Pay attention to the primary prevention of stroke
The incidence of stroke in China is increasing by 8.7% per year, which is higher than the world average, and is characterized by high incidence, high disability, high death rate, high recurrence rate and many complications. More than 76% of strokes are first-episode, so effective prevention is the best way to reduce the burden of stroke.
Cerebral atherosclerosis is an important cause of stroke, especially in China and Asian populations. Cerebral atherosclerosis can be divided into intracranial atherosclerosis and extracranial atherosclerosis. In China, symptomatic intracranial atherosclerotic stenosis is present in 33% to 50% of strokes and transient ischemic attacks. Early identification of cerebral atherosclerosis, screening of risk groups, and establishment of diagnostic criteria for assessment are important tools for primary stroke prevention.
Different versions are available according to hospital classification
At present, the situation of stroke prevention and control in China is still serious, and the primary prevention and comprehensive prevention of stroke still need to be strengthened. The standardized screening and diagnosis of cerebral atherosclerosis can help to provide early warning of the risk of atherosclerotic stroke. The Code of Practice for the Screening and Diagnosis of Cerebral Atherosclerosis (2014 Edition) (hereinafter referred to as the Code 2014 Edition) summarizes the well-defined risk factors for cerebral atherosclerosis, organizes reasonable screening methods and strategies, and finally formulates assessment and diagnosis criteria.
The Code 2014 Edition is divided into two versions, which are applicable to primary hospitals (community hospitals and medical examination institutions) and general hospitals (secondary and tertiary medical institutions). The general hospital version adds imaging examinations to the screening methods and requires detailed carotid ultrasound examinations, which contribute to the accuracy of diagnosis. The general hospital version is richer than the primary hospital version in terms of diagnostic criteria and risk stratification, and adds criteria for grading the degree of cerebral atherosclerosis.
The Code 2014 Edition summarizes and presents ten common, recognized and epidemiologically studied risk factors, including abnormal lipid metabolism, hypertension, diabetes (abnormal blood sugar), smoking (or smoke exposure), genetic factors, age, heavy alcohol consumption, obesity and poor dietary habits, lack of regular exercise, and high homocysteine. It is important to note that the risk factors for cerebral atherosclerosis are different from those for stroke. Detailed records and attention to patients’ risk factors are needed during screening, and appropriate monitoring and control of risk factors that can be intervened.
For people at risk for cerebral atherosclerosis, detailed questioning and documentation of clinical symptoms, such as the presence of stroke symptoms, is needed to help identify the risk group. In addition to the general physical examination, a neurological examination or at least a physician with basic knowledge of neurology is required, with emphasis on fundus examination and carotid auscultation.
High-risk patients are recommended to be transferred to general hospitals
The 2014 edition of the Code proposes for the first time diagnostic criteria for the assessment of cerebral atherosclerosis and the principles of risk stratification for cerebral atherosclerotic stroke.
For the assessment of cerebral atherosclerosis, primary hospitals can follow the following criteria.
1. Two or more risk factors of cerebral atherosclerosis; or one risk factor of cerebral atherosclerosis combined with clear corresponding clinical symptoms.
2. Positive findings on carotid auscultation; or difference in blood pressure between arms >20 mmHg; or ABI <0.9.
3, carotid ultrasound findings of cimt thickening, plaque formation; vascular stenosis or occlusion and other manifestations of cerebral atherosclerosis. 1+3 or 1+2+3 assessed as possible cerebral atherosclerosis.
The risk stratification of cerebral atherosclerotic stroke, primary hospitals can refer to the following criteria.
I. Low risk of cerebral atherosclerosis.
(1) Two or more risk factors for cerebral atherosclerosis; or one risk factor for cerebral atherosclerosis combined with clear corresponding clinical symptoms.
(2) No positive findings on carotid auscultation, and the difference in blood pressure between the arms is <20 mmhg.
(3) Carotid ultrasound found only cimt thickening, or three or less plaques (plaque nature is non-ulcerous plaque); or mild stenosis was found.
(4) 0.4≤abi<0.9.(1)+(2)+(3) assessed as low risk of cerebral atherosclerosis; as supporting evidence.
Second, high risk of cerebral atherosclerosis.
(1) Two or more risk factors for cerebral atherosclerosis; or one risk factor for cerebral atherosclerosis combined with clear corresponding clinical symptoms.
(2) Positive findings on carotid auscultation; or a difference of >20 mmHg in blood pressure in both arms.
(3)Carotid ultrasound finding of CIMT thickening with more than three plaques; or finding any plaque of ulcerative nature; or finding any vessel stenosis or occlusion.
(4) ABI < 0.4.(1)+(3) or (1)+(2)+(3) assessed as high risk for cerebral atherosclerosis. For supporting evidence.
Those with normal and low-risk screening results are advised to change their poor lifestyle, detect and integrate control of pre-existing risk factors, develop an appropriate drug regimen based on their specific condition, and review regularly. For those with high risk screening results, in addition to lifestyle changes and risk factor control, referral to a general hospital is recommended for further examination and treatment.
Clinicians must pay attention to the identification and control of risk factors for cerebral atherosclerosis and to the identification of people at risk for cerebral atherosclerosis, but it should be noted that screening is not recommended for the regular population. Further research and differentiation between primary and secondary risk factors is also needed. Screening and diagnosis should focus on individualized differences, and a comprehensive evaluation of individual risk is needed to select the most appropriate treatment plan.