, the second generation of new antidepressants, i.e., pentothal reuptake inhibitors (SSRIs), are preferred, followed by the first generation of classical antidepressants, i.e., tricyclic antidepressants (TCAs); (4) Regardless of depression and anxiety, psychotherapy (see above) and behavioral therapy (mainly relaxation therapy, such as biofeedback therapy, music therapy, yoga, sedation, etc.) should be supplemented. (see above) and behavioral therapy (mainly relaxation therapy, such as biofeedback therapy, music therapy, yoga gong, quiet qigong, etc.).
Prognosis
The mortality rate of cerebral infarction is lower than that of cerebral hemorrhage, and the prognosis of cerebral infarction is generally better than that of cerebral hemorrhage, but the prognosis of cerebral infarction with severe disease is not good, and the prognosis of cerebral infarction is related to the following factors.
1. The prognosis of cerebral infarction is related to the size of the blocked blood vessels: if the blocked blood vessels are small, the cerebral ischemia is small, the collateral circulation is easy to form, the recovery is faster, and the prognosis is better. If the blocked blood vessel is large, the cerebral ischemia range is large, the brain tissue is severely damaged, the recovery of clinical symptoms is slow, and the prognosis is poor.
2, related to the speed of onset: slow and gradual onset, easier to form collateral circulation, cerebral ischemia can be gradually compensated, the prognosis is better. Those with acute onset fail to establish collateral circulation and have a poorer prognosis.
3.Related to the number and quantity of infarction: the first attack has a better prognosis. However, one large infarction has a poor prognosis. The prognosis is worse for more than two infarcts, especially if both cerebral vessels are involved. The more foci of infarction, the worse the prognosis. Those with a single infarct foci have a better prognosis.
4.Related to the nature of the embolus: if the embolus is loose, in the process of running with the blood, it breaks itself and flows to the distal end of the blood flow, blocking small vessels, the prognosis is better. And fat embolus, air embolus, bacterial embolus, than the prognosis of cardiogenic embolus is serious. However, those with cardiogenic emboli causing brain abscess have a worse prognosis.
5.Related to the severity of focal localization symptoms: the prognosis is better if the localization symptoms such as hemiplegia and aphasia are lighter after the onset. On the contrary, those with more severe hemiplegic aphasia have a poorer prognosis.
6. Related to the degree of coma: the more serious the degree of coma and the longer it lasts, the worse the prognosis. If the patient is not in coma at the beginning of the disease, but enters coma later, and the degree of coma gradually increases, the prognosis is worse. If the patient is always awake, the prognosis is better.
7.Related to the presence or absence of comorbidities: such as combined bedsores, lung infection, urinary tract infection, diabetes, coronary artery disease, arrhythmia, heart failure, etc., the prognosis is poor, without comorbidities, the prognosis is better.
8, related to the patient’s age: older, poorer physical condition, poorer prognosis. Small age, good physical condition, good prognosis.
9, related to the use of drugs; Western drugs are fast-acting and have a targeted treatment, but the prognosis is generally not very good. The prognosis is better for some of the large compound modern Chinese medicines taken from the local area, among which the double-acting class is the best.
TCM care
Regarding the care of stroke, it has been discussed in Chinese medicine for a long time, for example, Zhu Danxi proposed: “Dizziness is the gradual of stroke”, Yuan? Luo Tianyi mentioned in “Health Treasure” that The wind in the towel door also mentioned: “Where the big finger, the second finger numbness or do not use, three years in the stroke of the patient.” Ming? Li Yongcui, in “Evidence and Treatment Huixi Fu? Prevention of stroke” also emphasizes: “Ping people numbness of the fingers, not inch vertigo, is a precursor of stroke, must be prevented. It is advisable to be cautious of living, diet, far from the house, and regulate the emotions.” The above discussion all indicates that the aura of stroke should be recognized and dealt with in time to prevent the occurrence of stroke. It is advisable to eat a light and easy to digest diet, avoid fatty, sweet, thick, windy, spicy and stimulating products, and prohibit smoking and alcohol, to maintain a relaxed mood, to live normally, to eat and drink in moderation, to avoid fatigue, to prevent stroke and recurrence. After the disease, care should be strengthened.