Patient's question:
How should the best treatment methods be used for elderly people with cerebral blood vessel blockage who cannot move their hands and feet on one side?Doctor's answer:
Stroke is a cerebrovascular disease caused by atherosclerosis of cerebral arteries, intimal injury of blood vessels leading to stenosis of cerebral artery lumen, and subsequent local thrombosis formation due to various factors, which exacerbates or completely occludes the artery, resulting in cerebral tissue ischemia, hypoxia, and necrosis, and causing neurological dysfunction.The main factors contributing to stroke include: hypertension, coronary heart disease, diabetes, overweight, hyperlipidemia, and a preference for fatty meats. Many patients have a family history. It is more common in middle-aged and elderly people aged 45–70.
### (1) Prodromal Symptoms of Stroke
Most stroke patients develop symptoms during periods of rest. Some may wake up to find facial drooping, hemiplegia, drooling, difficulty eating, or inability to pick up chopsticks, which often catch people off guard. Only some patients experience pre-stroke symptoms such as limb numbness, slurred speech, transient visual darkening, dizziness or vertigo, nausea, or blood pressure fluctuations (which can be either elevated or lowered). These prodromal symptoms are generally mild and brief, often being overlooked.
### (2) Clinical Manifestations of Stroke
The location and size of the infarction vary, with the most common manifestations being as follows:
(1) Sudden onset, often occurring during rest or sleep, with symptoms reaching their peak within hours or 1–2 days.
(2) Headache, dizziness, tinnitus, hemiplegia (which can affect a single limb or one side of the body), with the upper or lower limbs being more severely affected. Other symptoms may include difficulty swallowing, slurred speech, nausea, and vomiting. Severe cases may quickly lose consciousness. Each patient may exhibit several of these clinical manifestations.
(3) The significance of brain CT examination: Brain CT accurately shows the size and location of stroke lesions with an accuracy rate of 66.5%–89.2%, and accurately detects initial cerebral hemorrhage with a 100% accuracy rate. Therefore, early CT examination is helpful for differential diagnosis and excluding other lesions such as cerebral hemorrhage. This is crucial, as the treatment for early cerebral hemorrhage differs significantly from that for thrombotic stroke. When a stroke occurs within 24 hours, the lesion is smaller than 8 mm, or the lesion is located in the brainstem or cerebellum, brain CT may not provide an accurate diagnosis. Re-examination should be conducted if necessary to avoid delayed treatment.
(4) There is a condition called "lacunar stroke," where patients may have no symptoms or mild symptoms, and the disease is discovered incidentally during brain CT for other conditions. Some of these lesions may be old. This condition is more common in the elderly, who often have chronic diseases such as hypertension, atherosclerosis, hyperlipidemia, coronary heart disease, and diabetes. Lacunar stroke can recur repeatedly, and some patients may eventually develop symptomatic stroke, while others may remain stable for years. Therefore, attention should be paid to "asymptomatic stroke" in the elderly, and a proactive approach should be taken in prevention.
### (3) First Aid Measures for Stroke
Early and timely treatment is essential for stroke. Although it is less severe than cerebral hemorrhage, most stroke patients are elderly and frail, with multiple chronic conditions, requiring cautious medication use. Additionally, the infarct area can expand rapidly within a short period, leading to many complications, making the mortality rate of stroke relatively high, and the disability rate higher than that of cerebral hemorrhage.
The main treatment principles are to improve cerebral circulation, prevent cerebral edema, and treat complications.
1. Appropriate activity can help improve cerebral circulation. However, patients with unclear consciousness should be placed on bed rest with enhanced nursing care.
2. Improve cerebral blood circulation and increase cerebral blood flow to promote the formation of collateral circulation, aiming to reduce the size of the infarct. Medications such as low-molecular-weight dextran, 706 plasma, Naoxintong, compound Danshen injection, and Ligustrazine can be administered intravenously once or twice daily, with a fluid volume of 250–500 mL per dose, for 7–10 days. For patients with headache, nausea, vomiting, or impaired consciousness, 20% mannitol dehydration therapy can be used twice daily, with 250 mL per dose.
3. Thrombolysis therapy commonly uses urokinase and streptokinase to dissolve thrombi. Domestic urokinase (20,000–50,000 units) can be added to a 0.56 mol/L 10% glucose solution for intravenous infusion once daily, with a course of 10 days. Some also use urokinase for carotid artery administration to treat stroke, typically within 24 hours of onset. Due to the complexity of carotid artery puncture, this must be done in a hospital. Thrombolysis should be used early, as thrombi are more water-rich within the first day, making them easier to dissolve, resulting in faster efficacy and shorter courses. However, close monitoring is necessary to avoid severe complications such as cerebral hemorrhage.
