院内卒中再灌注治疗研究进展

院内卒中患者虽然卒中发病时置身医院环境，但由于其基础病情复杂、识别困难、治疗禁忌证多等因素，存在再灌注治疗延迟和再灌注率低等情况，是导致院内卒中预后不良的重要因素。针对院内卒中再灌注治疗流程中不同环节的延误原因，加强院内卒中识别、改进溶栓绿色通道流程、重视头颅影像学中灌注成像检查等措施有利于改善院内卒中再灌注治疗的延误。我国院内卒中救治体系尚未完善，未来需结合我国国情、院内卒中的特征以及先进中心的经验，加强绿色通道诊治流程建设和改良，以改善院内卒中患者的预后。     

中国脑血管病防治指南(节选)

第三章 卒中单元 一、概念 卒中单元（stroke unit）是指改善住院卒中患者的医疗管理模式，专为卒中患者提供药物治疗、肢体康复、语言训练、心理康复和健康教育、提高疗效的组织系统。卒中单元的核心工作人员包括临床医师、专业护士、物理治疗师、职业治疗师、语言训练师和社会工作者。基于以上概念，可以将卒中单元概括为以下特点：（1）针对住院的卒中患者，因此它不是急诊的绿色通道，也不是卒中的全程管理，只是患者住院期间的管理。（2）卒中单元不是一种疗法，而是一种病房管理系统。（3）这种新的病房管理体系应该是一种多元医疗模式（muhidisciplinary care system），也就是多学科的密切合作。（4）患者除了接受药物治疗，还应该接受康复治疗和健康教育。但是，卒中单元并不等于药物治疗加康复治疗，它是一种整合医疗（integrated care）或组织化医疗（organized care）的特殊类型。（5）卒中单元体现对患者的人文关怀，体现了以人为本。它将患者的功能预后以及患者和家属的满意度作为重要的临床目标，而不像传统的理念仅强调神经功能的恢复和影像学的改善。     

定量脑电图在脑血管病临床应用中的进展

定量脑电图是近年临床中常用的无创实时脑功能监测手段。脑血管病后神经网络受损所 致的神经电生理传导改变可通过皮层脑电图记录并总结出其规律性，结合计算机技术给予定量处理， 可为卒中的发展、预后以及卒中后抑郁、卒中后认知功能障碍的评估方面提供客观依据。现从定量脑 电图在卒中和卒中后相关疾病的特点及临床应用方面作一综述。     

缺血性卒中或短暂性脑缺血发作患者的卒中预防指南

这份新声明旨在为缺血性卒中或短暂性脑缺血发作存活者的缺血性卒中预防提供全面和及时的循证推荐，循证推荐包括对危险因素的控制，动脉粥样硬化性疾病的干预措施，心源性栓塞的抗栓治疗以及非心源性卒中抗血小板药的应用。另外，还为其他多种特殊情况下复发性卒中的预防提供了推荐、包括动脉夹层分离、卵圆孔未闭、高同型半胱氨酸血症、高凝状态、镰状细胞病、脑静脉窦血栓形成、女性卒中（特别是与妊娠和绝经后激素替代治疗相关卒中），脑出血后肮凝药的应用，以及该指南在高危人群中执行和应用的特殊措施。     

急性缺血性卒中出血转化的研究进展

出血转化是急性缺血性卒中再灌注治疗后的主要并发症之一，与缺血性卒中预后不良密 切相关。急性缺血性卒中的主要治疗方案，包括阿替普酶静脉溶栓、血管内治疗及抗血小板聚集药 物治疗等均可能导致出血转化。目前临床上尚无对缺血性卒中出血转化有效的预测方法，本文对缺 血性卒中出血转化的病因以及影像学和生物学标志物进展进行综述，旨在为出血转化的预防和治疗 提供参考。     

抗血小板治疗在血管内治疗缺血性脑血管病中的应用

血管内治疗能显著降低缺血性脑血管病的致残、病死及卒中复发率。随着神经介入技术 和材料以及患者筛选策略的进步，缺血性卒中患者应用血管内治疗也日益增加。抗血小板治疗作为 缺血性卒中预防和治疗的重要手段，是血管内治疗中的重要一环，阿司匹林、氯吡格雷等是基石性 抗血小板药物，但具体的用药方案尚不统一。本文回顾和总结了国内外指南针对缺血性脑血管病行 血管内治疗患者的抗血小板策略建议，以及重要血管内治疗研究中采用的抗血小板治疗方案，以期 为神经介入医师行血管内治疗时抗血小板药物的应用提供参考。     

缺血性卒中的个体化治疗的依据及策略

缺血性卒中是各种原因所导致的一组临床综合征,具有不同的病因、发病机制及临床表现。因此,缺血性卒中的处理应强调规范化诊断基础上的个体化治疗。本文从缺血性卒中的临床病理学特点及神经影像学改变出发,阐述了缺血性卒中患者的分型诊断原则和规范化治疗程序。     

