T/GXAS 868-2024 缺血性中风中西医结合诊疗规范

　　GXAS

　　A s s o c i a t i o n S t a n d a r d

　　T/GXAS 868—2024

　　Specifications for the diagnosis and treatment of ischemic stroke with

　　integrated traditional Chinese and Western medicine

　　缺血性中风中西医结合诊疗规范

　　(English Translation)

　　Issue date:2024-10-30 Implementation date:2024-11-05

　　Foreword

　　In case of any uncertainty or doubt regarding the contents of the English version, the Chinese original shall be deemed authoritative.

　　This document is drafted in accordance with the rules given in the following standards: GB/T 1.1-2020 Directives for standardization—Part 1: Rules for the structure and drafting of standardizing documents, GB/T 20000.11—2016 Guides for standardization—Part 11: General presentation of the English translation of Chinese national standards and GB/T 20000.10—2016 Guidelines for standardization—Part 10: General rules for the English translation of Chinese national standards.

　　Attention is drawn to the possibility that some elements of this standard may be the subject of patent rights. The issuing body of this document shall not be held responsible for identifying any or all such patent rights.

　　This document is proposed and publicized by the First Affiliated Hospital of Guangxi University of Chinese Medicine.

　　This document was prepared by Guangxi Association for Standardization.

　　This document was drafted by the following organizations: the First Affiliated Hospital of Guangxi University of Chinese Medicine, Ruikang Hospital Affiliated to Guangxi

　　University of Chinese Medicine, Nanning Hospital of Traditional Chinese Medicine, Guangxi International Zhuang Medicine Hospital Affiliated to Guangxi University of Chinese

　　Medicine, Qinzhou Hospital of Traditional Chinese Medicine, Traditional and Complementary Medicine Center of University Tunku Abdul Rahman, Ze Zhong Traditional Chinese Medicine Clinic, Baohe Sheng Traditional Chinese Medicine Clinic, William NG Acupuncture Center, Traditional Medicine Hospital in Ho Chi Minh City, Vietnam.

　　The ma in drafters of this document are Lian Gu, Wei Chen, Yongquan Zhang, Te K ian Keong, Zhi ling Cai, Yufei Wei, Yonghui Liu, Baoyun Liang, Xiaoxiao Song, X inke Du, Junwei Yang, Haohai L in, Shuyan Hu, Kaihua Wang, Jiaming Lin, Kuiyu Fan, Weitao Wang, Tingting Shen, Luejun Tang, Yan li Wu, Wira Yudha Lie, William NG and Jianje NGG.

　　Specifications for the diagnosis and treatment of

　　ischemic stroke with integrated traditional Chinese

　　and Western medicine

　　1 Scope

　　This document specifies the diagnosis, contra indications, treatment, and daily care requirements for ischemic stroke when employing an integrated approach combining traditional Chinese and Western medicine.

　　This document is applicable to the diagnosis and treatment of ischemic stroke when employing integrated traditional Chinese and Western medicine.

　　2 Normative references

　　This document has no normative references.

　　3 Terms and definitions

　　There are no terms or definitions that need to be defined in this document.

　　4 Diagnosis

　　4.1 Western medicine diagnosis

　　The diagnostic criteria and key points of Western medicine diagnosis can be found in the Guidelines for Clinical Management of Cerebrovascular Diseases in China (2nd Edition). Patients with suspected stroke shall undergo a head CT or MRI examination to rule out non-ischemic causes. In Western medicine, ischemic stroke is classified into acute stage (within 2 weeks of onset), convalescence stage (2 weeks to 6 months after onset), and sequelae stage (6 months after onset).

　　4.2 Traditional Chinese medicine (TCM) diagnosis

　　4.2.1 Main syndromes

　　In TCM, symptoms of ischemic stroke include sudden fainting, loss of consciousness, hem ip legia, facial and tongue deviation, and dysphasia. In mild cases, patients may not experience fainting or loss of consciousness; instead, they may present with symptoms such as hem ip legia, facial and tongue deviation, or disturbance in skin sensation.

