Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 33,991 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke. DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain!trillions and trillions of neuronsthatDIEeach day because there areNOeffective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.
What this blog is for:
My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
Tokyo, May 14 (Jiji Press)--A team including Takashi Shichita, a professor at the Institute of Science Tokyo's Medical Research Laboratory, has developed a drug candidate to suppress a type of protein that causes the rehabilitation-induced partial recovery of motor functions lost from a stroke to end after only about two months.
People who lost the abilities to move their hands or feet, or to speak due to the deaths of some nerve cells in their brains from the cerebral infarction can regain the functions to a certain extent through rehabilitation. The recovery normally lasts for about two months.
The recovery is possible because surviving nerve cells repair the neuron networks, with microglia, or cells in charge of brain immunity, helping the restoration process by secreting a protein called insulin-like growth factor 1, or IGF1.
In a genetic manipulation experiment using mice, Shichita and other members of the team discovered that microglia stopped secreting IGF1 after a while following a stroke due to the function of another protein, ZFP384. The same mechanism was confirmed in the brains of dead stroke patients.
The team developed the drug candidate to block the production of ZFP384. After injecting the drug into mice, the team found that microglia continued to secrete IGF1 and helped maintain the recovery of brain functions.
Since my medical team completely failed at
recovering my left hand, cutting anything is a recipe for danger. I am
currently getting meals from Home Chef with very limited cutting needed.
That will allow me to live independently for decades to come.
Is that considered cooking at home, certainly I'm not doing it from scratch? 3 days a week for me and since I'm getting it for two persons I freeze the other half for later.
Yes, Chef: Cooking at home is a good way to save money, eat fewer calories, and have more control over what you’re consuming. But new research has pointed to another potential health benefit of even just one home-cooked meal per week: lowered risk of dementia for older adults.
The Study: Researchers analyzed questionnaire responses from 10,978 adults aged 65 and older enrolled in the Japan Gerontological Evaluation Study and tracked dementia diagnoses over the following six years. Nearly 1,200 of them had developed dementia, but male and female participants who cooked meals from scratch had a 23% and 27% reduced risk of the disease, respectively.
The Takeaway: Even novice chefs cooking simple meals experienced benefits. Cooking at home was associated with an up to 67% lowered risk of dementia for adults who were less skilled at cooking. Learning new skills combined with the prepping, chopping, and measuring ingredients stimulated the brain in addition to improving diet, according to the researchers.
Keep in Mind: The study was observational, so it didn’t prove that cooking prevents dementia. Previous research indicates modifiable lifestyle habits, like diet, physical activity, and mental stimulation, can impact dementia risk.
My cooking is now delivered Home Chef with minimal prep, much simpler with only one useable hand. I figure with this delivery I can probably stay in the condo practically to the last month.
Objective: Rehabilitation for dementia is important in Roken
Geriatric Health Service Facilities in Japan. This study
evaluated the effects of a cooking program as rehabilitation for elderly
residents with dementia.
Methods: We carried out a
12-week cooking program based on the five principles of
brain-activating rehabilitation (BAR): fostering a pleasant atmosphere,
interactive communication, establishing social roles, giving
and receiving praise, and errorless learning. The program was
carried out in small groups and consisted of 90-min classes
once a week. Participants were 36 elderly residents with dementia (mean
85.4 ± 6.5 years) who were randomly divided into intervention
(n = 18) and control (n = 18) groups. The control group
participated in recreation and both groups received individual
conventional rehabilitation twice a week for 30 min. The effects of
intervention were evaluated using nine outcome measures.
Results:
A total of 29 participants were included in the analysis
(two-way analysis of variance). The attendance rate was 86.6%
in the intervention group (n = 13). The Yamaguchi Kanji Symbol
Substitution Test (executive function) showed significant
interaction (F(1, 27) = 4.305, P = 0.048) between the two
groups: the control group (n = 16) showed significant
deterioration (pre 4.9 ± 5.6 to post 3.0 ± 4.9; P = 0.032). The dementia
behavior disturbance scale also showed significant interaction
(F(1, 29) = 13.298, P = 0.001): the intervention group (n =
16) showed significant improvement (pre 21.6 ± 12.2 to post 11.4 ±
11.5; P < 0.001). No significant differences were observed in the
other outcome measures.
Conclusions: Our findings
suggest that a cooking program based on BAR can reduce the
behavioral and psychological symptoms of dementia and maintain
executive function.
Since my medical team completely failed at
recovering my left hand, cutting anything is a recipe for danger. I am
currently getting meals from Home Chef with very limited cutting needed.
That will allow me to live independently for decades to come.
Background
People have come to rely on restaurants and takeaway foods, and less on
cooking at home. We examined the association between home cooking and
dementia incidence, ascertained through administrative long-term care
records, and whether the benefits of home cooking differ by cooking
skills.
Methods
Participants in the Japan Gerontological Evaluation Study, a
population-based cohort study, were followed for 6 years. The incidence
of dementia was ascertained in 10 978 participants through data from the
public long-term care insurance system, which captures functionally
significant cognitive impairment requiring care. Cooking frequency and
skills were assessed in a baseline survey. Participants with high and
low frequencies of home cooking were matched in men and women based on
demographic, socioeconomic and health-related factors using propensity
score matching. Fine-Grey competing risk models were used, with death
treated as a competing event.
Results
During the follow-up, 1195 dementia cases were found. A total of 1347
male and 321 female pairs were matched between high (at least once a
week) and low (less than once a week) cooking frequencies. The
subdistribution hazard ratio (SHR) for high cooking frequency (vs low
cooking frequency) was 0.77 (95% CI 0.61 to 0.98) in men and 0.73 (95%
CI 0.54 to 0.98) in women. The benefits of higher cooking frequency were
more pronounced in those with low cooking skills (SHR 0.33, 95% CI 0.13
to 0.84).
Conclusions Creating an environment where people can cook meals when they are older may be important for the prevention of dementia.
Data availability statement
Data
are available upon reasonable request. The data that support the
findings of this study are available from JAGES Agency but restrictions
apply to the availability of these data, which were used under licence
for the current study, and so are not publicly available. Data are
however available from the corresponding author upon reasonable request
and with permission of JAGES Agency (dataadmin.ml@jages.net).
Great Catch-22 here; you need exercise to recover, but you really need 100% recovery to do the required exercises. Have your competent? doctor EXACTLY EXPLAIN HOW TO GET AROUND THAT PROBLEM!
I can almost guarantee your doctor and hospital will KNOW NOTHING AND DO NOTHING!
No human research will occur; nothing will be done! That is how fucking incompetent the whole stroke medical world is. Hopefully comeuppance will hit them all with a stroke. And they can regret their incompetence in not solving stroke to 100% recovery!
Al this incompetence is a result of NO leadership firing the incompetent persons!
Japanese researchers found that exercise triggers muscle cells to send mitochondria through the bloodstream to protect and repair brain tissue after stroke
Scientists at Juntendo University School of Medicine have uncovered a remarkable process that explains how exercise protects the brain from stroke damage. The research team discovered that physical activity triggers muscle cells to produce mitochondria that travel through the bloodstream and deliver healing benefits directly to injured brain tissue.
The study, published in the journal MedComm on Jan. 15, reveals that blood platelets act as tiny transport vehicles, carrying these cellular powerhouses from muscles to the brain. Once they arrive, the mitochondria help damaged neurons survive oxygen deprivation and support the repair of critical brain structures. The findings could eventually lead to new treatments for stroke patients who are too frail to exercise on their own.(Slight problem here, the penumbra resolves itself into dead brain in the first week, so you need this exercise immediately! HOW THE FUCK WILL YOUR DOCTOR ACCOMPLISH THAT?)
