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*Only for medical professionals to read for reference.
Ischemic stroke combined with hemorrhage restricts the application of drugs, and timely "brain protection" is more conducive to the patient's future recovery.
Stroke is the top three main cause of death in the world, and it has the characteristics of high morbidity, high disability, high mortality and high recurrence rate [1].
With the rapid development of my country's economy and the current population aging problem, the incidence of stroke in my country is increasing year by year.
Among them, ischemic stroke is the most common type of cerebrovascular disease.
More than half of the surviving patients are left with severe disabilities such as hemiplegia and aphasia, which brings a heavy burden to society and families [2].
At present, the treatment of acute ischemic stroke is mainly to give vascular recanalization within the effective time window to promote the recovery of blood flow in the ischemic penumbra, including intravenous thrombolysis and endovascular treatment (mechanical thrombectomy) [3- 5].
However, mechanical thrombectomy significantly increases the recanalization rate of acute ischemic stroke and effectively saves the penumbra brain tissue.
At the same time, there is also a greater potential risk.
The most important thing is the possibility of cerebral hemorrhage, which is as high as 46.
1 after thrombectomy treatment.
% Of patients will have complications of intracranial hemorrhage (ICH), which seriously affects the prognosis of stroke [6-7].
For patients with cerebral hemorrhage after thrombus removal, timely neuroprotective treatment is a better rescue measure.
In this issue, we invited Dr.
Ma Lin from Liaocheng People's Hospital of Shandong Province to share a classic case.
The basic situation of classic case review: Song XX, male, 55 years old.
Main complaint: slurred speech and weakness of the right limb for 5 hours.
He was admitted to the hospital at 06:59 on October 1, 2020.
History of present illness: The patient was slurred after going to the toilet at 2 am on October 1st, and his right limb activity was poor, manifested by the inability to lift the right upper limb, the inability to stand on the right lower limb, and the inability to communicate accurately with others, no headaches, dizziness, no Nausea, vomiting, no limb numbness and convulsions, no drinking water, choking, difficulty swallowing, ignorance of unclear objects and double vision.
Go to the local town hospital at 2:30.
Brain CT showed no hemorrhage at 2:48, showing high-density shadow of the left middle cerebral artery.
At 3:00, 67.
5mg of alteplase was given thrombolytic therapy.
After 4:00, the thrombolysis was completed.
The condition did not improve significantly, and he was transferred to our hospital for treatment.
There was no hemorrhage on brain CT in the emergency department at 6:30, and he was admitted to the neurology ward at 7:00.
Past medical history: Past "lumbar spondylopathy" for many years; denied history of hypertension, diabetes, coronary heart disease; denied history of drug and food allergy.
Specialized physical examination: lethargy, incomplete mixed aphasia, gaze to the left, central facial and tongue paralysis on the right, level 0 muscle strength of the right limb, low muscle tone, and pathological signs on the right (+).
National Institutes of Health Stroke Scale (NIHSS) score: 20 points.
Modified Rankin Scale (mRS) score: 4 points.
Auxiliary examination: Brain CT (2020.
10.
01 7:18): Spot-like low-density foci were seen in the basal ganglia on both sides, and the boundary of the foci was not clear; the morphology of the cerebrospinal fluid cavity system was normal; the midline structure was not displaced.
Image result: lacunar cerebral infarction.
Figure 1 Brain CT imaging results: Laboratory examination of lacunar cerebral infarction (2020.
10.
01): Coagulation mechanism: D-dimer (2.
202mg/L), fibrinogen degradation product (5.
49μg/mL); blood Analysis is normal; all biochemical items are normal.
According to the "Chinese Guidelines for Endovascular Treatment of Acute Ischemic Stroke 2018" [8]: Within 6 hours of onset, mechanical thrombectomy is strongly recommended when the following criteria are met: pre-stroke mRS score of 0 to 1; ischemic stroke is caused by the internal carotid artery Or MCAM1 segment occlusion; age ≥ 18 years; NIHSS score ≥ 6 points; Alberta stroke project early CT score (ASPECTS score) ≥ 6 points (Class I recommendation, level A evidence).
This patient has indications for bridging thrombectomy and underwent whole cerebral angiography + arterial thrombectomy at 7:30.
The patient returned to the ward at 2020.
10.