　　4.2.2 Syndrome differentiation

　　4.2.2.1 Acute stage

　　4.2.2.1.1 Meridian stroke

　　Main symptoms are as follows:

　　—— Wind phlegm entering the meridians pattern: skin sensation disturbance, numbness of limbs, facial and tongue deviation, dysarthria with tongue stiffness, and even hem ip legia

　　or limb cramps, accompanied by dark purple tongue with a white and greasy coating, and wiry and slippery pulse;

　　—— Wind yang ascending pattern: hem ip legia, hemianesthesia, dysarthria with tongue stiffness, facial and tongue deviation, dizziness and headache, insomnia, flushed face and red eyes, vexation and tantrum, bitter taste in mouth and dry pharynx, dry stools and red urine, accompanied by red or deep-red tongue with a little or thin yellow coating, and wiry and forceful pulse;

　　—— Yin deficiency stirring wind pattern: hem ip legia, facial and tongue deviation, dysarthria with tongue stiffness, hemianesthesia, restlessness and insomnia, dizziness and tinnitus, feverish palms and soles, accompanied by red or dark-red tongue with thin coating or no coating, and thready, wiry or rapid pulse.

　　4.2.2.1.2 Zang-Fu stroke

　　Main syndromes are as follows:

　　—— Blockage pattern:

　　● Phlegm heat-Fu Organ pattern: hem ip legia, dysarthria with tongue stiffness, facial and tongue deviation, hemianesthesia, excess phlegm, abdominal distention and constipation, and dizziness, accompanied by red tongue with a yellow and greasy coating or yellow, thick, and dry coating, and wiry and slippery pulse;

　　● Phlegm fire blocking the heart spirit pattern: sudden collapse, clenched jaw and wide-open eyes, rapid and coarse breathing, or limb convulsions, restlessness and agitation, facial and tongue deviation, hem ip legia, unconsciousness, and urinary and fecal incontinence, accompanied by red tongue with a yellow and greasy coating, and wiry, slippery and rapid pulse;

　　● Phlegm dampness misting the orifices pattern: sudden collapse and loss of consciousness, locked jaw, clenched hands, limb convulsions, urinary and fecal incontinence, dark complexion, a quite and untroubled state, coldness or even icy coldness of limbs, and excessive phlegm, accompanied by dark purple tongue with a white and greasy coating, and deep, slippery or slow pulse.

　　—— Collapse pattern: sudden collapse and loss of consciousness, profuse sweating, limp hands and cold extremities, closed eyes with open mouth, limb paralysis, weak breathing, pale complexion, dilated pupils, urinary and fecal incontinence, accompanied by flaccid and purple tongue with a white coating, and thready, weak or even collapsing pulse.

　　4.2.2.2 Convalescence and sequelae stage

　　Main syndromes are as follows:

　　—— Wind-phlegm with stagnant blood obstructing collaterals pattern: stiff tongue with dysphasia, distorted mouth and tongue, hem ip legia, and numbness of limbs. Darkish purple tongue, indicative of blood stagnation with a greasy coating. Wiry, slippery or astringent pulse;

　　—— Deficiency of qi and blood stasis pattern: hem ip legia, distorted mouth and tongue, stiff tongue with dysphasia, hemianesthesia, pale complexion, shortness of breath with lack of strength, or palpitations, spontaneous sweating, poor appetite, loose stools, and swollen hands and feet. Pale purple tongue with stagnant blood and a thin white coating, wiry and astringent or thready and weak pulse;

　　—— Deficiency of liver and kidney pattern: hem ip legia, stiffness in the affected limb, spasm and deformation, stiff tongue with dysphasia, or atrophy of the limb muscles. Red tongue with a thready pulse, or light red tongue with a deep and thready pulse.

　　5 Contra indications

　　5.1 Contra indications of TCM treatment

　　Individuals with a history of allergies to the recommended Chinese medicines should proceed with caution. Pregnant women, postpartum women, lactating women, and children should use these treatments with care.

　　5.2 Contra indications of Western medicine treatment

　　See the Guidelines for Clinical Management of Cerebrovascular Diseases in China (2nd Edition) for more details.

　　6 Treatment

　　6.1 Therapeutic regimen

　　Diagnose the type of disease through auxiliary examinations in Western medicine, implement an integrated treatment combining traditional Chinese and Western medicine, and strengthen daily care. Emphasis on therapeutic methods for ischemic stroke varies at different stages, and treatment may be tailored according to the following regimen:

　　—— Acute stage: emphasis on timely intervention to improve prognosis, focusing on vascular recanalization treatment to reduce disability and mortality. For patients who are eligible for intravenous thrombo lysis or endovascular treatment, intravent ions should be administered promptly; for patients who are not eligible, consider a drug regimen that combines traditional Chinese and Western medicine, while also intensify the management of comorbidities and complications;

　　—— Convalescence and sequelae stage: Use standardized rehabilitation treatment with proactive measures to prevent and address complications. The focus of treatment shifts to enhancing patients' daily living ability and reducing disability. Characteristic rehabilitation therapies from traditional Chinese medicine and Zhuang medicine may be utilized.