Research Assistant Professor Toshiki Inaba led the investigation alongside colleagues Nobukazu Miyamoto and Nobutaka Hattori at Juntendo’s Department of Neurology. The team conducted experiments using mouse models designed to replicate both stroke and dementia conditions, providing insights into how cellular communication might be harnessed for therapeutic purposes.
Watching mitochondria travel between cells
Miyamoto’s interest in mitochondrial migration began during a research fellowship at Massachusetts General Hospital and Harvard Medical School, where he first observed these cellular structures moving from one cell to another. That observation sparked the realization that mitochondrial transfer might offer treatment possibilities for various neurological conditions.
For the current study, researchers divided mice into groups and had some perform low-intensity treadmill exercise while others remained sedentary. The team then carefully tracked brain damage, movement abilities, memory function and changes in brain and muscle cells among both groups. They also measured mitochondrial levels and activity throughout the experiment.
The results showed clear advantages for the mice that exercised. These animals experienced less damage to white matter and myelin, the protective coating around nerve fibers. They also demonstrated better memory retention and movement capabilities compared to sedentary mice, while experiencing fewer complications following stroke events.
Researchers have demonstrated how mitochondria, which are abundant in muscle, could aid in stroke recovery through exercise-induced migration.(Photo courtesy of Dr. Toshiki Inaba from Juntendo University School of Medicine, Japan)
Platelets serve as cellular delivery system
The research revealed that exercise significantly increased mitochondrial production in both muscle tissue and the bloodstream. Blood platelets, typically known for their role in clotting, took on an unexpected function by capturing mitochondria from muscle cells and transporting them to the brain.
Once in the brain, these traveling mitochondria didn’t just reach neurons. They also made their way to support cells including oligodendrocytes, which produce protective myelin, and astrocytes, star-shaped cells that help form the blood-brain barrier. The mitochondria provided crucial support to cells in the damaged area and the surrounding region called the penumbra, where brain tissue remains vulnerable but potentially salvageable.
Inside these brain cells, the delivered mitochondria helped them endure low-oxygen conditions that typically cause widespread cell death after stroke. They supported the repair of white matter, the brain’s communication infrastructure, and reduced the cascade of complications that often follow stroke events.
Limited options drive search for new approaches
Current stroke treatment relies heavily on clot removal or dissolution, but these interventions only work within a narrow window after symptoms begin. Once that critical time frame passes, patients face limited therapeutic options. Physical rehabilitation and symptom management become the primary focus, yet many stroke survivors continue struggling with walking difficulties, speech problems and memory decline.
Exercise has long been recognized as beneficial for both stroke prevention and recovery. However, many stroke patients are elderly and lack the physical stamina required to exercise intensively enough to gain those protective benefits. This reality makes the search for alternative approaches particularly urgent.
Inaba acknowledged that while the research team has identified several technical and biological challenges through additional experiments, the approach holds promise for reducing neurological problems after stroke. The applications might extend beyond stroke to include mitochondrial diseases and related neurodegenerative conditions where current treatment options remain limited.
From mice to potential human therapies
The pathway from laboratory findings to clinical treatments typically spans years and requires extensive testing for safety and effectiveness. If the mitochondrial transfer approach proves successful in human trials, it could potentially allow stroke patients to receive the benefits of exercise through transfusions of platelet preparations enriched with mitochondria.
Such a treatment would be particularly valuable for patients who cannot engage in physical rehabilitation due to age, frailty or the severity of their condition. The approach might also offer hope for preventing the progression of vascular dementia, a condition that currently has no established treatments.
The research team’s work builds on growing scientific understanding of how cells communicate and share resources. By revealing the specific mechanism through which exercise protects the brain, the scientists have opened a new avenue for developing therapies that could help millions of stroke survivors worldwide maintain better neurological function and quality of life.
And you had to do a study on this? My god, the stupidity. The one and only stressor, if you are that blitheringly stupid, is there are NO 100% RECOVERY PROTOCOLS!
A qualitative study of stressors faced by older stroke patients in a convalescent rehabilitation hospital
This
study aimed to explore the stressors experienced by older patients with
stroke in convalescent rehabilitation wards in Japan. Semi-structured
interviews were conducted with four stroke patients aged > 65 years
who experienced a stroke for the first time in their lives. The
interviews were analyzed using the Steps for Coding and Theorization
method for qualitative data analysis. The results of the qualitative
analysis demonstrated that patients experienced specific stressors, such
as, difficulty in movement of the paralyzed hand, fear of stroke
recurrence, and dietary problems. Some stressors were manageable through
healthcare professionals’ active and sensitive communication
strategies. These stressors were derived from the theoretical framework
of “stressors related to hospitalization” and “stressors related to the
illness”. Additional stressors emerged from the interaction between
these two types within the theoretical framework. The results of this
study contribute to a deeper understanding of the specific stressors
experienced by older stroke patients during the recovery process.
Citation: Asada
Y, Nishio K, Iitsuka K, Yaeda J (2024) A qualitative study of stressors
faced by older stroke patients in a convalescent rehabilitation
hospital. PLoS ONE 19(8):
e0309457.
https://doi.org/10.1371/journal.pone.0309457
Editor: Chinh Quoc Luong, Bach Mai Hospital, VIET NAM
Received: February 24, 2024; Accepted: August 13, 2024; Published: August 26, 2024
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Stress is a nonspecific response of the body to external stimuli [1]. Stress varies as the stressors faced by individuals differ depending on their age, sex, and social role [2].
Stressors include physical, biological, chemical, psychological, and
social factors. The accumulation of these stressors causes stress,
which, if not adequately addressed, can lead to physical or mental
health problems, such as cardiovascular disease and depression,
respectively [3]. To prevent these stress-related diseases, it is imperative to identify and address the stressors.
Patients
often face various stressors in inpatient settings as their physical
and human environments differ significantly from those of their regular
home settings [4].
As the length of the hospital stay increases, patients may become
particularly vulnerable to stressors such as “concern for family” and
“anxiety about financial situation” [4].
The severity of a stroke, the age of the patient, and the presence of
underlying medical conditions are factors that tend to extend the
duration of hospitalization [5]. The incidence of stroke increases with age and is more common among older adults [6].
Moreover, patients present with a variety of symptoms, such as motor
paralysis and higher brain dysfunction, and their ability to perform
activities of daily living (ADL) becomes more limited. In particular,
convalescent rehabilitation hospitals have a prolonged hospital stay [7] as one of their goals is to help patients return to the community and their homes.
Much of what is known about stressors related to stroke involves the risk of stroke onset [8, 9],
and there are insufficient studies on the stressors faced by older
stroke patients in hospitals. Clarifying these unspoken stressors can
contribute to reducing the stress of hospitalization for older stroke
patients during convalescent rehabilitation, meeting their true needs,
and enriching their lives after discharge. Few studies have elicited
patients’ true feelings regarding stressors in convalescent
rehabilitation wards. The purpose of this study is to provide a deeper
understanding of the specific stressors experienced by older stroke
patients in convalescent rehabilitation wards during their hospital
stay.
Materials and methods
We
conducted a qualitative study and interviewed each participant
separately. The interview transcripts were analyzed according to the
“Steps for Coding and Theorization” method (SCAT), a sequential and
thematic qualitative data analysis technique [10–12].
This
study was conducted in accordance with the Consolidated Criteria for
Reporting Qualitative Research (COREQ), a checklist designed to improve
the transparency and reliability of qualitative research [13] (S1 Table in S1 File).
AKI, Kochi — About 40 stacks of stones resembling unique sculptures line
the coastline along more than 100 meters of a bicycle path on an
embankment that stretches from a fishing port in the city of Aki.
