READING B

PREVIEW

Stroke is the leading cause of death and long-term disability in China，which causes severe economic and social burdens.Stroke is an acute neurological deficit caused by an abnormality in the cerebral blood vessels，including arterial occlusion， stenosis or vascular rupture . Ischemic stroke and intracerebral hemorrhage are the two main types of stroke.Previous epidemiological studies have found a strong association between stroke and some potentially modifiable risk factors，suggesting that stroke could be prevented and the primary stroke prevention is a fundamental measure to reduce the risk of stroke.In addition，timely and effective treatment of stroke can prevent long-term disability and prolong lifespan.Thus，it is of great significance to conduct stroke prevention，standardize stroke diagnosis procedures and improve treatment efficacy to reduce the risk of stroke in China.

Questions for Discussion

Q1：Talk about the understanding of stroke from clinical and epidemiological aspects.

Q2：How to make efforts to promote the prevention and treatment of stroke in China？

Text B　Brief Introduction of Stroke in China

Stroke is an important cardiovascular disease that has become one of the major global public health problems.In China，stroke remains the leading cause of death and long-term disability，and contributes to a heavy economic burden.Data from the Global Burden of Disease （GBD）Study 2016 indicated that the estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% （95% uncertainty interval，23.5% to 26.2%），while China had the highest estimated risk of up to 39.3%.With the accelerated aging and urbanization of society，as well as widespread exposure to unhealthy lifestyles and cardiovascular risk factors，the incidence and prevalence of stroke have continued to rise over the past 30 years in China.The National Epidemiological Survey of Stroke in China （NESS-China）involved 480，687 adults aged ≥20 years from 31 provinces between 2012 and 2013，reporting an agestandardized stroke prevalence of 1，115 cases per 100，000 people，an annual age-standardized incidence of 247 cases per 100，000 people，and a mortality rate of 115 cases per 100，000 people，respectively.These data suggest that there are 11.1 million living stroke survivors，2.4 million new strokes，and 1.1 million stroke-related deaths each year.Moreover，stroke is characterized by high recurrence rates and combined cardiovascular events.Stroke places a heavy and enormous burden on the healthcare system in China.Over the past decades，Chinese experts have established the prevention and control concepts for stroke and carried out related work，and the government has taken several important steps to address stroke prevention and treatment.

Subtypes and Diagnosis

Stroke is an acute neurological deficit caused by an abnormality in the cerebral blood vessels，including arterial occlusion，stenosis，or vascular rupture.Stroke can be categorized as ischemic stroke，intracerebral hemorrhage，or subarachnoid hemorrhage .Ischemic stroke and intracerebral hemorrhage are the two main types of stroke.The NESS-China study indicated that ischemic stroke accounts for approximately 70% of all incident stroke cases and intracerebral hemorrhage accounts for 24%.Ischemic stroke is defined as an episode of neurological dysfunction caused by focal cerebral，spinal，or retinal infarction with symptoms persisting for more than 24 hours.Transient ischemic attack （TIA）is a similar event to ischemic stroke.A TIA is also a focal brain ischemia event that causes sudden，transient neurologic deficits，but is not accompanied by permanent brain infarction.The symptoms are usually transient，lasting from minutes to hours but less than 24 hours.Ischemic strokes can be further categorized according to the Trial of Org 10172 in Acute Stroke Treatment （TOAST）classification：large artery atherosclerosis ，small-vessel occlusion，cardioembolism，stroke of other determined etiology ，and stroke of undetermined etiology.Typical clinical features of ischemic stroke include loss of motor control and sensation in some regions of the body，visual changes and deficits， dysarthria ，loss of consciousness，and facial droop.

Intracerebral hemorrhage is defined as rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma .Although intracerebral hemorrhage accounts for 15%-30% of all strokes，it is one of the most disabling forms of stroke.It is reported that more than one third of intracerebral hemorrhage patients will not survive，and only twenty percent of patients will regain functional independence.The clinical features of intracerebral hemorrhage are similar to those of ischemic stroke.In addition，subarachnoid hemorrhage can give rise to the following set of signs and symptoms，including sudden onset of a severe headache， nausea ，vomiting， syncope ，and photophobia .

