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Stroke is the number one cause of death and disability in China, and China is facing the world's biggest stroke challenge
.
Effective stroke prevention and control is of great
significance to achieving the strategic goal of a healthy China and reducing poverty in China.
October 29, 2022 is the 17th World Stroke Day, and this year's campaign theme is "Recognize stroke one second earlier to save the brain from recovery"
.
In order to further enhance the public's understanding of stroke, "Medical Neurology Channel" and "Shanghai Changhai Hospital" held this event, and this article invited Professor Yang Pengfei from Shanghai Changhai Hospital to answer our questions about large-vessel occlusive ischemic stroke (AIS-LVO).
AIS-LLO is a common type of ischemic stroke, so what are the characteristics of this type of stroke compared to other types of ischemic stroke?
For this problem, Professor Yang Pengfei pointed out that its biggest feature is that occlusion occurs in large blood vessels, and this kind of stroke caused by blockage of large blood vessels is undoubtedly one of the most serious types of
stroke.
Because the coarse blood vessels supply a larger range of brain tissue, the infarction caused by it is more extensive, so such patients are more likely to present with severe symptoms
.
Although AIS-LVO only accounts for 1/4~1/3 of all strokes, it accounts for most of the stroke mortality rate, and it brings more harm than other types of stroke; In terms of treatment, traditional drug thrombolysis methods have limited effect and rely on interventional surgery to remove thrombes, so it is more difficult
to treat.
There are currently a variety of treatment modalities for stroke, such as direct thrombectomy, bridging therapy, and even thrombolysis after thrombectomy
.
For the treatment of AIS-LLO, Professor Yang Pengfei pointed out that the standard treatment of acute stroke is mainly thrombolysis, thrombectomy and different combinations of the two (bridging or counter-bridging).
There are different thrombolytic drugs for thrombolysis, and there are also different ways
to remove thrombes.
From the overall evidence, for patients with acute ischemic stroke within 4.
5 hours of onset, intravenous thrombolytic therapy
should be actively carried out clinically.
However, for patients with AIS-LLO, intravenous thrombolysis has a low recanalization rate for large vessel occlusion, so the proportion of patients who benefit clinically is not high
.
Whether it can be treated by thrombolysis plus thrombectomy (bridging) or direct thrombectomy, which method is better, is still controversial to a certain extent
.
On May 7, 2020, the results of China's "Efficacy Evaluation of Direct Arterial Treatment of Acute Large-vessel Occlusive Ischemic Stroke (DIRECT-MT)" in China showed that for patients with pre-circulation AIS-LVO within 4.
5 hours of onset in China, based on a credible cut-off value of 20%, The functional outcome of endovascular embolectomy alone is not inferior to that of alteplase intravenous thrombolysis combined with endovascular thrombectomy
.
Subsequently, 5 similar studies were published in JAMA, NEJM and LANCET journals, with different clinical results
.
Professor Yang Pengfei introduced that at the World Stroke Congress on October 27 this year, the results of a meta-analysis of 6 studies based on the patient level (IRIS study) were released for the first time, although the non-inferiority cut-off value of 5% did not confirm that direct thrombectomy is not inferior to bridging thrombectomy, but in-depth statistical analysis found that the research data could not confirm that bridging thrombectomy was superior to direct thrombectomy, and the advantage of bridging embolectomy was only 2%.
。
This means that 1 in 57 patients treated benefits from bridging therapy, and the benefits of pre-thrombolysis decrease with the onset to randomization (even within 4.
5 hours), implying that the benefits of bridging thrombectomy are more limited
in developing countries with relatively underdeveloped emergency systems, such as China.
In addition, the results of this publication do not address the differences in efficacy between different races, and Professor Yang Pengfei's team is leading this work, so let's wait and see
.
The timing of treatment for patients with AIS-LNO is critical, and the earlier the treatment, the higher the success rate and the better
the prognosis.
For how to shorten the time from the onset to the start of treatment of stroke patients, Professor Yang Pengfei put forward the following three points: 1.
The time from the onset of AIS-LVO patients to the start of treatment can basically be divided into three segments: the first paragraph is from the onset to the call for help: this stage clinically advocates the use of ambulances to send to hospitals capable of stroke treatment
.