卒中后吞咽困难的识别和管理指南

英国皇家医师协会的苏格兰学院指南协作组制定了一套关于卒中诊断治疗方面的国家指南,共包括四个部分,第一部分:卒中的诊断、急性期治疗和二级预防指南;第二部分:颈动脉狭窄和颈动脉内膜剥脱术指南;第三部分:卒中后吞咽困难的指南;第四部分:卒中康复、并发症的预防和处理以及出院计划指南。其中第三部分的吞咽困难指南已经在1997年发表了第一版,本刊所刊登的为2004年9月刚刚更新的第二版。该指南是目前国际上比较全面、系统的关于卒中后吞咽困难的指南,包括了吞咽困难筛查、评估、治疗等方面的内容。在后面的附件当中,提供了Logemann等所制定的筛查、评估的临床实用表格,以供参考。该指南的内容不适合非卒中的患者以及蛛网膜下腔出血的患者。每条建议后的A、B、C、D为建议级别。     

康复卒中单元在基层医院的运作与效果评价(附570例临床分析)

目的通过在基层医院建立和运作康复卒中单元，以探讨脑血管病新的管理模式及效果评定。方法将病情稳定、Barthel指数（BI）评分低于40分的570例脑卒中患者分别在康复卒中单元（观察组）和普通病房（对照组）进行为期3周的相关治疗，运用Ⅸ、Fugl-Meyer评估（FMA）以及汉密尔顿抑郁量表（HAMD）对患者日常生活活动能力、肢体运动功能以及抑郁和焦虑程度进行评定。比较患者的综合康复疗效。结果治疗前BI、FMA、HAMD在2组间均无显著差异（P〉0．05）；治疗后对照组以及观察组与其治疗前相比均有显著差异（P〈0．05），观察组与对照组治疗后相比也有显著差异（P〈0．05）。结论2组患者的治疗均有效，但康复卒中单元的效果更明显；康复卒中单元是基层医院实施脑血管病治疗更好的管理模式。     

卒中动物模型的研究进展

卒中是当今世界上发病率、致残率和致死率最高的重大疾病之一,其病理机制以及预防治疗措施仍然是目前研究的热点。卒中动物模型对于卒中的病理机制及其防治的研究具有重要意义。本文针对传统的和改良的卒中动物模型的制备方法及其优缺点进行综述。     

Ischaemic stroke

There are about 25.7 million stroke survivors worldwide. Ischaemic stroke remains the most common type of stroke. Numerous modifiable risk factors have been identified, including behaviors such as cigarette smoking and sedentary lifestyle and treatable medical comorbidities such as hypertension, hyperlipidemia and atrial fibrillation. Once considered irreversible, acute ischaemic stroke is now amenable to acute medical and endovascular therapies to reduce infarct volume. Many advances are expected in the years to come, particularly in the areas of prevention and recovery.     

ESO2008缺血性卒中和短暂性脑缺血发作治疗指南（摘要）

欧洲卒中组织（ESO）于2008年5月更新了欧洲卒中促进会(EUSI)2000和2003版的缺血性卒中和短暂性脑缺血发作的治疗指南。2008版指南包含了2003年以来的新进展。本文编译了2008版指南中的主要建议。     

Ischaemic oculomotor nerve palsy

Summary Of 61 patients with isolated third nerve palsy, 23 (38%) had the characteristic clinical features of an ischaemic oculomotor nerve palsy. The essential sign of this usually painful disorder of acute onset was a marked discrepancy between complete or severe paresis of the extraocular muscles innervated by the third nerve, and sparing of the pupillary sphincter. All patients had completely recovered within 3 months. Fourteen had a history or on follow-up had other cranial mononeuropathies. Except for two patients, all were above the age of 60 years. Of the 23 cases, 11 had diabetes mellitus and 8 an abnormal glucose tolerance test, while in 4 the latter was normal. Almost all had hypertension and were overweight, and half were smokers. In 18 patients, four or five vascular risk factors were present.     

Ischaemic brain oedema.

