急性缺血性脑卒中血管内治疗进展

血管再通恢复有效灌注是急性缺血性卒中(AIS)的治疗关键。基于AIS早期血管再通挽救缺血半暗带,从而改善患者神经功能预后的理念,近二十年来神经病学家致力于血管内治疗的探索,本文综合几项试验结果,对AIS血管内治疗的进展进行综述。     

1例低剂量阿替普酶静脉溶栓直接桥接动脉取栓患者的护理

卒中是导致人类致残和致死的主要疾病之一,急性缺血性卒中( Acute ischemic stroke,AIS)约占全部卒中的80％.AIS治疗的关键在于尽早开通阻塞血管,挽救缺血半暗带.目前早期开通血管的特异性治疗方法有静脉溶栓治疗及血管内介入治疗(包括血管内机械取栓、动脉溶栓、血管成形术)等.静脉溶栓是目前最主要恢复血流措施,药物包括重组组织型纤溶酶原激活剂(Rt-PA)、尿激酶和替奈普酶.Rt-PA(阿替普酶)和尿激酶是我国目前使用的主要溶栓药[1] ,现认为有效挽救半暗带组织时间窗为4.5 h内或6 h内.     

静脉溶栓治疗急性脑梗死大血管闭塞患者的血管再通情况及其影响因素分析

目的:分析静脉溶栓治疗急性脑梗死(ACI)大血管闭塞患者的血管再通情况及其影响因素。方法:接受静脉溶栓治疗的急性脑梗死大血管闭塞患者128例纳入研究,根据溶栓后血管再通情况分为血管再通组(97例)和血管未通组(31例),比较2组临床资料并分析血管再通的影响因素。结果:静脉溶栓血管再通率为75.78%;溶栓前美国国立卫生院脑卒中量表(NIHSS)评分、心源性脑栓塞和发病到静脉溶栓治疗时间是静脉溶栓后血管再通的独立影响因素(均P<0.05);血管再通组发生非症状性颅内出血(NSICH)的比例明显低于血管未通组,24 h神经功能恢复良好、7 d早期临床转归良好、90 d预后良好和生活自理患者的比例均显著高于血管未通组(均P<0.05);2组7 d和90 d的死亡率差异无统计学意义(P>0.05)。结论:ACI患者静脉溶栓的血管再通率较高,可显著改善患者预后;溶栓前NIHSS评分、心源性脑栓塞和发病到静脉溶栓治疗时间是静脉溶栓后血管再通的独立影响因素。     

多模式桥接治疗急性缺血性卒中临床疗效及安全性

目的:评估多模式桥接治疗急性缺血性卒中(AIS)的疗效及安全性。方法:回顾性分析2015年1月到2016年8月广东省中山市人民医院神经内科收治的AIS患者100例的临床资料,根据病情选择适当的再通血管方式:对起病4.5 h小时内、有静脉溶栓指征者,立刻予静脉溶栓治疗,同时送介入室行全脑血管造影,了解病变血管情况,如血管已再通则结束手术;对前循环在6小时内、后循环在24小时内无静脉溶栓指征,且无全脑管造影禁忌症者,均予急诊行全脑血管造影术,了解病变血管情况,若血管已再通则结束手术;对血管仍有闭塞或狭窄,则考虑予动脉溶栓或支架成型术或支架取栓术等多模式桥接开通血管,评价治疗后NIHSS评分改善率,3个月后随mRS评分。结果:100例AIS患者接受多模式桥接治疗,平均年龄62.72±14.16岁,入院时平均NIHSS评分8.49±4.48分,发病到我院时间平均为3.59±2.37小时,所有患者均获得血管再通,术后残余狭窄程度(25.27±19.77)%;术后死亡3例,1例死于肺部严重感染,2例死于术后高灌注出血,余97例术后NIHSS评分3.63±4.3分,3个月后随访87例mRS2分,NIHSS 2.16±2.01分。结论:多模式联合治疗急性缺血性卒中能够有效地再通血管,可有效提高治疗效果,改善神经功能,促进患者恢复,值得临床推广应用。     