These stone stacks are actually a form of rehabilitation for Morimi
Nagano, who has suffered two strokes. He began stacking in March to help
regain movement in his fingers.
Nagano, 64, initially used building blocks at home as part of his
rehabilitation. However, he had become quite inactive after injuring
both knees in the summer of 2021, and was concerned at the weight he was
gaining, especially around his belly. At his doctor’s recommendation,
Nagano began going for long walks early in the morning. During one of
these walks, the stones on the beach caught his eye — and inspired him
to start stacking.
Nagano has been good with his hands since he was a child and found that
the more he stacked stones, the more his enjoyment grew. He has even
built stacks made with over 60 stones. The delicately balanced piles of
rocks are striking, and some passersby even take photos of his
creations. Although the piles frequently topple, Nagano has not lost
heart. He intends to continue stacking stones because it brings him joy
and is part of his return to full health.
1Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
2Department of Public Health, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
3Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
4Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
5Department of Neurology, Osaka General Medical Center, Osaka, Japan
6Department of Neurology, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
7Department of Neurology, Toda Chuo General Hospital, Saitama, Japan
8Department of Neurology, Saitama Red Cross Hospital, Saitama, Japan
9Department of Neurology, Showa General Hospital, Tokyo, Japan
10Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
11Department of Stroke Neurology, National Hospital Organization, Osaka National Hospital, Osaka, Japan
12Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
13Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
14Department of Neurology, Nippon Medical School, Tokyo, Japan
15Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Background: Remote ischemic
conditioning (RIC) refers to the application of repeated short periods
of ischemia intended to protect remote areas against tissue damage
during and after prolonged ischemia.
Aim: We aim to evaluate the efficacy of RIC, determined by the modified Rankin Scale (mRS) score at 90 days after stroke onset.
Design and methods: This study is an
investigator-initiated, multicenter, prospective, randomized,
open-label, parallel-group clinical trial. The sample size is 400,
comprising 200 patients who will receive RIC and 200 controls. The
patients will be divided into three groups according to their National
Institutes of Health Stroke Scale score at enrollment: 5–9, mild; 10–14,
moderate; 15–20, severe. The RIC protocol will be comprised of four
cycles, each consisting of 5 min of blood pressure cuff inflation (at
200 mmHg or 50 mmHg above the systolic blood pressure) followed by 5 min
of reperfusion, with the cuff placed on the thigh on the unaffected
side. The control group will only undergo blood pressure measurements
before and after the intervention period. This trial is registered with
the UMIN Clinical Trial Registry (https://www.umin.ac.jp/: UMIN000046225).
Study outcome: The primary outcome will
be a good functional outcome as determined by the mRS score at 90 days
after stroke onset, with a target mRS score of 0–1 in the mild group,
0–2 in the moderate group, and 0–3 in the severe group.
Discussion: This trial may help
determine whether RIC should be recommended as a routine clinical
strategy for patients with ischemic stroke.
Introduction
In recent years, hyperacute reperfusion treatment has
progressed remarkably due to the establishment of recombinant
tissue-type plasminogen activator (rt-PA) and endovascular treatment
(EVT) (1, 2).
Although Japan is proceeding with a plan to accelerate the development
of an efficient care system for stroke patients (forming new stroke
centers and stroke care units), only 6–8% of patients can receive
hyperacute reperfusion therapy (3).
In Japan, edaravone has been used as an effective method to reduce
ischemic insults. However, it is not widely used internationally; it has
yet to demonstrate sufficient efficacy (4).
Remote ischemic conditioning (RIC) is a therapeutic
strategy in which several cycles of brief focal ischemia, followed by
reperfusion in the arms or legs, confer protection against the more
severe detrimental effects of ischemia in target organs (5–8).
Although the underlying mechanisms are not fully understood, current
evidence indicates that RIC reduces inflammation, oxidative stress, and
cerebral edema, mediated by humoral, immunoregulatory, and neurotrophic
factors (9).
Although the clinical application of RIC in patients with acute
ischemic stroke has been attempted, its efficacy has not yet been
validated (10–12). Moreover, no clinical trials have been conducted on acute ischemic strokes in Japan.
One reason for the inability to confirm the efficacy of
RIC in previous studies may be the use of a unified definition of a good
outcome as assessed by the modified Rankin Scale (mRS), regardless of
the neurological severity of the enrolled patients upon admission.
Another reason may be the lack of an established RIC protocol.
Therefore, this study aims to evaluate the efficacy of an RIC protocol
based on recent literature, determined by the mRS score at 90 days after
stroke onset, with a good outcome defined according to the severity at
enrollment.
Our
Japanese colleagues deserve much praise for finishing the first
randomized clinical trial of thrombectomy in Alberta Stroke Program
Early CT Score 3 to 5 patients showing an impressive therapy effect of
thrombectomy. The predominant use of magnetic resonance imaging for
patient selection, the low rate of alteplase therapy and its low dose
limit direct comparisons with patients treated outside of Japan. Another
limitation is the lack of benefit when using the traditional
metric–modified Rankin Scale score 0–2. We consider the results of
RESCUE-Japan LIMIT encouraging and a clear motivation to continue and complete other studies.
Footnotes
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
For Sources of Funding and Disclosures, see page xxx.
Correspondence
to: Jens Fiehler, MD, Department of Neuroradiology, O22, University
Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany.
Email fiehler@uke.de
The
revised Japan Stroke Society Guidelines for the Treatment of Stroke
were published in Japanese in July 2021. In this article, the extracted
recommendation statements are published. The revision keeps pace with
the great progress in stroke control based on the recently enacted Basic
Act on Stroke and Cardiovascular Disease in Japan. The guideline covers
the following areas: primary prevention, general acute management of
stroke, ischemic stroke and transient ischemic attack, intracerebral
hemorrhage, subarachnoid hemorrhage, asymptomatic cerebrovascular
disease, other cerebrovascular disease, and rehabilitation.
The
Japan Stroke Society Guideline 2021 for the Treatment of Stroke is a
totally revised version that is developed every 6 years, with two yearly
updates in the intervening periods. The guidelines have been developed
in conjunction with Japan Neurosurgical Society, the Japanese Society of
Neurology, the Japanese Association of Rehabilitation Medicine, the
Japanese Society of Neurological Therapeutics, the Japanese Society on
Surgery for Cerebral Stroke, and the Japanese Society for
Neuroendovascular Therapy. The guideline comprises 300 pages in
Japanese. In this English version, recommendations of each topic are
extracted and introduced. The guideline consists of seven chapters. Of
these, the chapters for ischemic stroke, intracerebral hemorrhage (ICH),
and subarachnoid hemorrhage are introduced in the main text and the
other four chapters, as part of the full guideline, are presented in the
supplemental material.
Method
The
Committee for Stroke Guideline 2021, selected from the members of the
Japan Stroke Society, developed the present guideline based on the
literature searched for the guidelines up to the 2019 version (papers
published up to December 2017) and additional papers published between
January 2018 and December 2019. In the Committee, there was no
distinction between those who reviewed the literature and those who
wrote the recommendations.
Taking into consideration the level of
evidence, the balance between “benefit” and “harm” of the intervention,
the influence of patient values and other factors, and the cost of the
intervention and medical resources, the Committee members determined the
grade of recommendations (Table 1).
The level of bodies of evidence for the recommendations was determined
by the Committee members after integrating the evidence of the relevant
references (Table 2). Detailed explanation is described in “Level of Evidence and Grade of Recommendation” in the full article in the supplemental material.
Table 1. Classification of grade of recommendation by the Committee (2021).
Table 1. Classification of grade of recommendation by the Committee (2021).