01 11:00, check the patient, the patient’s sedation state, lack of cooperation, stimulation of the right lower limb may be avoided, the right upper limb is inactive, but the patient suddenly experienced severe vomiting at around 16:00, urgent review Brain CT (16:06) showed that the left basal ganglia cerebral hemorrhage broke into the ventricle.
Figure 2 Brain CT imaging results: intracerebral hemorrhage in the left basal ganglia area and penetration into the ventricle; lack of uniform density in the cerebellum.
Diagnosis: 1.
Acute cerebral infarction (left cerebral hemisphere, left internal carotid artery); 2.
Intracerebral hemorrhage penetration Cerebral ventricle; 3.
Occlusion of the M1 segment of the left middle cerebral artery; 4.
Occlusion of the left internal carotid artery (C1 segment arterial dissection); 5.
Occlusion of the left anterior cerebral artery; 6.
Lumbar spondylosis.
Treatment plan: Lipid-lowering drugs: Rosuvastatin, 10 mg, orally, once a night.
Dehydration to lower intracranial pressure: mannitol, 250ml, intravenous drip, once every 6 hours; glycerol fructose, 250ml, intravenous drip, once every 8 hours.
Free radical scavenging/anti-inflammatory drugs: Edaravone, dextrocampine, concentrated solution for injection, 15ml intravenous drip, 2 times a day, 14 days.
Rehydration, nutritional support.
Acupuncture and rehabilitation promote the rehabilitation of limb muscles.
Lower extremity pneumatic pump treatment prevents venous thrombosis in lower extremities.
Discharge status (2020.
12.
01): Consciousness, no gaze, shallow right nasolabial fold, middle tongue extension, fluent speech, right upper limb muscle strength level 4, remaining limb muscle strength level 5, right pathological signs (+).
NIHSS: 2 points, mRS: 1 point.
Case provider Ma Lin, Shandong Province Liaocheng People’s Hospital, Deputy Chief Physician, Member of the First Neuroscience Professional Committee of Shandong Association of Gerontology, Member of the First Dementia and Cognitive Disorder Professional Committee of Shandong Association of Geriatrics, Chinese Medical Education Association, Vertigo Major The young member of the committee, Dr.
Ma Lin, a member of the first committee of the Liaocheng Chinese Medicine Society of Integrated Traditional Chinese and Western Medicine, Brain-Heart Treatment Professional Committee, commented that in this case, although the patient arrived at the local town hospital within the thrombolytic time window for timely thrombolytic treatment, thrombolysis After the end, the condition did not improve significantly. This patient had the indications for bridging embolization when he was transferred to our hospital, and the arterial embolization was performed in our hospital.
Symptoms of cerebral hemorrhage occurred after the thrombus was removed, and finally, the concentrated solution of edaravone and dexborneol injection was used for neuroprotective treatment.
When the patient was admitted to the hospital on October 1, he was in a serious condition and was in a state of lethargy.
His eyes were staring to the left, mixed aphasia, and the right limb muscle strength was 0.
After thrombolysis, bridging and thrombus removal, the patient suffered from cerebral hemorrhage.
The patient was treated with a concentrated solution of edaravone dexcamphanol injection.
By December 1, the patient had a clear mind, moved his eyes freely, spoke fluently, and his limbs and muscle strength were basically restored.
NIHSS also dropped from a high of 20 points at admission to 2 points.
, The mRS score was reduced from as high as 4 points to 1 point, and both scores were significantly reduced.
The overall prognosis of the patient was good, showing a surprising treatment effect.
In the case of cerebral hemorrhage, the patient was treated with concentrated solution of edaravone dexcamphanol injection without any adverse events, which proved that the combination of intravenous thrombolysis and intravascular treatment is safe, and the patient’s sufficient amount and sufficient amount in 14 days There was no obvious liver and kidney function damage after the treatment.
The concentrated solution of edaravone and dexcamphane for injection is scientifically compatible with two active ingredients: edaravone and dexcamphane.
Both can effectively block the cascade of neuronal damage caused by cerebral ischemia, and prevent the cascade of pathological changes, thereby exerting a synergistic therapeutic effect on cerebral ischemic injury, thereby reducing cell apoptosis and cell necrosis.
Reduce brain edema and protect ischemia-reperfusion injury.
Cerebral infarction combined with hemorrhage has always been a very difficult clinical problem in neurology.