　　6.2 Acute stage

　　6.2.1 Key points of treatment

　　Patients in the acute stage who are eligible for intravenous thrombo lysis or endovascular treatment shall be given corresponding treatment promptly. For those not eligible for these treatments, initiate a reasonable regimen that includes antiplatelet agents, anticoagulants, volume expansion, lipid regulation, plaque stabilization, and neuroprotection as soon as possible. For treatment methods and precautions, refer to the Guidelines for Clinical Management of Cerebrovascular Diseases in China (2nd Edition). Additionally, while adopting Western medicine treatment, TCM syndrome differentiation and treatment should be conducted concurrently.

　　6.2.2 Syndrome differentiation and treatment

　　6.2.2.1 Meridian stroke

　　6.2.2.1.1 Wind phlegm entering the meridians pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: dispelling wind, resolving phlegm, promoting blood flow, and activating collaterals:

　　● Recommended prescription: Ban Xia Bai Zhu Tian Ma Tang goes with Tao Ren Hong Hua decoct ion(appropriate addition or reduction in accordance with symptoms) ; or Zhong Feng admixture (preparation in the First Affiliated Hospital of Guangxi University of Chinese Medicine);

　　● Formula: Fa Ban Xia 8 g, Fu Ling 15 g, Chen Pi 6 g, Gan Cao 6 g, Bai Zhu 15 g, Tao Ren 10 g, Hong Hua 5 g, Xiang Fu 10 g, Qing Pi 6 g, Yan Hu Suo 12 g, Tian Ma 10 g, Sheng Jiang 10 g, Da Zao 10 g;

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 400 mL of liquid. Consume it warm, in two equal portions, after meals;

　　● Course of treatment: The treatment course lasts for 2 weeks; after one course of treatment, adjust the medication according to the patient's condition.

　　—— External therapeutic method: This treatment involves acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are DU 26(shuǐ gōu), PC 6(n âi guān), SP 6(sān y īn jiāo), HT 1(jí qu án), LU 5(chǐ zã) and BL 40(wěi zhōng). The supporting acupoints are ST 40(fēng lóng) and GB 20(fēng chí). Administer once daily, in conjuction with Zhuang medicine therapies: medicated thread moxibust ion, medicated bamboo cup therapy, and lotus needle cupping therapy for expelling stasis. Specific operational procedures are outlined in Annex A.

　　6.2.2.1.2 Wind yang ascending pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: Calming the liver and suppressing Yang, extinguishing wind and dredging collaterals:

　　● Recommended prescription: Tian Ma Gou Teng decoct ion( appropriate addition or reduction in accordance with symptoms);

　　● Formula: Tian Ma 12 g, Gou Teng 12 g, Shi Jue Ming 18 g, Zhi Zi 10 g, Huang Qin 10 g, Chuan Niu Xi 12 g, Du Zhong 10 g, Yi Mu Cao 10 g, Sang Ji Sheng 10 g, Ye Jiao Teng 10 g, Zhu Fu Shen 10 g;

　　Note: Decoct Shi Jue Ming first, followed by Gou Teng.

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 400 mL of liquid. Consume it warm, in two equal portions, after meals;

　　● Course of treatment: The treatment course lasts for 2 weeks; after one course of treatment, adjust the medication according to the patient's condition.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are DU 26(shuǐ gōu), PC 6(nâi guān), SP 6(sān y īn jiāo), HT 1(j í quán), LU 5(chǐ zã) and BL 40(wěi zhōng), and the supporting acupoints are KL 3(tài xī) and LR 3(tài chōng). Administer once daily, in conjunction with Zhuang medicine medicated bamboo cup therapy and Zhuang medicine lotus needle cupping therapy for expelling stasis. Specific operational procedures are outlined in Annex A.

　　6.2.2.1.3 Yin deficiency stirring wind pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: nourishing liver and kidneys, nourishing Yin and extinguishing wind:

　　● Recommended prescription: Zhen Gan Xi Feng decoct ion (appropriate addition or reduction in accordance with symptoms);

　　● Formula: Huai Niu Xi 15 g, Dai Zhe Shi 20 g, Long Gu 15 g, Mu Li 15 g, Gui Jia 15 g, Bai Shao 15 g, Xuan Shen 10 g, Tian Dong 10 g, Chuan Lian Zi 6 g, Sheng Mai Ya 6 g, Yin Chen 6 g, Gan Cao 6 g;

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 400 mL of liquid. Consume it warm, in two equal portions, after meals;

　　● Course of treatment: The treatment course lasts for 2 weeks; after one course of treatment, adjust the medication according to the patient's condition.