多模影像指导下个体化血管再通病人的护理

[目的]探讨在多模影像指导下急性缺血性卒中(AIS)病人接受重组组织型纤溶酶原激活剂(rtPA)静脉溶栓联合血管内治疗后护理工作的有效性及安全性,总结护理措施。[方法]筛选2014年1月—2014年12月就诊的17例行动静脉联合治疗的AIS病人为研究对象,在溶栓前以及溶栓后1h,2h,24h和出院时对其行美国国立卫生研究院神经功能缺损评分(NIHSS),评估神经功能缺损情况,出院时和溶栓后90d行改良Barthel指数(MBI)评分评估日常生活能力和改良Rankin量表(mRS)评估神经功能预后。[结果]17例病人中死亡1例,脑出血1例,蛛网膜下隙出血1例,其余14例病人出院时NIHSS评分(7.36分±7.51分)比溶栓前(16.57分±6.07分)降低,差异有统计学意义(P=0.000)。溶栓后90d日常生活能力MBI比出院时有所提高,差异有统计学意义(50.07分±13.57分vs 56.79分±13.12分,P=0.004)。病人90d时神经功能预后较出院时mRS评分有所改善,差异有统计学意义(1.71分±1.78分vs 2.57分±1.56分,P=0.001)。[结论]在多模影像指导下,卒中病人个体化管理可以缩短其就诊到溶栓的时间(静脉溶栓)和就诊到穿刺的时间(血管内治疗),扩展时间窗能增加病人接受溶栓治疗的机会,有效提高病人血管再通率,促进神经功能恢复和日常生活能力提高。     

急性缺血性卒中血管内机械再通的研究现状与展望

急性缺血性卒中如今已成为我国人口死亡的常见原因,静脉溶栓对大血管闭塞尤其是颈内动脉闭塞的患者再通率低,治疗效果有限。血管内机械再通作为一种新的治疗手段,现已成为急性缺血性卒中的重要治疗方法和研究热点。本文就近年来国际上大型的多中心血管内机械再通试验进行综述。     

不同静脉溶栓时间窗对进展性脑梗死血管再通及预后的影响

目的分析不同静脉溶栓时间窗对进展性脑梗死血管再通及预后的影响。方法选取我院2015年10月至2017年1月治疗的101例脑梗死患者,按照治疗方案分为对照组与观察组。对照组50例,于发病4.5 h内给予重组组织型纤溶酶原激活剂(rt-PA)溶栓治疗;观察组51例,于发病3 h内给予rt-PA溶栓治疗;比较两组患者溶栓后血管再通率及预后情况。结果观察组血管再通率高于对照组(P0.05),观察组神经功能缺损评分(NIHSS)、改良Rankin评分均优于对照组(P0.05)。结论超早期(3 h内)静脉溶栓可以增加患者血管再通率,提高患者预后生活质量,值得临床推广应用。     

瑞替普酶急诊溶栓治疗急性心肌梗死的临床研究

目的观察瑞替普酶(r-PA)急诊静脉溶栓治疗急性心肌梗死(AMI)不同时间窗溶栓治疗的血管再通率及安全性。方法符合入选标准的57例无溶栓禁忌证患者在常规治疗的基础上给予r-PA18mg+0.9%氯化钠50ml快速静脉溶栓治疗,30min后再给予r-PA18mg治疗。计算发病0.5～2h、>2～4h、>4～6h及>6～12h内溶栓再通率,并将6h内溶栓病例与将>6～12h溶栓病例进行再通率比较。结果 6h内溶栓再通率为86.67%,>6～12h溶栓再通率为41.67%,2者比较差异有统计学意义(P<0.05)。结论临床上应用r-PA急诊溶栓治疗AMI疗效好,再通率高,AMI溶栓时间越早再通率越高,且安全,副作用少。     

阿替普酶动、静脉溶栓治疗急性缺血性脑卒中的比较性研究

目的比较阿替普酶动、静脉溶栓治疗急性缺血性脑卒中(AIS)的疗效和安全性。方法选取具有溶栓适应征的100例AIS患者将其随机分为动脉溶栓组和静脉溶栓组,各50例,2组患者分别给予阿替普酶动脉溶栓治疗和阿替普酶静脉溶栓治疗,比较2组的临床疗效,采用美国国立卫生研究院卒中量表(NIHSS)比较治疗前、治疗后24 h、治疗后14 d NIHSS评分。3个月随访期间对患者的受累血管再通率、预后良好率、颅内出血发生率、死亡率进行观察和比较。结果 2组疗效和临床有效率差异均无统计学意义(P>0.05);治疗后24 h、14 d,2组患者的NIHSS评分均较治疗前显著下降(P<0.05);2组患者的长期疗效和安全性指标差异均无统计学意义(P>0.05)。结论 AIS发病早期应用阿替普酶进行静脉溶栓治疗或动脉溶栓治疗,均能够显著改善患者的神经功能,获得较高的血管再通率,有助于改善患者的预后,2种方法在临床疗效和安全性方面基本相当。     

急性缺血性脑卒中急诊急救中国专家共识（2018版）北大核心CSCD

急性脑卒中是一种发病率高、致残率高、病死率高、复发率高及并发症多的疾病.据统计,2013年中国卒中的年龄标化患病率为1114．8／10万人,发病率为246．8／10万人,死亡率为114．8／10万人。目前,急性缺血性卒中（acute ischemic stroke,AIS）最有效的治疗方法是时间窗内给予血管再通治疗,包括重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator,rt-PA）静脉溶栓和机械取栓,救治成功率与发病时间密切相关.     

