Internet Circulation: Some reports on ISTH congress showed that it would appear unnecessary to prolong anticoagulation over the standard duration of 6 months for the Cerebral vein thrombosis， what about your opinion on the duration of anticoagulation of CVT patients?
国际循环：在ISTH会议上一些报告显示治疗脑静脉血栓形成时没有必要延长标准的6个月疗程，您对于脑静脉血栓形成患者抗凝疗程的意见怎么看？
Professor Walter: This is certainly a very important questions that needs to be further explored. Currently， there are no clinical studies that have assessed the optimal duration of anticoagulation following cerebral vein thrombosis， however， the data we do have about recurrence rates suggests that recurrence rates are quite low in these patients. Also， the disease is more benign than we previously thought. It is very likely that most of these patients do not require anticoagulation for more than 6 months in only patients with permanent risk factors. So far， guidelines suggest treatment between 6 months and one year but many clinicians， because of the very unusual site， plan to treat these patients for longer. My impression is that it is not necessary.
Professor Walter：这当然是一个非常重要的问题，需要进一步探讨。目前，还没有评估脑静脉血栓形成抗凝最佳疗程的临床研究，然而，目前关于复发率的资料提示这类患者复发率很低。该病也比我们先前认为的要轻。除了伴随永久性危险因素的患者，大多数患者并不需要超过6个月的抗凝治疗。到目前为止，指南建议治疗6个月至1年，但许多医生治疗倾向于治疗更长时间。我觉得是没有必要的。
Internet Circulation：Would you please give us some advice on the prophylactic strategies for patients with acute stroke including acute ischemia stroke and acute hemorrhagic stroke?
国际循环： 您能给我们一些关于急性脑卒中包括急性缺血性卒中和急性出血性卒中患者的预防策略的建议吗？
Professor Walter: I would recommend that prevention of venous thromboembolism is applied to all immobilized patients with acute ischemic stroke. It appears that the most effective prophylactic strategy is low molecular weight heparin which is probably superior to unfractionated heparin. It looks like elastic stockings alone are not sufficiently effective in these very high risk population. There is a fear of bleeding complications， in particular intracranial bleeding， in patients with previous acute stroke when using anticoagulant strategies but current available data suggests that probably this risk is sufficiently acceptable. I would be quite reluctant to use anticoagulant strategies in patients with very large ischemic lesions， at least for the first 48 hours， or in patients with evidence of hemorrhagic infarction of the ischemic lesion. Data about the prevention of thrombosis in patients with hemorrhagic stroke are scarce. There is not much in the literature. I would be very careful to administer anticoagulant drugs， at least in the first few days. When the patient is stabilized it is probably safe to start anticoagulant drugs but these must be evaluated on an individual basis. Indeed if the patient remains immobilized after stroke the risk of venous thrombo-embolytic complications is important. I would start in the case of hemorrhagic stroke with mechanical prophylaxis. Probably， again， the elastic stockings alone are not enough so it would be useful to combine elastic stockings with intermediate thematic compression and， once the patient is stable， then prophylactic doses of low molecular weight or unfractionated heparin can be considered. That is my advice.
Professor Walter： 我建议对所有制动的急性缺血性卒中患者进行静脉血栓栓塞预防。最有效的预防策略是使用低分子量肝素，可能优于普通肝素。对这些高危人群单独使用弹力袜并非十分有效。进行抗凝治疗的急性卒中患者可能发生出血并发症，特别是颅内出血，但目前的资料表明，这方面的风险是可以接受的。我不大愿意对有非常大缺血性病变患者使用抗凝治疗，至少在头48小时内，或有出血性梗死证据的患者。关于出血性卒中患者血栓形成预防的资料很少，没有多少文献报道。至少在最初几天，应用抗凝药物时我会十分小心。当患者病情稳定，开始使用抗凝药物可能是安全的。事实上，如果患者卒中后制动，静脉血栓的风险很高。我首先会对出血性卒中患者进行机械性预防。也许，只有弹力袜是不够的，因此，弹力袜联合中间压缩可能有用，一旦患者病情稳定，可以考虑给予预防剂量的低分子量肝素或普通肝素。这是我的建议。
Internet Circulation: Please talk about the progress on the clinical utility of D-dimer in the early diagnosis of stroke subtypes.
国际循环：请您谈谈D-二聚体在早期诊断卒中亚型中的临床应用进展？
Professor Walter: There have been a few studies that have shown that the D-dimer levels increase differently among the different stroke subtypes. If you measure D-dimer early after stroke diagnosis， D-dimer levels are very high after cardioembolytic stroke， are lower after certain thrombotic strokes， and nearly normal after lacunar strokes. We made these observations about 7 years ago and published our studies in the Archives of Internal Medicine. There have been other studies that have substantially confirmed out observations afterwards， however D-dimer levels have not entered clinical use. As such， there have been no management studies including D-dimers so I don’t think， at this time， we can suggest is use in clinical practice. However， I think it could be a useful tool to speed up the diagnosis of stroke subtypes.
Professor Walter：一些研究显示在不同卒中亚型，D-二聚体水平增加不同。如果在卒中诊断后早期检测D-二聚体，在心脏栓塞卒中后D-二聚体水平非常高，而在血栓卒中后较低，而空洞性卒中几乎正常。7年前我们观察到这一现象，并发表在《内科学纪要》杂志上。后来其它一些研究也证实了我们的结果，然而，D-二聚体水平检测还没有进入临床应用。因此，还没有关于D-二聚体管理的研究，所以目前暂不不建议用于临床实践。不过，我认为它可能是加快卒中亚型诊断的一个有用工具。
Internet Circulation: Please talk about the utility and safety of anticoagulation in older arterial ischemic stroke.
国际循环：请您谈谈抗凝治疗在老年人动脉缺血性卒中的应用和安全性。
Professor Walter: In the treatment of arterial ischemic stroke， therapeutic doses of anticoagulant drugs have been shown to be associated with an increased risk of the hemorrhagic transformation of the ischemic lesion and the benefits of these treatment doses has not be demonstrated. In the first days the risk-to-benefit ratio is unfavorable in most cases. Indication of therapeutic doses of anticoagulant drugs are very limited， only in cases of patients with a clear and high risk of further embolizations and in patients with arterial dissection. In all other circumstances， that starting of therapeutic doses of anticoagulant drugs should be at least postponed for the first 48 hours if the patient is stable and the lesion small. Similarly therapeutic doses of anticoagulant drugs in cases with larger lesions postponed for a week or more. I think we must be very cautious because with parenchyma hematoma as a complication of ischemic stroke is clearly associated with a poorer prognosis. We must then be very careful not to provoke hematoma.
Professor Walter： 在动脉缺血性卒中的治疗中，研究显示治疗剂量抗凝药物与缺血性病变的出血风险增加有关，而治疗剂量的益处尚未被证实。在最初几天，风险收益比对大多数患者不利。抗凝药物治疗剂量的适应证很有限，仅用于有明显发生栓塞的高风险患者以及动脉夹层患者。在其它情况下，如果患者病情稳定且病变小，开始应用治疗剂量的抗凝药物，应至少推迟至48小时后。同样的，对于较大<