　　—— External therapeutic method: This treatment involves acupuncture with acupoint selection based on syndrome differentiation. The main acupoints are DU 26(shuǐ gōu), PC 6(nâi gu ān), SP 6(sān y īn jiāo), HT 1(j í quán), LU 5(chǐ zã) and BL 40(wěi zhōng).Supporting acupoints include GB 20(fēng chí) and KL 3(tài xī). Administer once daily, in conjuction with Zhuang medicine medicated bamboo cup therapy and Zhuang medicine lotus needle cupping therapy for expelling stasis. Specific operational procedures are outlined in Annex A.

　　6.2.2.1.4 Precautions

　　6.2.2.1.4.1 The above prescriptions should be taken warm after meals. Avoid consuming them cold on an empty stomach, as this may harm the spleen and stomach.

　　6.2.2.1.4.2 Avoid alcohol and raw or cold foods while taking the medicine.

　　6.2.2.1.4.3 For patients on prolonged medication, it is important to monitor liver and kidney function regularly.

　　6.2.2.1.4.4 The Chinese medicinal materials used shall adhere to the requirements outlined in the National Pharmacopoeia or relevant standards.

　　6.2.2.2 Zang-Fu stroke

　　6.2.2.2.1 Blockage pattern

　　6.2.2.2.1.1 Phlegm heat-Fu Organ pattern Therapeutic methods:

　　—— Internal therapeutic method: ventilating Fu organ and releasing heat,regulating Qi and resolving phlegm:

　　● Recommended prescription: Tao Ren Cheng Qi decoct ion (appropriate addition or reduction in accordance with symptoms);

　　● Formula: Tao Ren 10 g, Da Huang 6 g, Mang Xiao 10 g, Zhi Shi 10 g, Dan Nan Xing 8 g, Huang Qin 8 g, Quan Gua Lou 10 g, Hong Hua 5 g, Dan Pi 15 g, Huai Niu Xi 15 g;

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 200 mL of liquid，gavage feeding or nasogastric feeding;

　　● Course of treatment: The treatment course lasts for 2 weeks; after one course of treatment, adjust the medication according to the patient's condition.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are DU 26 (shuǐ gōu), DU 20 (bǎi huì) and PC 6(nâ i gu ān). The supporting acupoints are LI 4 (hã g ǔ) and LR 3(tà i chōng). Administer once daily, in conjuction with Zhuang medicine lotus needle cupping therapy for expelling stasis. Specific operational procedures are outlined in Annex A.

　　6.2.2.2.1.2 Phlegm fire blocking the heart spirit pattern Therapeutic methods:

　　—— Internal therapeutic method: clearing heat and resolving phlegm, extinguishing wind and opening orifices:

　　● Recommended prescription: Ling Jiao Gou Teng decoct ion (appropriate addition or reduction in accordance with symptoms), along with the additional use of Zhi Bao Dan or An Gong Niu Huang Wan to clear the heart and open orifices;

　　● Formula: Shui Niu Jiao 30 g, Gou Teng 15 g, Zhen Zhu Mu 30 g, Shi Jue Ming 15 g, Dan Nan Xing 8 g, Fa Ban Xia 8 g, Tian Zhu Huang 10 g, Huang Lian 6 g, Shi Chang Pu 12 g, Yu Jin 10 g;

　　Note: Decoct Shui Niu Jiao and Shi Jue Ming first, followed by Gou Teng.

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 200 mL of liquid，gavage feeding or nasogastric feeding;

　　● Course of treatment: The treatment course lasts for 2 weeks; after one course of treatment, adjust the medication according to the patient's condition.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are DU 26 (shuǐ gōu), DU 20 (bǎi huì) and PC 6(nâ i gu ān).The supporting acupoints are LI 4(hã g ǔ) and LR 3(tà i chōng). Administer once daily, in conjuction with Zhuang medicine medicated thread moxibust ion and Zhuang medicine lotus needle cupping therapy for expelling stasis. Specific operational procedures are outlined in Annex A.