From the onset of the disease to the call for help, it depends on the patient, his or her family or those around him
.
Only when people can recognize the symptoms of stroke and call 120 for help as soon as possible can the treatment time
be minimized.
And this involves public education
.
Therefore, from this stage, shortening the rescue time can be carried out
by improving the public's ability to recognize the symptoms of acute stroke onset.
2.
The second paragraph is from calling for help to transferring to a competent hospital
.
When the patient dials 120, whether the ambulance personnel can quickly arrive at the scene, whether they can carry out standardized treatment after arrival, and whether they can be quickly transferred to a hospital with treatment capacity after the treatment is completed, these three points are the key to
shortening the treatment time.
Therefore, at this stage, the time can be shortened from the following two points: professional ability training for ambulance personnel, and strengthening the communication between the emergency center and the sending hospital so that the ambulance staff can understand the stroke treatment capacity
of the sending hospital in advance.
3.
The third paragraph is post-hospital treatment
.
In this stage, the construction of the stroke center is crucial, and its core point is the smooth passage
of green channels in the hospital.
Talking about the basis of individual precision treatment of AIS-LVO patients, Professor Yang Pengfei believes that the precision treatment of stroke patients and the research we are currently carrying out are actually two levels of things
.
At present, large clinical trials pay more attention to the macro, targeting a specific treatment plan for a type of patient population to choose better, in order to grasp
the general direction of treatment.
For example, on October 28, the Center for Cerebrovascular Diseases of Shanghai Changhai Hospital and the George Institute for Global Health (China), an internationally renowned stroke research institution, jointly led the newly released "Study on Intensive Antihypertensive Treatment after Mechanical Thrombectomy for Acute Ischemic Stroke" (ENCHANTED-2/MT).
The study, published in LANCET, concluded that mechanical thrombectomy in patients with acute ischemic stroke is more harmful when blood pressure values below 120 mmHg are more harmful
.
This conclusion has great guiding significance
for the management of blood pressure in patients after mechanical thrombectomy of acute ischemic stroke.
However, the current research is aimed at the macroscopic patient population and cannot provide a reference
for the precise treatment of individual patients.
Individual precision treatment of patients is at the micro level, and the basis for treatment at this level requires in-depth subgroup analysis
from our follow-up studies.
For example, the difference between old age and young age in the patient population needs to be further explored
through subsequent subgroup analysis.
Jumping out of the research, talking about the overall treatment of stroke is also a treatment method
that follows the macro module.
Including thrombolysis indicators, the establishment of green channels, in fact, more based on
the population.
Individualized criteria, in terms of stroke treatment, are relatively few
.
The reason is that stroke treatment has not yet reached the stage of precision treatment, and the general direction problem at this stage has not yet been solved
.
Expert profiles
, selected into the National 10,000 People Program Youth Top Talents, Shanghai Youth Top Talents, Pujiang Plan, Health Commission Excellent Youth and Chenguang Program and other talent programs, He has won honors such as the Outstanding Young and Middle-aged Expert of Stroke Prevention and Treatment of the National Brain Defense Committee, Wang Zhongzhong China Neurosurgeon Youth Award, and served as a reviewer
for SCI journals such as NEJM and LANCET.
He has published more than 180 academic papers, more than 80 SCI papers, and representative papers have been published in NEJM and LANCET journals
.
The first person in charge presided over 11 national, provincial and ministerial projects, and won 4 provincial and ministerial first prizes
.
References:[1] Stroke Prevention and Control Engineering Committee of the National Health Commission, Neurointerventional Group of Neurosurgery Branch of Chinese Medical Association, Interventional Group of Radiology Branch of Chinese Medical Association, etc.
Chinese expert consensus on endovascular treatment of acute large-vessel occlusive ischemic stroke (2019 revised edition)[J].
2019
Where can I see more about stroke?
Come to the "Doctor Station" and take a look 👇
Studies have shown that 1 in 57 patients treated benefits from bridging therapy
Stroke is the number one cause of death and disability in China, and China is facing the world's biggest stroke challenge
.
Effective stroke prevention and control is of great
significance to achieving the strategic goal of a healthy China and reducing poverty in China.
October 29, 2022 is the 17th World Stroke Day, and this year's campaign theme is "Recognize stroke one second earlier to save the brain from recovery"
.