Risk Factors and Prevention

In a mega -case-control study of 13，447 patients with a first acute stroke （10，388 with ischemic stroke and 3，059 with intracerebral hemorrhage）and 13，472 controls from 32 countries，the INTERSTROKE study showed that 90.7% of the population-attributable risk of stroke is associated with ten potentially modifiable risk factors in all major regions of the world，as well as among all ethnic groups，sexes，and ages.The ten modifiable risk factors include hypertension，smoking，diabetes mellitus，physical activity，diet，psychosocial factors，abdominal obesity，alcohol，cardiac causes，and apolipoproteins .For the Chinese population，these ten risk factors together account for 94.3% of all strokes，95.2% of ischemic strokes，and 90.7% of hemorrhagic strokes.These findings suggest that stroke can be prevented，and primary stroke prevention is a fundamental measure to reduce the risk of stroke.

Hypertension is the most important modifiable risk factor for all types of stroke.A nationwide survey of 451，755 residents ≥18 years of age from 31 provinces，autonomous regions，and municipalities in mainland of China from 2012 to 2015 reported that 23.2% （≈244.5 million）of the Chinese adult population ≥18 years of age had hypertension，and another 41.3% （≈435.3 million）had pre-hypertension according to the Chinese guideline.In addition，among individuals with hypertension，46.9% were aware of their condition，40.7% were taking prescribed antihypertensive medications，and only 15.3% had controlled hypertension.The NESS-China study suggested that the prevalence of hypertension in stroke survivors in China is 84%，which is higher than most other countries，and it is estimated that 73% of the stroke burden in China is attributable to hypertension.Therefore，improving blood pressure control remains a crucial strategy in China.

Data from the GBD study suggested that air pollution has emerged as a significant contributor to the global stroke burden，especially in low-income and middle-income countries.In China，almost 22% of stroke-related disability-adjusted life-years （DALYs）in 2013 were attributed to ambient PM 2.5 air pollution.The China Kadoorie Biobank （CKB）study reported that solid fuel use for cooking and heating was associated with higher risks of cardiovascular（including ischemic heart disease death，stroke death and other cardiovascular death）and allcause mortality after a mean of 7.2 years of follow-up，and those switched from solid to clean fuels for cooking had a lower risk of cardiovascular mortality，and all-cause mortality in rural China.Reducing exposure to air pollution should be one of the main priorities to reduce stroke burden in China，and other low-income and middle-income countries.

Healthcare organizations and Stroke societies （such as Chinese Stroke Society，Stroke Prevention and Control Society，and the Chinese Stroke Association）have conducted varied public educational activities on stroke prevention across the country，including treating hypertension，healthy eating habits，stopping smoking，and so on.As the increasing burden of stroke in China，the primary prevention strategies still need to be improved.

Stroke Identification

Timely and effective treatment of stroke can prevent long-term disability and save lives.However，prehospital delays are common，and only a small proportion of stroke patients are aware of the initial symptoms of a stroke.Improving community awareness of initial stroke symptoms and the establishment of an alert system to cater for patients likely to experience stroke at home may be promising methods to help expedite transport to hospital.Dr.Zhao Jing from Shanghai Minhang Hospital proposed "Stroke 1-2-0" as a novel educational strategy suitable for China.The medical emergency telephone number is 120 in China，which can be adapted as a convenient mnemonic tool for rapid stroke recognition in Chinese.These numbers are transformed into three stroke recognition actions，where "1" represents "first，look for an uneven face"，"2" represents "second，examine for arm weakness"，and "0" represents"zero （absence of）clear speech".If stroke is suspected or identified through this three-step observation，the emergency number 120 must be dialed.The use of Stroke 1-2-0 as a mnemonic tool links stroke identification with the emergency service telephone number，and can be easily remembered even by those with minimal education.

