Highlights

The clinical management of ischaemic cerebrovascular diseases comprises a total of 287 recommendations, including 136 new recommendations and 15 revised recommendations from the version in 2019. These highlights reflect significant new therapeutic options developed in recent times that will impact the daily management of patients with acute ischaemic stroke (AIS).

Reperfusion therapy

Tenecteplase (TNK) 0.25 mg/kg intravenous push has been proven non-inferior to intravenous standard dosage of recombinant tissue plasminogen activator (rt-PA) to treat patients with AIS with <4.5 hours of onset (Section 3.1).

For patients with anterior circulation large vessel occlusion (LVO) type of AIS who present within 4.5 hours of symptom onset, the efficacy of intravenous TNK (0.25 mg/kg) is non-inferior to intravenous rt-PA (0.9 mg/kg) before intra-arterial (IA) mechanical thrombectomy (MT). The TNK might offer better reperfusion outcomes, while the incidence of symptomatic intracerebral haemorrhage (sICH) remains similar (Section 3.1).

For patients with AIS with anterior circulation LVO and a large core infarct within 24 hours of onset and who meet the inclusion criteria of the RESCUE-Japan LIMIT, ANGEL-ASPECT and SELECT 2 trials, IA MT is recommended (Section 3.2).

For patients with acute basilar artery occlusion (BAO) within 6 hours of onset who meet the inclusion criteria of the ATTENTION trial, IA MT is recommended (Section 3.2).

Patients with acute BAO within 6–12 hours of onset are recommended for IA MT when they meet the inclusion criteria of the ATTENTION or BAOCHE trials (Section 3.2).

Patients with acute BAO within 12–24 hours of onset are recommended for MT when they meet the inclusion criteria of the BAOCHE trial (Section 3.2).

Antiplatelet therapy

Intravenous tirofiban can be beneficial in those patients who meet the RESCUE BT2 trial inclusion criteria (Section 4.1).

For patients with non-cardioembolic minor ischaemic stroke (IS) (National Institutes of Health Stroke Scale (NIHSS) score ≤3) or high-risk transient ischaemic attack (TIA) (ABCD2 score ≤4) who present within 24 hours of symptom onset, if CYP2C19 gene testing can be tested and the patient carries CYP2C19 loss-of-function (LoF) alleles, ticagrelor plus aspirin for 21 days (ticagrelor loading dose of 180 mg on the first day, followed by 90 mg two times per day) and continue with ticagrelor monotherapy (90 mg two times per day) for 90 days are recommended (Section 4.2).

For patients with moderate IS (NIHSS score of 4–5) who present within 24 hours of symptom onset, ticagrelor plus aspirin for 30 days (ticagrelor loading dose of 180 mg on the first day, followed by 90 mg two times per day) may reduce the risk of recurrent stroke and death within 30 days (Section 4.2).

Brain cytoprotection

Brain cytoprotection with edaravone dexborneol (intravenous 37.5 mg/dose, once every 12 hours, for 14 days) may improve clinical outcomes in patients with AIS (Section 5.1).

DL-3-n-butylphthalide (NBP), 25 mg, dissolved in 100 mL sodium chloride and given as intravenous injection two times per day for the first 14 days, followed by soft 0.2 g capsules of NBP three times a day for the next 76 days, may serve as an adjunct treatment to reperfusion therapy and have the potential to improve functional outcomes in patients with AIS (Section 5.1).

Risk factor management

For patients who cannot tolerate statins or have contraindications to statin therapy, the use of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors or ezetimibe may be considered (Section 9.2).

For patients with IS or TIA with fasting triglycerides (TG) ≥135 mg/dL (1.52 mmol/L), who have received moderate or high-intensity statin therapy, a glycated haemoglobin (HbA1c) level <10%, and no history of pancreatitis, atrial fibrillation, or severe heart failure, treatment with icosapent ethyl (2 g two times per day) can reduce the risk of stroke recurrence (Section 9.2).

