Glucocorticoids are the first-line therapy of many neurological disorders, with the treatment regimen varying across types and characteristics of neurological disorders. This article reviews the national and international guidelines and expert consensuses in the past decade on glucocorticoids treatment for neurological disorders, and summarizes recommendations from the latest Chinese guidelines and consensuses. In summary, the most frequently used pulse therapy of glucocorticoids in China is intravenous infusion of high-dose (usually 1000 mg/d) methylprednisolone in a short period (often <5 d), followed by gradual tapering, bridging with oral prednisone or direct discontinuation. The treatment regimen for children and juveniles is similar to that for adults but the dose is adjusted by body weight. Pharmacodynamics of glucocorticoids should be considered for the treatment of perinatal women. To provide appropriate glucocorticoids treatment for patients with neurological disorders, clinicians should fully understand features of each neurological disorder and clinical characteristics of individual patient.
Severe ischemic stroke is characterized by severe neurological deficits, sometimes accompanied by cardiovascular and respiratory dysfunction, which could lead to severe disability and death. This article reviews the national and international trials of reperfusion treatment for severe ischemic stroke in recent 20 years, and summarizes relevant clinical guidelines and expert consensuses. In general, intravenous thrombolysis is not restricted for patients with severe neurological deficits, but should be cautiously considered for patients with large infarction. Patients with large vessel occlusion could benefit from endovascular treatment, and whilst prevention and treatment for brain edema are important for patients with very large infarction. For patients who have received reperfusion therapies, the target for the management of blood pressure should incorporate the status of recanalization and a stable level of blood pressure should be maintained.
In China, there are more than 2 million new strokes annually, and the disability-adjusted life-years due to stroke were higher than any other disease. With aging of the population, inadequate control of vascular risk factors such as hypertension, and uneven distribution of specialized stroke care, the burden of stroke will continue to increase. Despite improved health care quality in China, the availability of specialized stroke care varies across the country, especially in rural areas. Stroke prevention, management and research face unique and severe challenges due to rough terrain and economic underdevelopment in Southwest China. In the future, efforts should be made to provide more balanced availability of specialized stroke care services across China, promote generalization of evidence-based practice, and carry out more high-quality research to improve outcomes of stroke patients, with special attention to the rural population and Southwest China.
Stroke is a severe disease with high incidence, high recurrence, high disability, and high mortality rates. China has the highest prevalence of stroke in the world, where it is a leading cause of death and disability for adults. There is a struggling way to prevent and control stroke to reduce the disease burden. This review summarizes the temporal trends and characteristics of stroke in China, with an aim to provide baseline reference for stroke prevention and treatment in China. There was an increase in the incidence and prevalence of stroke in China in the past 15 years. The incidence, prevalence, mortality, and disability-adjusted life years of stroke in China were higher than those in developed countries such as the United Kingdom, the United States, and Japan. High-quality studies and standardized diagnosis and treatment are needed to overcome challenges in stroke prevention and treatment in China.
Massive and severe cerebral infarction can lead to a high mortality and disability rate, and it is the bottleneck of preventing and treating cerebrovascular disease. Once the malignant brain edema of massive cerebral infarction or the critical status of severe cerebral infarction occurs, the treatment effect is very poor. Therefore, we should not only focus on the treatment of critical cerebral infarction, but also prevent its occurrence. It is clinically important to prevent the occurrence of this critical condition in advance and to prevent the occurrence of massive cerebral infarction and severe cerebral infarction. This article points out that some patients with massive or severe cerebral infarction can be prevented from becoming critically ill. The definition, key risk factors and corresponding prevention and treatment strategies of critical cerebral infarction have also been proposed. Critical cerebral infarction can be divided into two categories with or without malignant brain edema, and the risk factors and prediction and prevention strategies by categories andphases can be studied separately.
ObjectiveTo investigate the association between the imaging markers of ischemic cerebral small vessel disease and the occurrence of large hemispheric infarction (LHI).MethodsWe consecutively enrolled the patients with cerebral infarction in the middle cerebral artery blood supply area who admitted to the Department of Neurology, West China Hospital, Sichuan University between January 1st, 2015 and March 30th, 2016, and underwent head CT/MRI scans within one month of onset. LHI was defined as: the hypodensity was larger than 1/2 of the blood supply area of middle cerebral artery or more than 1/3 of the cerebral hemisphere within 6 hours on head CT at admission, or the infarction area was larger than 2/3 of the ipsilateral hemisphere on head MRI at admission. The basic clinical data and imaging data were collected, and the independent predictors of LHI and its independent correlation with ischemic cerebrovascular disease were explored by univariate and multivariate analyses.ResultsA total of 503 patients were included, 111 (22.1%) with LHI and 392 (77.9%) with non-LHI. Compared with the non-LHI patients, the LHI patients had a lower prevalence of white matter lesions, a lower Fazekas score, a lower prevalence of Fazekas score > 1, a lower prevalence of lacunae, a lower proportion of diabetes mellitus, a higher atrial fibrillation proportion of history, a shorter time from onset to treatment, a higher National Institute of Health Stroke Scale (NIHSS) score at admission, and a lower Glasgow Coma scale score; the distributions of TOAST types and locations of vascular stenosis were different (P<0.05). Multivariate analyses showed that white matter lesions [odds ratio (OR)=0.182, 95% confidence interval (CI) (0.050, 0.660), P=0.010], higher Fazekas score [OR=0.770, 95% CI (0.611, 0.970), P=0.027], and Fakazes score > 1 [OR=0.490, 95%CI (0.259, 0.928), P=0.029] were independent protective factors of LHI, while lacunae was not an independent factor of LHI [OR=0.583, 95% CI (0.265, 1.279), P=0.178]. Higher NIHSS score and history of atrial fibrillation were independent risk factors for LHI (P<0.001).ConclusionsThe occurrence and severity of white matter lesions (higher Fazekas score and Fazekas score > 1) are more in non-LHI group, and are independently related to the occurrence of LHI. The results suggest that ischemic preconditioning may have a protective effect on brain.