Stroke Treatment

Intravenous thrombolysis （tissue-type plasminogen activator，tPA）has served as a primary therapy for acute ischemic stroke.While the licensed time window extends to three hours from symptom onset，recent data suggest that the trial window can be extended up to 4.5 h with overall benefit.The treatment is more effective when given early after symptom onset.After thrombolysis，10% more patients survive and live independently.Despite its benefits，there is a risk that thrombolysis can cause bleeding.Thrombectomy is a treatment that physically removes a clot from the brain.It usually involves inserting a mesh device into an artery in the groin ，moving it up to the brain，and pulling the clot out.It only works with people where the blood clot is in a large artery.Like thrombolysis，it has to be carried out within hours of a stroke starting.Only a small proportion of stroke cases are eligible for thrombectomy，but it can have a big impact on those people by reducing disability.Endovascular thrombectomy has become part of the standard treatment for patients who have acute ischemic stroke due to large-vessel occlusion in the anterior cerebral circulation.

Antiplatelets and statins are the most commonly prescribed medications in the acute phase of ischemic stroke in China.The CHANCE （Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events）trial has recruited 5，170 patients with minor ischemic stroke or TIA from 114 centers in China，and shown that dual antiplatelet therapy with clopidogrel and aspirin was more effective for the prevention of stroke recurrence.

The management of acute intracerebral hemorrhage is challenging.Currently no medical treatments have been shown definitively to improve the outcome.The treatment principle has been focusing on stopping the bleeding，removing the clot and relieving pressure on the brain.The majority of patients suffering intracerebral hemorrhage are present with elevated BP levels in the acute phase，and about two-thirds of Chinese patients receive early antihypertensive therapy.The INTERACT2 （Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial）trial，a large clinical trial assigned 2，839 intracerebral hemorrhage patients to one of two different blood pressure control strategies （systolic level ＜140 mmHg within 1 hour vs.SBP＜180 mmHg）.Although this trial failed to find a significant reduction in the rate of the primary outcome of death or severe disability，intensive BP lowering appeared safe，and numerous secondary outcomes appeared to be superior to the intensive strategy.Furthermore，patients with intracerebral hemorrhage are frequently recommended for surgery，such as hemostatic therapy and hematoma evacuation ，but the efficacy and safety still need to be investigated.

Efforts and Future Directions

In 2009，the Ministry of Health of the People's Republic of China launched the Stroke Prevention and Treatment Project of the National Health Commission （SPTPC）to meet the challenge of stroke.SPTPC actively promotes the establishment of a stroke prevention and treatment system in China.The health committees of all provinces，autonomous regions，and municipalities directly under the central government have established stroke prevention and treatment committees/leading groups and expert groups to organize medical institutions，emergency units，disease control institutions，and primary health care units.SPTPC also carried out standardized training and promotion of prevention and treatment technology for cerebrovascular diseases，significantly improving the ability of stroke treatment.In the next step，SPTPC will continue to participate in the screening and intervention of high-risk populations of stroke，improve the construction of regional stroke prevention and control system，vigorously promote the construction of stroke center and standardize the algorithm for the stroke diagnosis，increase the treatment efficacy，consolidate quality control and standardization work，and improve the mode of mobile stroke and remote diagnosis and treatment.

In recent years，great progress has been made in the prevention and treatment of stroke in China.However，as the prevalence and incidence of stroke are still increasing，the prevention and treatment of stroke still face huge challenges，and the system needs to be further improved.

Words and Expressions

stenosis （器官）狭窄

I developed spinal stenosis in my c-spine.

rupture 使破裂

His stomach might rupture from all the acid.

episode 一段经历；发病

Immediately following an episode of stroke，the innate immune system is activated.

retinal 视网膜的

There are potential side effects：burning and retinal discoloration.

atherosclerosis 动脉粥样硬化

Gum problems increase the risk of atherosclerosis .

dysarthria 构音障碍

The type of dysarthria determines the treatment.

parenchyma 实质；软细胞组织

The lung parenchyma appeared echo rich and patchy.

ventricular 心室的；脑室的

The patient underwent external decompression and external ventricular drainage.

trauma 痛苦经历；创伤

The patient suffered severe brain trauma .

nausea 恶心

Symptoms include nausea and giddiness.

syncope 晕厥

Most of the post-exercise syncopes were vasodepressor syncopes .

photophobia 畏光

The woman presented with photophobia and reduced vision.

