Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders:executive summary and 2019 update of clinical management of spontaneous subarachnoid haemorrhage

caused by ruptured cerebral aneurysm is a severe subtype of haemorrhagic stroke.Although the incidence of SAH is relatively low among all cerebrovascular diseases,the mortality is the highest.The critical management of SAH is challenging.We provide this evidence-based guideline to present current and comprehensive recommendations for the diagnosis and treatment of non-trauma SAH.Methods A formal literature search of MEDLINE(1 January 1990-30 June 2019)was performed.Data were synthesised with the use of evidence tables.Writing group members met by teleconference to discuss data-derived recommendations.The Chinese Stroke Association’s levels of evidence grading algorithm was used to grade each recommendation.The guideline draft was reviewed by Chinese Stroke Association’s Stroke Fellow Committees.It is intended that this guideline be fully updated every 3 years.results Evidence-based guidelines are presented for the care of patients presenting with non-trauma SAH.The focus of the guideline was subdivided into transfer and systems of care,diagnosis flowchart,aetiology and differentiation,prevention of rebleeding,surgical and endovascular repair of ruptured aneurysms,management of vasospasm and delayed cerebral ischaemia,management of hydrocephalus,management of seizures and management of medical complications.Conclusions The guideline offers a framework for SAH management.Early professional and aggressive care of SAH might help dramatically.

Rationale and design of Patient-centered Retrospective Observation of Guideline-Recommended Execution for Stroke Sufferers in China: China PROGRESS

Background In 2009,China launched ambitious healthcare reform plans to provide affordable and equitable basic healthcare for all patients,including the substantial number of patients who had a stroke.However,little is known about the pattern of evidence-based stroke care and outcomes across hospitals,regions and time during the last decade.Aims The Patient-centered Retrospective Observation of Guideline-Recommended Execution for Stroke Sufferers in China(China PROGRESS)Study aims to use findings from a representative sample of Chinese hospitals over the last decade to improve future stroke care for patients hospitalised with ischaemic stroke(IS)or transient ischaemic attack(TIA).Design The China PROGRESS Study will use a two-stage cluster sampling method to identify over 32000 patient records from 208 hospitals across the Eastern,Central and Western geographical regions in China.To assess the temporal trends in patient characteristics,treatment and outcomes,study investigators will select records from 2005,2010 and 2015.A double data reading/entry system will be developed to conduct this assessment.A central coordinating centre will monitor case ascertainment,data abstraction and data management.Analyses will examine patient characteristics,testing patterns,in-hospital treatment and outcomes,and variations across regions and across time.Conclusions The China PROGRESS Study is the first nationally representative study that aims to better understand care quality and outcomes for patients with IS or TIA before and after the national healthcare reform in China.This initiative will translate findings into clinical practices that improve care quality for patients who had a stroke and policy recommendations that allow these changes to be implemented widely.Ethics approval This study has also been approved by the central institutional review board(IRB)at Beijing Tiantan Hospital.

Chinese Stroke Center Alliance:a national effort to improve healthcare quality for acute stroke and transient ischaemic attack:rationale,design and preliminary findings

Background In June 2015,the Chinese Stroke Association(CSA)initiated the Chinese Stroke Center Alliance(CSCA)to establish the national hospital-based stroke care quality assessment and improvement platform.This article outlines its objectives,operational structure,patient population,quality improvement(QI)intervention tools,data elements,data collection methodology and current patient and hospital data.Methods The CSCA is a national,hospital-based,multicentre,voluntary,multifaceted intervention and continuous QI initiative.This multifaceted intervention includes stroke centre development,written care protocols,workshops and a monitoring/feedback system of evidencebased performance measures.The data coordinating centre of the CSCA resides at the China National Clinical Research Center for Neurological Diseases,Beijing Tiantan Hospital.results As of July 2017,1576 hospitals in China have contributed detailed clinical information to serve as a benchmark for the stroke care quality of 433264 patients with acute stroke/transient ischaemic attacks(TIA),including 352572(81.38%)acute ischaemic stroke,30362(7.01%)TIA,42080(9.71%)spontaneous intracranial haemorrhage,5505(1.27%)subarachnoid haemorrhage and 2745(0.63%)not specified stroke.Conclusion The CSCA programme is designed to establish a continuous national stroke registry and help healthcare providers develop stroke centres and treat patients in a consistent manner in accordance with accepted national guidelines and,ultimately,improve patient outcomes.It supports the CSA mission to reduce stroke burden in China.