4. Hyperbaric oxygen therapy has proven effective in treating stroke and significantly reduces disability rates. It should be used early, once daily, with a course of 10 sessions. Each session lasts 90–110 minutes and must be conducted in a closed, pressurized cabin, which is limited by conditions.
5. Regulate blood pressure and control high blood lipids and blood glucose to manage risk factors. However, blood pressure should not be lowered too quickly in cases of high blood pressure, and it should be appropriately increased if blood pressure is too low. Stroke patients often have high blood sugar, which is unfavorable for treatment and must be actively controlled.
6. For comatose patients, maintain airway patency, perform timely sputum suction, turning and back percussion, and limb movement to prevent pneumonia and bedsores.
### (4) Prevention Measures for Stroke
Stroke prevention is divided into primary, secondary, and tertiary prevention. Primary prevention refers to measures taken before the onset of stroke, secondary prevention refers to preventing recurrence after onset, and tertiary prevention refers to preventing complications of stroke. Secondary prevention is particularly important. China's stroke recurrence rate within 5 years is as high as 40%, which is more than three times the international average of 10%. This is mainly due to insufficient awareness of secondary prevention. Fortunately, the national authorities have already paid attention to this issue, and Tianxin Tai's Thromboembolism Heart and Pulse (a Chinese medicine approved and funded by the state for secondary prevention of stroke) has been launched.
Stroke is prone to recurrence, and each recurrence is generally more severe.
Aspirin is recommended at a low dose (0.1–0.3 g per day). However, clinical studies show a 47% resistance rate to aspirin, meaning patients should check for resistance before taking it. Otherwise, it may be ineffective and even cause gastrointestinal bleeding.
Chinese medicine has the advantage of fewer side effects and is more effective than Western medicine in preventing stroke recurrence. Other options include Tianxin Tai's Thromboembolism Heart and Pulse, Antithrombotic Pills, Cinnarizine, and Naoxintong, which should be taken long-term, preferably after meals.
Long-term low-dose statin therapy has been clinically studied for stroke prevention abroad, but long-term use can cause liver and kidney damage.
When prodromal symptoms appear, low-molecular-weight dextran, compound Danshen injection, and 4% sodium bicarbonate injection can be administered intravenously once daily for 7–10 days.
Actively treat hypertension, diabetes, and coronary heart disease, maintain a positive and open attitude, avoid emotional excitement and excessive fatigue.
Limit sodium intake, control weight, and avoid smoking and alcohol. Pay attention to preventing conditions that may trigger stroke, such as fever, dehydration, diarrhea, and excessive sweating.
### References:
1. What is atherosclerotic stroke?
Atherosclerotic stroke, also known as atherosclerotic thrombotic stroke, is caused by atherosclerosis and thrombosis of cerebral arteries, leading to stenosis or occlusion of cerebral blood vessels, resulting in acute cerebral hypoperfusion and local ischemic necrosis of brain tissue. Patients may experience hemiplegia, aphasia, and other focal brain damage symptoms, belonging to ischemic cerebrovascular disease. It is more common in the elderly. High-fat diets, diabetes, and smoking increase the risk.
The main factors leading to cerebral vessel obstruction are two:
- Cerebral thrombosis, caused by lesions of the blood vessel itself, often due to atherosclerosis leading to rough intimal surfaces and narrowed lumen. Under certain conditions, such as low blood pressure, slow blood flow, and increased blood viscosity with clotting factors like platelets, a thrombus forms in the vessel.
- Cerebral embolism, where thrombi from other parts of the body detach and block cerebral vessels. These emboli may originate from rheumatic heart disease, fat emboli during fractures, air emboli, or tumor emboli, etc.
Thrombotic stroke onset is slow, often occurring during sleep or rest, possibly due to lower blood pressure and slower blood flow during rest. The progression from onset to peak symptoms often takes tens of minutes or even days. In contrast, embolic stroke onset is usually rapid, reaching its peak within seconds or minutes.
2. What is hemorrhagic stroke?
Hemorrhagic stroke refers to the occlusion of the main cerebral artery or its branches, or thrombosis, followed by arterial recanalization, where blood leaks from the diseased vessel or breaks through into brain tissue. The mechanism may involve diffuse ischemia and hypoxia in the brain tissue supplied by the occluded vessel, leading to increased permeability or paralysis of vessel walls, especially capillaries. When collateral circulation is re-established or overperfused, blood flow attempts to enter damaged vessels, causing bleeding.