mega 巨大的

He has become mega rich.

apolipoprotein 载脂蛋白

The gene transcription of apolipoprotein A5 is controlled by several factors.

ambient 周围的；外界的

The design cuts out most of the ambient noise.

expedite 加快；促进

We have developed rapid order processing to expedite deliveries to customers.

mnemonic 记忆的

Many of them use a mnemonic method.

plasminogen 血纤维蛋白溶酶原

Urokinase，a human plasminogen activator，is used clinically to promote the dissolution of thrombi.

clot 凝块，血块

They removed a clot from his brain.

groin 腹股沟

I underwent an operation on my groin once.

anterior 前面的

Cardioembolism is more frequently located in the anterior circulation.

antiplatelet 抗血小板的

There is currently no robust evidence to support the use of venous antiplatelet agents.

statin 他汀类

Statin drugs lower cholesterol.

hemostatic 止血的

The speed of laser operation for cutting the department of hemostatic steps can be improved.

hematoma 血肿

That head bump is now blamed for triggering the hematoma .

evacuation 清除

Each house had a helipad for a fast evacuation .

Language Point

ischemic stroke 缺血性卒中

the most common kind of stroke；caused by an interruption in the flow of blood to the brain（as from a clot blocking a blood vessel）

Carotid artery stenosis is one of the major causes of ischemic stroke .

intracerebral hemorrhage 脑出血

hemorrhage caused by non-traumatic parenchymal vascular rupture

Clinically brain cell injury after intracerebral hemorrhage （ICH）always causes dysfunction or death on such patients.

subarachnoid hemorrhage 蛛网膜下腔出血

Subarachnoid hemorrhage （SAH）is a clinical syndrome caused by rupture of pathological blood vessels at the base or surface of the brain and direct inflow of blood into the subarachnoid space，also known as primary subarachnoid hemorrhage，which is a very serious and common disease.

Ruptured cerebral aneurysm is one of the important reasons for subarachnoid hemorrhage .

accounts for 占……比例

The brain accounts for merely three percent of body weight.

give rise to 使发生，引起

Low levels of choline in the body can give rise to high blood pressure.

cater for 迎合；供应伙食；为……提供所需

The university started some new language programs to cater for China's Silk Road Economic Belt.

intravenous thrombolysis 静脉溶栓

Thrombus-dissolving drugs are used in venous tube to recanalize vascular.

All patients were treated with intravenous thrombolysis therapy.

EXERCISES

Task 1：Vocabulary Application

Fill in the blanks with the words given below.Change the form where necessary.

1.While guidelines acknowledge uncertainty over the safety and efficacy of intravenous alteplase in acute ___________ patients with a clinical history of potential bleeding diathesis，concerns over excessive bleeding contribute to underutilization of in ___________ patients with AIS.

2.Diabetes mellitus enhances coronary ___________ and impairs microcirculation leading to left ___________ （LV）dysfunction.

3.Achromatopsia is an early-onset，___________ dystrophy characterized by reduced visual acuity，pendular nystagmus，___________ and color blindness.

4.___________ diseases，especially acute coronary syndromes，are closely associated with atherosclerotic plaque progression and ___________ .

5.At least one-third of adults in high-income countries with stroke caused by spontaneous（nontraumatic）___________ are already taking oral antithrombotic（ ___________ or anticoagulant）drug therapy because of their comorbidities and other risk factors for vascular disease.

Task 2：Writing

For this part，you are allowed to write a composition to express your views on how to perform primary prevention for stroke in our daily life.You should write at least 150 words but no more than 300 words.

Task 3：Oral Presentation

Observational studies have reported that elevated BP is associated with adverse short-and long-term clinical outcomes after acute ischemic stroke.However，clinical trials have generally found a neutral effect of early blood pressure decrease on clinical outcomes after acute ischemic stroke.On one hand，BP-decreasing treatment may reduce vascular damage，cerebral edema，and hemorrhagic transformation of the cerebral infarction.On the other hand，early BP reduction may also decrease cerebral perfusion of the ischemic tissue and further increase the size of the cerebral infarction.Please debate whether it is necessary to decrease BP early after stroke.

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