I. Problems that should not be ignored in the treatment of cerebral infarction: 1. Surgical awareness: (As long as CT shows midline shift, emergency neurosurgical consultation is requested regardless of the presence of impaired consciousness.) Surgical interventions, including cerebrospinal fluid drainage can be used to treat increased intracranial pressure due to hydrocephalus. Surgical decompression and resection are recommended for patients with large cerebellar infarcts resulting in brainstem compression and hydrocephalus. In patients with large cerebral hemisphere infarction, surgical decompression and resection can save lives, but survivors will be left with severe neurological deficits. 2.Infusion route: daily intravenous infusion in the affected limb for more than ten hours will make it very difficult to restore motor function in the future, advocating subclavian vein puncture infusion and opposing long s infusion in the affected limb, which can provide active or passive functional exercise for the affected limb at an early stage and prevent venous thrombosis in the lower limb. In principle, it is forbidden to input any fluid that is irritating to the blood vessels from the lower limb, especially the affected lower limb. 3.Sedation and analgesia: A few patients are agitated due to headache or pain in a certain area, they should be sedated promptly and effectively to relieve pain and avoid increasing cerebral edema. 4.Glucose: Chinese guidelines recommend that acute stroke patients with increased blood glucose should use insulin to control blood glucose below 8.3 mmol/L. The problem of blood glucose, which has been compared with the factors interfering with the efficacy of 1000 cerebral infarction patients, found that the primary factor that can be artificially changed but is often ignored is hyperglycemia. The fact that hypertonic glucose aggravates the anaerobic enzymolysis of sugar in the local ischemic region and produces excessive lactic acid, thereby aggravating local brain damage, is well accepted and 50% glucose dehydration is no longer used. It is best not to enter any glucose solution for 1 week during the acute phase of cerebral infarction; even 5% glucose can cause transient hyperglycemia during the time limit of entry, which is detrimental to the repair of cerebral infarction. Nutritional problems can be supplied by oral intake or nasal feeding. 5.Adjustment of position and pressure: when the blood pressure is high, the head should be slightly elevated by 10°-30°, if the blood pressure is low, the head should be at the same level as the shoulder; when the blood pressure continues to fall to less than 90 mmHg systolic pressure, even the head low and foot high position can be adopted. It is appropriate to maintain blood pressure around 180-185/100-106 mmHg in the acute phase. The clinical measurement of blood pressure is sometimes not standardized or the quality of the monitoring instrument is problematic to the extent that the blood pressure measurement is inaccurate, and these details need to be brought to the attention of the clinician. 6, head cooling: regardless of the presence of fever, the use of ice bags, ice caps and other measures to reduce the temperature of the head in the acute phase is quite beneficial to save the semi-dark band, and if the patient with cerebral infarction is accompanied by fever, the damage to brain cells is even greater, and should be cooled in a timely manner early. 7.Tracheotomy: the unobstructed airway of critically ill patients is crucial, and the change of oxygen partial pressure and carbon dioxide partial pressure will directly affect brain metabolism and internal environment. If oxygenation is not enough to solve the problem, tracheotomy should be performed early, do not hesitate to avoid losing a good opportunity for rescue. 8, limb rehabilitation: early use of acupuncture treatment and early exercise of the affected limb can significantly reduce the degree of disability. Clinical infusion in the affected limb for dozens of days without activity so that the lesson of complete disability is not uncommon. Second, adjust blood pressure: Many experts believe that in general, patients in the acute stage of cerebral infarction are contraindicated to use antihypertensive drugs. Unless the blood pressure is very high and may damage the heart function, such as systolic blood pressure (SBP) > 220 mmHg, diastolic blood pressure (DBP) > 120 mmHg, it is recommended to cautiously adopt the antihypertensive methods that can easily control the amount of drugs, such as intravenous nitroglycerin under close monitoring of blood pressure, once the blood pressure drops, that is, slow down the drip rate, so that the blood pressure is maintained at about 180-185/100-105 mmHg is appropriate. Pay special attention to the acute stage of cerebral infarction, try not to use sublingual nifedipine or intramuscular injection of reserpine to lower blood pressure, so as not to aggravate cerebral ischemia by lowering blood pressure too fast. Patients with acute ischemic cerebrovascular disease rarely have hypotension. Decreased blood volume is the most common cause and should be promptly infused, while avoiding excessive dehydration. Injectable antihypertensive drug agents, such as labetalol, are best used in the acute phase of cerebral infarction, and oral antihypertensive drugs should not be given easily. Some people also advocate that drugs such as sodium