急性脑梗死患者重组组织型纤溶酶原激活剂静脉溶栓前后的血液动力学改变

目的 观察急性脑梗死患者重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator，rt-PA）超早期静脉溶栓治疗后脑血液动力学变化及临床转归。方法 2002年9月至2006年4月发病3h以内的急性脑梗死患者，符合美国国家神经疾病和卒中研究National Institute of Neurological Disorders and Stroke，NINDS）溶栓入选标准，用rt-PA 0.9 mg/kg（最大剂量不超过90 mg）溶栓治疗。同时用经颅多普勒超声（TCD）于患者溶栓前、溶栓中、溶栓后24 h、3 d、2周和1个月分别监测其病变血管血液动力学变化。结果 18例患者进行了脑血液动力学监测。男15例、女3例，平均年龄（65±9）岁。溶栓前美国国立卫生院卒中量表（National Institures of Health Stroke Scale，NIHSS）评分6～16分，平均（11.4±2.8）分。溶栓前TCD检查TIBI 0级1例，1级3例，2级8例，3级3例，4级2例（大脑中动脉严重狭窄），5级1例（腔隙性脑梗死）。从发病至开始溶栓的时间2～3 h，平均（2.80±0.20）h。闭塞动脉在溶栓过程中再通2例，溶栓后1 h内再通1例，24 h内再通4例，溶栓再通4 h后再闭塞1例，其余无变化。溶栓前与溶栓后24 h、3 d、2周、1个月的NIHSS评分及TIBI分级均有统计学差异，NIHSS评分与TIBI存在明显的负相关关系。结论 溶栓前后脑血液动力学改变与神经功能变化明显相关，脑血液动力学监测有助于深入了解卒中的发病机制和溶栓疗效。

Hemodynamic Changes of Acute Ischemic Stroke Patients Treated with Intravenous rt-PA

Objective To investigate cerebral hemodynamic change and outcomes of acute stroke patients receiving intravenous(IV) recombinant tissue plasminogen activator (rt-PA) in an ultra early stage by transcranial Doppler(TCD) .Methods Patients receiving standard IV rt-PA therapy (0.9-mg/kg dose, maximum 90 mg, 10% bolus, 90% continuous infusion) within the first 3 hours after the onset of acute stroke and fulfilling the criteria of the National Institute of Neurological Disorders and Stroke protocol, were performedby TCD before IV thrombolysis and subsequently at 24 hours, 3days, 2 weeks and 1month after the therapy.Results Totally 18 patients received IV rt-PA and TCD monitoring. The mean age of those patients was 64.6±8.84 years old and 15 of them were male. The mean score of the National Institutes of Health(NIH) Stroke Scale score was 11.4±2.8 [ranging from 6 to 16]. Before thrombolysis, TCDmonitoring showed that 1 patient was in Thrombolysis in Brain Ischemia(TIBI) flow grade 0, 3 in TIBI grade I, 8 patients in TIBI II, 3 patients in TIBI III, 2 patients in TIBI grade IV (serious middle cerebral artery stenosis) and 1 patient in TIBI V(lacuna infarction). The average time from the onsetto IV rtPA was 2.80±0.20h, ranging from 2 to 3 hours. Recanalization occurred in 2 patients during IV-tPA infusion , 1 patient within 1 hour after IV-tPA infusion and 4 patients within 24 hours. The artery occlusion recurred in 1 patient after 4 hours of recanalization. Others have no changes. Therewas a significant difference before and after thrombolysis(24h, 3d, 2 weeks, and 1 month) in NIH stroke scale and TIBI flow grade. Both are inverted correlativity.Conclusion TCD monitoring reveals that the change of cerebral blood flow has significant correlation with the changes of neurological function. To investigate cerebral hemodynamic change can help to study the pathogenesis and effect of treatment.