The application of drugs is limited and only neutral treatments such as brain protection can be taken.
The injury mechanism of cerebral infarction and hemorrhage is related to the production of free radicals, inflammation around the lesion, and other factors.
Therefore, this patient was treated with a concentrated solution of edaravone and dexcampine for a sufficient course of treatment.
Internally, the progress of the lesion is inhibited, and the therapeutic effect of "turning decay into a miracle" is achieved.
Early use of the concentrated solution of edaravone dexcamphanol injection will better help patients improve their prognosis and help them return to normal life earlier.
References: [1] Jauch EC, Cucchiara B, Adeoye O, et al.
Part 11: adult stroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care[J].
Circulation, 2010, 122 (18 Suppl 3) ：S818-S828.
[2] Song Yunjun, Yu Haixia, Guan Yanan, et al.
Research progress of intravenous thrombolytic therapy in acute ischemic stroke[J].
Hebei Medicine, 2018, 024(002): 350-352.
[3] Röther J, Ford GA, Thijs VN.
Thrombolytics in acute is chaemic stroke: historical perspective and future opportunities[J].
Cerebrovasc Dis, 2013, 35(4): 313-319.
[4] Albers GW, Lansberg MG, Kemp S , Et al.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)[J].
Int J Stroke, 2017, 12(8): 896-905.
[5] Jovin TG, Saver JL, Ribo M, et al.
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods[J].
Int J Stroke, 2017, 12(6): 641-652.
[6] Zhou Zhiguo, Zhu Qingfeng.
Clinical analysis of 16 cases of cerebral hemorrhage after mechanical thrombus removal in acute ischemic stroke[J].
Journal of Shanxi Medical College for Staff and Workers, 2018, v.
28(05): 21-24.
[ 7] Analysis of predictive factors of intracranial hemorrhage after mechanical thrombectomy in acute ischemic stroke[J].
Magnetic Resonance Imaging, 2021, 12(01): 9-14.
[8] Chinese Stroke Society.
Acute Ischemic Stroke Blood Vessel Chinese Guidelines for Endotherapy 2018[J].
Chinese Journal of Stroke, 2018, 013 (007): 706-729.
Ischemic stroke combined with hemorrhage restricts the application of drugs, and timely "brain protection" is more conducive to the patient's future recovery.
Stroke is the top three main cause of death in the world, and it has the characteristics of high morbidity, high disability, high mortality and high recurrence rate [1].
With the rapid development of my country's economy and the current population aging problem, the incidence of stroke in my country is increasing year by year.
Among them, ischemic stroke is the most common type of cerebrovascular disease.
More than half of the surviving patients are left with severe disabilities such as hemiplegia and aphasia, which brings a heavy burden to society and families [2].
At present, the treatment of acute ischemic stroke is mainly to give vascular recanalization within the effective time window to promote the recovery of blood flow in the ischemic penumbra, including intravenous thrombolysis and endovascular treatment (mechanical thrombectomy) [3- 5].
However, mechanical thrombectomy significantly increases the recanalization rate of acute ischemic stroke and effectively saves the penumbra brain tissue.
At the same time, there is also a greater potential risk.
The most important thing is the possibility of cerebral hemorrhage, which is as high as 46.
1 after thrombectomy treatment.
% Of patients will have complications of intracranial hemorrhage (ICH), which seriously affects the prognosis of stroke [6-7].
For patients with cerebral hemorrhage after thrombus removal, timely neuroprotective treatment is a better rescue measure.
In this issue, we invited Dr.
Ma Lin from Liaocheng People's Hospital of Shandong Province to share a classic case.
The basic situation of classic case review: Song XX, male, 55 years old.
Main complaint: slurred speech and weakness of the right limb for 5 hours.
He was admitted to the hospital at 06:59 on October 1, 2020.
History of present illness: The patient was slurred after going to the toilet at 2 am on October 1st, and his right limb activity was poor, manifested by the inability to lift the right upper limb, the inability to stand on the right lower limb, and the inability to communicate accurately with others, no headaches, dizziness, no Nausea, vomiting, no limb numbness and convulsions, no drinking water, choking, difficulty swallowing, ignorance of unclear objects and double vision.
Go to the local town hospital at 2:30.
Brain CT showed no hemorrhage at 2:48, showing high-density shadow of the left middle cerebral artery.