Predictors of dysphagia screening and pneumonia among patients with acute ischaemic stroke in China:findings from the Chinese Stroke Center Alliance(CSCA)

Background and purpose Guidelines recommend dysphagia screening to identify those at high risk of pneumonia.However,little is known about the prevalence and predictors of dysphagia screening and pneumonia among patients with acute ischaemic stroke in China.Methods Using data from the Chinese Stroke Center Alliance,which is a multicentre,prospective,consecutive patient enrolment programme,univariate and multivariate analyses were conducted to identify patient and hospital characteristics associated with dysphagia screening and pneumonia during acute hospitalisation.Results Of 790811 patients admitted to 1476 hospitals,622718(78.7%)underwent dysphagia screening,and 64398(8.1%)developed pneumonia.Patients in stroke units were more likely to be screened for dysphagia than those not in stroke units(OR 1.50;95%CI 1.48 to 1.52),while patients with a past history of stroke were less likely to be screened(OR 0.87;95%CI 0.86 to 0.88).Dysphagia screening(OR 1.46;95%CI 1.30 to 1.65),dysphagia(OR 7.31;95%CI 7.15 to 7.46),and admission to stroke units(OR 1.17;95%CI 1.14 to 1.19)were significantly associated with a greater risk of pneumonia.Conclusions Dysphagia was a critical factor in the development of pneumonia.Nearly one in five patients with acute ischaemic stroke in the Chinese Stroke Center Alliance were not screened for dysphagia.Pneumonia prevention during acute hospitalisation is dependent not only on dysphagia screening but also on the effectiveness of subsequent dysphagia management interventions.Further studies are needed to elucidate the relationship between dysphagia screening,stroke unit care and pneumonia in patients with acute ischaemic stroke.

Gastrointestinal bleeding during acute ischaemic stroke hospitalisation increases the risk of stroke recurrence

Objective Gastrointestinal(GI)bleeding in patients who had a stroke is strongly associated with a higher risk of death and loss of independence.However,it is unknown whether GI bleeding increases risk for recurrence of stroke.In this study,we assess the potential relationship between GI bleeding and stroke recurrence in patients within 12 months of an acute ischaemic stroke(AIS),using the China National Stroke Registry(CNSR).Methods This study included 22216 patients who had an ischaemic stroke included in the CNSR from 2007 to 2008.We analysed baseline patient characteristics,GI bleeding and outcomes of patients who had an AIS,specifically stroke recurrence at 3,6 and 12 months.We used multivariable logistic regression to evaluate a possible association between GI bleeding and stroke recurrence.results Of the 12415 patients included in our study,12.3%,15.5%and 17.7%had a stroke recurrence at 3,6 and 12 months,respectively.GI bleeding was an independent stroke recurrence risk factor in patients after ischaemic stroke at 3 months(adjusted OR 1.481,95%CI 1.118 to 1.962),6 months(adjusted OR 1.448,95%CI 1.106 to 1.896)and 12 months(adjusted OR 1.350;95%CI 1.034 to 1.763).Conclusion GI bleeding was associated with the increased risk of stroke recurrence after an AIS.

Tranexamic acid for acute intracerebral haemorrhage growth based on imaging assessment (TRAIGE): a multicentre, randomised, placebo- controlled trial