Evolution of endovascular mechanical thrombectomy for acute ischemic stroke

Acute ischemic stroke (AIS) is a common medical problem associated with significant morbidity and mortality worldwide. A small proportion of AIS patients meet eligibility criteria for intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator, and its efficacy for large vessel occlusion is poor. Therefore, an increasing number of patients with AIS are being treated with endovascular mechanical thrombectomy when IVT is ineffective or contraindicated. Rapid advancement in catheter-based and endovascular device technology has led to significant improvements in rates of cerebral reperfusion with these devices. Stentrievers and modern aspiration catheters have now surpassed earlier generation devices in the degree and rapidity of revascularization. This progress has been achieved with no concurrent increase in risk of major complications or mortality, both when used alone or in combination with IVT. The initial randomized controlled trials comparing endovascular therapy to IVT for AIS failed to show superior outcomes with endovascular treatment, but key limitations of each trial may limit the significance of these results to current practice. While endovascular devices and operator experience continue to evolve, we are optimistic that this will be accompanied by improvements in patient outcomes. This review highlights the major endovascular devices used in current practice and the trials which have investigated their efficacy.     

Mechanical thrombectomy for acute ischemic stroke

The therapy of acute ischemic stroke aims at fast recanalization of the occluded brain vessel. In contrast to intravenous thrombolysis (IVT), endovascular approaches yield higher recanalization rates especially in large vessel occlusions. Mechanical thrombectomy with the Merci Retriever received FDA approval in 2004 as an adjunct to IVT or in the case of failed recanalization after IVT. The time window for treatment is 8 h from stroke onset. However, the recanalization rate was 55 %, still leaving space for further improvement. In addition to the Merci Retriever, the Penumbra System received FDA approval in 2008. The newest endovascular approach comprising retrievable intracranial stents results in an increased recanalization rate exceeding 90 % and has markedly reduced the time to recanalization. On the other hand, the complication rate has not increased yet. These promising results suggest a combined therapy for acute ischemic stroke. In a first step IVT can be started independently of the size of the treating hospital and in a next step the patient is transferred to a neuroradiological center. If vessel occlusion persists, additional endovascular recanalization is performed (bridging concept). Patients who don't qualify for IVT are candidates for mechanical thrombectomy up to 8 h after stroke onset.     

Idarucizumab for Intravenous Thrombolysis and Endovascular Thrombectomy in Acute Stroke: A Case Report

BackgroundNon–vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, are widely used to prevent ischemic stroke in patients with nonvalvular atrial fibrillation. Nonetheless, stroke occurs in 1–2% of patients, and the use of NOACs may increase the bleeding risk for patients who are receiving acute treatment of intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT). Idarucizumab, a monoclonal antibody developed to bind dabigatran, has been proven safe and effective for patients with uncontrolled bleeding or for patients planning to receive emergent procedures. It is now accepted that patients taking dabigatran with recurrent stroke may benefit from IVT after idarucizumab. However, there are limited data regarding idarucizumab use in patients planning to have EVT.Case ReportWe present the case of a male patient taking dabigatran who had a stroke and who was treated with idarucizumab followed by combined IVT and EVT. The patient had immediate recanalization of the occluded vessel and near total recovery of function after 3 months.Why Should an Emergency Physician be Aware of This?Our case report supports the evidence that patients presenting with acute ischemic stroke (AIS) despite being under dabigatran therapy should be evaluated for reversal by idarucizumab which can contribute to the eligibility for IVT as well as EVT. It has also been proved to provide better outcomes for patients with AIS. The availabilities of specific reversal agents for NOACs will probably alter the current management of patients with AIS.     

Acute stroke therapy: beyond i.v. tPA

Although intravenous tissue plasminogen activator (i.v. tPA) has been approved for treating acute ischemic stroke, it must be given within 3 hours of stroke onset and only after ruling out hemorrhagic stroke by computed tomography. Several medical centers are turning to angiography to guide intra-arterial infusion of thrombolytic agents and mechanical endovascular interventions.     

