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    Home > Active Ingredient News > Study of Nervous System > Professor Wang Yilong: "Chinese Expert Consensus on Perforator Atherosclerosis" Interpretation of the main points of stroke "miscellaneous" talk·No. 5

    Professor Wang Yilong: "Chinese Expert Consensus on Perforator Atherosclerosis" Interpretation of the main points of stroke "miscellaneous" talk·No. 5

    • Last Update: 2021-06-30
    • Source: Internet
    • Author: User
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    "Chinese Stroke Journal" is a high-level academic journal of the medical profession headed by the Ministry of Science and Technology of the People's Republic of China, sponsored by the Chinese Institute of Science and Technology Information, and undertaken by the Chinese Stroke Society
    .

    In order to strengthen the medical information exchange in the field of cerebrovascular diseases, improve the academic level of medicine, and serve the majority of medical technology and health workers, the Chinese Journal of Stroke and the Yimaitong platform jointly launched a series of columns-"Stroke "Miscellaneous" Talks"
    .

    This column selects the high-quality content related to stroke in each issue of the Chinese Journal of Stroke, adapts it, and publishes it on the "Yimaitong Neurology" public account.
    I look forward to learning and discussing stroke-related diseases with you! This article has been officially authorized by "Chinese Stroke Journal", please do not reprint without authorization
    .

    Review of previous issues ↓↓↓ Issue 1: Why is it said that playing games can treat cognitive impairment? This review tells you the second issue: How to build a high-quality biobank of cerebrovascular diseases? The Temple of Heaven experience is here! Phase 3: The lower the level of T3 and FT3, the more severe the cognitive impairment in stroke patients? Shijiazhuang City People’s Hospital published an important correlation analysis No.
    4: Minor head trauma can also cause stroke in children? Lan Yina and Lu Jinhao from the General Hospital of the People's Liberation Army reported that a rare case of perforator atherosclerosis (BAD) is a common type of acute ischemic stroke, which was first proposed by Caplan in 1989
    .

    Common perforating arteries include lenticular artery (LSA), median parapontine artery (PPA), thalamus geniculate artery, anterior choroidal artery, Heubner's artery and thalamic perforating artery
    .

    At present, the pathogenesis, diagnosis and treatment of BAD are still inconclusive
    .

    Based on recent research results, the Cerebral Small Vascular Disease Branch of the Chinese Stroke Society has launched the "Chinese Expert Consensus on Perforator Atherosclerosis" (hereinafter referred to as the "Consensus")
    .

    Professor Wang Yilong from Beijing Tiantan Hospital, Capital Medical University, interpreted this "consensus" as follows
    .

    The original source of the article: Men Xuejiao, Chen Weiqi, Xu Yuyuan, et al.
    Chinese Expert Consensus on Perforator Atherosclerosis[J].
    Chinese Journal of Stroke, 2021, 16(05): 508-514.
    Literature download link: http: // Professor Wang Yilong Chief Physician, Professor, and Doctoral Supervisor, Chief Scientist of the Neurology Center, Associate Dean, Beijing Tiantan Hospital, Capital Medical University Distinguished professor of Beijing Brain Science and Brain-like Research Center, deputy director of the Department of Clinical Trials and Clinical Research, Capital Medical University, concurrently deputy director of the Cerebral Small Vascular Disease Branch of the Chinese Stroke Society, executive director of the Youth Council of the Chinese Stroke Society, and neurology of the Chinese Medical Association Academic positions include the deputy chairman of the Youth Committee of the branch and the deputy chairman of the Youth Committee of the Neurology Physician Branch of the Chinese Medical Doctor Association
    .

    The main research direction is the clinical research of cerebral small vessel disease
    .

    As the first/corresponding author, he has published many original works in magazines such as JAMA, BMJ, Lancet N, and Circulation
    .

    National Outstanding Youth Science Foundation, Ministry of Education (Youth) Changjiang Scholars, the Central Organization Department "people" program, outstanding young Beijing university scientists, the seventh 'Aglaia medical Youth Award', and the young Beijing scholar winner
    .

     The "Consensus" proposes that there are four main pathogenesis mechanisms of BAD: ①The atherosclerotic plaque of the carrier artery blocks the opening of the perforating artery, and the mechanism of causing BAD is aortic atherosclerosis; ②The atherosclerotic plaque of the carrier artery extends to The opening of the perforating artery causes vascular occlusion, and the plaque that causes BAD is located at the junction of the responsible aorta and the perforating artery; ③Atherosclerotic plaque at the opening of the perforating artery causes vascular occlusion; ④The instability of the opening of the perforating artery Plaque shedding causes vascular occlusion (Figure 1)
    .

    Figure 1 The pathological form of perforator atherosclerosis.
    The "Consensus" classifies BAD according to the blood supply area and clinical manifestations: ➤ According to the blood supply area, BAD can be divided into LSA and PPA lesions
    .

