As we all know, cerebral infarction is a disease with high disability rate and high mortality rate, and the incidence is getting higher and higher in recent years, and it is developing to younger and younger, patients aged 30-40 can be seen clinically, but most of them are middle-aged and older than 45 years old, which seriously affects the physical and mental health of patients and increases the economic burden to their families. Therefore, people will have questions about whether cerebral infarction can be treated? How should the correct treatment of cerebral infarction be carried out?
Cerebral infarction is a common brain disease, and this disease is treatable. The treatment of cerebral infarction cannot be generalized, and highly targeted treatment plans should be determined according to different etiologies, pathogenesis, clinical types, onset time, etc., and individualized treatment with typing and staging as the core should be implemented. On the basis of general medical support treatment, measures such as improving cerebral circulation, cerebral protection, anti-cerebral edema and lowering cranial pressure can be used as appropriate. Usually, the disease can be divided into acute phase (1-2 weeks), recovery phase (2 weeks-6 months) and sequelae phase (after 6 months) according to the course of the disease, with 3-6 hours also known as ultra-early phase. The focus is on thrombolytic therapy within the time window of <6 hours and the staging of the acute phase. Lacunar cerebral infarction should not be dehydrated, mainly to improve circulation; large and medium infarction should be actively anti-cerebral edema to lower cranial pressure and prevent brain herniation formation.
1.Thrombolytic therapy
”Time is of the essence in acute cerebral infarction, and the time window of thrombolytic therapy for acute cerebral infarction is very narrow, and the key to salvage is whether correct thrombolytic therapy can be obtained within the first 3-6 hours of onset (within 3-6 hours of onset is called ultra-early thrombolysis), which can save ischemic brain tissue, avoiding ischemic brain tissue necrosis and preventing recurrence and complications.
It has been conclusively demonstrated that intravenous thrombolytic therapy with recombinant tissue-type fibrinogen activator (rt-PA) applied within 3 h of onset not only significantly reduces the risk of death and severe disability, but also greatly improves the quality of life of survivors. In acute ischemic stroke patients with no significant hypointense changes in brain CT and clear consciousness, intravenous thrombolytic therapy with urokinase within 6 h of onset is relatively safe and effective.
(1) Urokinase: 1 million IU-1.5 million IU, dissolved in 100-200 ml of saline, and continued to be intravenous for 30 min.
(2) rtPA: the dose is 0.9mg/kg (the maximum dose is 90mg), first push 10% intravenously (1min), and the rest of the dose is continuous intravenous drip for 60min.
The efficacy of thrombolytic therapy is certainly obvious, but not all patients are suitable. Indications to be noted are: age 18-75 years; onset within 6h, signs of cerebral impairment persist for more than 1 hour and are relatively severe; intracranial hemorrhage has been excluded by brain CT. Instead, intracranial hemorrhage is present; a history of myocardial infarction in the last 3 months; oral anticoagulants have been taken and INR > 1.5; heparin therapy has been received within 48 hours (aPTT outside the normal range); platelet count < 100,000/mm3 and blood glucose < 2.7 mmol/L (50 mg); and blood pressure > 180 mmHg systolic or > 100 mmHg diastolic are contraindicated.
Do not place nasogastric tube, urinary catheter or intra-arterial pressure measuring catheter too early. Clinically, it should be noted that thrombolysis beyond the time window will not increase the therapeutic effect and will increase reperfusion injury and bleeding complications, so thrombolysis should not be used, and thrombolytic therapy should be disabled in patients in recovery period.
2.Fiber-lowering therapy
A lot of evidence shows that fibrinogen and blood viscosity in plasma are increased in the acute phase of cerebral infarction. Snake venom preparations can significantly reduce plasma fibrinogen levels, and also increase fibrinolytic activity and inhibit thrombosis, which is more suitable for patients with combined hyperfibrinogenemia. Early cerebral infarction (especially within 12 hours) can be treated with fibrin-lowering therapy.
(1) Bactrim: Bactrim can significantly reduce the level of fibrinogen and improve the symptoms of acute cerebral infarction quickly with mild adverse effects, but attention should also be paid to the tendency of bleeding.
(2) Fibrinogen-lowering enzyme: It can effectively reduce the fibrinogen level in the blood of cerebral infarction patients, improve the neurological function and reduce the recurrence rate of stroke, with better effect within 6 hours of onset. It is worth noting that fibrinogen decreases below 130mg/dl increases the tendency of bleeding.
③Other fibrin-lowering agents: earthworm kinase, herbicase, etc.
3.Anticoagulation therapy
The purpose of anticoagulation therapy is mainly to prevent early recurrence of ischemic stroke, prolongation of thrombus and prevention of secondary thrombosis of small vessels blocking the distal end, and to promote collateral circulation. Commonly used.
(1) normal heparin (UFH).
(2) low molecular heparin (LMWH).
When anticoagulation is used, coagulation should be closely monitored. Routine and immediate use of anticoagulants is not recommended for patients with acute cerebral infarction. In patients treated with thrombolysis, anticoagulant use within 24 hours is generally not recommended. In patients with cardiogenic infarction (e.g. prosthetic valve, atrial fibrillation, myocardial infarction with attached wall thrombus, left atrial thrombosis, etc.), the application of anticoagulation is prone to recurrent stroke.
4.Anti-platelet agents
Most patients without contraindications to non-thrombolysis should be started on aspirin or clobigrel as soon as possible after stroke (preferably within 48 hours).
(1) Aspirin: 300mg/d for 10 days, then 50-100mg/d for maintenance. early use of aspirin is effective in reducing mortality and disability, with no significant increase in symptomatic cerebral hemorrhage, but concomitant application with thrombolytic drugs may increase the risk of bleeding.
(2) Clobigrel 75mg, 1 time/d.
5.Volume expansion
For patients with general cerebral infarction, there are no adequate randomized clinical control studies to support that volume expansion and pressure increase can improve the prognosis, but for acute cerebral infarction due to cerebral blood flow hypoperfusion, such as watershed infarction, volume expansion therapy can be considered as appropriate, but attention should be paid to possible aggravation of cerebral edema, cardiac failure and other complications.
6.Neuroprotective agents
Cytidine diphosphorylcholine, olanzapine, ganglioside, cerebral protein hydrolysate, etc.
7.Chinese herbal medicine treatment
A large number of studies have proved that Chinese herbal medicine has unique advantages in the treatment of cerebral infarction. Some single components or multiple drug combinations of TCM, such as Danshen, Chuanxiongzin, thromboxane, safflower and Ginkgo biloba preparations, can reduce platelet aggregation, anticoagulation, improve cerebral blood flow and reduce blood viscosity. Acupuncture, physiotherapy, and rehabilitation training of TCM, and more targeted identification and treatment of different patients by TCM play an important role in all stages of treatment for patients with cerebral infarction.