The recanalization rate of arterial vessels after stroke is high. Japanese scholar T. Toyama reported that 40%–75% of occluded vessels can recanalize, mostly within 2–3 days after onset, with some recanalizing months or even years later. Pathophysiological studies in China have also confirmed that hemorrhagic stroke results from arterial recanalization. The faster the recanalization, the higher the risk of bleeding. Embolic stroke has a higher risk of hemorrhagic transformation than non-embolic stroke. Large infarcts are more common than small ones. Early use of anticoagulants, thrombolytics, volume expanders, and vasodilators, as well as early surgical intervention, can increase the risk of hemorrhagic stroke.
The primary disease of hemorrhagic stroke is stroke, with arterial recanalization leading to concurrent bleeding. Clinical features include worsening of existing symptoms and signs, along with new symptoms and signs. The severity of symptom worsening depends on the amount of bleeding, the timing of secondary bleeding, and the use of anticoagulants, thrombolytics, volume expanders, and vasodilators. Generally, small symptoms worsen slightly. Secondary bleeding within 1 week of stroke often causes more severe symptoms. Symptoms worsen little after the second week. Early use of anticoagulants, thrombolytics, and vasodilators can worsen clinical symptoms, such as impaired consciousness, increased intracranial pressure, worsened hemiplegia, or new signs, with poor prognosis in severe cases. Sometimes, even without symptom worsening, secondary bleeding may occur if treatment is ineffective after a period.
The occurrence of hemorrhagic stroke is associated with early patient activity, emotional excitement, blood pressure fluctuations, and inappropriate early treatment with anticoagulants or vasodilators. Therefore, patients should control emotions, receive active dehydration treatment, prevent blood pressure fluctuations, and avoid early use of vasodilators, especially anticoagulants, to prevent hemorrhagic stroke.
3. What is lacunar stroke?
Lacunar stroke is named based on pathological diagnosis and refers to fresh or old ischemic lesions in the deep brain with diameters of 15–20 mm. These small artery occlusions can cause multiple brain softening lesions of varying sizes, eventually forming cavities. Due to different blood vessels being involved, different neurological symptoms may occur. The most common symptoms are headache, dizziness, insomnia, memory loss, limb numbness, motor dysfunction, and difficulty speaking (). Severe cases may develop dementia, hemiplegia, or aphasia.
This disease severely affects the health of middle-aged and elderly people. In the past, diagnosis relied solely on neurological examinations, EEG, cerebral angiography, and cerebrospinal fluid tests, making clinical diagnosis difficult. With the widespread use of CT and MRI, the diagnosis rate of lacunar stroke has significantly improved.
How does lacunar stroke occur? Most cases are believed to be caused by hypertension and cerebral atherosclerosis. Long-term hypertension can lead to small artery hardening and hyaline degeneration, resulting in vessel occlusion. Additionally, changes in the elderly, such as increased blood viscosity, enhanced platelet aggregation, reduced red blood cell deformability, elevated blood lipids, and slow blood flow, contribute to a hypercoagulable state and reduced cerebral blood flow, making small artery occlusion and lacunar stroke more likely.
How can lacunar stroke be prevented? First, actively prevent and treat hypertension. Middle-aged and elderly patients (over 40) should have regular blood pressure checks to detect and treat hypertension early. Regular blood rheology tests should also be conducted to monitor dynamic changes in blood viscosity. Hyperlipidemia and hyperviscosity should be actively treated. Second, pay close attention to the prodromal symptoms of cerebrovascular disease and effectively control recurrent transient ischemic attacks. Since lacunar stroke is not easily detected without special examinations, middle-aged and elderly patients with unexplained personality changes, dizziness, memory loss, motor dysfunction, or unclear speech should be taken seriously and not ignored. In addition to rest, doctors should provide active and effective treatment.
4. How is lacunar stroke diagnosed?
(1) Most cases occur in people over 50, with a history of long-term hypertension, atherosclerosis, or heart disease.
(2) Onset is relatively slow, with symptoms reaching their peak within hours or days.
(3) Clinical symptoms are relatively mild, with few cases of headache, vomiting, or impaired consciousness.
(4) Neurological signs are more localized and simple, such as pure motor hemiplegia, pure sensory stroke, ataxic hemiplegia, or dysarthria-hands.