    The clinical manifestations of ischemic cerebrovascular disease in the blood supply area of ​​LSA often include: lateral dyskinesia, hemisensory impairment, cognitive function decline, aphasia and mental disorders in dominant hemisphere lesions, and hemispheric neglect in non-dominant hemisphere lesions Disease and so on
    .

    The clinical manifestations of ischemic cerebrovascular disease in the PPA blood supply area often include: lateral movement disorder, dysarthria, hemisensory dysfunction, ataxia, central facial paralysis and other symptoms
    .

    ➤ According to clinical manifestations, BAD can be divided into the following three forms: ① Stereotyped TIA: Typical representatives include internal capsule warning syndrome and pons warning syndrome
    .

    ②Acute lacunar infarction: The clinical manifestations are similar to the classic lacunar syndrome caused by small vessel disease
    .

    ③END: manifested as symptoms of cerebral infarction in the acute phase, followed by deterioration of neurological function, progressive worsening of the disease, and even total hemiplegia
    .

    Regarding the auxiliary examination of BAD, the "Consensus" pointed out that HR-MRI can clearly show the position, size, composition and stability of plaques after image reconstruction
    .

    Hospitals with conditions can perform MRI whole brain wall imaging (WBVWI) on LSA, and WB-VWI can visualize the perforating arteries with large intracranial diameters (such as LSA)
    .

    Perfecting the examination of intracranial and extracranial blood vessels and heart will help to identify the etiology and pathogenesis of stroke
    .

    Improve laboratory tests, including blood (including platelet count), serum lipids, glycated hemoglobin, of Hcy, cystatin C, coagulation tests (including D- dimer), rheumatism and cancer indicators
    .

    The "Consensus" puts forward the diagnostic criteria for BAD based on the blood supply area, and further standardizes the diagnosis of BAD in clinical work
    .

    LSA regional ischemic stroke: ①Meet the diagnostic criteria of acute ischemic stroke; ②DWI shows that the infarcts in the corresponding blood supply area involve 3 levels and above in the horizontal position; ③The blood supply area of ​​LSA is: most of the putamen and the outer part of the globus pallidus , The head and body of the caudate nucleus, the forelimbs of the internal capsule, the upper part of the internal capsule and the radiating crown around the ventricle
    .

    PPA regional ischemic stroke: DWI showed that the infarct was connected to the brain surface on the ventral side of the pons, and the lesion was close to the midline, on one side, and not beyond the midline
    .

    Exclusion criteria: ①imaging showed that the responsible large vessel stenosis ≥50%; ②imaging showed that the intracranial aorta, external carotid artery and vertebral artery had unstable plaques that could cause arterial-arterial embolism; ③DWI showed the presence of cortical infarction and watershed infarction and multiple cerebral infarction; cerebral infarction caused ④ other specific causes, such as immune or infectious vasculitis, cardiogenic cerebral embolism, fat embolism, and platelet coagulation abnormalities
    .

    Regarding the treatment of BAD, the "Consensus" pointed out that no matter which form of BAD, the current treatment lacks strong evidence-based medical evidence, which needs to be confirmed by further clinical studies
    .

    It is recommended that no matter what kind of clinical manifestations, on the basis of early rt-PA intravenous thrombolysis, head MRA+DWI examination should be completed as soon as possible, and HR-MRI and enhanced sequence examination should be carried out if possible
    .

    For patients with END, experts unanimously recommend the use of tirofiban within 12 to 24 hours (intravenous infusion of tirofiban 0.
    4 μg·kg-1·min-1 for 30 minutes, followed by intravenous infusion of 0.
    1 μg·kg -1·min-1 for at least 24 to 48 hours); for patients with clinical manifestations of TIA, most experts believe that the application of tirofiban is effective, and experts recommend that tirofiban be used as soon as symptoms appear (intravenous infusion of tirofiban) Non-shift 0.
    4 μg·kg-1·min-1 for 30 min, followed by intravenous infusion of 0.
    1 μg·kg-1·min-1 for at least 24 to 48 h)
    .

    Subsequent to cilostazol-based dual antiplatelet therapy, or cilostazol combined with anticoagulant therapy
    .

    Cilostazol 200 mg daily combined with aspirin 100 mg daily (load 300 mg) or clopidogrel daily 75 mg (load 225 mg) combined for at least 1 week after changing to any antiplatelet drug alone can significantly slow down If the disease progresses, if it is not effective, you can switch to cilostazol combined with argatroban or low molecular weight heparin anticoagulation therapy
    .

     To sum up, the "Consensus" proposes that the current WB-VWI technology can display LSA, but it cannot display other smaller diameter perforating arteries.
    The 7T high-field magnetic resonance technology can be further developed to observe smaller diameter perforating arteries.
    , To identify the cause of BAD
    .

    The mechanism and treatment of disease progression in clinical BAD patients are still in the research stage
    .

    At present, there is still a lack of strong evidence-based medical evidence for the treatment of BAD patients, and further multi-center, large-scale clinical treatment experiments are needed to improve the prognosis of BAD patients
    .

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