Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of clinical management of ischaemic cerebrovascular diseases

Abstract

Aim: Stroke is the leading cause of disability and death in China. Ischaemic stroke accounts for about 60%-80% of all strokes. It is of considerable significance to carry out multidimensional management of ischaemic cerebrovascular diseases. This evidence-based guideline aims to provide the latest detailed and comprehensive recommendations on the diagnosis, treatment and secondary prevention of ischaemic cerebrovascular diseases.

Methods: We had performed comprehensive searches of MEDLINE (via PubMed) (before 30 June 2019), and integrated the relevant information into charts and distributed to the writing group. Writing group members discussed and determined the recommendations through teleconference. We used the level of evidence grading algorithm of Chinese Stroke Association to grade each recommendation. The draft was reviewed by the Guideline Writing Committee of Chinese Stroke Association Stroke and finalised. This guideline is fully updated every 3 years.

Results: This evidence-based guideline is based on the treatment, care and prevention of ischaemic cerebrovascular diseases, which emphasises on pathogenesis evaluation, intravenous thrombolysis, endovascular therapy, antiplatelet therapy, prevention and treatment of complications, and risk factor management.

Conclusions: This updated guideline presents a framework for the management of ischaemic cerebrovascular diseases. Timely first-aid measures, professional care in the acute stage, and proactive secondary prevention will be helpful to patients.

Keywords: Diagnosis; Guidelines; Ischemic Cerebrovascular Diseases; Management.

Figure 1

The management flow chart of patients with acute ischaemic stroke. CTA, CT angiography; CXR, chest X-ray; DBP, diastolic blood pressure; IV, intravenous; SBP, systolic blood pressure; TIA, transient ischaemic attack.

Figure 2

Intravenous recombinant tissue plasminogen activator (IV rt-PA) administration in patients with ischaemic stroke within 4.5 hours of onset.

Figure 3

Endovascular treatment in patients with acute ischaemic stroke (AIS). BP, blood pressure; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; rt-PA, recombinant tissue plasminogen activator.

Figure 4

Antiplatelet treatment in patients with acute ischaemic stroke (AIS). INR, international normalised ratio; NOAC, novel oral anticoagulant. ¹Non-disabling ischaemic cerebrovascular events refer to ischaemic cerebrovascular events without significant disability sequelae, including: 1. Transient ischemic attack (TIA) 2. Mild ischaemic stroke 3.Symptoms quickly relieved without significant disability sequelae. ²High-risk events include: 1. High-risk TIA (ABCD 2≥4 points) and mild stroke with 24h within onset. 2. Acute multiple cerebral infarction 3. Intracranial or extracranial aortic atherosclerotic stenosis ≥50%.

Figure 5

Management of cerebral oedema/high intracranial pressure in patients with acute ischaemic stroke. BP, blood pressure; NICU, neurological intensive care unit.

Figure 6

Haemorrhagic transformation management in patients with acute ischaemic stroke. INR, international normalised ratio.

Figure 7

Epilepsy management within 24 hours after stroke onset.

Figure 8

Diagnosis process for unexplained embolic stroke. CTA, CT angiography; ESUS, embolic stroke of undetermined source; MRA, magnetic resonance angiography.

Figure 9

Blood pressure (BP) management in patients with acute ischaemic stroke (AIS).

Figure 10

Blood pressure management in patients with acute ischaemic stroke. LDL-C, low-density lipoprotein-cholesterol; TIA, transient ischaemic attack; LOR B, Class IIB Recommendation .