Reperfusion Therapies for Acute Ischemic Stroke: An Update

Acute ischemic stroke is a major cause of morbidity and mortality in developed countries. Intravenous thrombolysis with tissue plasminogen activator (tPA) within 4.5 hours of symptoms onset significantly improves clinical outcomes in patients with acute ischemic stroke. This narrow window for treatment leads to a small proportion of eligible patients to be treated. Intravenous or intra-arterial trials, combined intravenous/intra-arterial trials, and newer devices to mechanically remove the clot from intracranial arteries have been investigated or are currently being explored to increase patient eligibility and to improve arterial recanalization and clinical outcome. New retrievable stent-based devices offer higher revascularization rates with shorter time to recanalization and are now generally preferred to first generation thrombectomy devices such as Merci Retriever or Penumbra System. These devices have been shown to be effective for opening up occluded vessels in the brain but its efficacy for improving outcomes in patients with acute stroke has not yet been demonstrated in a randomized clinical trial. We summarize the results of the major systemic thrombolytic trials and the latest trials employing different endovascular approaches to ischemic stroke.     

Emergency Management of Acute Ischemic Stroke

With the advent of new therapeutic options for acute ischemic stroke, expeditious evaluation of patients with suspected stroke has become imperative. Goals of the initial evaluation are to determine the time of symptom onset, severity of the neurologic deficit, and to exclude intracranial hemorrhage and other mimics of acute ischemic stroke. CT and MRI perfusion studies may demonstrate the presence of an ischemic penumbra and aid in identification of patients who may benefit from thrombolysis. Intravenous recombinant tissue plasminogen activator (IV rtPA) remains the gold standard for acute ischemic stroke treatment, and the therapeutic time window recently has been extended to 4.5 h in certain patients. Catheter-based intra-arterial thrombolysis is being used increasingly as “rescue therapy” after IV rtPA and as primary therapy in select patients who are ineligible for intravenous therapy. Trials investigating the efficacy and safety of intra-arterial therapy are ongoing.     

熄风通脑汤结合尿激酶溶栓治疗急性脑梗死疗效观察

目的观察熄风通脑汤结合尿激酶溶栓治疗急性脑梗死的临床疗效。方法将符合入组标准的60例急性脑梗死患者随机分为中西药结合组和单纯西药组。两组患者均给予尿激酶静脉滴注,中西药结合组同时加用熄风通脑汤口服。在溶栓前后不同时间评价两组患者的神经缺损积分、功能独立性评估量表(FIM量表)评分、CT及实验室检查结果。结果从溶栓后第7天开始,两组患者神经功能缺损评分(NIHSS)间差异有统计学意义(P<0.05)。溶栓后第90天,两组患者FIM评分分别为(88.5±9.4)分和(81.3±9.0)分,差异有统计学意义(P<0.01)。中西药结合组和单纯西药组脑出血发生率分别为3.3%和10.0%。结论熄风通脑汤结合尿激酶溶栓治疗急性脑梗死效果显著,且副作用小。     

Modern Medical Management of Acute Ischemic Stroke

The modern management of patients with ischemic stroke begins by having a system in place that organizes the provision of preventive, acute treatment, and rehabilitative services. In the acute setting, initial evaluation is aimed at rapidly establishing a diagnosis by excluding stroke mimics, distinguishing between ischemic and hemorrhagic strokes, and determining if the patient is a candidate for treatment with intravenous tissue plasminogen activator (IV-tPA, alteplase). In some centers, select patients who do not qualify for administration of IV-tPA may be considered for endovascular intervention. General measures include the use of platelet antiaggregants, treatment of fever, blood pressure management, and continuation of statins if the patient has already been taking them. Post-acute evaluation and management is aimed at secondary prevention and optimizing recovery, including recognition and treatment of post-stroke depression.     

Antithrombotic Therapy for Prevention and Treatment of Ischemic Stroke

Atherosclerosis involving the cervical vessels, intracranial vessels, or the aorta is the most common cause of ischemic stroke. Occlusive lesions of small penetrating brain arteries cause small lacunar strokes, which account for about 20% of ischemic strokes. Emboli from a variety of cardiac sources, particularly atrial fibrillation, account for about 25%. Efforts to prevent and treat ischemic stroke are complicated by the variety of etiologies underlying it and the selection of antithrombotic or thrombolytic therapy appropriate to the particular etiology.     

An alternative facility for a stroke unit in a community hospital

Objective

The administration of tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS) within three hours from onset of neurological symptoms is presently accepted as the standard treatment for suitable individuals, since it has been shown that it improves their outcome. The aim of this retrospective study was to report our experience with tPA administration in a subunit of a department of internal medicine adapted specifically for that goal.