(5) Brain EEG, cerebrospinal fluid, and cerebral angiography show no abnormalities.
(6) CT can confirm the diagnosis. Commonly, 3–10 mm low-density areas are present, and lesions smaller than 2 mm cannot be detected by CT.
5. What is hemorrhagic lacunar syndrome?
Before the widespread use of CT, lacunar syndrome was considered a special manifestation of stroke caused by occlusion of deep penetrating branches of cerebral deep arteries. However, with the widespread use of CT, clinicians have observed that small amounts of intracranial bleeding can also cause symptoms similar to lacunar stroke, which is now referred to as hemorrhagic lacunar syndrome.
Hemorrhagic lacunar syndrome is more common in middle-aged and elderly people over 50, with a history of hypertension. It often occurs suddenly during activity and progressively worsens within minutes or hours, reaching its peak. Clinically, it can present with various symptoms similar to lacunar syndrome, such as pure motor hemiplegia, pure sensory stroke, ataxic hemiplegia, dysarthria-hands, or sensory-motor stroke. However, due to small bleeding amounts, limited lesion scope, localized hematoma, and no involvement of ventricles or subarachnoid space, as well as no damage to the ascending reticular activating system, there are no symptoms of meningeal irritation such as headache, dizziness, nausea, vomiting, or nuchal rigidity. Neither consciousness, intelligence, nor pupillary changes are present. Lumbar puncture shows normal cerebrospinal fluid pressure, and biochemical and routine tests are normal. Therefore, it is easily misdiagnosed as lacunar stroke, and cranial CT is the primary method for differential diagnosis. Clinical reports show that lesions are often located in the internal capsule, putamen, thalamus, and pons, presenting as small high-density shadows.
The causes of hemorrhagic lacunar syndrome are mainly due to hypertension, which can lead to hardening, fat hyaline degeneration, rupture, and leakage of small arteries in the deep brain.
Hemorrhagic lacunar syndrome has a good prognosis, with recovery possible within about 1 month of treatment, and usually no residual neurological deficits.
6. What is a large infarction and how is it differentiated from cerebral hemorrhage?
Large infarction is caused by occlusion of the main cerebral artery, presenting as large areas of low-density shadows on CT, often involving one brain lobe or crossing multiple lobes, with extensive brain tissue damage. Clinically, in addition to general stroke symptoms, it is accompanied by impaired consciousness and increased intracranial pressure.
When the symptoms of impaired consciousness and increased intracranial pressure are prominent in large infarction, it is similar to cerebral hemorrhage, making diagnosis difficult. Cranial CT is essential for diagnosis, but if CT is not available, the following points can serve as differential diagnostic criteria:
(1) Large infarction often has a history of thrombosis, with prodromal symptoms such as limb weakness, numbness, or dizziness appearing days or weeks before onset.
(2) Onset often occurs during labor, defecation, drinking, or emotional excitement, suggesting a higher likelihood of cerebral hemorrhage. Traditionally, stroke is considered to occur during rest.
(3) More than 70% of cerebral hemorrhage patients have a history of hypertension, and most experience significant blood pressure increases at the onset. Large infarction often lacks similar phenomena.
(4) Cerebral hemorrhage patients often have headache, vomiting, and other symptoms of increased intracranial pressure at onset. Large infarction shows increased intracranial pressure later and progressively worsens.
(5) Meningeal irritation is more common in cerebral hemorrhage and appears earlier. Large infarction generally shows no such signs or appears later.
7. What is watershed infarction?
Watershed infarction refers to ischemic damage in the marginal areas between two arterial supply zones, primarily occurring in the superficial parts of the hemisphere. It can affect one or both hemispheres, but is more common on one side. The incidence rate accounts for about 10% of ischemic cerebrovascular diseases. The causative factors differ from those of thrombotic and embolic stroke. The most common cause is various factors leading to decreased blood pressure or insufficient blood supply from a single artery, resulting in adequate blood supply near the artery's proximal end but reduced supply in the distal terminal marginal area, leading to ischemic infarction.
Watershed infarction is more common in the elderly over 60. Clinical symptoms and signs depend on the location and severity of the damage. Cerebral cortex watershed infarction often shows no symptoms. Anterior watershed infarction refers to ischemic areas in the superficial region between the anterior and middle cerebral arteries, presenting as recurrent numbness, weakness, or mild hemiplegia on one side. Posterior watershed infarction refers to ischemic areas in the superficial layer between the middle and posterior cerebral arteries, with the most common symptom being hemianopia and cortical sensory-motor deficits. Subcortical watershed infarction occurs in the deep layer between the middle cerebral artery, with hemiplegia being more common, and more than half of patients may experience sensory-motor deficits. Basal ganglia watershed infarction refers to ischemic infarction among the groups of arteries in the basal ganglia, often presenting as pure motor or sensory deficits of one side, or central facial palsy.
