2018年 · 第51卷第04期

In the past 20 years, the introduction of evidence-based medicine in the field of stroke for clinical diagnosis, treatment and clinical research has been widely recognized by experts, scholars and clinicians at home and abroad. Reference to evidence-based guidelines, consensus or pathways for standardized and individualized diagnosis and treatment of stroke has become a trend. However, despite the huge number of clinical studies published in China, the evidence of our own large-sample, high-quality randomized controlled trials that can be recognized as cited by the guidelines is still very limited^[1,2]。 How can clinicians use valuable clinical resources more rationally, provide more high-quality evidence for hot, difficult and controversial issues in clinical practice, and publish it in a standardized way, so as to ultimately promote the progress of clinical medicine and improve human health? Faced with this urgent problem, this issue published the "Consensus on Clinical Research Standards of Acute Stroke in China 2018" formulated by the Neurology Branch of Chinese Medical Association and its Cerebrovascular Disease Group^[3]It is hoped that it can provide a reference for clinicians to effectively carry out clinical research on acute stroke at the bedside. In this paper, we introduce the concept and connotation of PICOS elements from the perspective of clinicians (rather than methodologists), and discuss the key common issues in the consensus as follows.

Cerebral hemorrhage is a major disease that causes human death and disability, but there is still a lack of effective treatment. Recent studies have found that most patients with cerebral hemorrhage have hematoma enlargement at the early stage of onset, and early hematoma enlargement is an important cause of aggravation and poor prognosis of cerebral hemorrhage^[1]。 How to reduce hematoma enlargement in early stage of cerebral hemorrhage is a key problem in the treatment of acute cerebral hemorrhage. Hypertension is undoubtedly an important factor in cerebral hemorrhage and hematoma enlargement, and appropriate control of hypertension has become the main strategy in the treatment of acute cerebral hemorrhage. However, what level of blood pressure should be lowered to the best level is still controversial in academic circles.

Since the 21st century, with the clinical practice of standardized prevention and treatment of cerebrovascular diseases and the urgent demand for clinical research evidence in health decision-making, the continuous increase of national investment in scientific research and the unprecedented attention of domestic universities and hospitals to scientific research, the research of cerebrovascular diseases in China has entered a new era. However, according to the years of review experience of many experts, among the large number of cerebrovascular disease studies, there are still few high-quality clinical studies that are recognized at home and abroad and can be used as guidelines, which is seriously disproportionate to the current scientific research investment and the number of papers. In order to standardize the clinical research of stroke and improve the research quality, as early as 1986, the Chinese Neuropsychiatric Society (the predecessor of the Neurology Branch of the Chinese Medical Association) adopted the "Suggestions on the Clinical Research of Stroke" at the Second National Academic Conference on Cerebrovascular Diseases held in Yangzhou^[1], and was published in the 1988 Chinese Journal of Neuropsychiatry^[2]。 Subsequently, 7 scales related to the study were revised, organized and published^[3]These research specifications have not been revised for more than 30 years. In order to further improve the clinical research level and quality of cerebrovascular diseases in China and output more clinical research evidence that can be recognized internationally and domestically, since 2015, the Neurology Branch of Chinese Medical Association and its Cerebrovascular Disease Group organized experts to write the "Consensus on Clinical Research Standards of Acute Stroke in China". After many discussions and extensive solicitation of opinions, this consensus was repeatedly revised, hoping to provide a reference for the majority of medical staff who encounter problems in clinical work and are interested in solving problems through clinical research.

Hemichorea is caused by the contraction of proximal and distal muscles, limited to the rapid, irregular, unconscious dance-like movements of one limb and face, mainly secondary to diabetes, stroke, brain tumor, cerebral cortical degeneration, rheumatic fever, trauma, and postoperative thalamus. Poststroke hemichorea is mostly caused by extrapyramidal basal ganglia or subthalamic nucleus lesions. There are rare cases of hemichorea caused by frontal or occipital lobe infarction abroad. At present, there are no related reports of hemichorea caused by cortical stroke in China. A case of acute hemichorea presenting as a small infarction of frontal cortex admitted to us is reported as follows.

1eukoencephalopathy with cerebral calcifications and cysts (LCC) is a clinical syndrome characterized by white matter degeneration, calcification and cystic degeneration on imaging. LCC was created in 1996 by Labrune et al.^[1]It was first reported, and then there were scattered reports all over the world. In recent years, two cases of LCC were diagnosed and treated in our hospital, which are now reported as follows.

