| Unchanged | Hyperbaric oxygen therapy is not recommended for patients with AIS unless caused by air embolism. Hyperbaric oxygen therapy is related to claustrophobia, middle ear barotrauma and the increased risk of seizures. | III | B |
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5.4 Mechanical augmentation of blood flow
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| Unchanged | Mechanical augmentation of blood flow to treat patients with AIS has not been perfected. The curative effect is not sure and only can be used in clinical trials. | IIb | B |
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5.5 Blood volume expansion and defibrinogen therapy
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| Unchanged | It is not recommended for routine use of blood volume expansion or haemodilution therapy in patients with AIS. | III | A |
| Unchanged | In patients with AIS with hyperfibrinogenaemia, the effectiveness of defibrinogen therapy remains to be determined. | IIb | B |
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5.6 Neural regulation therapy
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| New recommendation | Remote ischaemic conditioning may be controversial for some patients with AIS. | IIb | B |
| Applying an ischaemic stimulus distant from the brain (remote ischaemic conditioning, for example, transient limb ischaemia) after a stroke can induce neuroprotection. The RECAST was a pilot blinded placebo-controlled trial in 26 patients with AIS, randomised 1:1 to receive four cycles of remote ischaemic conditioning within 24 hours of ictus. The results of the study found that remote ischaemic conditioning after acute stroke was well tolerated and appeared safe and feasible. The NIHSS score was significantly reduced at 90 days in the treatment group (median NIHSS score 1 (IQR 0.5–5) vs 3 (IQR 2–9.5), p=0.04).99 The RICAMIS trial, including 1893 patients with moderate AIS, was conducted at 55 hospitals in China to assess the efficacy of remote ischaemic conditioning. Treatment with remote ischaemic conditioning compared with usual care significantly increased the likelihood of excellent neurological function at 90 days (67.4% vs 62%, risk difference 5.4%, 95% CI 1.0% to 9.9%, OR 1.27, 95% CI 1.05 to 1.54, p=0.02).100 The REPOST study was a randomised, single-blind, placebo-controlled clinical trial. Eighty-eight patients with IS in the past 24 hours were randomised 1:1 to repeated remote ischaemic postconditioning (rIPostC) or sham conditioning. The study found no significant improvement in infarct size or clinical outcome in patients with AIS treated with repeated rIPostC.101 However, the inclusion rate was lower than expected, and no definite conclusions about the effectiveness of rIPostC could be drawn. |
| Revised | There is no evidence that transcranial near-infrared laser therapy for IS is beneficial. Therefore, using transcranial near-infrared laser treatment in IS is not recommended. | III | B |
| Previous data suggested that transcranial near-infrared laser therapy for stroke held promise as a therapeutic intervention through data published in the NEST-1 and NEST-2 trials.102–104 The NEST-3 trial examined the application in patients with moderate stroke (NIHSS score 7–17) who did not receive intravenous rt-PA.105 The study was halted due to futility after analysing the first 566 patients, as no benefit of transcranial laser therapy over sham treatment was observed. Currently, there is no evidence supporting the efficacy of transcranial laser therapy in treating IS. |
| New recommendation | Transcranial magnetic stimulation therapy may contribute to motor and cognitive function recovery in patients with AIS. | IIb | C |
| Two RCTs have ascertained the efficacy of low-frequency transcranial magnetic stimulation (TMS) therapy in ameliorating motor function deficits and cognitive impairments. However, these trials had limited sample sizes.106 107 Given the variations in stimulation parameters across studies, conducting additional comprehensive clinical trials is essential to refine the optimal treatment parameters for TMS. |
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5.7 High-dose albumin therapy
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| Unchanged | The routine use of high-dose albumin therapy in patients with AIS is not recommended. | III | A |