Diagnosing watershed infarction is difficult based solely on clinical symptoms, and CT is a reliable diagnostic method.
8. What is traumatic stroke and what is the pathogenesis of traumatic stroke in children?
Traumatic stroke is caused by head trauma. This disease is more common in adolescents and is always accompanied by a history of head trauma. Neurological typically appear within 24 hours of the injury. Cases with symptoms appearing 2 weeks or immediately after the injury are less common. Cerebral angiography, CT, or MRI can help confirm the diagnosis.
In recent years, with the widespread use of CT, the diagnosis rate of traumatic stroke in children has significantly improved. The pathogenesis is related to intimal injury and vascular spasm. Sudden head and neck extension or flexion during head trauma can cause traction on neck vessels, leading to or. This may directly form traumatic thrombi or reflexively cause vascular spasm. Vascular spasm itself provides conditions for thrombus formation. Additionally，、，，。，，。，。，，，，，。，，，。
9. Why is stroke more likely to occur in the morning?
We often encounter cases where elderly people wake up in the morning to find one limb numb and weak, with poor mobility, or even complete hemiplegia, or accompanied by symptoms such as inability to speak. When taken to the hospital for examination，doctors diagnose it as stroke.
So why is stroke more likely to occur in the morning? It is believed to be related to the physiological diurnal variations in arterial blood pressure, catecholamine，and fibrinogen activity in the body.
(1) Blood pressure fluctuations: Due to the influence of the biological clock，blood pressure has a clear diurnal rhythm. Overall，when people go to sleep at night，blood pressure naturally drops to a certain extent，and blood flow slows down，forming the physiological and pathological basis for stroke occurring in the morning.
(2) Changes in blood coagulability: Some people have found through 24-hour blood tests that catecholamine and fibrinogen activity in the body increase from 2 to 6 a.m.，with increased red blood cell hematocrit and viscosity，making blood coagulability stronger. Additionally，after a long night of sleep without food or drink，kidney glomerular filtration continues，leading to plasma loss and more concentrated blood with higher viscosity，making stroke more likely.
(3) Some scholars also point out that fixed side during sleep may twist the neck，compress the carotid artery，reduce blood supply，or cause poor venous return，which may be related to the occurrence of stroke.
Given these factors，it is suggested that elderly patients with cerebrovascular disease risk factors should drink some plain water before going to sleep to help prevent stroke，especially for those who drink more alcohol before bed. Additionally，sleeping posture should be paid attention to to prevent the carotid artery from being compressed due to fixed side.
10. What is the mechanism of ischemia-reperfusion injury after stroke?
Clinical observations show that after the occluded blood vessel of a stroke patient recanalizes (thrombolysis or spontaneous recanalization)，neurological deficits on the affected side may worsen in some cases. Animal experiments have also confirmed that reperfusion can exacerbate existing ischemic brain tissue damage. Thus，brain injury caused by ischemia not only occurs during insufficient tissue perfusion but more importantly during the reperfusion phase，a phenomenon known as ischemia-reperfusion injury. Within certain limits，the longer the ischemia duration，the more severe the reperfusion injury. If ischemia duration is equal，the longer the reperfusion duration，the greater the tissue damage.
The mechanism of ischemia-reperfusion injury is believed to be related to the following factors:
(1) No-reflow phenomenon: After ischemia，reperfusion of brain tissue does not restore blood flow to the ischemic tissue，but continues to ischemia and injury worsens. This is thought to be related to swelling of neurons and endothelial cells，leukocyte blockage in microcirculation.
(2) Calcium overload: Intracellular Ca exceeds normal levels，even up to 200 times the normal level. The mechanism is increased membrane permeability，calcium channel opening，and Ca entering the cell against the concentration gradient. Calcium overload is a common pathway for various causes leading to neuronal necrosis.
(3) Role of free radicals: During ischemia-reperfusion，sudden increases in oxygen supply lead to the production of large amounts of free radicals，damaging cell membranes and proteins，finally causing cell death.
(4) Lack of high-energy phosphate compounds，affecting cell function recovery.
