阿替普酶静脉溶栓前应用依达拉奉对老年急性脑梗死预后的影响

目的 探讨老年急性脑梗死病人在应用阿替普酶(recombinant tissue plasminogen activator,rt-PA)静脉溶栓前预先使用依达拉奉的有效性和安全性.方法 采用回顾性分析的方法,纳入2014～2018年南京医科大学第二附属医院脑卒中登记系统中接受rt-PA静脉溶栓及依达拉奉联合治疗的老年...     

Determination of plasma tissue type plasminogen activator and plasminogen activator inhibitor activity in patients with ischemic stroke

Plasma tissue-type plasminogen activator and plasminogen activator inhibitor were determined during the acute, recovery and sequelae stages of patients with ischemic stroke by chromophoric substrate assay. The result showed that t-PA activity was elevated during the acute phase, remained elevated during the recovery stage and declined during the sequelae stage. Lowering of PAI activity was found during acute phase, which reversed during recovery phase and remained significantly elevated during sequelae stage. As a result, the ratio of PAI/t-PA fluctuated during different stages of the disease. Significant elevation of PAI and PAI/t-PA ratio during sequelae stage may be one of the risk factors of further thrombosis and contribute partly to the high relapsing rate of the disease. In addition, a positive correlation was found between PAI and serum cholesterol content.     

Rare severe hypofibrinogenemia induced by tissue plasminogen activator in stroke patients: Case report

Rationale:Severe hypofibrinogenemia after intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) is rare and easily overlooked, but hypofibrinogenemia increases the risk of major bleeding. However, it is unclear when hypofibrinogenemia reaches the peak and when hypofibrinogenemia is resolved.Patient concerns:Case 1 was of a 66-year-old man who was hospitalized due to sudden onset of vague speech and right hemiplegia for 4 hours. Case 2 was of an 84-year-old woman who was hospitalized for sudden onset of left hemiplegia and vague speech for 4 hours. In case 1, fibrinogen levels decreased from normal values to <0.25 g/L within 4.5 hours after commencing IVT and returned to normal at 35 hours later. In case 2, fibrinogen levels decreased from 1.1 to <0.25 g/L within 2 hours after commencing IVT and normalized 36.5 hours later.Diagnoses:Both patients were diagnosed with rt-PA-related hypofibrinogenemia.Interventions:No antiplatelet or symptomatic treatment was administered during the period of hypofibrinogenemia.Outcomes:Fibrinogen levels gradually recovered. In case 1, the patient did not experience cerebral hemorrhage during hypofibrinogenemia. His symptoms improved significantly within 1 week. In case 2, repeat computed tomography revealed minor cerebral hemorrhage, but no deterioration in her condition was noted until she was discharged.Lessons:Rapid, severe, and prolonged hypofibrinogenemia may occur after IVT with rt-PA, which may increase the risk of massive hemorrhage and affect the related therapy. Prompt diagnosis of hypofibrinogenemia is important for preventing complications. We recommend checking the fibrinogen levels routinely after IVT. Fibrinogen replacement therapy and platelet transfusion are the main management routes for rt-PA-related symptomatic intracranial hemorrhage.     

Beyond tissue plasminogen activator: mechanical intervention in acute stroke

Mechanical interventions in acute ischemic stroke promise to provide emergency physicians with tools to treat patients in whom conventional thrombolysis might be ineffective or contraindicated, including most patients with stroke who arrive at the emergency department beyond the 3-hour time window for intravenous tissue plasminogen activator. A systematic MEDLINE literature review was performed. Endovascular interventions currently in early human clinical trials include the use of lasers, ultrasonography, angioplasty, microsnares, and a variety of clot-retrieval devices. Potential advantages of these approaches include more rapid recanalization of occluded vessels, reduced or no exposure to fibrinolytic agents, and a longer treatment window. Early safety trials are promising, with serial improvements in device design to minimize trauma to cerebrovascular endothelium and accelerate vessel recanalization. The purpose of this review is to provide the emergency medicine community with an understanding of these promising and emerging approaches to acute stroke therapy.     