In order to further enhance the public's understanding of stroke, "Medical Neurology Channel" and "Shanghai Changhai Hospital" held this event, and this article invited Professor Yang Pengfei from Shanghai Changhai Hospital to answer our questions about large-vessel occlusive ischemic stroke (AIS-LVO).
AIS-LVO patients have more severe symptoms,
The disability rate is higher
AIS-LLO is a common type of ischemic stroke, so what are the characteristics of this type of stroke compared to other types of ischemic stroke?
For this problem, Professor Yang Pengfei pointed out that its biggest feature is that occlusion occurs in large blood vessels, and this kind of stroke caused by blockage of large blood vessels is undoubtedly one of the most serious types of
stroke.
Because the coarse blood vessels supply a larger range of brain tissue, the infarction caused by it is more extensive, so such patients are more likely to present with severe symptoms
.
Although AIS-LVO only accounts for 1/4~1/3 of all strokes, it accounts for most of the stroke mortality rate, and it brings more harm than other types of stroke; In terms of treatment, traditional drug thrombolysis methods have limited effect and rely on interventional surgery to remove thrombes, so it is more difficult
to treat.
The treatment modalities of AIS-LGO remain controversial
There are currently a variety of treatment modalities for stroke, such as direct thrombectomy, bridging therapy, and even thrombolysis after thrombectomy
.
For the treatment of AIS-LLO, Professor Yang Pengfei pointed out that the standard treatment of acute stroke is mainly thrombolysis, thrombectomy and different combinations of the two (bridging or counter-bridging).
There are different thrombolytic drugs for thrombolysis, and there are also different ways
to remove thrombes.
From the overall evidence, for patients with acute ischemic stroke within 4.
5 hours of onset, intravenous thrombolytic therapy
should be actively carried out clinically.
However, for patients with AIS-LLO, intravenous thrombolysis has a low recanalization rate for large vessel occlusion, so the proportion of patients who benefit clinically is not high
.
Whether it can be treated by thrombolysis plus thrombectomy (bridging) or direct thrombectomy, which method is better, is still controversial to a certain extent
.
On May 7, 2020, the results of China's "Efficacy Evaluation of Direct Arterial Treatment of Acute Large-vessel Occlusive Ischemic Stroke (DIRECT-MT)" in China showed that for patients with pre-circulation AIS-LVO within 4.
5 hours of onset in China, based on a credible cut-off value of 20%, The functional outcome of endovascular embolectomy alone is not inferior to that of alteplase intravenous thrombolysis combined with endovascular thrombectomy
.
Subsequently, 5 similar studies were published in JAMA, NEJM and LANCET journals, with different clinical results
.
Professor Yang Pengfei introduced that at the World Stroke Congress on October 27 this year, the results of a meta-analysis of 6 studies based on the patient level (IRIS study) were released for the first time, although the non-inferiority cut-off value of 5% did not confirm that direct thrombectomy is not inferior to bridging thrombectomy, but in-depth statistical analysis found that the research data could not confirm that bridging thrombectomy was superior to direct thrombectomy, and the advantage of bridging embolectomy was only 2%.
。
This means that 1 in 57 patients treated benefits from bridging therapy, and the benefits of pre-thrombolysis decrease with the onset to randomization (even within 4.
5 hours), implying that the benefits of bridging thrombectomy are more limited
in developing countries with relatively underdeveloped emergency systems, such as China.
In addition, the results of this publication do not address the differences in efficacy between different races, and Professor Yang Pengfei's team is leading this work, so let's wait and see
.
The treatment of AIS-LLO's patients is a matter of time
The timing of treatment for patients with AIS-LNO is critical, and the earlier the treatment, the higher the success rate and the better
the prognosis.
For how to shorten the time from the onset to the start of treatment of stroke patients, Professor Yang Pengfei put forward the following three points: 1.
The time from the onset of AIS-LVO patients to the start of treatment can basically be divided into three segments: the first paragraph is from the onset to the call for help: this stage clinically advocates the use of ambulances to send to hospitals capable of stroke treatment
.
From the onset of the disease to the call for help, it depends on the patient, his or her family or those around him
.
Only when people can recognize the symptoms of stroke and call 120 for help as soon as possible can the treatment time
be minimized.