　　6.2.2.2.1.3 Phlegm dampness misting the orifices pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: dispelling phlegm to calm wind, and aromatically warming to open orifices:

　　● Recommended prescription: Di Tan decoction (appropriate addition or reduction in accordance with symptoms), supp lemented by Su He Xiang Wan for alleviating depression and opening the orifices;

　　● Formula: Dan Nan Xing 8 g, Jiang Ban Xia 8 g, Fu Ling 15 g, Ju Hong 6 g, Shi Chang Pu 12 g, Dan Shen 15 g, Zhu Ru 10 g, Yu Jin 12 g, Jiang Chan 10 g;

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 200 mL of liquid，gavage feeding or nasogastric feeding;

　　● Course of treatment: The treatment course lasts for 2 weeks; after one course of treatment, adjust the medication according to the patient's condition.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are DU 26 (shuǐ gōu), DU 20 (bǎi huì) and PC 6(nâi gu ān). The supporting acupoints are LI 4(hã g ǔ) and LR 3(tài chōng). Administer once daily, in conjuction with Zhuang medicine therapies, medicated thread moxibust ion, medicated bamboo cup therapy, and lotus needle cupping therapy for expelling stasis. Specific operational procedures are outlined in Annex A.

　　6.2.2.2.2 Collapse pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: restore Yang to rescue the collapsing, tonify Qi to prevent exhaustion:

　　● Recommended prescription: Shen Fu decoction combined with Sheng Mai powder (appropriate addition or reduction in accordance with symptoms);

　　● Formula: Ren Shen 30 g, Pao Fu Zi 12 g, Sheng Jiang 6 g, Wu Wei Zi 10 g, Shan Yu Rou 10 g;

　　Note: Decoct Pao Fu Zi first and decoct Ren Shen separately.

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 200 mL of liquid，gavage feeding or nasogastric feeding;

　　● Course of treatment: The treatment course lasts for 2 weeks; after one course of treatment, adjust the medication according to the patient's condition.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are DU 26 (shuǐ gōu), DU 20 (bǎi huì) and PC 6(nèi guān). The supporting acupoints are RN 4(guān yuán) and RN 6(qì hǎi). Administer once daily, in conjuction with Zhuang medicine medicated thread moxibust ion. Specific operational procedures are outlined in Annex A.

　　6.2.2.2.3 Precautions

　　6.2.2.2.3.1 Adjust the dosage and usage of medication according to the patient's condition. For those in critical condition, the medication may be decocted and administered immediately or continuously for 24 hours via nasogastric feeding. For patients in coma, apply medication through oxygen inhalation combined with medicinal liquid hot compressed on the chest and abdomen front and back.

　　6.2.2.2.3.2 The Chinese medicinal materials used shall adhere to the requirements outlined in the National Pharmacopoeia or relevant standards.

　　6.3 Convalescence and sequelae stage

　　6.3.1 Key points of treatment

　　During the recovery period, patients should be administered external therapeutic methods of TCM, in conjunction with oral antibiotics, circulation-enhancing medications and neuroprotective drugs. They are encouraged to engage in appropriate exercise and to strengthen their daily care routines in order to control risk factors. In the sequelae stage, antiplatelet or anticoagulant, circulation-enhancing and neuroprotective drugs can be selected according to the condition. Nutritional support and psychological intervention should be strengthened. Once stabilized, rehabilitation treatment should be standardized. It is recommended to employ characteristic rehabilitation therapies of TCM to actively manage complications and prevent recurrent ischemic strokes. For Western medicine treatment methods and precautions, refer to the Guidelines for Clinical Management of Cerebrovascular Diseases in China (2nd Edition).

　　6.3.2 Syndrome differentiation and treatment

　　6.3.2.1 Convalescence and sequelae stage

　　6.3.2.1.1 Wind-phlegm with stagnant blood obstructing collaterals pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: dispelling pathogenic wind and eliminating phlegm, dispersing blood stasis and promoting collateral circulation:

　　● Recommended prescription: Jie Yu Dan (appropriate addition or reduction in accordance with symptoms);

　　● Formula: Shi Chang Pu 12g, Yuan Zhi 10g, Tian Ma 10g, Quan Xie 3g, Jiang Chan 10g, Dan Nan Xing 8g, Tian Zhu Huang 10g, Fa Ban Xia 8g, Chen Pi 6g, Di Long 10g, Xi X ian Cao 10g, Sang Zhi 15g, Ji Xue Teng 20g, Dan Shen 15g, Hong Hua 5g;

　　Note: Quan Xie should be stir-fried with alcohol.

　　● Decoct ion: one dose per day, decoct ing in water to yield 400mL, take warm twice daily after meals;

　　● Course of treatment: The treatment course lasts for 4 weeks. After completing one course, adjust the medication according to the patient's condition, with a total of

　　3 to 4 courses recommended.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection on syndrome differentiation. The primary acupoints are PC 6(nâi guān), SP 6(sān y īn jiāo), HT 1(j í quán), LU 5(chǐ zã) and BL 40(wěi zhōng), and the supporting acupoints are ST 40(f ēng lóng) and GB 20(fēng chí). Administer once daily, in conjuction with Zhuang medicine therapies: medicated thread moxibust ion, medicated bamboo cup therapy, and lotus needle cupping therapy for expelling stasis. During the sequelae stage, medicated thread moxibust ion may be omitted. Specific operational procedures are outlined in Annex A.

