China is the world’s most affected area by stroke, a common disease among middle-aged and elderly people, which can be fatal or disabling if not treated in time. As the director of the Department of Neurology of the Ninth Hospital, Liu Jianren is experienced in stroke treatment. He said that acute stroke must be rescued in a timely manner, and that intravenous thrombolysis can be performed within four and a half hours of onset, and arterial intervention can be used to open the blood vessels within six to eight hours, which is a revolutionary progress in stroke treatment in the past two decades.
Stroke treatment network
Neurology is a second-level discipline on a par with major internal medicine and deals with many diseases, such as stroke, epilepsy, encephalitis, peripheral nerve diseases, brain tumors, Alzheimer’s disease, Parkinson’s disease, acromegaly, and neuromuscular diseases. Among them, stroke has the highest morbidity and mortality rate, while proper prevention and treatment are more effective.
Stroke, also known as stroke, is a sudden-onset cerebral blood circulation disorder with high morbidity, disability, and mortality rates, making it one of the biggest threats to human health. Stroke has a disability rate of 75% and is the leading cause of death in China with 1.2 million deaths per year.
Stroke is divided into ischemic stroke and hemorrhagic stroke, of which ischemic stroke (sometimes called cerebral infarction, cerebral infarction and cerebral embolism) accounts for about 80% of all strokes, which refers to the softening and necrosis of local brain tissue due to impaired blood circulation, ischemia and hypoxia. It mainly occurs due to atherosclerosis and thrombosis of the arteries supplying blood to the brain, narrowing or even occluding the lumen, resulting in focal acute cerebral blood supply deficiency and onset, or emboli from other parts of the body entering the cerebral circulation through the blood flow and blocking the cerebral arteries.
For stroke resuscitation, time is life, and we must race against time, which puts very high demands on the stroke resuscitation process.
At 10:00 p.m. on June 20, a 51-year-old male patient was urgently transferred from the emergency room of a hospital in Jiading District, Shanghai, to the neurology department of Shanghai Jiuxin Hospital. At the local hospital, this patient was diagnosed with acute basilar artery occlusion, which is the most severe of all ischemic strokes (cerebral infarction). Due to the occlusion of the basilar artery, the patient experienced ischemia in the brainstem, followed by vertigo, vomiting, hemiparesis, coma, respiratory and even cardiac arrest. Doctors at the local hospital informed the patient that since the CT showed high density signs of the basilar artery, suggesting that the thrombosis of the large arteries was also critical, the effect of pure intravenous thrombolysis was often not good and more suitable for combined arteriovenous revascularization treatment technology, which is only carried out in very few hospitals such as Shanghai Jiuxin Hospital around the clock. After listening to the local doctors, the family decided to send the patient to the stroke center of Shanghai Jiuyuan Hospital for resuscitation immediately.
After clinical and laboratory evaluation, the neurology and emergency room staff decided to perform combined arteriovenous revascularization treatment. The first step was to give intravenous thrombolytic drugs, and while the thrombolytic drugs were administered intravenously, the patient was sent to the DSA interventional operating room for intra-arterial interventional opening, which revealed an occlusion of the basilar artery, the most important center supplying respiration and heartbeat. The physicians immediately administered mechanical embolization therapy. After 30 minutes, the patient’s vital cerebral artery was completely opened by both drug action and mechanical debridement, and the patient quickly became conscious and was safely transferred back to the general ward. The next day, the patient’s neurological function was further significantly restored, and the right limb, which was completely hemiplegic, started to move.
Liu Jianren said, “This fast and effective green channel for stroke treatment was made possible by the remote stroke treatment network established by Shanghai Jiuyuan Hospital with Jiading District Central Hospital, Changning District Central Hospital and Pudong Gongli Hospital, through which the remote network platform allows stroke doctors to exchange and improve their skills online. It also allows some hospitals with limited technical conditions to quickly gain experience in accepting stroke patients, and in case of critical situations, they can also send critical patients to stroke centers urgently for further treatment.”