(5) Role of white blood cells: Experiments have found increased white blood cell infiltration in ischemia-reperfusion brain tissue. Reperfusion with blood without white blood cells or anti-inflammatory drugs like ibuprofen to reduce tissue infiltration can protect ischemic tissue.
11. How is large infarction treated and what is the prognosis?
The key to acute-phase treatment of large infarction is to control intracranial pressure，reduce brain edema，prevent brain herniation，and promote functional recovery of the affected brain tissue. Hyperosmolar dehydration agents，diuretics，and hormones can be given promptly. Brain cell activators may also be administered as appropriate. The timing of dehydration agent use depends on the condition，and after 1–2 weeks of treatment，if the patient's impaired consciousness disappears and intracranial pressure returns to normal，vasodilators and blood-activating herbs can be given. However，it should be noted that vasodilators and blood-activating herbs must be used at the right time and not blindly or too early，as this may lead to a "blood-thief syndrome" and worsen the condition. At the same time，attention should be paid to controlling blood pressure，maintaining water and electrolyte balance，and preventing and treating complications.
Large infarction，due to severe brain tissue damage，has a higher mortality and disability rate than multiple infarction. The prognosis depends on factors such as the location and size of the infarction and the severity of complications. Generally，the prognosis is relatively poor.
12. How is traumatic stroke in children treated and what is the prognosis?
Traumatic stroke in children is primarily treated with treatment. First，the patient should be kept as calm as possible and cooperate actively with medication. Second，、、，、、2、、、。2~3，.
Traumatic stroke in children generally has a good prognosis，mainly related to the following factors: ①，.②，，.③CT，.④，，，.
13. What is stroke without hemiplegia?
With the widespread use of CT and MRI，clinicians frequently encounter cases of brain infarction confirmed by CT or MRI but without limb sensory or motor deficits，which is referred to as stroke without hemiplegia.
What are the factors or causes of stroke without hemiplegia? This may be due to small lesions and limited brain tissue damage，without affecting motor pathways or with mild damage to them. Alternatively，the lesions may be located in the basal ganglia、top lobe、frontal lobe、temporal lobe，or cerebellum，as these areas often do not affect motor pathways，or even large areas without causing limb paralysis. Some believe that the number of brain infarctions detected by CT or MRI often exceeds clinical localization，as this may be due to lesions in the "quiet zones" of the brain or undetected damage to higher brain functions.
Stroke without hemiplegia has，CT，，，，、、、、，、、、，CT，.
14. What is the prognosis of stroke?
The mortality rate of stroke is lower than that of cerebral hemorrhage，and the general prognosis is slightly better than that of cerebral hemorrhage，but severe stroke has a poor prognosis. The prognosis of stroke depends on the following factors.
(1) The size of the obstructed vessel: If the obstructed vessel is small，the cerebral ischemia range is small，collateral circulation is easier to form，recovery is faster，and the prognosis is better. If the obstructed vessel is large，the cerebral ischemia range is large，brain tissue damage is severe，clinical symptoms recover slowly，and the prognosis is worse.
(2) The speed of onset: Slowly progressive onset is easier to form collateral circulation，allowing gradual compensation for cerebral ischemia，and the prognosis is better. Acute onset is worse.
(3) The number and size of the infarction: The first recurrence has a better prognosis. However，a single large infarction has a worse prognosis. Recurrent infarctions，especially those affecting both cerebral vessels，have a worse prognosis. The more infarctions，the worse the prognosis. A single infarction has a better prognosis.
(4) The nature of the embolus: If the embolus is loose，it may break apart during blood circulation and flow to the distal end to block small vessels，leading to a better prognosis. Fat emboli、air emboli、bacterial emboli are worse than cardiac emboli. However，cardiac emboli causing cerebral abscess has a worse prognosis.
(5) The severity of focal: Focal symptoms such as hemiplegia and aphasia with mild severity have a better prognosis. Severe focal symptoms have a worse prognosis.
(6) The severity and duration of coma: Severe coma with a longer duration has a worse prognosis. If the patient is conscious at onset but later enters a coma with gradually worsening severity，the prognosis is worse. If the patient remains conscious throughout，the prognosis is better.
(7) The presence of complications: Complications such as bedsores、pneumonia、urinary tract infection、diabetes、coronary heart disease、irregular heartbeat、heart failure，have a worse prognosis. Without complications，the prognosis is better.
(8) The patient's age: Older age and poor constitution have a worse prognosis. Younger age and good constitution have a better prognosis.