　　6.3.2.1.2 Deficiency of qi and blood stasis pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: Promoting blood circulation to disperse blood stasis and tonify ing Qi to unclog the meridians:

　　● Recommended prescription: Bu Yang Huan Wu decoction (appropriate addition or reduction in accordance with symptoms);

　　● Formula: Huang Qi 30 g, Dang Gui 10 g, Chi Shao 20 g, Di Long 10 g, Chuan Xiong 5 g, Hong Hua 10 g, Tao Ren 10 g, Chuan Niu Xi 20 g, Ji Xue Teng 30 g;

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 400 mL of liquid. Consume it warm, in two equal portions, after meals;

　　● Course of treatment: The treatment course lasts for 4 weeks. After completing one course, adjust the medication according to the patient's condition, with a total of

　　3 to 4 courses recommended.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are PC 6(nâi guān), SP 6(sān y īn jiā o), HT 1(j í quán), LU 5(chǐ zã) and BL 40(wěi zhōng).The supporting acupoints are ST 36(zú sān lǐ)and RN 6(Qì hǎi). Administer once daily, in conjuction with Zhuang medicine therapies: medicated thread moxibust ion, medicated bamboo cup therapy, plastering therapy, and lotus needle cupping therapy for expelling stasis. During the sequelae stage, medicated bamboo cup therapy and lotus needle cupping therapy for expelling stasis may be omitted. Specific operational procedures are outlined in Annex A.

　　6.3.2.1.3 Deficiency of liver and kidney pattern

　　Therapeutic methods:

　　—— Internal therapeutic method: nourishing liver and kidneys:

　　● Recommended prescription: Zuo Gui Wan combined with Di Huang Yin Zi decoction (appropriate addition or reduction in accordance with symptoms);

　　● Formula: Shu Di Huang 20g, Gou Qi 15g, Shan Yu Rou 10g, Shi Hu 10g, Mai Dong 10g, Shou Wu 12g, Ji Xue Teng 15g, Dang Gui 6g, Chen Pi 7 g;

　　● Decoct ion: Take one dose per day. Decoct the medication in water to obtain 400 mL of liquid. Consume it warm, in two equal portions, after meals;

　　● Course of treatment: The treatment course lasts for 4 weeks. After completing one course, adjust the medication according to the patient's condition, with a total of

　　3 to 4 courses recommended.

　　—— External therapeutic method: Utilize acupuncture with acupoint selection based on syndrome differentiation. The primary acupoints are PC 6(nâi guān), SP 6(sān y īn jiā o), HT 1(j í quán), LU 5(chǐ zã) and BL 40(wěi zhōng). The supporting acupoints are KL

　　3(tài xī) and RN 4 (guān yuán). Administer once daily, in conjuction with Zhuang medicine therapies: medicated thread moxibust ion, medicated bamboo cup therapy, and plastering therapy. During the sequelae stage, medicated bamboo cup therapy may be omitted. Specific operational procedures are outlined in Annex A.

　　6.3.2.1.4 Precautions

　　6.3.2.1.4.1 The above prescriptions should be taken warm after meals. Avoid consuming them cold on an empty stomach, as this may harm the spleen and stomach.

　　6.3.2.1.4.2 For patients on prolonged medication, it is important to monitor liver and kidney function regularly. If there is any worsening of condition or the appearance of gastrointestinal symptoms, discontinue the medication immediately and seek medical attention as soon as possible, if necessary.

　　6.3.2.1.4.3 The prescribed medications are not suitable for individuals with a history of allergies. Pregnant women, women in labor, lactating mothers, and children should use them with caution.

　　6.3.2.1.4.4 The Chinese medicinal materials utilized shall adhere to the requirements outlined in the National Pharmacopoeia or relevant standards.

　　7 Daily care

　　7.1 Develop good living habits, including maintaining a low-salt and low-fat diet, quitting smoking, limiting alcohol consumption, controlling weight, and engaging in appropriate aerobic exercises.

　　7.2 Stay away from triggering factors and regularly screen for risk factors associated with ischemic stroke. Additionally, refrain from overexertion and avoid staying up late for prolonged periods.

　　7.3 Attach great importance to the secondary prevention of ischemic stroke.

　　7.4 Enhance rehabilitation exercises to improve various functional impairments and prevent the onset of disuse syndrome.

　　7.5 Avoid exposure to wind and cold, carefully plan daily routines, balance work and rest, regulate diet, keep a worry-free mind, and prevent the recurrence of ischemic stroke.