Chapter 2. Ischemic stroke and transient ischemic attack
Acute ischemic stroke
Intravenous thrombolysis
Intravenous
thrombolysis with recombinant tissue-type plasminogen activator
(alteplase, 0.6 mg/kg) is recommended for patients with acute ischemic
stroke who can be treated within 4.5 h of onset and for whom the
indication has been carefully determined (Grade of recommendation: A, Level of evidence (LOE): High).
Intravenous thrombolysis should be initiated as quickly as possible (at least within 1 h of patient arrival; Grade A, LOE High).
If
the onset time is unknown, intravenous thrombolysis may be considered
for patients in whom ischemic changes on diffusion-weighted imaging are
not evident on fluid-attenuated inversion recovery imaging (Grade C, LOE Moderate).
Intravenous
recombinant tissue-type plasminogen activator other than alteplase is
not recommended at present time because of the lack of sufficient
evidence in Japan (Grade D, LOE Moderate).
(Clinical
Question) Even in patients with mild ischemic stroke, intravenous
thrombolysis may be reasonable after careful consideration of the
indications (Grade C, LOE Moderate).
Intra-arterial revascularization
In
patients with acute ischemic stroke—if they met all the following
criteria: (a) acute occlusion of the internal carotid artery or the M1
segment of the middle cerebral artery, (b) modified Rankin Scale (mRS)
score 0 or 1 before onset, (c) Alberta Stroke Program Early CT Score
(ASPECTS) ⩾ 6 in computed tomography (CT) or diffusion-weighted imaging,
(d) National Institutes of Health Stroke Scale (NIHSS) ⩾ 6, and (e)
age ⩾ 18 years, in addition to medical therapy including intravenous
thrombolysis with recombinant tissue-type plasminogen activator
(alteplase)—mechanical thrombectomy using stent retriever or aspiration
catheter within 6 h of onset (as soon as possible) is recommended (Grade A, LOE High).
In
patients with ischemic stroke due to acute occlusion of the internal
carotid artery or the M1 segment middle cerebral artery more than 6 h
from the last known well time, after the judgment of indication based on
neurological symptoms and quantitative evaluation of imaging,
mechanical thrombectomy within 16 h of the last known well time is
recommended (Grade A, LOE Moderate). In addition, the initiation of the same treatment within 16 to 24 h is reasonable (Grade B, LOE Moderate).
In
patients with acute ischemic stroke due to large artery occlusion in
the anterior circulation who have broad extent of ischemia with
ASPECTS < 6, mild symptoms with NIHSS score < 6, occlusion of the
M2 segment middle cerebral artery, or mRS score ⩾ 2 before the onset,
mechanical thrombectomy within 6 h of onset may be reasonable (Grade C, LOE Low).
In
patients with acute ischemic stroke due to the basilar artery
occlusion, mechanical thrombectomy may be reasonable if the
effectiveness is judged to outweigh the safety after careful
consideration on a case-by-case basis (Grade C, LOE Low).
In
patients with ischemic stroke due to acute occlusion of the internal
carotid artery or the M1 segment or the proximal M2 segment middle
cerebral artery, mechanical thrombectomy without intravenous
thrombolysis within 4.5 h of onset may be considerable (Grade C, LOE Moderate).
In
patients with ischemic stroke due to acute occlusion of the middle
cerebral artery who have moderate to severe neurological symptoms and no
or only minor ischemic changes on CT, selective local intra-arterial
fibrinolysis within 6 h of onset is reasonable (Grade B, LOE High).
In
patients with acute ischemic stroke due to severe stenosis or occlusion
of the intracranial artery or extracranial carotid artery, the
effectiveness of percutaneous transluminal angioplasty or stenting is
not well established (Grade C, LOE Low).
Antiplatelet therapy
In
patients with acute ischemic stroke in the early phase of onset (within
48 h), oral administration of aspirin 160 to 300 mg/day is recommended (Grade A, LOE High).
In
patients with mild non-cardioembolic stroke in the early phase of onset
up to the subacute phase (within 1 month as a rough indication),
treatment with dual antiplatelet therapy (aspirin and clopidogrel) is
recommended (Grade A, LOE High).
In patients with
non-cardioembolic stroke within 48 h of onset, cilostazol 200 mg/day as
single antiplatelet therapy or dual antiplatelet therapy with low-dose
aspirin may be considered (Grade C, LOE Moderate).
In patients with non-cardioembolic stroke, ozagrel sodium 160 mg/day may be considered (Grade C, LOE Moderate).
Anticoagulation
In
patients with non-cardioembolic and non-lacunar stroke within 48 h
after onset, intravenous administration of argatroban (selective
thrombin inhibitor) may be considered (Grade C, LOE Moderate).
In
patients with acute ischemic stroke, the use of unfractionated heparin,
low-molecular-weight heparin (unapproved in Japan), or heparinoid (not
covered by Japanese Health Care Insurance System) may be considered (Grade C, LOE Moderate).
In
patients with acute ischemic stroke who have non-valvular atrial
fibrillation (NVAF), direct oral anticoagulant (DOAC) may be considered
at an appropriate timing after considering the risk of hemorrhagic
infarction (Grade C, LOE Low).
Medication for cerebral edema
In
patients with acute major ischemic stroke due to cardioembolic stroke
or atherothrombotic infarction and who have intracranial hypertension,
intravenous hypertonic glycerol (10%) may be considered (Grade C, LOE Low).
In patients with acute ischemic stroke, mannitol (20%) may be considered (Grade C, LOE Low).
Neuroprotective agents
In patients with acute ischemic stroke, edaravone is reasonable (Grade B, LOE Moderate).
Hemodilution therapy
In patients with acute ischemic stroke, the effectiveness of plasma expander is not well established (Grade C, LOE High).
In patients with acute ischemic stroke, extracorporeal circulation is not recommended (Grade D, LOE Low).
Hyperbaric oxygen therapy
In patients with acute ischemic stroke, the effectiveness of hyperbaric oxygen therapy is not well established (Grade C, LOE Low).
Therapeutic hypothermia
In patients with acute ischemic stroke, therapeutic hypothermia is not recommended (Grade D, LOE Low).
Dyslipidemia
In patients with acute ischemic stroke, the start of HMG-CoA reductase inhibitor (statin) may be considered (Grade C, LOE Low).
In
patients with acute ischemic stroke, who were using statin before
stroke onset, discontinuation of oral statin is not recommended (Grade D, LOE Low).
Even
in patients with acute ischemic stroke, who have undergone intravenous
thrombolysis or intra-arterial revascularization, statin therapy may be
considered (Grade C, LOE Low).
Regenerative therapy
In patients with acute ischemic stroke, neural regenerative therapy is not recommended (Grade D, LOE Low).
Decompressive craniectomy
In
patients with unilateral hemispheric large infarct in the territory of
the middle cerebral artery—if they met the following criteria: (a) 18 to
60 years, (b) NIHSS score exceeds 15, (c) NIHSS Item 1a score is ⩾1,
(d) infarct in the territory of the middle cerebral artery occupies at
least 50% in CT or the range of infarct exceeds 145 cm3 in diffusion-weighted image, and (e) within 48 h after onset—decompressive craniectomy with duraplasty is recommended (Grade A, LOE High).
In
patients with infarct in the territory of the middle cerebral artery
who are aged 60 years or older, meeting the criteria for indication of
decompressive craniectomy except age, decompressive craniectomy may be
considered (Grade C, LOE Moderate).
In patients
with cerebellar infarction who have moderate consciousness disorder due
to hydrocephalus, ventricular drainage may be considered (Grade C, LOE Low).
In addition, in patients presenting severe consciousness disorder such
as coma due to compression of the brain stem, posterior fossa
decompression is reasonable (Grade B, LOE Low).