Objects The center of Evidence Based Medicine (EBM) in China has organized several extra-curricular trainings in summer vacations for medical students, so as to enable them get involved in the practice of Evidence Based Medicine, we were wondering whether these training courses served as an effective supplement to EBM education in class and what it exactly brought to us, with a primary concern about research capability in field of EBM. Methods We conducted questionnaire survey with undergraduate students whose enrolling years range from 2001 to 2005 in West China Medical School of Sichuan University, and divided them into a stratification of five groups according to enrolling years. Then we paired the trained students with untrained ones at a ratio of 1׃2. The final number of included students was 216, of which 72 had been trained while other 144 had not. Epidata 3.0, Excel and SPSS 13.0 were used for data collecting and analyzing, respectively. Chi-square test was adopted for result interpretation. Results Compared to those without training experience, trained students were prone to choose medical specialized databases (Plt;0.05) when they search for some academic publications. In terms of selecting and quality evaluation, the trained were more dependent on systematic reviews (Plt;0.05). Meanwhile, they also showed critical thinking more than that of untrained (Plt;0.05). In addition, the fruit of published theses was in favor of those trained ones. Conclusions Those who have taken part in extra-curricular training of EBM surpass those untrained in ability of scientific research. To some extent, we are still in shortage of educational resources; this extra-curricular training course can play a complementary role for EBM education, as effective and necessary.
Objective To explore the clinical and imaging features of patients with acute dizziness and assess their associations with 3-month prognosis. Methods We enrolled adult patients with a chief complaint of acute dizziness, who were admitted to the Neurological Clinic at the Emergency Department of West China Hospital, Sichuan University between January 1st and May 31st 2022. We collected clinical and imaging features at baseline for each patient. The primary outcome was recurrent dizziness within 3 months after index dizziness. Secondary outcome was stroke within 3 months after index dizziness. Results A total of 1 322 patients who visited the Neurological Clinic were included, of which 617 (46.7%) had a chief complaint of acute dizziness. Among 222 patients who performed emergent brain and neck CT angiography, 1 patient presented with intracerebral haemorrhage. Among the remaining 221 patients, 206 patients completed 3-month follow-up, with 76 patients reported recurrent dizziness and 7 patients had stroke (6 ischaemic, 1 hemorrhagic). The multivariate logistic regression showed that chronic dizziness duration and parenchymal hypodensity on brain CT were each associated with a higher risk of recurrent dizziness. Compared with those who did not report stroke, the stroke patients were more likely to present with hypertension, headache symptoms, and exhibit parenchymal hypodensity on baseline CT (P<0.05). Conclusions In patients with acute dizziness, those with chronic dizziness duration and parenchymal hypodensity on baseline CT were associated with a higher risk of 3-month recurrent dizziness. Acute dizziness patients experiencing 3-month stroke often have hypertension, headache symptoms, and parenchymal hypodensity on baseline CT.
Severe/massive ischaemic stroke is difficult to treat and has poor prognosis. There are limited studies for specific treatment of these conditions and no consensus on their definitions. This proposal suggests definitions and a flowchart for the diagnosis and treatment of these conditions. We focus on predicting and preventing malignant oedema at an early stage, monitoring the level of consciousness and vital signs, and the prevention and management of complications (eg. pulmonary infections). We particularly provide suggestions for the treatment with intravenous thrombolysis, endovascular treatment, antiplatelet and anticoagulation. More studies are warranted to support individualised management of infarct swelling, intracranial hypertension and early rehabilitation for severe/massive ischaemic stroke.
Massive cerebral infarction with malignant brain edema has poor prognosis with very high mortality, despite aggressive medical treatment. Surgical decompression is recommended by Chinese and international clinical guidelines for patients with massive cerebral infarction, however, there is no standardized diagnosis and treatment protocol in clinical practice. Following the principle of evidence-based medicine and based on the diagnosis and treatment norms of the participating hospitals of Severe Ischaemic Stroke Collaboration in recent years, we recommend this consensus statement of the standardized surgical decompression for malignant brain edema in massive cerebral infarction.