　　Annex A

　　(Normative)

　　External therapies of TCM

　　A.1 Medicated thread moxibust ion of Zhuang medicine

　　A.1.1 Acupoint selection

　　For the upper limbs, acupoints including LI 15 (jiān yú)，LI 11 (qū chí)， LI 10 (shǒu s ān lǐ ), SJ 5 (wài guān) and LI 4 (hã gǔ) may be selected; for the lower limbs, acupoints such as GB 30 (huán tiào), GB 34 (yáng l íng quán), ST 36 (zú sān lǐ), ST 41 (jiě xī) and BL 60 (kūn lún) may be selected. For those with deviation of the face and eyes, selection goes to ST 4 (dì cāng), ST 6 (jiá chē), LI 4(hã gǔ), ST 44 (nâi tíng) and LV 3 (tài chōng), and then to other acupoints such as EX-HN16 (qiān zhâng), DU 26 (shuǐ gōu), ST 2 (sì bái) and ST 7 (xià guān) according to the lesions.

　　A.1.2 Moxibust ion based on pattern differentiation

　　The determination of moxibust ion techniques (light, medium or heavy) should be based on the patient's condition. In clinical practice, the target acupoint should be aligned with the bead-like spark le on the thread. Following the flex ion movements of the wrist and thumb, the thumb presses the ignited end of the thread onto the acupoint in a steady and agile manner at an angle of 30 ° to 60 ° , similar to a sparrow pecking at food. Once the sparkle is extinguished, the thread should be picked up immediately; this is called 1 Zhuang. For the Yin pattern, after performing moxibust ion, the thumb rubs the acupoint in a clockwise direction for a few seconds. For the Yang pattern, the rubbing technique should not be applied. Refer to Figure A.1 for an illustration of medicated thread moxibust ion of Zhuang medicine.

　　Figure A.1 Medicated thread moxibust ion of Zhuang medicine

　　A.1.3 Course of treatment

　　For the Y in pattern, 1 to 3 Zhuangs should be performed at each target acupoint, while for the Yang pattern, 1 to 2 Zhuangs are recommended, up to 3 times a day. The most desired therapeutic effect can be achieved when the ash of the ignited medicated thread left on the acupoint turns white. The course of treatment should be adjusted according to the individual patient's response and specific circumstances.

　　A.1.4 Precautions

　　The heat of the medicated thread shall be meticulously regulated to prevent burning the patient's skin. The bead-like sparkle produced offers optimal therapeutic outcomes. During the moxibust ion treatment, patients should refrain from consuming foods that are considered “triggering” or “heat-inducing”, including raw onions, beef, horsemeat, seafood, and bamboo shoots. Moxibust ion is contra indicated for pregnant women, women in the postpartum period, nursing mothers, as well as for the eyeballs and genital areas of both males and females.

　　A.2 Medicated bamboo cup therapy of Zhuang medicine

　　A.2.1 Acupoint selection

　　Selection goes to hua tuo jia ji points, the foot taiyang bladder channel, the hand taiyang large intestine channel, the foot shaoyang gallbladder channel, the foot yangming stomach channel and the foot taiyin spleen channel.

　　A.2.2 Cup boiling

　　The bamboo cups should be submerged in boiling Zhuang medicinal solution and boiled for 15 to 20 minutes for treating the Y in pattern, and for 5 to 14 minutes for treating the Yang pattern. A.2.3 Cup retaining

　　The practitioner should hold the bamboo cup with tweezers in the right hand and a clean towel in the left hand, then swiftly invert the cup onto the towel to remove any excess liquid. Once the excess liquid has drained off, the practitioner should use the thumb, index finger, and middle finger of the right hand to grasp the bottom of the cup and test its temperature by placing the inner side of their forearm against it. Once the temperature is confirmed to be suitable, the bamboo cup should be swiftly placed onto the treatment area. After a brief moment, it should be rotated gently to ensure a tight adherence to the skin. For the Y in pattern, the cup should be rotated clockwise by 10 ° to 30 ° at a slow speed and with gentle force. For the Yang pattern, it should be rotated counterclockwise by the same degree range but at a slightly faster speed and with heavier force. The cup should remain in place for a duration of 5 to 15 minutes, depending on the severity of the patient's condition.

