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Diagnosis and treatment of acute cerebral infarction

Treatment principles

Restore blood supply to cerebral ischemic area as soon as possible

Prevention and treatment of ischemic brain edema

Prevent and treat complications

Give systematic and individualized rehabilitation early

Control blood pressure

Hypertension is the most important risk factor for cerebral hemorrhage and cerebral infarction;

After controlling for other risk factors, for every 10mmHg increase in systolic blood pressure, the relative risk of stroke increased by 49%, and for every 5mmHg increase in diastolic blood pressure, the relative risk of stroke increased by 46%;

A clinical randomized controlled trial of systolic hypertension in the elderly in China showed that after 4 years of follow-up, the blood pressure treatment group had a 58% reduction in stroke mortality compared with the placebo control group.

(1) Further strengthen publicity and education, strive to raise residents’ awareness of stroke prevention, and take the initiative to care about their blood pressure; it is recommended that people ≥35 years old measure blood pressure every year1, and patients with hypertension should measure blood pressure frequently (at least every 2 to 3 months) 1 time) to adjust the dosage

(2) Hospitals at all levels should establish a blood pressure measurement system for the first diagnosis of adults as soon as possible

(3) All localities should actively create conditions to establish demonstration communities of a certain scale, regularly screen hypertensive patients in the population and provide appropriate treatment and follow-up

(4) For early or mild patients, first adopt lifestyle change treatment, and those whose effect is still not good for 3 months should be treated with antihypertensive drugs.

General treatment-blood pressure

Elevated blood pressure in the acute phase of ischemic stroke usually does not require special treatment

When systolic blood pressure>220mmHg or diastolic blood pressure>120mmHg and mean arterial pressure>130mmHg, appropriate antihypertensive treatment

If persistent low blood pressure (systolic blood pressure <90mmHg) occurs, blood volume needs to be supplemented and cardiac output increased first

After the acute phase (4 weeks), if the patient can tolerate it, keep it below 140/90mmHg as much as possible

Control blood sugar

Diabetes is an important risk factor for cerebrovascular disease. The risk of stroke in patients with type 2 diabetes is doubled

(1) People with risk factors for cardiovascular and cerebrovascular diseases should check their blood sugar regularly, and if necessary, measure glycosylated hemoglobin (HbAlc) and glycosylated plasma albumin.

(2) Diabetes patients should first control their diet and strengthen physical exercise. Those who are still unsatisfied with blood sugar control for 2 to 3 months should use oral hypoglycemic drugs or insulin treatment

(3) It is more important to actively treat high blood pressure, control weight and lower cholesterol levels

blood sugar

Diabetes and stress can raise blood sugar. When it exceeds 11.1mmol/L, insulin therapy should be given immediately to control blood sugar below 8.3mmol/L;

When you start using insulin, you should monitor your blood sugar once every 1 to 2 hours to prevent hypoglycemia.

Brain edema

Cerebral edema is more common in large area infarction

Reducing intracranial pressure, maintaining adequate cerebral perfusion and preventing brain herniation are the goals of treatment. Available 20% mannitol, furosemide, glycerol fructose and albumin, etc.

infection

Stroke patients (especially those with impaired consciousness) are prone to respiratory and urinary tract infections in the acute stage

Turn over and knock your back frequently to prevent aspiration and pneumonia

Avoid intubation and indwelling catheters as much as possible. Intermittent catheterization and acidification of urine can reduce urinary tract infections

If it occurs, select sensitive antibiotics based on bacterial culture and drug sensitivity test

Stress ulcer

The elderly and severe stroke patients are prone to stress ulcers in the acute stage;

It is recommended to routinely use intravenous antiulcer drugs (H2 receptor antagonists or proton pump inhibitors);

For patients with gastrointestinal bleeding, ice salt water gastric lavage and local application of hemostatic drugs (Yunnan Baiyao, thrombin, etc.) should be performed.

Control body temperature

The hypothalamic body temperature regulation center is damaged, complicated by infection or heat absorption, dehydration and increased body temperature, which can increase brain metabolism, oxygen consumption and free radical production, thereby increasing the mortality and disability rate of stroke patients;

Physical cooling (alcohol rubbing bath, ice cubes, etc.) should be the main method, and artificial sub-hibernation should be given when necessary.