It is also worth mentioning that the “remote stroke network” allows doctors to communicate with each other in real time through social tools (smart phones) and software such as WeChat for medical information (text, radiology pictures or video). Liu Jianren said, “The exchange and discussion of CT and MRI neuroradiology images, advice and consultation on complex conditions, and the possibility of real-time communication between doctors, greatly facilitate the efficiency of doctors’ treatment, but also make medical resources more effective allocation and use, so that doctors from large and small hospitals can communicate and achieve common progress, and on this basis, the value of rescue On this basis, the ‘critical and difficult patients’ will be concentrated in the large hospitals with more developed medical conditions.”
Intra-arterial intervention for embolization
In the past 20 years, there has been no special breakthrough in the rescue of acute stroke patients, except for intravenous thrombolysis. The advent of intra-arterial interventional embolization has undoubtedly revolutionized stroke care.
For acute stroke patients within 4.5 hours of onset, intravenous thrombolysis can help many patients recover,” said Liu. However, intravenous thrombolysis has its limitations, such as it is not suitable for patients with bleeding tendencies, has a low opening rate for patients with acute occlusion of large arteries, and the onset time must be within 4.5 hours; whereas arterial thrombolysis or embolization makes up for its shortcomings. In contrast, arterial thrombolysis or bolus retrieval has a higher revascularization rate than intravenous thrombolysis, and arterial thrombolysis on top of intravenous thrombolysis is very beneficial. In patients with severe stroke with large artery occlusion, the combination of these two approaches, together with a rapid resuscitation process, can be very effective. The efficacy of this approach has been proven abroad.”
What exactly does arterial interventional embolization therapy look like? Liu Jianren said that the so-called intra-arterial interventional embolization refers to the use of the body’s natural vascular channels, with the help of modern imaging technology, to open the patient’s occluded cerebral arteries through tiny catheters, stents and other devices in a minimally invasive way. Arterial intervention is usually done in a special catheterization chamber. During the treatment, the doctor punctures a soft catheter about 0.5 mm thick through the patient’s femoral artery, and the catheter is guided by a micro-guide wire into the arterial vessels within the brain, where the arterial embolism is found by contrast contrast, and the stent is released and then the embolization operation is performed. Generally, local anesthesia at the femoral artery puncture is sufficient, but general anesthesia is required if necessary.
”The intracranial vessels are very delicate, and the thickness of the intracerebral artery wall is only 0.09 mm, which is one-tenth of the thickness of the heart vessels. The operation in such a delicate cerebral artery can be risky if you are not careful.” Liu Jianren describes it this way, “Life is at a moment’s notice. With modern imaging technology magnifying the intracranial vessels several times, the doctor’s operation is very delicate and gentle to avoid damaging the intracerebral vessels; some patients experience some discomfort when removing the embolus under local anesthesia, which is a normal phenomenon.”
Neurologists often repeatedly mention the phrase: in the rescue of stroke patients, time is life. A recent retrospective cohort study of 58,353 patients undergoing intravenous thrombolysis suggests that for every 15-minute reduction in time from onset to treatment within a 4.5-hour window, there is a 4% reduction in in-hospital mortality, a 4% reduction in the risk of symptomatic bleeding, and a 3% increase in walk-out rates. Therefore, shortening this time window as much as possible will make a significant difference in patient outcomes. Liu said, “Stroke patients need to be assured of medication within 4.5 hours of onset, and this time includes the time spent on the way to the hospital and during preoperative examinations, which requires patients to rush to the hospital within one to two hours of onset. With arterial embolization, the time window for patients can be extended by 2-3 hours on top of the original one, which will increase the number of treatable patients.”
Risks and benefits go hand in hand
Through the combined arterial and venous approach, the rate of recanalization of occluded vessels is greatly increased, bringing many patients back from the death line. However, the combined arteriovenous approach requires the establishment of a set of resuscitation system, which is a test of the hospital’s management and other comprehensive capabilities.
Under the coordination of the hospital leadership, a whole set of treatment system has been established to deal with acute stroke, and a 24-hour stroke green channel has been set up to integrate emergency medicine, radiology, neurology and surgery, catheterization, etc., to develop a scientific treatment process. The treatment is performed within one hour of arrival.