nitroprusside or nitroglycerin can be used, but blood pressure must be monitored, and even under ICU supervision for antihypertensive treatment. Some special cases must be hypotensive, such as simultaneous myocardial infarction, hypertensive encephalopathy, fundus bleeding, entrapment aneurysm, thrombolytic therapy, etc. Antiplatelet therapy: Chinese guidelines recommend that most patients without contraindications to thrombolysis should be started on aspirin as soon as possible after stroke (preferably within 48 hours). Patients with thrombolysis should be treated with aspirin or a combination of aspirin and pentoxifylline extended-release agents 24 hours after thrombolysis. The recommended dose of aspirin is 150 -300 mg/d, with a change to a prophylactic dose after 4 weeks. Japanese guidelines recommend oxybutynin sodium 160 mg/day administered by drip as a treatment for patients with cerebral thrombosis (cerebral infarction other than cardiogenic infarction) in the acute phase (within 5 days of onset). Aspirin 160-300 mg/day orally is recommended as treatment for patients with early onset cerebral infarction (within 48 hours). US guidelines For most patients, aspirin should be administered within 24 to 48 h of stroke onset. Aspirin is not recommended as adjunctive therapy within 24 h of thrombolytic therapy. Aspirin should not be used as an alternative to other early treatments, particularly intravenous rtPA therapy, for acute ischemic stroke. No recommendation can be made for the emergency use of other antiplatelet coagulation agents. Despite criticism in one form or another, mannitol is preferred for both dehydration and price. If economic conditions allow, human albumin should be used alternatively, which can help reduce cerebral edema by increasing colloid osmotic pressure. A study by Professor M.D Ginsberg, Director of the Cerebrovascular Disease Research Center, Miami Medical School, USA, found that moderate or high doses of human serum albumin had a significant neuroprotective effect on acute ischemic stroke, especially on cortical nerve cells for sure. Glycerol fructose is not ideal for dehydration and can be used as an adjunctive dehydrating agent for patients who cannot eat and helps in energy supply. Combined with herbal medicine helps dehydration and has less effect on electrolyte disorders, such as light osmosis to obtain wet herbs. Osmotherapy is recommended in patients whose condition is worsened by increased intracranial pressure, including brain herniation syndrome . There is no conclusive evidence that mannitol and is effective in the acute phase of cerebrovascular disease. V. Statins: Statin therapy should be started as early as possible in the acute phase of stroke! Both the Chinese expert recommendations and the ASA 2008 guidelines recommend the use of risk stratification-based statin interventions for secondary prevention of stroke. Chinese experts recommend immediate initiation of intensive statin therapy regardless of LDL-C levels when there is evidence of arterial-arterial embolism or when there is evidence of atherosclerotic vulnerable plaque classified as very high risk – type 1. Patients with any of diabetes, coronary artery disease, metabolic syndrome, or inability to quit smoking are classified as very high risk-II, and the LDL-C value for initiating intensive statin therapy is >2.1 mmol/L, with an LDL-C target value of <2.1 mmol/L. Patients with other stroke or TIA are at high risk, and the LDL-C value for initiating standard statin therapy is >2.6 mmol/L, with an LDL-C target value of <2.6 mmol/L. There is insufficient clinical evidence as to what dose of statins should be used in acute cerebral infarction. However, based on small clinical studies of coronary artery disease and acute cerebral infarction, it is generally accepted that an intensive statin regimen is recommended. From the perspective of secondary stroke prevention, patients with atherosclerosis-prone plaque/arterio-arterial embolism should all receive intensive statin therapy. Therefore, further clarification of the pathogenesis would certainly help in the selection of statin regimens before clinical information on risk stratification is available. (i) Intravenous thrombolysis: recombinant tissue-type fibrinogen activator (rtPA) rtPA is an effective treatment for cerebral infarction in the acute phase when the following conditions (Table 1) are present. However, when these conditions are not met, the prognosis may be poor. rtPA treatment is associated with symptomatic intracranial hemorrhage, which may sometimes be lethal (Class I). The management of intracranial hemorrhage after rtPA therapy remains a problem. The best way to prevent bleeding complications is to be rigorous in patient selection and to give careful adjunctive treatment. Close observation and monitoring of patients and early management of hypertension are also essential. Anticoagulants and antiplatelet agents should be administered only after 24 h of rtPA therapy. Intravenous rtPA therapy is currently the only FDA-approved treatment for acute ischemic stroke. This therapy is still in clinical trials in Japan. (1) severe neurological deficit (2) exclusion of SAH (3) treatment within 3 h of symptom onset (4) no history of head trauma or stroke in the last 3 months (5) no myocardial infarction in the last 3 months (6) no gastrointestinal or urinary bleeding in the last 21 d (7) no major surgery in the last 14 d (8) no arterial