觉醒型缺血性卒中进展后动脉内治疗1例并文献复习

目的 探讨多模式影像学选择的觉醒型缺血性卒中（WUS）患者进行静脉溶栓以及动脉内治疗的临床疗效。方法 解放军第306医院对1例WUS患者进行静脉溶栓桥接动脉取栓并急诊支架成形术治疗,随访90天,将临床资料进行总结与分析。结果 经过静脉溶栓后患者症状部分缓解,很快再次加重,随即进行动脉取栓并发现责任大脑中动脉重度狭窄,取栓后血流不能维持,给予急诊支架植入。病情演变过程复杂,最终结局良好,神经功能缺损改善。90天随访：患者痊愈,NIHSS 0分,mRS 0级。结论 对于WUS患者,通过多模式影像学选择后进行静脉溶栓以及动脉内治疗是安全有效的。     

拉萨市急性缺血性脑卒中静脉溶栓流程优化效果初探

  目的  探索优化卒中绿色通道救治流程对提高拉萨市急性缺血性脑卒中(acute ischemic stroke,AIS)溶栓质量的效果。  方法  回顾性纳入2019年8月—2021年12月西藏自治区卒中中心连续上报的采用重组组织型纤溶酶原激活剂静脉溶栓的所有AIS患者。按照患者就诊时卒中绿色通道救治流程是否优化,将其分为优化前组(2019年8月—2021年6月)、优化后组(2021年7—12月)。比较两组静脉溶栓质量及患者预后。  结果  共纳入34例接受静脉溶栓治疗的AIS患者(平均每月溶栓1.2例),其中优化前组16例、优化后组18例。基线、溶栓后即刻、溶栓后24 h美国国立卫生研究院卒中量表评分分别为6.5(3.0, 12.0)分、3.0(1.0, 5.5)分、2.0(0, 6.3)分。与优化前组比较,优化后组入院至静脉溶栓时间显著缩短[(67.1±37.8)min比(108.9±53.8)min, P=0.035],发病至静脉溶栓时间[(176.7±69.7)min比(199.1±47.8)min, P=0.065]、入院至静脉溶栓时间≤60 min达标率(50.0%比18.8%,P=0.061)、溶栓短期疗效良好患者占比(77.8%比62.5%,P=0.336)数值均有所改善,但差异无统计学意义。  结论  优化西藏自治区卒中中心绿色通道救治流程后,拉萨市静脉溶栓AIS患者的院内救治时间明显缩短,有助于提高AIS早期治疗的急救效率。     

Fibrinolysis: strategies to enhance the treatment of acute ischemic stroke

Summary

Stroke is a major cause of disability worldwide, and is the second leading cause of death after ischemic heart disease. Until recently, tissue‐type plasminogen activator (t‐PA) was the only treatment for acute ischemic stroke. If administered within 4.5 h of symptom onset, t‐PA improves the outcome in stroke patients. Mechanical thrombectomy is now the preferred treatment for patients with acute ischemic stroke resulting from a large‐artery occlusion in the anterior circulation. However, the widespread use of mechanical thrombectomy is limited by two factors. First, only ? 10% of patients with acute ischemic stroke have a proximal large‐artery occlusion in the anterior circulation and present early enough to undergo mechanical thrombectomy within 6 h; an additional 9–10% of patients presenting within the 6–24‐h time window may also qualify for the procedure. Second, not all stroke centers have the resources or expertise to perform mechanical thrombectomy. Nonetheless, patients who present to hospitals where thrombectomy is not an option can receive intravenous t‐PA, and those with qualifying anterior circulation strokes can then be transferred to tertiary stroke centers where thrombectomy is available. Therefore, despite the advances afforded by mechanical thrombectomy, there remains a need for treatments that improve the efficacy and safety of thrombolytic therapy. In this review, we discuss: (i) current treatment options for acute ischemic stroke; (ii) the mechanism of action of fibrinolytic agents; and (iii) potential strategies to manipulate the fibrinolytic system to promote endogenous fibrinolysis or to enhance the efficacy of fibrinolytic therapy.

     

Endovascular therapy of stroke

Standard therapy of acute ischaemic stroke during the first three hours after symptom onset is intravenous thrombolysis. When contraindications exist, an endovascular approach might be possible. Intraarterial administration of thrombolytic drugs is the most common way. Additionally, there is an increasing use of mechanical tools that are expected to be faster and more effective. Three principles of mechanical thrombolysis are known: aspiration, extraction and fracturing of the thrombus. Different tools were tested clinically and some demonstrated its high efficiency. Larger studies are needed to compare those tools. Apart from recanalization of a cerebral vessel occlusion implantation of a stent might be necessary for prophylaxis of recurrent stroke.     

Is Sonothrombolysis an Effective Stroke Treatment?

New therapeutic strategies under development aim to improve recanalization rates and clinical outcomes after ischemic stroke. One such approach is ultrasound (US)‐enhanced thrombolysis, or sonothrombolysis, which can improve thrombolytic drug actions and even intrinsic fibrinolysis. Although the mechanisms are not fully understood, it is postulated that thrombolysis enhancement is related to nonthermal mechanical effects of US. Recent results indicate that US with or without microbubbles may be effective in clot lysis of ischemic stroke even without additional thrombolytic drugs. Sonothrombolysis is a promising tool for treating acute ischemic stroke, but its efficacy, safety, and technical details have not been elucidated and proved yet in stroke treatment.