Ischaemic brain oedema appears to involve two distinct processes, the relative contribution and time course of which depend on the duration and severity of ischaemia, and the presence of reperfusion. The first process involves an increase in tissue Na+ and water content accompanying increased pinocytosis and Na+, K+ ATPase activity across the endothelium. This is apparent during the early phase of infarction and before any structural damage is evident. This phenomenon is augmented by reperfusion. A second process results from a more indiscriminate and delayed BBB breakdown that is associated with infarction of both the parenchyma and the vasculature itself. Although, tissue Na+ level still seems to be the major osmotic force for oedema formation at this second stage, the extravasation of serum proteases is an additional potentially deleterious factor. The relative importance of protease action is not yet clear, however, degradation of the extracellular matrix conceivably leads to further BBB disruption and softening of the tissue, setting the stage for the most pronounced forms of brain swelling. A number of factors mediate or modulate ischaemic oedema formation, however, most current information comes from experimental models, and clinical data on this microcosmic level is lacking.Clinically significant brain oedema develops in a delayed fashion after large hemispheric strokes and is a cause of substantial mortality. Neurological signs appear to be at least as good as direct ICP measurement and neuroimaging in detecting and gauging the secondary damage produced by stroke oedema. The neuroimaging characteristics of the stroke, specifically the early involvement of greater than half of the MCA territory, are, however, highly predictive of the development of severe oedema over the subsequent hours and days. None of the available medical therapies provide substantial relief from the oedema and raised ICP, or at best, they are temporizing in most cases. Hemicraniectomy appears most promising as a method of avoiding death from brain compression, but the optimum timing and manner of patient selection are currently being investigated. All approaches to massive ischaemic brain swelling are clouded by the potential for survival with poor functional outcome. It is possible to manage blood pressure, serum osmolarity by way of selective fluid administration, and a number of other systemic factors that exaggerate brain oedema. Broad guidelines for treatment of stroke oedema can therefore be given at this time.     

Ischaemic stroke provoked by sexual intercourse

The association between long term risk factors and stroke has been well established, but very little is known about factors that may precipitate acute stroke. We describe two young women presenting with ischaemic stroke triggered by sexual intercourse. Patient 1 presented with a cardioembolic stroke probably secondary to the interaction between a patent foramen ovale and thrombophilic abnormalities; Patient 2, presenting with orgasmic headache, had a cryptogenic striatocapsular infarct. Sexual intercourse should be considered as an unusual, but possible, trigger of cerebral ischaemia, especially in young patients presenting with cryptogenic stroke.     

Ischaemic cerebral infarction in young adults

Fifty six patients aged 17 to 45 years who had Ischemic Cerebral Infarction (I.C.I.) were studied. The following etiologies were established: 1. Juvenile atherosclerosis (21 patients); 2. Cerebral embolism either from cardiac (10 patients) and from unknown source (3 patients); 3. Secondary coagulopathies (4 patients); 4. Non atherosclerotic vasculopathies (6 patients); 5. Traumas of skull and neck (3 patients); 6. Migraine (2 patients); 7. Oral contraceptives use (1 patient). In 6 cases the etiology remained unknown. Young subjects with I.C.I. are a heterogeneous group: however in most of them a reasonable cause can be found. The occurrence of acute death (14%) was high, while recurrent stroke (5%) and non acute death (3%) were rare when compared to older patients. At the follow-up 80% had a very little residual motor deficit but only 43% were able to return to previous work.     

Ischaemic stroke: new frontiers.

Lot of advancement has taken place, not only in the management but also in the pathophysiology and imaging modalities in patients of stroke. Indolent chronic infections, particularly those due to H. pylori, have been identified as one of the risk factors. The mechanism of inflammation in inducing a precoagulant state has also been worked out. SPECT studies have detected ischaemic areas before appearance of CT abnormalities. CT angiography identifies abnormalities in the 'circle of willis' in posterior circulation strokes much better, and helps weigh the risk versus benefit of thrombolysis. With experiance in use of r-TPA, the list of contra indications and precautions has become longer than its indications. Newer drugs like lubeluzole and edselen have also been recommended. Various other drugs e.g. aptiganel hydrochloride, MDL 28170, 'basic fibroblast growth factor' and 'superoxide dismutase' are at an experimental stage. The concept of a 'stroke cocktail' may be in vogue soon. Controversies still exit regarding the exact indication of prophylactic anticoagulant and the 'international normalized ratio' (INR) to be achieved. Guidelines have been laid down for the approach to patients with asymptomatic carotid artery stenosis. However, the paramount message in stroke care is dissipation of the concept of 'brain attack', amongst the primary care medical and para-medical personnel.     

急性缺血性卒中的抗血小板治疗

急性缺血性卒中患者血小板被激活，抗血小板治疗可减少早期脑梗死的复发，减轻脑损伤的体积，降低早期死亡和改善存活者的长期预后。但抗血小板治疗增加非致死性或症状性颅内出血的发生率。阿司匹林是证据最充分且得到各国指南推荐的治疗急性缺血性卒中的抗血小板药物，对未溶栓治疗的急性缺血性卒中患者应尽早开始阿司匹林治疗。氯吡格雷、血小板糖蛋白Ⅱb/IIIa受体抑制剂、双嘧达莫、西洛他唑等单药用于治疗急性缺血性卒中的安全性和疗效目前尚无足够的证据。抗血小板药物联合应用的疗效和可能的风险尚需进一步研究。