Deep vein thrombosis

Old age, severe paralysis and atrial fibrillation all increase the risk of deep vein thrombosis and increase the risk of pulmonary embolism

Encourage patients to move as soon as possible, raise the lower limbs, and avoid intravenous infusion of the lower limbs

Special treatment-ultra-early thrombolysis

If the time window is within 3 hours, the screening criteria for patients, thrombolytic indications, and the patient’s consent, intravenous and intraarterial thrombolysis is possible

Commonly used drugs are urokinase and tissue plasminogen activator (rtPA)

Thrombolytic therapy recommendations

(1) Intravenous thrombolytic therapy should be actively used for patients with acute ischemic stroke within 3 hours after the onset of strict selection. RTPA is the first choice. When rTPA is used unconditionally, urokinase can be used instead

(2) Patients with acute ischemic stroke whose onset is 3 to 6 hours can be treated with intravenous urokinase thrombolysis, but the selection of patients should be stricter

(3) For patients with acute ischemic stroke whose onset is 3 to 6 hours, in experienced and qualified units, research on intra-arterial thrombolysis can be considered

(4) The time window and indications for thrombolysis of basilar artery thrombosis can be appropriately relaxed

(5) Thrombolysis beyond the time window will not increase the therapeutic effect, and will increase reperfusion injury and bleeding complications. Thrombolysis is not suitable, and thrombolytic therapy should be disabled for patients during recovery.

Anti-platelet aggregation treatment recommendations

Most patients with acute cerebral infarction who have not undergone thrombolysis without contraindications should take aspirin 100-325 mg/d or oral clopidogrel 75 mg/d within 48 hours

Patients with thrombolysis should take aspirin 24 hours after thrombolysis

The recommended dose of aspirin is 150~300mg/d, divided into two doses, and changed to the preventive dose after 4 weeks

Anticoagulant treatment recommendations

(1) Patients with general acute cerebral infarction are not recommended to use anticoagulants routinely immediately;

(2) For patients using thrombolytic therapy, it is not recommended to use anticoagulants within 24 hours;

(3) When there are no contraindications in the following situations (such as bleeding tendency, severe liver and kidney disease, blood pressure >180/100mmHg), you can consider the selective use of anticoagulants: ① Cardiac infarction (such as artificial valve, atrial fibrillation, Patients with myocardial infarction accompanied by mural thrombosis, left atrial thrombosis, etc.) are prone to relapse stroke. ②Patients with ischemic stroke accompanied by protein C deficiency, protein S deficiency, and active protein C resistance; patients with symptomatic extracranial dissecting aneurysms; patients with intracranial and extracranial artery stenosis. ③ Patients with cerebral infarction in bed can use low-dose heparin or corresponding dose of LMW to prevent deep vein thrombosis and pulmonary embolism.

Recommendations for defibrosis treatment

(1) Early stage cerebral infarction (especially within 12 hours) can be treated with defibrinating treatment; patients with hyperfibrinogenemia should be actively treated with defibrinating

(2) Strictly grasp the indications and contraindications

(3) Commonly used drugs: Batroxobin; defibrase; other defibrase preparations: such as lumbrokinase, acutin, etc.

Other treatments

Brain protection therapy: including free radical scavengers (edaravone), opioid receptor blockers, which reduce ischemic brain damage by reducing brain metabolism and intervening in ischemia-induced cytotoxic mechanisms

Surgical treatment: Cerebral infarction caused by the main artery of the cerebral hemisphere, severe cerebral edema and life-threatening, or large-scale infarction of the cerebellum compresses the brainstem, surgical decompression treatment

Rehabilitation treatment: should be carried out early and follow the principle of individualization. Short-term and long-term treatment plans should be developed. Patients should be given targeted physical and technical training to reduce the disability rate, improve the recovery of nerve function and improve the quality of life

prevention

Actively look for vascular risk factors and deal with them accordingly

Control blood pressure

Control diabetes

Lower blood lipid

Quit smoking, alcohol, obesity

Treat heart disease etc.

Referral indications

Those who cannot be distinguished from cerebral hemorrhage, cerebral embolism, brain tumor, subdural hematoma and brain abscess

Within 3 hours of onset, meet the thrombolytic standard, and the patient agrees to thrombolysis without thrombolytic conditions

Large-area cerebral infarction with severe edema, obvious space-occupying effect combined with disturbance of consciousness, or brain herniation

Patients with large-area cerebellar infarction and signs of brain stem compression requiring emergency surgery

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