Other surgical therapy
In
patients with acute ischemic stroke, urgent surgical therapy including
carotid endarterectomy (CEA), bypass surgery, and surgical clot removal
by craniotomy may be considered (Grade C, LOE Low).
Acute and chronic management of transient ischemic attack
In
patients of suspected transient ischemic attack (TIA), evaluation of
the mechanism as soon as possible after admission and immediate
initiation of treatment for stroke prevention is recommended (Grade A, LOE High).
The use of risk prediction score (e.g. ABCD2 score) is reasonable to
predict risk of stroke and determine treatment strategy (Grade B, LOE Moderate).
In
TIA patients within 48 h after onset, aspirin 160 to 300 mg/day is
recommended for prevention of recurrence during the acute phase (Grade A, LOE High).
In high-risk TIA patients with ABCD2 score ⩾ 4, dual antiplatelet
therapy (aspirin and clopidogrel) limited to the acute phase is
reasonable (Grade B, LOE High).
In patients with
post-acute TIA, management in accordance with prevention of stroke for
patients with ischemic stroke is recommended (Grade A, LOE Moderate).
Ischemic stroke in the chronic stage
Non-cardioembolic stroke—antiplatelet therapy
Administration of antiplatelet drugs is recommended for the prevention of recurrent non-cardioembolic stroke (Grade A, LOE High).
Antiplatelet
drugs that are effective for the prevention of recurrent
non-cardioembolic stroke (available in Japan) are aspirin 75 to
150 mg/day, clopidogrel 75 mg/day, and cilostazol 200 mg/day at present
time (Grade A, LOE High), as well as ticlopidine 200 mg/day (Grade B, LOE Moderate).
Coadministration of aspirin and dipyridamole is not recommended in Japan (Grade D, LOE Moderate).
Long-term
dual antiplatelet therapy is not recommended because it is not
demonstrated to have a significant effect of stroke prevention compared
to single antiplatelet therapy, but rather increases hemorrhagic
complications (Grade D, LOE High). However, in patients with
non-cardioembolic stroke who have stenosis/occlusion of a major
extracranial or intracranial artery or two or more vascular risk
factors, dual antiplatelet therapy including cilostazol is reasonable (Grade B, LOE Moderate).
In
patients with history of ischemic stroke or TIA who undergo a procedure
or minor surgery where bleeding is easily controlled (e.g. tooth
extraction or cataract surgery), continuation of aspirin is recommended (Grade A, LOE Moderate). In addition, continuation of other antiplatelet drugs is reasonable (Grade B, LOE Low).
In patients at high risk for thromboembolism who undergo
gastrointestinal endoscopy with high risk of bleeding, replacement with
aspirin or cilostazol may be considered (Grade C, LOE Low).
Non-cardioembolic stroke—CEA
In
patients with symptomatic severe carotid artery stenosis (NASCET
70–99%), in addition to the best medical treatment including
antiplatelet therapy, CEA by an operator at an institution experienced
in surgery and perioperative management is recommended (Grade A, LOE High). In patients of severe stenosis with post stenotic collapsing (near occlusion), CEA may be also considered (Grade C, LOE Moderate).
In
patients with symptomatic moderate carotid artery stenosis, in addition
to the best medical treatment including antiplatelet therapy, CEA by an
operator at an institution experienced in surgery and perioperative
management is reasonable (Grade B, LOE High).
In
elderly patients with carotid artery stenosis for whom carotid
revascularization should be considered, CEA rather than carotid artery
stenting (CAS) is reasonable (Grade B, LOE High).
In patients with symptomatic severe or moderate carotid artery stenosis, CEA early after the onset is reasonable (Grade B, LOE Moderate).
(Clinical
Question) In patients with symptomatic mild carotid artery stenosis,
who are refractory to medical therapy, and imaging examination indicates
ulcer or unstable plaque, although its effectiveness is not well
established, CEA may be reasonable (Grade C, LOE Low).
Non-cardioembolic stroke—endovascular treatment of carotid arteries
In
patients with symptomatic severe carotid artery stenosis who have risk
factors for CEA (cardiac disease, severe respiratory disease,
contralateral carotid artery occlusion, contralateral recurrent
laryngeal nerve palsy, history of irradiation or surgical approach for
neck, restenosis after CEA), in addition to the best medical therapies
including antiplatelet therapy, CAS by an operator at an institution
experienced in surgery and perioperative management is reasonable (Grade B, LOE Moderate).
In
patients with symptomatic severe carotid artery stenosis who have no
risk factors for CEA, in addition to the best medical therapies
including antiplatelet therapy, CAS by an operator experienced at an
institution in surgery and perioperative management may be reasonable (Grade C, LOE Moderate).
Non-cardioembolic stroke—endovascular treatment of intracranial arteries
In
patients with symptomatic stenosis of intracranial artery or
extracranial vertebral artery, the effectiveness of percutaneous
transluminal angioplasty or stenting is not well established (Grade C, LOE Moderate).
In
patients with minor stroke or TIA due to symptomatic occlusion or
stenosis of internal carotid artery or middle cerebral artery, after
carefully considering its indication based on the timing of onset, age,
mRS, and quantitative assessment of cerebral circulation,
extracranial-intracranial bypass by an experienced operator with very
few perioperative complications is reasonable (Grade B, LOE Moderate).
Cardioembolic stroke—anticoagulation
In
patients with ischemic stroke or TIA and NVAF, anticoagulant therapy
with a DOAC or warfarin for prevention of stroke recurrence is
recommended (Grade A, LOE Moderate).
In patients
younger than 70 years who undergo warfarin therapy for NVAF, prothrombin
time-international normalized ratio (PT-INR) 2.0 to 3.0 is recommended (Grade A, LOE Moderate). In patients aged 70 years or older, PT-INR 1.6 to 2.6 is reasonable (Grade B, LOE Low).
In patients with ischemic stroke or TIA and NVAF who can be treated with DOACs, DOAC rather than warfarin is recommended (Grade A, LOE Moderate).
It
is recommended to select a DOAC and adjust its dosage considering the
renal function, age, body weight, and concomitant drugs (Grade A, LOE Low).
In
patients with ischemic stroke or TIA after mechanical valve
replacement, it is recommended to maintain PT-INR between 2.0 to 3.0
with warfarin (Grade A, LOE Moderate). DOAC should not be used (Grade E, LOE Moderate).
In
patients with ischemic stroke or TIA who have rheumatic mitral stenosis
and atrial fibrillation, it is recommended to maintain PT-INR between
2.0 to 3.0 with warfarin (Grade A, LOE Low).
In
patients with ischemic stroke or TIA who have cardiomyopathy or heart
failure and atrial fibrillation, anticoagulant therapy is recommended (Grade A, LOE Low).
In
patients with ischemic stroke or TIA who undergo usual tooth extraction
or gastrointestinal endoscopy, continuation of DOAC or warfarin (PT-INR
within the therapeutic range) without withdrawal is reasonable (Grade B, LOE Low).
If gastrointestinal endoscopy with high risk of bleeding is performed,
continuation of warfarin (PT-INR within the therapeutic range) is
reasonable. In patients with NVAF, it is also reasonable to consider
temporal switching to DOAC. In patients using DOAC, it is reasonable to
continue DOAC until the day before the procedure, discontinue it on the
morning of the procedure, and then resume it on the morning after the
procedure after confirming that there is no bleeding (Grade B, LOE Low).
Management of risk factors—hypertension
In patients who experience ischemic stroke or TIA, antihypertensive therapy for prevention of recurrence is recommended (Grade A, LOE High).
In
patients who experience ischemic stroke or TIA, with bilateral severe
carotid artery stenosis, occlusion of major intracranial artery, or
without vascular assessment, a target value of <140/90 mm Hg for
antihypertensive therapy is reasonable (Grade B, LOE Low).