Background Studies show tranexamic acid can reduce the risk of death and early neurological deterioration after intracranial haemorrhage.We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in intracerebral haemorrhage patients susceptible to haemorrhage expansion.Methods We did a prospective,double-blind,randomised,placebo-controlled trial at 10 stroke centres in China.Acute supratentorial intracerebral haemorrhage patients were eligible if they had indication of haemorrhage expansion on admission imaging(eg,spot sign,black hole sign or blend sign),and were treatable within 8 hours of symptom onset.Patients were randomly assigned(1:1)to receive either tranexamic acid or a matching placebo.The primary outcome was intracerebral haematoma growth(>33% relative or>6 mL absolute)at 24 hours.Clinical outcomes were assessed at 90 days.Results Of the 171 included patients,124(72.5%)were male,and the mean age was 55.9±11.6 years.89 patients received tranexamic acid and 82 received placebo.The primary outcome did not differ significantly between the groups:36(40.4%)patients in the tranexamic acid group and 34(41.5%)patients in the placebo group had intracranial haemorrhage growth(OR 0.96,95% CI 0.52 to 1.77,p=0.89).The proportion of death was lower in the tranexamic acid treatment group than placebo group(8.1%vs 10.0%),but there were no significant differences in secondary outcomes including absolute intracranial haemorrhage growth,death and dependency.Conclusions Among patients susceptible to haemorrhage expansion treated within 8 hours of stroke onset,tranexamic acid did not significantly prevent intracerebral haemorrhage growth.Larger studies are needed to assess safety and efficacy of tranexamic acid in intracerebral haemorrhage patients.

Haemostatic therapy in spontaneous intracerebral haemorrhage patients with high-risk of haematoma expansion by CT marker: a systematic review and meta- analysis of randomised trials

Background and purpose Current randomised controlled trials(RCTs)showed an uncertain benefit of haemostatic therapy on preventing haematoma expansion and improving the outcome in patients with intracerebral haemorrhage(ICH).This meta-analysis aims to systematically evaluate the effect of haemostatic agents on the prevention of haemorrhage growth in patients with high-risk spontaneous ICH predicted by CT signs in RCTs.Methods A comprehensive search of PubMed,EMBASE and Cochrane library from 1 January 2005 to 30 June 2021 was conducted.RCTs that compared haemostatic agents with placebo for the treatment of spontaneous patients with ICH with high-risk haemorrhage growth were included.The primary endpoint was haematoma expansion at 24 hours.Other major endpoints of interest included 90-day functional outcome and mortality.Results The meta-analysis included four RCTs that randomised 2666 patients with ICH with high-risk haemorrhage growth.Haemostatic therapy reduced the rate of haematoma expansion at a marginally statistically significant level when compared with placebo(OR 0.84;95% CI 0.70 to 1.00;p=0.051).Subgroup analysis for patients with black hole sign on CT revealed a significant reduction of haematoma expansion with haemostatic therapy(OR 0.61;95% CI 0.39 to 0.94;p=0.03).However,both the primary analysis and subgroup analyses showed that haemostatic therapy could not reduce the rate of poor functional outcome(modified Rankin Scale>3)or death.Conclusions Haemostatic therapy showed a marginally significant benefit in reducing early haematoma expansion in patients with high-risk spontaneous ICH predicted by markers on CT scan.However,no significant improvement in functional outcome or reduction of mortality was observed.

CO_(2) combining power and outcomes in patients with acute ischaemic stroke or transient ischaemic attack

Background and purpose The clinical significance of carbon dioxide combining power(CO_(2) CP)in ischaemic cerebrovascular disease is not well established,and the role of CO_(2) CP in the prognosis of acute ischaemic stroke(AIS)or transient ischaemic attack(TIA)has not been reported.The objective of the study was to investigate the associations between CO2CP and clinical outcomes in patients with AIS or TIA.Methods Data were derived from the China National Stroke Registry III.Patients were classified into five groups by quintiles of CO_(2) CP levels and three groups according to the normal range of CO_(2)CP(23-29 mmol/L).Multivariable Cox and logistic regressions were adopted to explore the associations of CO_(2) CP levels with all-cause death and poor functional outcomes(modified Rankin Scale(mRS)3-6/2-6)at 3 months and 1 year.Results Among 9531 patients included in the study,the median(IQR)CO_(2) CP was 24.9(23.0-27.0)mmol/L.After adjustment for potential confounders,patients in the first CO_(2) CP quintile(21.1-23.3 mmol/L)had higher risk of all-cause death and poor functional outcomes(mRS score of 3-6/2-6)(HR or OR with 95% CI 2.37(1.32 to 4.25),1.49(1.20 to 1.83)and 1.21(1.03 to 1.42),respectively)compared with those in the fourth quintile.Similar results were found for outcomes at 1 year.Furthermore,all associations were also significant when CO_(2) CP was<23 mmol/L compared with CO_(2) CP of 23-29 mmol/L.Conclusions Decreased CO_(2) CP was associated with high risk of all-cause death and poor functional outcomes in patients with AIS or TIA.