Introduction

The incidence of stroke in the Chinese population continues to rise, accounting for nearly one-fourth of the global annual stroke cases.1 Among adults aged 40 years or above in China, IS accounted for approximately 86.8% of all strokes.2 Timely updates to the guidelines can provide new evidence-based recommendations for diagnosis, acute-phase treatment, prevention and management of complications, and secondary prevention for IS.3

Since the publication of the 2019 Chinese Stroke Association (CSA) guidelines, notable advancements have emerged in acute-phase reperfusion therapy and antiplatelet treatments for secondary IS prevention. The findings of several high-quality randomised controlled trials (RCTs) conducted in China will have an impact on stroke care.4–6 Some new lipid-lowering agents are also helpful in stroke prevention.

We conducted a comprehensive search of MEDLINE (via PubMed) up to 31 August 2023, and compiled the relevant information into a tabular format. The writing team established the level of recommendation through multiple rounds of online and offline discussions. Each recommendation was graded using the evidence grading algorithm developed by the CSA (table 1). The updated guideline kept the nine sections: definitions, emergency assessment and diagnosis, reperfusion therapy, antiplatelet therapy, other treatments in the acute phase, general supportive treatment and management of complications, early evaluation of the aetiology and pathogenesis, interventions targeting aetiology and pathogenesis, risk factor management and long-term intervention.

Table 1

The recommended classification and levels of evidence developed by the Chinese Stroke Association

Section 1: definitions associated with ischaemic cerebrovascular diseases

The definitions associated with ischaemic cerebrovascular diseases are shown in table 2.

Table 2

Relative definitions of ischaemic cerebrovascular disease

Section 2: emergency assessment and diagnosis of patients with AIS

The acute care process for patients with AIS is shown in figure 1. The emergency diagnostic and examination process flow chart for patients with AIS is shown in figure 2.

Figure 1

The acute care process for patients with acute ischaemic stroke. BP, blood pressure; CTA, CT angiography; CXR, chest X-ray; DBP, diastolic BP; IA, intra-arterial; INR, international normalised ratio; IV, intravenous; LVO, large vessel occlusion; MT, mechanical thrombectomy; NIHSS, National Institutes of Health Stroke Scale; SBP, systolic BP; SCR, serum creatinine; TIA, transient ischaemic attack.

Figure 2

The emergency diagnostic and examination process flow chart for patients with acute ischaemic stroke (AIS). CTA, CT angiography; MRA, magnetic resonance angiography; US, ultrasonography.

Section 3: reperfusion therapy for AIS

The management process of intravenous thrombolysis for patients with AIS within 4.5 hours of symptom onset is shown in figure 3. The management process of intravenous thrombolysis for patients with AIS with an onset between 4.5 and 9 hours or wake-up stroke is shown in figure 4. The flow chart for IA MT in patients with AIS is shown in figure 5.

Figure 3

The management process of intravenous (IV) thrombolysis for patients with acute ischaemic stroke (AIS) within 4.5 hours of symptom onset. CTA, CT angiography; IA, intra-arterial; LVO, large vessel occlusion; MT, mechanical thrombectomy.

Figure 4

The management process of intravenous (IV) thrombolysis for patients with acute ischaemic stroke (AIS) with an onset between 4.5 and 9 hours or wake-up stroke. DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; IA, intra-arterial; LVO, large vessel occlusion; MT, mechanical thrombectomy; rt-PA, recombinant tissue plasminogen activator.

Figure 5

The intra-arterial (IA) mechanical thrombectomy (MT) for patients with acute ischaemic stroke. ASPECTS, Alberta Stroke Program Early CT Score; BAO, basilar artery occlusion; DA, direct aspiration; IAT, intra-arterial thrombolysis; IV, intravenous; LVO, large vessel occlusion; mRS, modified Rankin Scale; NICU, neurological intensive care unit; NIHSS, National Institutes of Health Stroke Scale.

