Remote ischemic preadaptation therapy —— helps twins with smog “get out of the fog” Xuanwu Hospital of Capital Medical University Gao Hua One day in November 2012, a young mother from Luohe, Henan Province, brought her 7-year-old twin sons into the consultation room of Professor Ji Xunming at Xuanwu Hospital. “Dr. Ji, save my children!” The young woman, Ms. Du, recounted that her two children had been sick from time to time since they were three years old in kindergarten, with the older son suffering from dizziness and the second son from headaches, on average once every half month. At that time, the family did not care, thinking that the children had a cold and would be fine after taking some medicine. Unexpectedly, in June 2012, the eldest son suddenly convulsions with left limb weakness, sent to Luohe City Hospital diagnosed as cerebral infarction, after examination was considered to be “smog”. The second son’s usual abnormal symptoms, Ms. Du also for his systematic examination, the results are also suffering from the same disease. This sad news almost broke the young mother’s heart. After her older son gradually recovered, Ms. Du decided to bring her two children to Beijing for medical treatment. After many inquiries, Ms. Du and her son found Professor Ji Xunming of Xuanwu Hospital of Capital Medical University. Professor Ji recommended MRI, TCD (transcranial Doppler ultrasound), carotid ultrasound, blood tests and other tests. The results of these tests showed that both twins had “intracerebral and vascular manifestations consistent with smoker’s disease”. After a comprehensive analysis, Prof. Ji Xunming proposed a new approach to the treatment of smog, namely the use of medication (vitamin B1 and nimodipine tablets) and the addition of remote ischemic preadaptation therapy (physical therapy with a mercury sphygmomanometer). Nimodipine tablets can selectively dilate cerebral blood vessels, increasing cerebral blood flow without affecting cerebral metabolism, and can be combined with physiotherapy to promote compensatory vessel formation and establish good collateral circulation. After more than nine months of treatment, Ms. Du was surprised to find that the dizziness and headaches that had plagued her two children for years never came back. Smoker’s disease is a cerebrovascular disease characterized by chronic progressive stenosis or occlusion of the terminal internal carotid arteries and the beginning segments of the anterior and middle cerebral arteries bilaterally, and secondary to the formation of a characteristic skull base anomalous vascular network. This abnormal vascular network at the base of the skull resembles “smoke” on cerebral angiography, and is called “smoky vessels”. The cause of smoky vascular disease has not yet been elucidated. Transient ischemic attacks or strokes are the main manifestation in children due to progressive narrowing of the internal carotid artery, and cerebral hemorrhage is more common in adults. The treatment of smog is divided into pharmacological and surgical treatment. The drugs used for the treatment of smog are vasodilators, antiplatelet drugs and anticoagulants, which have certain clinical efficacy. The surgical treatment of smog is effective, mainly through cerebral revascularization to increase cerebral blood flow and reduce the occurrence of stroke. Professor Ji Xunming pointed out that ischemic preadaptation therapy is an effective treatment for smog and is a new therapy. It is easy to perform and can be done at home with a mercury sphygmomanometer. So how did this physical therapy method enable two children with smog to “get out of the fog”? Remote ischemic pre-adaptation can prevent cerebral ischemia Can a home mercury sphygmomanometer treat smog? The principle of using a mercury sphygmomanometer to prevent and treat smog is called remote ischemic pre-adaptation, as introduced by Professor Ji Xunming. Remote ischemic pre-adaptation refers to the protection of some organs of the body (such as the upper limbs) against subsequent severe or fatal ischemic hypoxia by inducing other organs (such as the heart, brain, liver and kidneys) other than the ischemic organ after a brief, reversible ischemic hypoxic stimulus. For example, if you normally need to eat two bowls of rice to get full, after this training, your body gradually adapts to eat one bowl of rice and feel less hungry. Even if you have to go hungry for a few days, you will be able to tolerate hunger better than others. Remote ischemic preadaptation therapy is not only effective before severe ischemia, but also when severe ischemia occurs, and after severe ischemia occurs, it can also produce the effect of reducing the damage and improving the prognosis. The therapy can control or reduce the occurrence of cerebral ischemic events (such as dizziness, limb numbness, hemiparesis, etc.), improve the blood flow to the brain tissue in the ischemic area so that the blood flow meets the metabolic needs and helps to improve the symptoms. In other words, patients who usually use this treatment can effectively prevent the occurrence of ischemic stroke, and even if they still have a stroke attack, they can tolerate ischemia and hypoxia for a longer period of time than others and have a smaller infarct area, which can buy more time and opportunities for further intervention and treatment. Using a blood pressure monitor Twice a day This treatment is endogenous, that is, it mobilizes the body’s own defense and repair functions to achieve the prevention and treatment of cerebral ischemia. This method requires no hospitalization, no surgical risk, stable effect, no attenuation, no lifelong treatment, and has a unique effect on the treatment of small and medium-sized vascular lesions. It is suitable for patients with a family history of triple high and cardiovascular disease, middle-aged or older people with high-risk factors, those who are unwilling or unable to tolerate surgical treatment, and patients with smog, young stroke or other unexplained cerebrovascular stenosis or occlusion. The patient is placed in a lying or semi-sitting position with both upper limbs at the same level as the heart. The mercury sphygmomanometer cuff is wrapped around the middle and upper part of one upper arm and the balloon is pressurized to 180-220 mmHg and maintained for 5 minutes, followed by a 5-minute rest period by releasing the balloon pressure. Repeat each time for 5 consecutive rounds for a total of 50 minutes, twice a day. It is recommended to do it once in the morning and once in the afternoon, alternating between the upper limbs bilaterally for 6 months as a course of treatment. Through repeated ischemia repeated perfusion training on the limbs, the body gradually produces anti-hypoxia protective substances and cytokines, which reach many organs of the whole body through the whole body blood circulation, especially acting on the heart and brain, increasing the adaptability of the heart and brain to ischemia, and facilitating the formation of lateral limb circulation in the ischemic region. In terms of safety, we found that when the blood flow is blocked in both upper limbs at the same time, it does not cause an increase in blood pressure, change in heart rate, increase in intracranial pressure and cerebral hemorrhage, and a large number of studies have confirmed the safety and effectiveness of this training. In addition to remote ischemic preconditioning, it is also necessary to control blood pressure, blood glucose and blood lipids, quit smoking and alcohol, change dietary habits and strengthen exercise. Remote ischemic preadaptation training is effective, simple and risk-free, and is well received by patients. At present, Xuanwu Hospital has applied this technique to treat more than 1000 patients with cerebral ischemia. Through 4 years of follow-up, the frequency and degree of transient ischemic attacks have improved, and the improvement rate of cerebral blood flow and cerebral metabolism has reached 95.2%. Remote ischemic pre-habilitation is effective and is a new and proven treatment for patients with smog. Since smog is a chronic progressive cerebrovascular disease, the progression of the disease depends on a combination of factors such as the progression of vascular occlusion, the compensation of collateral circulation, the age of onset, and the symptoms and severity of the disease. Therefore, patients with smog disease should be closely followed up while trained with this remote ischemic preadaptation method so that appropriate surgical treatment can be taken in time to prevent the occurrence of stroke.