In
patients who experience ischemic stroke or TIA, without bilateral
severe carotid artery stenosis and occlusion of major intracranial
artery, who present with lacunar infarction, or undergoing
antithrombotic therapy, as lower target value of blood pressure is
favorable if possible, a target value of <130/80 mm Hg for
antihypertensive therapy is reasonable (Grade B, LOE Moderate).
Management of risk factors—diabetes mellitus
In
patients with chronic ischemic stroke, the effectiveness of blood
glucose control for the prevention of stroke recurrence is not well
established (Grade C, LOE Moderate).
Diabetes mellitus treatment with pioglitazone, an insulin sensitizer, for the prevention of stroke recurrence is reasonable (Grade B, LOE Moderate).
Management of risk factors—dyslipidemia
In
patients with non-cardiogenic stroke or TIA, proactive administration
of HMG-CoA reductase inhibitors (statins) for prevention of recurrent
non-cardiogenic stroke or TIA is recommended (Grade A, LOE Moderate).
In
patients with non-cardiogenic stroke or TIA, a target value of
LDL-cholesterol <100 mg/dL for lipid control to prevent recurrence of
non-cardiogenic stroke or TIA is reasonable (Grade B, LOE Moderate).
In
patients with non-cardiogenic stroke or TIA and coronary artery
disease, a target value of LDL-cholesterol <70 mg/dL for stroke
prevention may be reasonable (Grade C, LOE Moderate).
In
patients with ischemic stroke under lipid control with statin,
coadministration of ethyl icosapentate product for prevention of stroke
recurrence is reasonable (Grade B, LOE Low).
Management of risk factors—obesity and metabolic syndrome
Treatment of obesity and metabolic syndrome for prevention of stroke recurrence may be considerable (Grade C, LOE Low).
Cryptogenic stroke and embolic stroke of undetermined source—antithrombotic therapy
In patients with cryptogenic stroke or embolic stroke of undetermined source, antiplatelet therapy with aspirin is reasonable (Grade B, LOE Moderate).
In patients with cryptogenic stroke or embolic stroke of undetermined source, dabigatran and rivaroxaban are not recommended (Grade D, LOE Moderate).
In
patients with cryptogenic stroke who do not have a history of
hypertension or posterior circulation infarcts not involving the
brainstem, warfarin may be considered (Grade C, LOE Low).
In
patients with cryptogenic stroke and embolic stroke of undetermined
source who have aortic atheromatous lesion, warfarin (PT-INR ⩾ 1.5)
instead of aspirin may be considered (Grade C, LOE Low).
Paradoxical embolic stroke including cryptogenic stroke with patent foramen ovale (PFO)
In
patients with paradoxical embolic stroke (definite or suspected), it is
recommended to consider a policy for prevention of stroke recurrence
based on reliable pathophysiological diagnosis by stroke specialist (Grade A, LOE Low).
In addition, it is also recommended to decide treatment policy through a
process of shared decision-making involving stroke specialist,
cardiologist, and patients (Grade A, LOE Low).
In
patients with embolic stroke of undetermined source suspected of
involving PFO, either antiplatelet therapy or anticoagulation for
prevention of stroke recurrence is reasonable (Grade B, LOE Moderate). In patients with venous thromboembolism, anticoagulant therapy is recommended (Grade A, LOE Low). Even in patients without venous thromboembolism, anticoagulant therapy rather than antiplatelet therapy may be considered (Grade C, LOE Moderate).
In
patients younger than 60 years old with cryptogenic stroke suspected of
involving PFO (including definitive paradoxical embolism), percutaneous
PFO closure is reasonable (Grade B, LOE High). Especially, in
patients with high-risk PFO (e.g. large shunt or atrial septal
aneurysm), percutaneous PFO closure is recommended (Grade A, LOE High).
In
patients aged 60 years or older with cryptogenic stroke suspected of
involving PFO (including definitive paradoxical embolism), the
effectiveness of percutaneous PFO closure is not well established (Grade C, LOE Low).
Continuation of antithrombotic therapy after percutaneous PFO closure is reasonable (Grade B, LOE Low).
In
patients with paradoxical cerebral embolism due to pulmonary
arteriovenous fistula, percutaneous closure of pulmonary arteriovenous
fistula to prevent stroke recurrence is reasonable (Grade B, LOE Low).
Cerebral metabolism/circulation improving drug
In patients with sequela of ischemic stroke such as dizziness, ibudilast may be considered (Grade C, LOE Low).
Elevated hematocrit or fibrinogen level
In patients with ischemic stroke, treatment of elevated hematocrit level is not recommended (Grade D, LOE Low).
In patients with ischemic stroke, treatment of elevated fibrinogen level may be considered (Grade C, LOE Low).
Regenerative therapy
In patients with chronic ischemic stroke, neural regenerative therapy is not recommended (Grade D, LOE Low).
Chapter 3. Intracerebral hemorrhage
Prevention of ICH
In patients with hypertension, antihypertensive therapy for prevention of ICH is recommended (Grade A, LOE High).
It is reasonable to instruct heavy drinkers to reduce their alcohol consumption and smokers to quit smoking (Grade B, LOE Moderate).
In
patients who require prophylactic treatment for thromboembolism, the
selection of antithrombotic drugs considering the risk of ICH is
reasonable (Grade B, LOE High).
Acute management for hypertensive ICH
Management of blood pressure
In
patients with acute ICH, it is reasonable to lower elevated blood
pressure to systolic blood pressure <140 mm Hg as early as possible
and maintain this limit for 7 days (Grade B, LOE Moderate). Maintaining a lower systolic blood pressure limit of >110 mm Hg may be reasonable (Grade C, LOE Low).
Intensive
antihypertensive therapy to reduce systolic blood pressure by >90 mm
Hg is not recommended to avoid acute kidney injury (Grade D, LOE Moderate).
Continuous intravenous infusion of calcium antagonist or nitrate is reasonable as antihypertensive drugs for acute ICH (Grade B, LOE Low). The appropriate use of nicardipine among calcium antagonists may be reasonable (Grade C, LOE Low).
Early switching to oral antihypertensive drugs, if possible, may be reasonable (Grade C, LOE Low).
Hemostatic therapy
In patients with hypertensive ICH, administration of tranexamic acid may be considered (Grade C, LOE Moderate).
In
patients of acute hypertensive ICH without abnormality in coagulation
system and without antithrombotic therapy, blood products including
coagulation factors should not be administered (Grade E, LOE High).
Management of brain edema and intracranial hypertension
In patients with acute ICH who have intracranial hypertension, intravenous hypertonic glycerol may be considered (Grade C, LOE Low).
In
patients with progressive increase of intracranial pressure due to
hematoma or edema, and with worsening of clinical findings associated
with compression on surrounding tissues, intravenous administration of
mannitol may be considered (Grade C, LOE Moderate).
In patients with acute ICH who had brain edema, administration of corticosteroid is not recommended (Grade D, LOE High).
In
patients with intracranial hypertension due to acute ICH, it may be
considerable to elevate head and upper body position by 30° (Grade C, LOE Low).
Management of chronic hypertensive ICH
Hypertension
In
patients after hypertensive ICH, a target value of <130/80 mm Hg for
antihypertensive therapy is reasonable as poor blood pressure control
often causes recurrent ICH (Grade B, LOE Moderate).
In
patients at high risk of ICH recurrence, more intensive
antihypertensive therapy with a target value of <120/80 mm Hg may be
reasonable (Grade C, LOE Low).
It is reasonable to
consider complication of microbleeds, use of antithrombotic drugs, and
age, to select patients at high risk of ICH recurrence (Grade B, LOE Moderate).