Setting

The study was carried out in a subunit of a department of internal medicine. This subunit was equipped with all necessary items for monitoring vital signs. The patients received 0.9 mg/kg of tPA intravenously and remained under around-the-clock supervision by highly trained nurses.

Subjects

Thirty one patients (11 women and 20 men), diagnosed with AIS between 2004 and 2008, and eligible for tPA treatment, were included in the study.

Results

The interval from the onset of stroke to tPA administration (onset to treat time OTT) was 145 ± 2.2 min, whereas the interval from door-to-needle was 100 ± 4 min. Two patients (6.4%) died during hospitalization because of severe intracerebral hemorrhage. Three patients with hemiparesis (9.6%) developed minor hemorrhages detected by brain CT. The mean length of stay was 8.8 ± 0.6 days.

Conclusions

Our results are comparable with those obtained in stroke units in other countries. The suggested model offers a possibility for appropriate and rapid thrombolysis for AIS in a community hospital lacking special stroke unit. Moreover, the suggested alternative does not require extensive economic investment, since there is no need for additional staff, and permits the use of already existing hospital facilities.     

Current Endovascular Approach to the Management of Acute Ischemic Stroke

Purpose of Review

The review provides an overview of current endovascular management of patients with acute ischemic stroke in the light of recent landmark trials proving unequivocal benefit of the intervention.

Recent Findings

Several randomized trials looking at selective groups of patients presenting after an acute ischemic stroke due to large vessel occlusion in the anterior circulation demonstrated an overwhelming benefit of the endovascular treatment compared to intravenous thrombolysis, leading to expedited changes in the American Heart Association/American Stroke Association guidelines. Nonetheless, there are a relative large number of patients that were not included in those trials that might still benefit from endovascular treatment (acute posterior circulation-related strokes or acute embolic occlusion of middle cerebral artery beyond the main trunk for instances) and in which further studies are needed. We also briefly discuss endovascular techniques, post-procedure care, and endovascular treatment delivery models to expedite stroke patient assessment and rapid transport using updated and improved workflow protocols to provide timely recanalization.

Summary

Endovascular treatment of acute occlusion of a proximal large artery in the anterior circulation is currently the standard of care. Time and quality of recanalization are the most important variables that determine the outcome. The indication for endovascular therapy in different scenarios (acute embolic occlusion in the posterior circulation or more distal branch occlusions) has to be individualized according to each patient’s particular characteristics until new evidence is provided.

     

急性缺血性脑卒中患者自我怜悯水平及其影响因素研究

背景 自我怜悯是近年国外积极心理学的研究热点,是检测患者心理健康水平的重要指标.故探究急性缺血性脑卒中患者自我怜悯水平及其影响因素对提高患者心理健康水平具有重要意义.目的 探讨急性缺血性脑卒中患者自我怜悯水平及其影响因素.方法 选取2019年7月—2020年8月在广州市红十字会医院、广州医科大学附属第一医院、广州医科大...     

急性缺血性脑卒中抗栓治疗中脑微出血的临床特点分析

目的探讨急性缺血性脑卒中(AIS)患者在采用抗栓治疗方案干预后,并发脑微出血(CMB)的临床发生率,分析其可能的危险因素以及影像学特点。方法本研究中所有患者在入院后根据临床评估情况给予单独抗血小板治疗方案或双联抗血小板治疗方案进行药物干预。治疗结束时行磁敏感加权成像检查评估CMB情况。比较CMB组和无CMB组临床资料的差异。结果研究共纳入240例患者,70例(29.17%)并发CMB。CMB组病灶分布于基底节区48例(68.57%)、皮质-皮质下41例(58.57%)、丘脑26例(37.14%)、脑干24例(34.29%)、小脑16例(22.86%);微出血灶大小为0~108μm,平均为14.02±0.32μm。CMB组的年龄、饮酒史、高血压史、脑出血史、收缩压、舒张压与无CMB组比较存在显著性差异(P0.05)。结论 AIS患者使用抗栓治疗方案干预后易并发CMB,临床上对此应予以格外关注。     