Section 3.1 Intravenous thrombolysisSection 4: antiplatelet therapy for acute ischaemic cerebrovascular disease

The antiplatelet treatment process for patients with AIS is shown in figure 6.

Figure 6

The antiplatelet treatment process for patients with acute ischaemic stroke (AIS). bid, two times per day; NIHSS, National Institutes of Health Stroke Scale; TIA, transient ischaemic attack.

Section 4.1 Single antiplatelet therapySection 4.2 Dual antiplatelet therapySection 4.3 Triple antiplatelet therapySection 5: other treatments in the acute phaseSection 5.1 Brain cytoprotectionSection 5.2 Brain cytoprotectionSection 5.3 Hyperbaric oxygen therapySection 6: general supportive treatment and management of complications

The management process for brain oedema/intracranial hypertension is shown in figure 7. The management process for haemorrhagic transformation in patients with AIS is shown in figure 8. The management process for the first seizure within 24 hours of stroke onset is shown in figure 9.

Figure 7

The management process for brain oedema/intracranial hypertension. BP, blood pressure; NICU, neurological intensive care unit.

Figure 8

The management process for haemorrhagic transformation in patients with acute ischaemic stroke. INR, international normalised ratio.

Figure 9

The management process for the first seizure within 24 hours of stroke onset.

Section 7: early evaluation of aetiology and pathogenesis of ischaemic cerebrovascular disease

The diagnostic process for cryptogenic stroke is shown in figure 10.

Figure 10

The diagnostic process for cryptogenic stroke. CSF, cerebrospinal fluid; CTA, CT angiography; DSA, digital subtraction angiography; MRA, magnetic resonance angiography; TCD, transcranial Doppler; TEE, transoesophageal echocardiography; TIA, transient ischaemic attack; TTE, transthoracic echocardiography.

Section 8: interventions targeting aetiology and pathogenesis

The treatment strategy for valvular heart disease is shown in figure 11.

Figure 11

The treatment strategy of valvular heart disease. TIA, transient ischaemic attack.

Section 9: risk factor management and long-term intervention

The flow chart for blood pressure management within 72 hours after the onset of AIS is shown in figure 12. The flow chart for lipid-lowering management in patients with AIS is shown in figure 13. The flow chart for blood glucose management in patients with AIS is shown in figure 14.

Figure 12

The blood pressure (BP) management within 72 hours after the onset of acute ischaemic stroke (AIS). IA, intra-arterial; IV, intravenous; MT, mechanical thrombectomy; rt-PA, recombinant tissue plasminogen activator.

Figure 13

The lipid-lowering management in patients with acute ischaemic stroke. *Very high risk includes a history of multiple major ASCVD events or one major ASCVD event and multiple high-risk conditions. Major ASCVD events: history of ischaemic stroke; recent acute coronary syndrome (within the past 12 months); history of myocardial infarction (other than recent acute coronary syndrome event listed above); symptomatic peripheral arterial disease (history of claudication with ankle-brachial index <0.85 or previous revascularisation or amputation). High-risk conditions: age ≥65 years; heterozygous familial hypercholesterolaemia; history of coronary artery bypass surgery or percutaneous coronary intervention outside of the major ASCVD events; diabetes; hypertension; chronic kidney disease (estimated glomerular filtration rate, 15–59 mL/min/1.73 m2); current smoking. ASCVD, atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; PCSK9, proprotein convertase subtilisin/kexin 9.

Figure 14

The flow chart for blood glucose management in patients with acute ischaemic stroke. GLP-1, glucagon-like peptide-1; HbA1c, glycated haemoglobin; OGTT, oral glucose tolerance test; SGLT2, sodium-glucose cotransporter 2.

9.1 Blood pressure management9.2 Management of abnormal lipid metabolism9.3 Management of abnormal glucose metabolism9.4 Management of other risk factorsEthics statementsPatient consent for publication

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