　　A.2.4 Cup sliding

　　Cup sliding should be administered on a larger, more muscular area of the patient's body. After applying lubricating oil on the selected skin area, the practitioner should press the skin near the cup's edge with one hand while holding the bamboo cup with the other. The cup should be moved back and forth across the skin until petechiae appear in the therapeutic area. For the Y in pattern, the sliding motion should be gentle and slow to achieve light red or red petechiae on the treated skin area. For the Yang pattern, a heavier and faster motion is required to produce dark red or light purple petechiae. Refer to Figure A.2 for an illustration of medicated bamboo cup therapy of Zhuang medicine.

　　Figure A.2 Medicated bamboo cup therapy of Zhuang medicine

　　A.2.5 Course of treatment

　　Typically, the treatment ought to be administered once daily; however, adjustments may be necessary based on each patient's individual response and specific circumstances.

　　A.2.6 Precautions

　　Before performing cup retention, ensure that the cup is thoroughly emptied of any excess liquid to prevent burns. Removing of the cup should be gentle and swift, avoiding any forceful pulling. It is advisable for the patient to receive treatment for 1 to 2 hours after meals, stay warm and avoid bathing within 4 to 6 hours (period) following the treatment. Pregnant women, postpartum women, breastfeeding mothers, women during menstruation, children, and individuals with bleeding disorders are not recommended for this therapy. If small blisters appear after cupping, it is crucial to take special care to avoid rubbing or breaking them; instead, allow them to heal and absorb naturally over time. In the case of larger blisters, a sterilized needle can be used to carefully puncture and drain the fluid. After doing so, apply an iodine tincture to the area and cover it with sterile gauze.

　　A.3 Plastering therapy of Zhuang medicine

　　A.3.1 Preparation of medicated plasters

　　Mix an appropriate amount of Zhuang medicine powder with rice wine for treating the Y in pattern, and with rice vinegar for treating the Yang pattern; blend the ingredients thoroughly until they are evenly combined.

　　A.3.2 Plastering

　　Medicated plasters of an appropriate size should be selected based on the specific treatment area. For the Y in pattern, the plasters should be heated to a temperature ranging between 40 ℃ and 50 ℃, but no heating is necessary for the Yang pattern. First, a tendon manipulation should be conducted on the treatment area for a duration of 5

　　to 10 minutes to ensure the patient's comfort. Next, it is important to test the temperature of the plaster on the back of your hand before applying the plaster with its adhesive side to the patient's skin. Finally, only when the patient has confirmed that the plaster is not too hot, it should be firmly attached to the treatment area using adhesive tape. Refer to Figure A.3 for an illustration of plastering therapy of Zhuang medicine.

　　Figure A.3 Plastering therapy of Zhuang medicine

　　A.3.3 Course of treatment

　　The plaster can be applied for a duration of 4 to 6 hours, with each application occurring every other day. A complete course of treatment consists of a total of 7 applications. The course of treatment should be tailored based on the individual patient's response and specific circumstances.

　　A.3.4 Precautions

　　If the patient experiences skin itching, red rash, pain, or any other discomfort, the application of the plaster shall be discontinued immediately. Pregnant women, postpartum women, breastfeeding mothers and individuals with allergic tendencies should use it with caution.

　　A.4 Lotus needle cupping therapy of Zhuang medicine for expelling stasis

　　A.4.1 Acupoint selection

　　Bei liang and Lianhua are commonly selected acupoints.

　　A.4.2 Acupuncture and cupping

　　The practitioner should grasp the lotus needle and tap the skin at the selected acupoint three times consecutively. Next, ignite the blood cup (fire cup) to create a vacuum and promptly place it over the acupoint. Once a small amount of bleeding is observed inside the cup, leave it in place for 10 to 15 minutes. To remove the cup, the practitioner should press the skin near it with one hand and swiftly lift it off with the other, then clean any blood from the skin using sanitary paper. Finally, thoroughly disinfect the treated area twice to ensure cleanliness and prevent infection. Refer to Figure A.4 for an illustration of lotus needle cupping therapy for expelling stasis of Zhuang medicine.

　　Figure A.4 Lotus needle cupping therapy for expelling stasis of Zhuang medicine

　　A.4.3 Course of treatment

　　The treatment should be performed twice a week, with adjustments made to the course of treatment based on the individual patient's response and specific circumstances.

　　A.4.4 Precautions

　　The treatment is contra indicated for pregnant women, postpartum women, individuals with high fever and convulsions, and those with coagulation disorders. Areas with broken skin, ulcers, scars, severe edema, and superficial large blood vessels should be avoided during the treatment. Elderly and frail individuals, as well as patients with deficiency patterns or hemopathy, should use the treatment with caution. Strict attention should be paid to aseptic procedures during the treatment process and to proper wound care after removing the cup.

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