Surgical treatment for hypertensive ICH
Craniotomy and neuroendoscopic surgery
In
patients with minor hemorrhage of hematoma volume <10 mL or mild
neurological symptoms, regardless of location of hematoma, surgical
treatment should not be performed (Grade E, LOE Moderate). In addition, in patients with deep coma (Japan Coma Scale 300), hematoma evacuation is not recommended (Grade D, LOE Low).
In
patients with intracerebral or intraventricular hemorrhage who are
considered for surgical treatment, neuroendoscopic surgery or
stereotactic hematoma evacuation may be considered (Grade C, LOE Moderate).
Putaminal
hemorrhage: In patients with moderate neurological symptoms, hematoma
volume ⩾ 31 mL, and severe compression findings due to hematoma,
hematoma evacuation may be considered (Grade C, LOE Moderate). In patients with consciousness disorder of about Japan Coma Scale 20 to 30, stereotactic hematoma evacuation is reasonable (Grade B, LOE Moderate), and craniotomy with hematoma evacuation or neuroendoscopic surgery may be also considered (Grade C, LOE Moderate).
Thalamic hemorrhage: Hematoma evacuation as treatment in acute phase is not recommended (Grade D, LOE Low).
Lobar hemorrhage: In patients with hematoma located at a depth of ⩽1 cm from brain surface, surgery may be considered (Grade C, LOE Moderate).
Cerebellar
hemorrhage: In patients with hematoma of ⩾3 cm in the maximum diameter,
and with worsening neurological symptoms, or in patients with
obstructive hydrocephalus due to compression on brainstem by hematoma,
hematoma evacuation is reasonable (Grade B, LOE Low).
Brainstem hemorrhage: hematoma evacuation in the acute phase is not recommended (Grade D, LOE Low).
In patients suspected of obstructive hydrocephalus due to intraventricular hemorrhage, ventricular drainage is reasonable (Grade B, LOE Moderate). Intraventricular administration of fibrinolytic drugs for hematoma evacuation may be also considered (Grade C, LOE Moderate).
Non-hypertensive ICH
Arteriovenous malformation
For
unruptured cerebral arteriovenous malformation (AVM), medical therapy
for symptoms may be considered rather than surgical intervention (Grade C, LOE Moderate).
In some cases, intervention by surgical excision, endovascular
embolization, or radiosurgery alone or by the combination thereof may be
considered (Grade C, LOE Low).
Re-hemorrhage
often occurs in cerebral AVM with hemorrhage. In such case, surgical
excision, stereotactic radiosurgery, or endovascular embolization alone
or by the combination thereof may be considered together with the
treatment of acute ICH by taking the bleeding risk and surgical risk
into consideration (Grade C, LOE Low).
If the risk
of surgical excision is high and the lesion is small (⩽10 mL in volume
or ⩽3 cm in maximum diameter), stereotactic radiosurgery may be
considered (Grade C, LOE Low).
For Spetzler-Martin Grade I and II AVMs, surgical excision may be considered (Grade C, LOE Low).
For Spetzler-Martin Grade III AVMs, surgical excision or a combination
of endovascular embolization and subsequent surgical excision may be
considered (Grade C, LOE Low). For Spetzler-Martin classification Grade IV and V AVMs, conservative therapy may be considered (Grade C, LOE Low).
For
cerebral AVMs with convulsion, surgical excision and stereotactic
radiosurgery may be considered to suppress epileptic seizure (Grade C, LOE Low).
Dural arteriovenous fistula (dAVF)
For
asymptomatic dAVF without reflux to cortical veins in cerebral
angiography, conservative observation with regular follow-up using MRI
may be considered (Grade C, LOE Moderate).
For
symptomatic dAVF or dAVF with reflux to cortical veins in cerebral
angiography, active treatment with endovascular therapy, surgical
excision, or stereotactic radiosurgery alone or a combination thereof
may be considered depending on the site or hemodynamics (Grade C, LOE Moderate).
Although
endovascular therapy is the first choice for the transverse/sigmoid
sinus dAVF, combination with surgical excision and stereotactic
radiosurgery may be considered if occlusion cannot be achieved (Grade C, LOE Low).
For the cavernous sinus dAVF, endovascular embolization may be considered (Grade C, LOE Low).
For the dAVF at the anterior cranial fossa, tentorium, or craniocervical junction, surgical excision may be considered (Grade C, LOE Low).
If surgical excision is difficult, a combination of surgical excision
and endovascular therapy or endovascular therapy alone may be considered
(Grade C, LOE Low).
Cavernous hemangioma
For asymptomatic solitary cavernous hemangioma, it is reasonable to perform conservative observation (Grade B, LOE Moderate).
If it is located in a non-eloquent area enabling easy approach,
surgical excision may be considered to prevent future hemorrhage (Grade C, LOE Low).
For
symptomatic cavernous hemangioma (hemorrhage, poorly controlled
convulsion, and progressive neurologic symptoms) where the lesion is
located near the brain surface including the brain stem, surgical
excision may be considered (Grade C, LOE Low).
For
symptomatic cavernous hemangioma located in a surgically unresectable
deep region including the brain stem, stereotactic radiosurgery may be
considered with a low radiation dose to prevent re-hemorrhage (Grade C, LOE Moderate).
Developmental venous anomaly
Developmental venous anomaly is generally benign, and it is reasonable to follow up conservatively if asymptomatic (Grade B, LOE Low).
Other
vascular malformations, such as cavernous hemangioma, may be
complicated with symptomatic developmental venous anomaly including
cases with hemorrhagic onset. In such cases, it is not recommended to
surgically resect developmental venous anomaly responsible for normal
venous reflux (Grade D, LOE Low).
Stereotactic
radiosurgery is not recommended for developmental venous anomaly because
of the low therapeutic effect and the high risk for complications (Grade D, LOE Low).
ICH associated with brain tumor
If
severe visual disturbance/visual field defect, oculomotor nerve palsy,
or consciousness disorder is noted due to pituitary apoplexy, it may be
considerable to perform surgical excision (Grade C, LOE Low). It may be considerable to perform surgical excision in the early phase of onset (Grade C, LOE Low).
In
ICH associated with metastatic brain tumor, surgical therapy may be
considered if the tumor and hematoma cause the mass effect and the
cancerous foci outside the brain are controlled (Grade C, LOE Low).
ICH associated with antithrombotic therapy
It
is reasonable to administer prothrombin complex concentrate to patients
with ICH taking a vitamin K antagonist (warfarin) with the PT-INR of
⩾2.0 (Grade B, LOE Moderate). In such cases, it is reasonable to administer vitamin K together to avoid a re-increase in PT-INR (Grade B, LOE Low).
It is reasonable to administer idarucizumab to patients with ICH taking a direct thrombin inhibitor (dabigatran; Grade B, LOE Low). Platelet transfusion is evenly not recommended for patients with ICH taking antiplatelet agents (Grade D, LOE Moderate).
Administration of protamine sulfate may be considered for patients with ICH during infusion of unfractionated heparin (Grade C, LOE Low).
For
ICH during thrombolytic therapy, it may be considered to evaluate
coagulation factor disorder and correct it with the use of appropriate
blood product, and so on (Grade C, LOE Low).
Antithrombotic
therapy should be basically discontinued to patients with ICH receiving
antithrombotic therapy. If blood pressure is high, it may be considered
to lower the systolic blood pressure to <140 mm Hg (Grade C, LOE Low).
It
may be considered to inhibit absorption by oral activated charcoal or
enhance diuretic excretion by fluid loading to patients with ICH shortly
after the last dose of DOACs (Grade C, LOE Low).