puncture at a non-compressible site in the last 7 d (9) no history of intracranial bleeding ( (10) blood pressure is not high (systolic blood pressure <185 mmHg, diastolic blood pressure <110 mmHg) (11) no evidence of active bleeding or acute trauma (fracture) on physical examination (12) no oral anticoagulants, such as oral anticoagulants INR should be ≤ 1.5 (13) within the last 48 h if heparin therapy, aPTT should be in the normal range (14) platelet count ≥ 100 × 109 / L (15) No postictal seizures with residual neurological deficits (16) CT exclusion of multiple lobar infarcts (hypodensity range >1/3 of the cerebral hemisphere) (17) Patient or family understands the possible risks and benefits of treatment (b) Timely and accurate intravenous administration of fibrinogenic drugs can also achieve better therapeutic outcomes. There are reports of better results with fibrin-lowering drugs in patients with cerebral infarction within 24 hours of onset. It is possible that the therapeutic time window of fibrinolytic drugs is wider than that of thrombolytic drugs and has a wider application. Individual patients with excessive fibrinogen within 72 hours can still be used as appropriate to prevent reinfarction. Anticoagulation therapy: Treatment guidelines in China and the United States: in general, immediate use of anticoagulants is not recommended for patients with acute cerebral infarction. Brain metabolism drugs and neuroprotective agents: After clinical observation, some people believe that it is appropriate not to use brain metabolism drugs during the acute phase of cerebral infarction for 1 week, and the treatment during this period is more beneficial to future recovery if the brain metabolism is reduced. Eight, antibiotics: antibiotics as the prevention of nosocomial infection should not be advocated. When nosocomial infection has been determined to occur, antibiotics should be applied quasi-fully, without following the principle of gradual escalation from so-called low-grade to high-grade antibiotics selected for general infection, otherwise it is easy to delay treatment. Prophylactic antiepileptic therapy is not recommended for stroke patients at risk of epileptic seizures. For acute epileptic seizures in stroke, anti-spasmodic treatment is available. After control of an isolated epileptic seizure or acute epileptic seizure, long-term anti-spasmodic drugs can be discontinued; if persistent status epilepticus occurs, it can be treated according to the principles of treatment of persistent status epilepticus; if another epileptic seizure occurs 2-3 months after stroke, long-term drug treatment should be given according to the conventional treatment of epilepsy. The Japanese guidelines consider epilepsy as an independent risk factor associated with death in the acute phase, and prophylactic treatment for several days is also possible in elderly patients with large hemorrhagic infarcts in the parieto-occipital cortex. Seizures occurring after 14 days of stroke have a high likelihood of recurrent seizures and may become symptomatic epilepsy in the future, for which continuous treatment is recommended. The US guidelines state that there is no information on the effectiveness of prophylactic anticonvulsants. Information on the efficacy of anticonvulsants in the treatment of patients with post-stroke epilepsy is also very X. Management of progressive stroke Caplan believes that the solution is primarily to increase cerebral blood flow. It has also been shown that other solutions, such as altering the coagulation status (with heparin or antiplatelet agents) and the use of neuroprotective drugs, are not beneficial and are not considered to have a significant effect in the presence of insufficient blood flow. Improvement of blood flow can be achieved in two main ways, namely by opening the arteries or by systemic treatment strategies to increase collateral circulation flow. Opening of the artery can be achieved by mechanical means such as surgery and angioplasty and/or endovascular stenting, or thrombolysis. However, many arteries fail to open or have a high incidence of complications such as reperfusion bleeding and edema due to prolonged occlusion to the point of reopening. A growing body of evidence suggests that increasing cerebral blood flow by dealing with the systemic circulation may have therapeutic value and can limit the progression of cerebral ischemia. Studies have demonstrated that increasing blood pressure with drugs and increasing the volume of expanded blood in experimental animals and humans with albumin infusions can limit the volume of cerebral infarction. Studies have shown that the only effective treatment for patients with progressive lacunar infarction is to increase cerebral blood flow. In a small preliminary study of 10 consecutive patients with lacunar infarcts, it was found that lowering the patient’s blood pressure often led to worsening of the disease. In addition, increasing blood flow by intravenous infusion of blood volume expanding drugs was effective in ameliorating the deterioration and resulted in improvement in all patients. Unfortunately, however, this treatment has not been evaluated in controlled trials, and the primary and most important goal should be to obtain more blood flow to the ischemic area. Although anticoagulants, antiplatelet agents and neuroprotective drugs may be useful, they may have a limited effect if perfusion is persistently inadequate.