急性缺血性脑卒中伴吞咽困难患者营养支持治疗临床观察

目的:探讨三种营养支持治疗方法对急性缺血性脑卒中伴吞咽困难患者的临床价值。方法:回顾性分析急性缺血性脑卒中伴吞咽困难患者150例的临床资料。按不同营养方式分为3组:肠内营养治疗组(EN组),肠外营养治疗组(PN组),肠内外联合营养治疗组(EN+PN组),每组50例。分别于住院第1、第7及第14天检测患者血清总蛋白(TP)、白蛋白(ALB)、前白蛋白(PA)、甘油三酯(TG)、血红蛋白(Hb)及淋巴细胞计数(LYM)等,记录3组治疗期间并发症的发生率,并以美国国立卫生研究院卒中量表(NIHSS)评分评价神经功能缺损情况。结果:EN+PN组TP、ALB、PA、Hb及LYM等指标优于EN组和PN组(均P0.05)。而EN组与PN组比较,仅PA下降程度差异有统计学意义。入院第14天时,EN+PN组并发症发生率显著低于EN组和PN组(P0.05),而EN组和PN组比较无明显差异。第14天时,3组神经功能缺损情况与入院时比较差异均有统计学意义(P0.05);EN+PN组神经功能恢复情况显著优于EN组和PN组(P0.05),而EN组和PN组比较差异无统计学意义。结论:采用肠内外联合营养治疗可有效改善患者的营养状况、降低并发症发生率、促进神经功能恢复,短期临床结局优于肠内或肠外营养支持治疗组,而肠内与肠外营养治疗组比较并无优势。     

血管内支架介入在缺血性脑卒中治疗中的价值研究

目的探讨血管内支架介入在缺血性脑卒中治疗中的价值。方法选取2010年1月—2012年6月我院神经内科收治的行脑血管介入治疗的缺血性脑卒中患者20例,治疗前后采用美国国立卫生研究院卒中评分量表(NIHSS)对患者神经功能进行评定,并观察并发症发生情况。结果患者介入治疗均获成功,血管狭窄部位恢复正常血管直径和形态,残余狭窄率10%。2例患者颈动脉支架于球囊扩张后出现一过性心率减慢,7例患者使用保护伞收集到多枚淡黄色粥样硬化斑块,1例患者椎动脉起始部狭窄于手术中使用球扩支架后出现头晕、恶心、呕吐。患者术后NIHSS评分低于术前(P0.05)。结论充分做好术前、术中及术后准备工作,合理利用血管内支架介入对缺血性脑卒中患者的治疗起着至关重要的作用。     

他汀类药物与急性缺血性卒中

他汀类药物的非降脂作用已得到越来越多的临床试验证实.近来的临床观察发现,缺血性卒中发病前和急性期使用他汀类药物可限制神经功能缺损的严重程度、降低病死率和改善预后;而长期使用他汀类药物者突然停药,可加重卒中损害,增高复发风险.虽然使用他汀类药物可能轻微增高出血风险,但毫无疑问,使用他汀类药物已成为防治缺血性卒中的最重要手段之一.     

急性缺血性卒中血管内治疗围手术期血压管理

急性缺血性卒中具有高发病率、高致残率和高死亡率的特点。血管内治疗在急性缺血性卒中治疗的有效性和安全性已得到认可,但有关围手术期血压调控的研究较少,最佳血压调控管理策略仍未达成共识。文章对血管内治疗围手术期血压管理进行了综述。     

机械血栓切除术后"成功"再通的前循环卒中患者的转归:TICI 3与TICI 2b比较

目的 探讨急性前循环卒中机械取栓后脑梗死溶栓(Thrombolysis in Cerebral Infarction, TICI)再通分级TICI 2b与TICI 3患者的转归差异.方法 回顾性纳入机械血栓切除术后"成功"再通的急性前循环卒中患者,并分为TICI 2b(几乎完全再通)组和TICI 3(完全再通)组.转归良好定义为发病后3个月时改良Rankin量表评分0~2分.结果 共纳入83例患者.TICI 2b级38例(45.8%),TICI 3级45例(54.2%);49例(59.0%)转归良好,34例(40.9%)转归不良.TICI 3组转归良好率显著高于TICI 2b组(68.9%对47.4%;χ2=3.946,P=0.047).多变量logistic回归分析显示,校正年龄、高血压、糖尿病、基线收缩压、三酰甘油、静脉溶栓、ASITN/SIR侧支循环分级后,TICI 3级是发病后3个月时转归良好的独立预测因素[优势比(odds ratio, OR)3.759,95%可信区间(confidence interval, CI)1.098~12.871;P=0.035],而基线NIHSS评分较高(OR 0.820,95% CI 0.715~0.941;P=0.005)和空腹血糖较高(OR 0.610,95% CI 0.410~0.906;P=0.014)是发病后3个月时转归不良的独立预测因素.结论 机械血栓切除术后"成功"再通的急性前循环缺血性卒中患者转归存在差异,TICI 3的患者显著优于TICI 2b的患者.     