Cerebral hemorrhage refers to primary non-traumatic intraparenchymal hemorrhage. The annual incidence of cerebral hemorrhage in the world is (10~30) /100,000, accounting for 10% ~15% of all strokes^[1]。 The incidence of cerebral hemorrhage in Asia and low-income countries is about twice that of developed countries in Europe and America, and it is increasing year by year^[2]。 Despite the active exploration of surgical and medical drug therapy, the intervention and treatment measures for patients with cerebral hemorrhage are still widely controversial and have little effect on long-term neurological recovery^[3]。 Clearer clarification of the pathological process of brain tissue injury after cerebral hemorrhage can help us out of this predicament. Many clinical studies have confirmed that there are different degrees of hypoperfusion in the tissues around hematoma after cerebral hemorrhage and affect the prognosis of patients^[4,5,6,7]。 At the same time, most studies in recent years have shown that intensive antihypertensive management after cerebral hemorrhage is safe and effective, but it is still doubtful whether it will cause hypoperfusion of brain tissue and cause secondary brain injury^[8]。 Therefore, the study and evaluation of cerebral blood flow perfusion in patients with cerebral hemorrhage is particularly important. In view of this, we summarize and discuss the recent clinical studies on the changes of cerebral blood flow perfusion after cerebral hemorrhage.

Approximately 75% of stroke patients experience increased blood pressure after stroke, with 56% having systolic blood pressure ≥140 mmHg (1 mmHg =0.133 kPa) and 13% having systolic blood pressure ≥185 mmHg^[1]。 2014 Fischer et al.^[2]A population-based study showed that the blood pressure of patients after the onset of stroke increased by an average of 40.7 mmHg. Cerebral hemorrhage is the most important subtype of stroke, and the blood pressure increase of patients with cerebral infarction is more significant than that of cerebral infarction (the mean first systolic blood pressure after the onset is 189.8 mmHg and 158.5 mmHg), and it can still be maintained at a high level for days or even weeks after the onset. Many observational studies have confirmed that the higher the blood pressure in the acute phase of cerebral hemorrhage, the more likely it is to increase the neurological deterioration, the worse the prognosis, and the higher the mortality rate^[3,4]。 A Multi-center Large Sample Cohort Study in China^[5]It is shown that the systolic blood pressure exceeds 140-150 mmHg within 12 h after the onset of cerebral hemorrhage, and the risk of death or disability of patients is doubled. However, the timing of lowering blood pressure and the target of blood pressure control in the acute phase of cerebral hemorrhage are still controversial. One view is that the increase of blood pressure can promote the enlargement of hematoma and the increase of edema around hematoma, which will promote the poor outcome of patients^[6,7]。 Another view is that low blood pressure control in the acute phase of cerebral hemorrhage can lead to ischemic damage to the brain tissue around the hematoma^[8,9,10]。 Therefore, giving "reasonable" blood pressure management to patients in the acute phase of cerebral hemorrhage is of great significance for curbing early neurological deterioration and improving later clinical prognosis. We will mainly review the possible mechanism of blood pressure increase in the acute phase of cerebral hemorrhage, the safety and prognosis of intensive antihypertensive, the correlation between blood pressure control and hematoma enlargement, and the choice of antihypertensive drugs.

On April 6-8, 2017, the 17th China Cerebrovascular Disease Conference (CCCD) 2017 was held in Xiamen, Fujian Province. This conference was sponsored by Chinese Medical Association and Neurology Branch of Chinese Medical Association, and hosted by Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association, Neurology Branch of Fujian Medical Association and Xiamen Medical Association. The opening ceremony was presided over by Professor Wang Ning, Standing Committee Member of Neurology Branch of Chinese Medical Association and Chairman of Neurology Branch of Fujian Medical Association. Professor Liu Ming, head of cerebrovascular diseases group of Neurology Branch of Chinese Medical Association, Professor Cui Liying, chairman of Neurology Branch of Chinese Medical Association, Professor Chen Xiaochun, deputy director of Fujian Provincial Health and Family Planning Commission, and Su Zhi, secretary of the Party Committee and vice president of Chinese Medical Association, respectively delivered speeches to the conference.

The Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association, known internationally as "Chinese Stroke Society (CSS)", was formally established in Beijing in July 2002. So far, the cerebrovascular disease group has lasted for 6 sessions (see Annex 1 for the list of members of previous cerebrovascular disease groups, and see the information of previous national cerebrovascular disease conferences sponsored by the Neurology Branch of Chinese Medical AssociationTable 1The guidelines/consensus published by previous cerebrovascular groups are shown in Annex 2).