急性脑梗死超早期的r-tPA溶栓治疗

目的　探讨重组组织型纤溶酶原激活物 (r- t PA)溶栓治疗发病 6h内脑梗死的疗效及并发症。方法　共收集本院 2 0 0 1～ 2 0 0 3年 43例溶栓治疗的急性脑梗死病例 ,其中 32例经静脉溶栓 ,1 1例经动脉溶栓。分别对两组病例进行溶栓前后的 NIHSS,ESS及 ADL量表评分 ,根据 3个月时的随访记录判断溶栓疗效 (分为治愈、显效、有效、无效 )。结果　静脉溶栓组和动脉溶栓组的总有效率分别为 79.3%、90 .9% ;治愈率分别为2 7.6%、45.5% ,溶栓后脑出血率分别为 1 0 .3%、1 8.2 % ,但由于动脉组例数较少 ,两组疗效差异无统计学意义。结论　 6 h内溶栓治疗是安全有效的 ,低 NIHSS的患者有较好转归。     

重组组织型纤溶酶原激活剂对伴心房颤动急性脑梗死患者的疗效

目的观察伴心房颤动(房颤)急性脑梗死患者使用重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓的疗效。方法收集发病时间<4.5h的65例应用rt-PA静脉溶栓治疗的急性脑梗死患者,将41例无房颤患者作为非房颤组和24例伴房颤患者作为房颤组;观察溶栓后2组脑出血的发生率、病死率;采用美国国立卫生研究院卒中量表(NIHSS)进行神经功能缺损程度评分;应用改良的Rankin量表(mRS)评估综合生活能力。结果 2组治疗后的NIHSS评分均较治疗前显著降低,且2组各时间点NIHSS评分比较,差异有统计学意义(P<0.05)。2组30d的mRS评分比较,差异有统计学意义(P=0.025)。房颤组脑出血发生率和病死率虽高于非房颤组,但差异均无统计学意义(12.50%vs 2.44%,16.67%vs 2.44%,P>0.05)。结论对于由房颤引起的急性脑梗死患者rt-PA静脉溶栓治疗有效。     

Gene polymorphisms of tissue plasminogen activator and plasminogen activator inhibitor-1 in patients with antiphospholipid antibodies

OBJECTIVE: Impaired fibrinolytical outcomes may be one of the pathogenic factors for thrombotic events in patients with antiphospholipid antibodies (aPL). We investigated the consequences of the gene polymorphisms of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) in patients positive for aPL. METHODS: Seventy-seven Japanese and 82 British patients with aPL were examined for Alu-repeat insertion (I)/deletion (D) polymorphism of the tPA gene by polymerase chain reaction (PCR), and 4G/5G polymorphism in the PAI-1 promoter gene by site-directed mutagenesis-PCR and restriction fragment length polymorphism analysis. Correlations between these polymorphisms and clinical symptoms of antiphospholipid syndrome (APS) (arterial thrombosis, venous thrombosis, miscarriage) were analyzed. RESULTS: Significant differences in the allele frequencies of these genes did not exist between patients and controls. There was no significant correlation between these gene polymorphisms and clinical symptoms of APS in patients with aPL. CONCLUSION: Polymorphisms of the tPA or PAI-1 genes probably do not significantly influence the risk of anerial thrombosis, venous thrombosis, or pregnancy morbidity in patients with aPL.     

Increased fibrinogen,von Willebrand factor and tissue plasminogen activator levels in insulin resistant South Asian patients with ischaemic stroke

The aim of this study was to determine differences in atherothrombotic risk factors in South Asian subjects with a history of ischaemic stroke and South Asian subjects free from personal and family history of clinically detectable stroke. Eighty South Asian patients with ischaemic stroke (confirmed on cranial computerised scan) and 80 South Asian controls with similar age and gender distributions were recruited at random. The frequency of hypertension (P=<0.0001), myocardial infarction (P=0.003) and diabetes mellitus (<0.0001) were significantly higher in stroke patients. Stroke patients had lower high-density lipoprotein cholesterol (0.95 vs. 1.1 mmol/l, P=<0.0001), higher plasma glucose (8.1 vs. 6.6 mmol/l, P=0.01) and trendwise higher HBA(1C) (6.4 vs. 6.0%, P=0.09). There was no difference in insulin levels but insulin resistance was significantly higher in stroke patients (3.75 vs. 2.66, P=0.01). Stroke patients showed elevated levels of fibrinogen (3.78 vs. 3.41 mg/dl, P=0.02), von Willebrand factor (1.78 vs. 1.50 IU/ml, P=0.006) and tissue plasminogen activator (12.8 vs. 11.3 ng/ml, P=0.04), but the differences did not persist after adjustment for glucose, triglycerides, HDL, WHR, and BMI. Higher levels of fibrinogen, von Willebrand factor and t-PA in South Asian stroke patients disappeared after adjustment for features of insulin resistance syndrome but persisted after adjustment for presence of diabetes, confirming that these changes are essentially dependant on features of insulin resistance syndrome. A prospective study would be required to elucidate the role of thrombotic risk factors in South Asians with ischaemic stroke.     