At 3:00, 67.
5mg of alteplase was given thrombolytic therapy.
After 4:00, the thrombolysis was completed.
The condition did not improve significantly, and he was transferred to our hospital for treatment.
There was no hemorrhage on brain CT in the emergency department at 6:30, and he was admitted to the neurology ward at 7:00.
Past medical history: Past "lumbar spondylopathy" for many years; denied history of hypertension, diabetes, coronary heart disease; denied history of drug and food allergy.
Specialized physical examination: lethargy, incomplete mixed aphasia, gaze to the left, central facial and tongue paralysis on the right, level 0 muscle strength of the right limb, low muscle tone, and pathological signs on the right (+).
National Institutes of Health Stroke Scale (NIHSS) score: 20 points.
Modified Rankin Scale (mRS) score: 4 points.
Auxiliary examination: Brain CT (2020.
10.
01 7:18): Spot-like low-density foci were seen in the basal ganglia on both sides, and the boundary of the foci was not clear; the morphology of the cerebrospinal fluid cavity system was normal; the midline structure was not displaced.
Image result: lacunar cerebral infarction.
Figure 1 Brain CT imaging results: Laboratory examination of lacunar cerebral infarction (2020.
10.
01): Coagulation mechanism: D-dimer (2.
202mg/L), fibrinogen degradation product (5.
49μg/mL); blood Analysis is normal; all biochemical items are normal.
According to the "Chinese Guidelines for Endovascular Treatment of Acute Ischemic Stroke 2018" [8]: Within 6 hours of onset, mechanical thrombectomy is strongly recommended when the following criteria are met: pre-stroke mRS score of 0 to 1; ischemic stroke is caused by the internal carotid artery Or MCAM1 segment occlusion; age ≥ 18 years; NIHSS score ≥ 6 points; Alberta stroke project early CT score (ASPECTS score) ≥ 6 points (Class I recommendation, level A evidence).
This patient has indications for bridging thrombectomy and underwent whole cerebral angiography + arterial thrombectomy at 7:30.
The patient returned to the ward at 2020.
10.
01 11:00, check the patient, the patient’s sedation state, lack of cooperation, stimulation of the right lower limb may be avoided, the right upper limb is inactive, but the patient suddenly experienced severe vomiting at around 16:00, urgent review Brain CT (16:06) showed that the left basal ganglia cerebral hemorrhage broke into the ventricle.
Figure 2 Brain CT imaging results: intracerebral hemorrhage in the left basal ganglia area and penetration into the ventricle; lack of uniform density in the cerebellum.
Diagnosis: 1.
Acute cerebral infarction (left cerebral hemisphere, left internal carotid artery); 2.
Intracerebral hemorrhage penetration Cerebral ventricle; 3.
Occlusion of the M1 segment of the left middle cerebral artery; 4.
Occlusion of the left internal carotid artery (C1 segment arterial dissection); 5.
Occlusion of the left anterior cerebral artery; 6.
Lumbar spondylosis.
Treatment plan: Lipid-lowering drugs: Rosuvastatin, 10 mg, orally, once a night.
Dehydration to lower intracranial pressure: mannitol, 250ml, intravenous drip, once every 6 hours; glycerol fructose, 250ml, intravenous drip, once every 8 hours.
Free radical scavenging/anti-inflammatory drugs: Edaravone, dextrocampine, concentrated solution for injection, 15ml intravenous drip, 2 times a day, 14 days.
Rehydration, nutritional support.
Acupuncture and rehabilitation promote the rehabilitation of limb muscles.
Lower extremity pneumatic pump treatment prevents venous thrombosis in lower extremities.
Discharge status (2020.
12.
01): Consciousness, no gaze, shallow right nasolabial fold, middle tongue extension, fluent speech, right upper limb muscle strength level 4, remaining limb muscle strength level 5, right pathological signs (+).
NIHSS: 2 points, mRS: 1 point.
Case provider Ma Lin, Shandong Province Liaocheng People’s Hospital, Deputy Chief Physician, Member of the First Neuroscience Professional Committee of Shandong Association of Gerontology, Member of the First Dementia and Cognitive Disorder Professional Committee of Shandong Association of Geriatrics, Chinese Medical Education Association, Vertigo Major The young member of the committee, Dr.