Incidence and Mortality of Acute Disseminated Encephalomyelitis in China: A Nationwide Population-based Study

Dear Editor,Acute disseminated encephalomyelitis(ADEM)is an immune-mediated demyelinating disorder characterized by a widespread attack of inflammation in the brain and spinal cord that damages myelin[1].ADEM is life-threatening and among the most frequent demyelinating disorders in childhood[2].

Body mass index and clinical outcomes in patients with intracerebral haemorrhage:results from the China Stroke Center Alliance

Background and aim Obesity paradox has aroused increasing concern in recent years.However,impact of obesity on outcomes in intracerebral haemorrhage(ICH)remains unclear.This study aimed to evaluate association of body mass index(BMI)with in-hospital mortality,complications and discharge disposition in ICH.Methods Data were from 85705 ICH enrolled in the China Stroke Center Alliance study.Patients were divided into four groups:underweight,normal weight,overweight and obese according to Asian-Pacific criteria.The primary outcome was in-hospital mortality.The secondary outcomes included non-routine discharge disposition and in-hospital complications.Discharge to graded II or III hospital,community hospital or rehabilitation facilities was considered non-routine disposition.Multivariable logistic regression analysed association of BMI with outcomes.Results 82789 patients with ICH were included in the final analysis.Underweight(OR=2.057,95%CI 1.193 to 3.550)patients had higher odds of in-hospital mortality than those with normal weight after adjusting for covariates,but no significant difference was observed for patients who were overweight or obese.No significant association was found between BMI and non-disposition.Underweight was associated with increased odds of several complications,including pneumonia(OR 1.343,95%CI 1.138 to 1.584),poor swallow function(OR 1.351,95%CI 1.122 to 1.628)and urinary tract infection(OR 1.532,95%CI 1.064 to 2.204).Moreover,obese patients had higher odds of haematoma expansion(OR 1.326,95%CI 1.168 to 1.504),deep vein thrombosis(OR 1.506,95%CI 1.165 to 1.947)and gastrointestinal bleeding(OR 1.257,95%CI 1.027 to 1.539).Conclusions In patients with ICH,being underweight was associated with increased in-hospital mortality.Being underweight and obese can both increased risk of in-hospital complications compared with having normal weight.

GRP per capita and hospital characteristics associated with intravenous tissue plasminogen activator adherence rate:evidence from the Chinese Stroke Center Alliance

Background Timely delivery of intravenous tissue plasminogen activator(IV-rt PA)is pivotal to eligible patients who had a stroke while achieving higher rates of IV-rt PA has been problematic.This paper focuses on investigating influential factors associated with the administration of IV-rt PA,primarily per capita gross regional product(GRP)and healthcare system factors.Methods The study included 980 hospitals in the Chinese Stroke Center Alliance where 158003 patients who had an acute ischaemic stroke received IV-rt PA between August 2015 and August 2019.The adherence rate to IV-rt PA within 4.5 hours time window in each hospital was the primary outcome.Influential factors were grouped into two categories:macroeconomic status and hospital characteristics.The outcome was analysed using multivariable linear regression.Results GRP per capita(β=2.37,p<0.001),hospital stroke centre certification(β=3.77,p<0.001),number of neurologists(β=0.12,p<0.001),existence of emergency services for neurological treatment(β=7.43,p=0.014),presence of emergency department(β=10.03,p=0.019)and cooperating with emergency centre(β=4.65,p=0.029)were significantly positively associated with the adherence rate to IV-rt PA.Conclusions Higher GRP per capita,affluent neurological personnel,well-equipped emergency services for neurological treatment and routine cooperation with the emergency centre were important for enhancing the adherence rate to IV-rt PA among patients who had an acute ischaemic stroke in China.