After
ICH, during antithrombotic medication, it is reasonable to resume the
use of antithrombotic agents taking the re-hemorrhage risk into
consideration (Grade B, LOE Moderate).
ICH associated with chronic kidney disease and end-stage renal disease
For
acute ICH in patients with chronic kidney disease, it is reasonable to
lower blood pressure intensively while paying attention to worsening of
renal function due to excess reduction of blood pressure (Grade B, LOE Low).
For patients on hemodialysis, it may be considered to avoid hemodialysis during the initial 24 h after onset of ICH (Grade C, LOE Low).
In addition, it may be considered to select peritoneal dialysis or
continuous hemofiltration (and continuous hemodiafiltration) rather than
hemodialysis and switch continuous hemofiltration through intermittent
hemofiltration or continuous hemodiafiltration to maintain hemodialysis
while observing the stabilization of neurologic symptoms (Grade C, LOE Low).
Nafamostat
mesylate may be considered as an anticoagulant during hemodialysis, and
it has a shorter half-life and a lower risk of hemorrhagic
complications than unfractionated heparin (Grade C, LOE Low).
Chapter 4. Subarachnoid hemorrhage
Prevention of aneurysm rupture
To
prevent the onset of subarachnoid hemorrhage, smoking cessation, blood
pressure control, and alcohol savings or avoidance is recommended (Grade A, LOE Moderate).
Initial managements
In
aneurysmal subarachnoid hemorrhage, rapid and appropriate diagnosis and
treatment by specialists are recommended since delayed diagnosis leads
to poor outcome (Grade A, LOE Low).
When noncontrast head CT cannot detect subarachnoid hemorrhage, MR imaging or lumbar puncture is reasonable (Grade B, LOE Moderate).
When
the diagnosis of aneurysmal subarachnoid hemorrhage is made, it is
reasonable to keep the patient at rest and avoid invasive tests or
procedures immediately after onset to avoid rebleeding (Grade B, LOE Moderate).
It is reasonable to provide adequate pain relief and sedation to prevent rebleeding (Grade B, LOE Low). In mild- or moderate-grade cases, it is reasonable to lower the systolic blood pressure to <160 mm Hg (Grade B, LOE High).
In
poor-grade cases, the maintenance of cerebral circulation is important,
and it is reasonable to administer hyperosmotic diuretics and manage
systemic circulation paying attention to cardiopulmonary complications (Grade B, LOE Low).
When
no vascular abnormality is found on admission examination, it is
reasonable to repeat the examination later with a certain interval (Grade B, LOE Low).
Treatments of ruptured aneurysms
Microsurgical
repair with open surgery or endovascular treatment should be performed
to prevent rebleeding from the ruptured aneurysms (Grade A, LOE Low).
It
is reasonable to decide whether to treat the cerebral aneurysm with
open surgery or endovascular treatment based on the overall findings of
the patient and the cerebral aneurysm (Grade B, LOE Moderate).
It
is reasonable to perform open surgery or endovascular treatment to
prevent rebleeding within 72 h after the onset in World Federation of
Neurosurgical Societies (WFNS) Grade I to III patients without any
limitations of age, systemic complications, or difficulty of treatment (Grade B, LOE Moderate).
In
patients with WFNS Grade IV, the adequacy of open surgery or
endovascular treatment may be determined, considering the patient’s age
and the location of the aneurysm (Grade C, LOE Low).
In
patients with WFNS Grade V, open surgery or endovascular treatment may
be considered when their neurological conditions improve after admission
(Grade C, LOE Low).
Open surgery for ruptured aneurysms
Timing of open surgery
It is reasonable to perform open surgery within 72 h after the onset of subarachnoid hemorrhage (Grade B, LOE Moderate).
If the patient is admitted after 72 h of onset, open surgery may be performed after the delayed vasospasm period has passed (Grade C, LOE Low).
Procedures of open surgery
For microsurgical repair of aneurysms, neck clipping is recommended using specialized clips (Grade A, LOE Low).
In
patients with unclippable aneurysms, it may be reasonable to perform
aneurysm trapping or proximal parent artery occlusion with surgical
revascularization as necessary (Grade C, LOE Low).
If
any of the above treatments are not feasible to achieve, it is
reasonable to perform aneurysm coating or wrapping to reinforce the
aneurysm wall (Grade B, LOE Low).
Perioperative managements of open surgery
Induced
hypotension during open surgery may reduce the risk of aneurysm
rupture, but the effect of excessive hypotension is not well established
(Grade C, LOE Low).
It is reasonable to avoid hyponatremia during perioperative period in acute phase of aneurysmal subarachnoid hemorrhage (Grade B, LOE Low). It may be reasonable to maintain circulating blood volume and serum protein concentration within the normal ranges (Grade C, LOE Low).
Endovascular treatment for ruptured aneurysms
Timing of endovascular treatment
It is reasonable to perform endovascular treatment as early as possible after the onset of subarachnoid hemorrhage (Grade B, LOE Moderate).
Procedures of endovascular treatment
It is reasonable to perform coil embolization when suitable based on the location, shape, and size of the aneurysm (Grade B, LOE Moderate).
It is reasonable to obtain highest possible obliteration rate using appropriate assisting measures (Grade B, LOE Moderate).
Perioperative managements of endovascular treatments
When
ischemic complications are suspected after endovascular treatment is
completed, it may be reasonable to promptly search for the cause and
treat it (Grade C, LOE Moderate).
In chronic
stage, it is reasonable to follow up for a long period by paying
attention to the density of coil mass, the recanalization of aneurysms
or obliterated arteries, and the regrowth of aneurysms (Grade B, LOE Moderate).
Conservative treatments
If
surgical or endovascular treatment is not performed, it is recommended
to prevent rebleeding with conservative treatment as much as possible (Grade A, LOE Low).
Prevention
of vasospasm-induced delayed cerebral ischemia, managements of
cardiopulmonary function and nutrition, and prevention of infection are
recommended (Grade A, LOE Low).
In chronic stage, it is recommended to prevent hydrocephalus with suitable procedures (Grade A, LOE Low).
Treatment for delayed cerebral vasospasm
It is reasonable to remove subarachnoid clots with a cisternal drainage after open surgery (Grade B, LOE Moderate). Lumbar drainage or external ventricular drainage may be reasonable after endovascular treatment (Grade C, LOE Low).
Intravenous administration of fasudil or ozagrel sodium is reasonable to prevent delayed cerebral vasospasm (Grade B, LOE Low).
Triple H (hypervolemia, hemodilution, and hypertension) therapy may be considered to improve impaired cerebral hemodynamics (Grade C, LOE Low).
Alternatively, hyperdynamic therapy may be considered to maintain
normal circulating blood volume and enhance cardiac function (Grade C, LOE Low).
Endovascular
treatments such as selective intra-arterial administration of
vasodilators or percutaneous transluminal angioplasty may be considered (Grade C, LOE Moderate).
Chapter 5. Asymptomatic cerebrovascular disease
Chapter 6. Other cerebrovascular diseases
Chapter 7. Rehabilitation for subacute to chronic stroke
Declaration of conflicting interests The
author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Disclosures All
the authors completed the declaration of their conflicts of Interest
(COIs) to the office of the Japan Stroke Society. COIs for all the
authors are below the maximum amount for the inauguration of committee
members of guidelines in the Japanese Association of Medical Sciences
COI Management Guideline.
Kentaro Ishizuka
Takao Hoshino
Sono Toi1, 
Megumi Hosoya
Yasuto Sato
Yoshiki Yagita
Kenichi Todo
Manabu Sakaguchi
Takashi Ohashi
Kenji Maruyama
Ryosuke Doijiri
Hiroshi Yamagami
Yasuyuki Iguchi
Teruyuki Hirano
Kazuo Kitagawa