ICU中急性缺血性脑卒中患者败血症发生情况及其影响因素研究

背景 15%~25%的急性缺血性脑卒中(AIS)患者死于细菌性肺炎,其中约5%出现败血症,但ICU中AIS患者败血症的影响因素尚不明确。目的分析ICU中AIS患者败血症发生情况及其影响因素。方法选取2015年3月-2019年3月唐山市协和医院ICU收治的AIS患者364例,回顾性分析其败血症发生情况及病原菌,分析ICU中AIS患者发生败血症的影响因素采用单因素分析及多因素Logistic回归分析。结果 (1) 364例AIS患者中225例发生败血症,发生率为61.8%;225例败血症患者病原菌主要为肺炎克雷伯菌(占26.22%)、铜绿假单胞菌(占19.11%)、金黄色葡萄球菌(占16.44%)、鲍曼不动杆菌(占13.33%)。(2)不同年龄、性别、病灶部位及有无高血压、吸烟史患者败血症发生率比较,差异无统计学意义(P>0.05);有无意识障碍、侵入性操作、糖尿病、营养不良、慢性阻塞性肺疾病(COPD)及是否预防性应用抗生素、使用糖皮质激素患者败血症发生率比较,差异有统计学意义(P<0.05)。发生败血症患者入院时急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、美国国立卫生研究院卒中量表(NIHSS)评分、格拉斯哥昏迷量表(GCS)评分高于未发生败血症患者(P<0.05)。(3)多因素Logistic回归分析结果显示,意识障碍[OR=9.526,95%CI(1.321,68.695)]、侵入性操作[OR=2.784,95%CI(1.484,5.223)]、糖尿病[OR=12.604,95%CI(1.006,157.969)]、营养不良[OR=3.536,95%CI(1.171,10.681)]、COPD[OR=7.569,95%CI(1.351,42.387)]、预防性应用抗生素[OR=3.459,95%CI(1.483,8.067)]、入院时APACHEⅡ评分[OR=9.718,95%CI(1.466,64.418)]、入院时NIHSS评分[OR=5.228,95%CI(1.214,22.515)]、入院时GCS评分[OR=3.873,95%CI(2.354,6.372)]是ICU中AIS患者发生败血症的独立影响因素(P<0.05)。结论 ICU中AIS患者败血症发生率较高,为61.8%;意识障碍、侵入性操作、糖尿病、营养不良、COPD、预防性应用抗生素及入院时APACHEⅡ评分、NIHSS评分、GCS评分升高是ICU中AIS患者发生败血症的危险因素。     

急性缺血性卒中机械取栓治疗的现状

在出现不可逆性神经细胞损伤之前迅速安全地再通血管、恢复血流以挽救缺血半暗带组织,是急性缺血性卒中（acute ischemic stroke, AIS ）的主要治疗目标。目前,在AIS早期开通血管的方法主要是静脉溶栓,但由于其治疗时间窗短、血管再通率低、出血并发症发生率高等原因,效果常不令人满意。近年来,随着机械取栓装置的研发及介入技术的发展,使得AIS的治疗时间窗显著延长,血管开通率显著提高,临床转归显著改善,机械取栓治疗已显示出良好的应用前景。     

卒中单元管理模式对脑卒中患者疗效的综合评估

目的:探讨卒中单元管理模式对脑卒中患者的疗效。方法:对2007年7月至2008年12月收住我院卒中单元502例脑卒中患者的疗效进行评估,与同时收住我院神经内科普通病房的624例脑卒中患者比较,比较两组住院期病死率、复发率、并发症、平均住院时间、平均住院费用、神经功能评价(national institutes of health stroke scale,NIHSS)、生活能力评价(Barthelindex,BI)、患者及家属的满意度及发病后3个月时卒中复发率、病死率及BI。结果:卒中单元和普通病房住院的脑卒中患者入院时一般情况、危险因素、卒中类型、入院时卒中严重程度等方面的比较无显著性的差异;住院期间卒中单元组患者肺部感染、尿路感染及深静脉血栓(DVT)发生率均低于普通病房组,两组比较有显著性的差异,P<0.05;两组患者入院时NIHSS评分和BI评分无显著性差异,治疗3~4周后两组患者的NIHSS评分均有降低,BI评分均有增高,但以卒中单元组患者改变更为明显,两组比较有显著性差异(P<0.05);卒中单元组患者住院期及发病后3个月病死率、复发率、生活活动能力(BI指数)、患者及家属的满意度均优于普通病房组患者(P<0.05),而平均住院时间和平均住院费用的比较两组无显著性的差异。结论:卒中单元管理模式能降低脑卒中患者的并发症、病死率和复发率,提高脑卒中患者