And this involves public education
.
Therefore, from this stage, shortening the rescue time can be carried out
by improving the public's ability to recognize the symptoms of acute stroke onset.
2.
The second paragraph is from calling for help to transferring to a competent hospital
.
When the patient dials 120, whether the ambulance personnel can quickly arrive at the scene, whether they can carry out standardized treatment after arrival, and whether they can be quickly transferred to a hospital with treatment capacity after the treatment is completed, these three points are the key to
shortening the treatment time.
Therefore, at this stage, the time can be shortened from the following two points: professional ability training for ambulance personnel, and strengthening the communication between the emergency center and the sending hospital so that the ambulance staff can understand the stroke treatment capacity
of the sending hospital in advance.
3.
The third paragraph is post-hospital treatment
.
In this stage, the construction of the stroke center is crucial, and its core point is the smooth passage
of green channels in the hospital.
There is still a lack of basis for the precise treatment of AIS-LGO patients
Talking about the basis of individual precision treatment of AIS-LVO patients, Professor Yang Pengfei believes that the precision treatment of stroke patients and the research we are currently carrying out are actually two levels of things
.
At present, large clinical trials pay more attention to the macro, targeting a specific treatment plan for a type of patient population to choose better, in order to grasp
the general direction of treatment.
For example, on October 28, the Center for Cerebrovascular Diseases of Shanghai Changhai Hospital and the George Institute for Global Health (China), an internationally renowned stroke research institution, jointly led the newly released "Study on Intensive Antihypertensive Treatment after Mechanical Thrombectomy for Acute Ischemic Stroke" (ENCHANTED-2/MT).
The study, published in LANCET, concluded that mechanical thrombectomy in patients with acute ischemic stroke is more harmful when blood pressure values below 120 mmHg are more harmful
.
This conclusion has great guiding significance
for the management of blood pressure in patients after mechanical thrombectomy of acute ischemic stroke.
However, the current research is aimed at the macroscopic patient population and cannot provide a reference
for the precise treatment of individual patients.
Individual precision treatment of patients is at the micro level, and the basis for treatment at this level requires in-depth subgroup analysis
from our follow-up studies.
For example, the difference between old age and young age in the patient population needs to be further explored
through subsequent subgroup analysis.
Jumping out of the research, talking about the overall treatment of stroke is also a treatment method
that follows the macro module.
Including thrombolysis indicators, the establishment of green channels, in fact, more based on
the population.
Individualized criteria, in terms of stroke treatment, are relatively few
.
The reason is that stroke treatment has not yet reached the stage of precision treatment, and the general direction problem at this stage has not yet been solved
.
Expert profiles
Professor Yang Pengfei
Chief physician, professor, doctoral supervisor, executive director of the Cerebrovascular Disease Center of the First Affiliated Hospital of Naval Medical University (Shanghai Changhai Hospital), deputy secretary-general of the National Brain Defense Commission Young and Middle-aged Expert Committee, youth committee member of the Neurosurgery Branch of the Chinese Medical Association, youth member of the Neurointervention Branch of the Chinese Stroke Society, etc.
, selected into the National 10,000 People Program Youth Top Talents, Shanghai Youth Top Talents, Pujiang Plan, Health Commission Excellent Youth and Chenguang Program and other talent programs, He has won honors such as the Outstanding Young and Middle-aged Expert of Stroke Prevention and Treatment of the National Brain Defense Committee, Wang Zhongzhong China Neurosurgeon Youth Award, and served as a reviewer
for SCI journals such as NEJM and LANCET.
He has published more than 180 academic papers, more than 80 SCI papers, and representative papers have been published in NEJM and LANCET journals
.
The first person in charge presided over 11 national, provincial and ministerial projects, and won 4 provincial and ministerial first prizes
.
References:[1] Stroke Prevention and Control Engineering Committee of the National Health Commission, Neurointerventional Group of Neurosurgery Branch of Chinese Medical Association, Interventional Group of Radiology Branch of Chinese Medical Association, etc.
Chinese expert consensus on endovascular treatment of acute large-vessel occlusive ischemic stroke (2019 revised edition)[J].
2019
Where can I see more about stroke?
Come to the "Doctor Station" and take a look 👇