Clinical characteristics in diabetic stroke patients

The impact of diabetes was prospectively studied during a 5-year period in 428 unselected and consecutive patients with acute cerebrovascular disease of whom 18% were diabetic. Cerebral infarction was more frequent in diabetics (81 vs 70%, p less than 0.02) whereas transient cerebral ischaemia was less frequent (4 vs 14%, p less than 0.01). Case fatality rate during hospitalization was higher in the diabetic than in the non-diabetic patients (28 vs 15%, p less than 0.02). Patients who died during hospitalization, diabetic as well as non-diabetic, had significantly higher blood glucose concentrations on admission compared with patients who survived. Hematocrit values were higher in the diabetic than in the non-diabetic patients (p less than 0.02). Diabetics had higher systolic blood pressure levels than the non-diabetics in the acute phase (p less than 0.005). The diabetic stroke patients more often had a history of hypertension, atrial fibrillation, heart failure and angina pectoris than non-diabetics stroke patients and diabetic control patients without stroke. Stroke patients, not known to be diabetic, had larger mean oral glucose tolerance test curve areas when compared with healthy controls but not when compared with hospitalized controls. We propose that diabetes increases the risk for stroke through other concurrent risk factors, cardiac disorders in particular.     

血清尿酸对重组组织型纤溶酶原激活剂静脉溶栓缺血性卒中患者短期转归的影响

目的探讨血清尿酸（serumuricacid,SUA）水平对接受重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator, rtPA）静脉溶栓的急性缺血性卒中患者短期转归的影响。方法纳入接受静脉rtPA溶栓治疗的急性缺血性卒中患者。根据出院时改良Rankin量表（ modified Rankin Scale, mRS）评分分为转归良好组和转归不良组。转归良好定义为基线美国国立卫生研究院卒中量表（National Institute of Health Stroke Scale, NIHSS）评分≤7分患者mRS评分为0分,NIHSS评分为8~14分者mRS评分为0~1分,NIHSS评分≥15分者mRS评分为0~2分。对2组人口学资料、临床资料和实验室指标进行比较和分析。结果纳入接受静脉rtPA溶栓治疗的急性缺血性卒中患者108例,转归良好组66例（61．11％）,转归不良组42例（38．89％）。转归不良组患者年龄[（62．21±10．25）岁对（57．83±10．457）岁;t＝2．138,P＝0．035]、基线NIHSS 评分（中位数和四分位数间距）[10（8~12）分对4（3~7）分;Z＝5．537,P＜0．001]以及2型糖尿病（40．48％对12．12％;χ2＝11．600, P＝0．001）和既往卒中史（9．52％对9．09％;χ2＝4．366,P＝0．037）的构成比显著高于转归良好组,而SUA水平[（323．119±87．869）mmol／L对（385．961±76．166）mmol／L;t＝3．936,P＜0．001]显著低于转归良好组。多变量logistic回归分析显示,既往2型糖尿病史[优势比（odds ratio, OR）5．471,95％可信区间（confidence interval, CI）1．472~20．334;P＝0．011]和基线 NIHSS 评分较高（OR 1．306,95％CI 1．147~1．486;P＜0．001）为短期临床转归不良的独立危险因素,而 S UA 水平较高（ OR 0．992,95％CI 0．986~0．998;P＝0．015）为短期临床转归不良的独立保护因素。结论 SUA水平增高是静脉rtPA溶栓患者短期转归良好的独立保护因素。