Due to the sudden nature of stroke, urgent thrombolysis and arterial retrieval are often required in the middle of the night. Compared with the previous intravenous thrombolysis, arterial thrombolysis requires the cooperation of 120 doctors, emergency physicians, radiology, neurosurgery, anesthesiologists, and a team of medical and technical nurses in the catheterization laboratory, and the medical cost is higher than that of intravenous thrombolysis. Liu Jianren said, “After a long period of time, we have developed a rare tacit understanding and trust in the thrombolysis of stroke patients, which has greatly improved the efficiency of stroke treatment and won more precious time for patients. This tacit cooperation comes from the effective coordination of the hospital and the dedication of the medical and nursing staff.”
During his study in Germany and the United States, Liu Jianren had seen many internationally renowned stroke centers actively performing stroke recanalization therapy, which made Liu feel that combined arteriovenous revascularization therapy was the future direction of stroke treatment. After returning to the Ninth Hospital, he started to perform combined static arterial revascularization therapy, which is at the forefront in Shanghai.
The emergence of any new technology is always accompanied by controversy. A while ago, the effectiveness of interventional treatment for acute stroke was still controversial in the medical community. Last month, with several important international clinical research results successively proving the effectiveness of arterial thrombolysis for stroke, doctors were more confident that “intra-arterial thrombolysis, which has been proven effective by four large international research institutions, will rewrite the international guidelines for emergency stroke treatment. Last year, the number of intravenous thrombolysis cases in Jiu Hospital was 70, and the average was administered within three hours of onset, part of which was combined arteriovenous treatment, which is at the forefront in Shanghai. Compared with the previous rate of thrombolysis treatment in China, which was less than 1%, this figure is quite advanced. The achievement is also due to the high priority of the leadership of the Ninth Hospital and the full coordination of all departments.”
Of course, any treatment comes with both risks and benefits. Although intravenous thrombolytic therapy has been approved by the U.S. FDA for 20 years and is a routine treatment in foreign countries, which does not even require family and patient signatures before medication; however, it still faces the difficulty of promotion in China, which is related to multiple factors such as the medical system and disease awareness. Current data show that intravenous thrombolysis has significant efficacy in 30% of patients, but there is still a 1.5% to 5% chance of bleeding. Such objective and realistic resistance discourages physicians from performing thrombolysis and improving the patient’s condition. Some physicians simply do not do it for fear of accidents. Many patients’ families also tend not to understand. Therefore there is a need for better education and communication between both sides.
”Performing stroke interventions, doctors will face great risks together with patients and have to work late at night, but such hard work is worth it because it is beneficial to patients.” According to Jianren Liu, “After the confirmation of large clinical studies in recent years, combined arteriovenous treatment is more beneficial than harmful for patients, and it is the responsibility of every doctor to use the methods that do work for patients.”
According to Jianren Liu, “Combined arteriovenous therapy is not simply a matter of technique, but a matter of responsibility. A good doctor should not only have good technology, but also have the kindness of a doctor’s heart, to save lives and help the injured as the mission, dare to take responsibility, not to escape for fear of taking risks, the patient’s family is generally understanding of doctors.”
Liu Jianren is confident about the establishment of the stroke treatment system, he said, “Shanghai has many elderly people and a high incidence of stroke, the Department of Neurology of the Ninth Hospital will play an important role in rescuing critically ill cerebrovascular patients. With the establishment of emergency stroke access and the popularization of combined arteriovenous treatment methods, the success rate of emergency stroke will continue to improve. We also hope to develop some new materials and technologies for the benefit of patients next. Research on the regularity of clinical disease changes and treatment effects in stroke is currently underway. With the completion of the stroke prevention and treatment network, the municipal stroke center, represented by the Ninth Hospital, will actively drive the lower level hospitals to construct a stroke prevention and emergency system, improve the standardized stroke prevention and treatment in county hospitals, and gradually change the philosophy of doctors and patients, so that more patients will have a chance to be treated effectively.”