Ma Lin, a member of the first committee of the Liaocheng Chinese Medicine Society of Integrated Traditional Chinese and Western Medicine, Brain-Heart Treatment Professional Committee, commented that in this case, although the patient arrived at the local town hospital within the thrombolytic time window for timely thrombolytic treatment, thrombolysis After the end, the condition did not improve significantly. This patient had the indications for bridging embolization when he was transferred to our hospital, and the arterial embolization was performed in our hospital.
Symptoms of cerebral hemorrhage occurred after the thrombus was removed, and finally, the concentrated solution of edaravone and dexborneol injection was used for neuroprotective treatment.
When the patient was admitted to the hospital on October 1, he was in a serious condition and was in a state of lethargy.
His eyes were staring to the left, mixed aphasia, and the right limb muscle strength was 0.
After thrombolysis, bridging and thrombus removal, the patient suffered from cerebral hemorrhage.
The patient was treated with a concentrated solution of edaravone dexcamphanol injection.
By December 1, the patient had a clear mind, moved his eyes freely, spoke fluently, and his limbs and muscle strength were basically restored.
NIHSS also dropped from a high of 20 points at admission to 2 points.
, The mRS score was reduced from as high as 4 points to 1 point, and both scores were significantly reduced.
The overall prognosis of the patient was good, showing a surprising treatment effect.
In the case of cerebral hemorrhage, the patient was treated with concentrated solution of edaravone dexcamphanol injection without any adverse events, which proved that the combination of intravenous thrombolysis and intravascular treatment is safe, and the patient’s sufficient amount and sufficient amount in 14 days There was no obvious liver and kidney function damage after the treatment.
The concentrated solution of edaravone and dexcamphane for injection is scientifically compatible with two active ingredients: edaravone and dexcamphane.
Both can effectively block the cascade of neuronal damage caused by cerebral ischemia, and prevent the cascade of pathological changes, thereby exerting a synergistic therapeutic effect on cerebral ischemic injury, thereby reducing cell apoptosis and cell necrosis.
Reduce brain edema and protect ischemia-reperfusion injury.
Cerebral infarction combined with hemorrhage has always been a very difficult clinical problem in neurology.
The application of drugs is limited and only neutral treatments such as brain protection can be taken.
The injury mechanism of cerebral infarction and hemorrhage is related to the production of free radicals, inflammation around the lesion, and other factors.
Therefore, this patient was treated with a concentrated solution of edaravone and dexcampine for a sufficient course of treatment.
Internally, the progress of the lesion is inhibited, and the therapeutic effect of "turning decay into a miracle" is achieved.
Early use of the concentrated solution of edaravone dexcamphanol injection will better help patients improve their prognosis and help them return to normal life earlier.
References: [1] Jauch EC, Cucchiara B, Adeoye O, et al.
Part 11: adult stroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care[J].
Circulation, 2010, 122 (18 Suppl 3) ：S818-S828.
[2] Song Yunjun, Yu Haixia, Guan Yanan, et al.
Research progress of intravenous thrombolytic therapy in acute ischemic stroke[J].
Hebei Medicine, 2018, 024(002): 350-352.
[3] Röther J, Ford GA, Thijs VN.
Thrombolytics in acute is chaemic stroke: historical perspective and future opportunities[J].
Cerebrovasc Dis, 2013, 35(4): 313-319.
[4] Albers GW, Lansberg MG, Kemp S , Et al.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)[J].
Int J Stroke, 2017, 12(8): 896-905.
[5] Jovin TG, Saver JL, Ribo M, et al.
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods[J].
Int J Stroke, 2017, 12(6): 641-652.
[6] Zhou Zhiguo, Zhu Qingfeng.
Clinical analysis of 16 cases of cerebral hemorrhage after mechanical thrombus removal in acute ischemic stroke[J].
Journal of Shanxi Medical College for Staff and Workers, 2018, v.
28(05): 21-24.
[ 7] Analysis of predictive factors of intracranial hemorrhage after mechanical thrombectomy in acute ischemic stroke[J].
Magnetic Resonance Imaging, 2021, 12(01): 9-14.
[8] Chinese Stroke Society.
Acute Ischemic Stroke Blood Vessel Chinese Guidelines for Endotherapy 2018[J].
Chinese Journal of Stroke, 2018, 013 (007): 706-729.
