Mechanical thrombectomy for acute ischemic stroke: The road thus far

Early restoration of flow to perfuse the salvageable brain tissue in acute ischemic stroke significantly reduces mortality and morbidity. Recanalization of large vessel occlusions has not been more than 10-20% with intravenous thrombolysis. Use of mechanical devices in acute ischemic stroke has shown promise in greater recanalization rates and hopefully will yield more optimal stroke outcomes. The results of the recent trials appear promising as the devices continue to evolve, become more operator friendly, and patient outcomes improve.     

急性缺血性脑卒中的神经保护治疗

脑卒中是影响人类健康的主要疾病之一,为我国城市人口死亡的首位原因。约三分之一的脑卒中幸存者残留不同程度的神经功能障碍。急性缺血性脑卒中治疗的最重要途径为改善脑血流(溶栓)和阻断神经元缺血性病理生化级联反应,即神经保护治疗。一、神经保护治疗的合理性脑梗死的发生取决于两个基本条件,即脑血流量(cerebralbloodflow,CBF)下降的严重程度和缺血持续的时间。脑缺血后,若脑循环在一段时间内恢复,脑功能可获完全恢复,该时间为“再灌注时间窗”。由于脑缺血后引起的病理生理变化持续存在,即使重新建立起足够的脑循环,仍可能产生延迟…     

急性缺血性脑卒中的诊治

急性缺血性脑卒中的分型有助于确定治疗原则。静脉溶栓治疗及血管取栓治疗是最有效的恢复脑再灌注的特异治疗方法。抗栓治疗、改善循环、降纤、扩容、神经保护、传统医药及对并发症的管理对预后有重要影响。康复治疗是促进卒中患者功能恢复、减少并发症、提高生活质量的重要措施。卒中后应尽早开始二级预防。     

如何评价中医药治疗急性缺血性脑卒中

脑卒中是严重的社会医学问题,是我国人口死亡和成人残疾的首位原因,因而积极探索急性脑卒中的治疗以减少病死率和残疾率的意义重大自然不言而喻.然而,长期及大量投入的基础研究却未能对临床治疗提供有意义的帮助,包括最新的神经保护治疗试验均以失败告终[1,2]值得推荐的、有证据支持的急性缺血性卒中的临床治疗仍然是起病48 h内使用阿司匹林、起病4.5 h内对合适的患者进行溶栓治疗以及卒中单元的组织化处置[3].这种令人尴尬的局面自然而然地促使人们另辟蹊径,对传统医学发生兴趣.     

Endovascular treatment strategies for acute ischemic stroke

The limitations of intravenous thrombolysis therapy have paved the way for the development of novel endovascular technologies for use in the setting of acute stroke. These technologies range from direct intraarterial thrombolysis to various thrombus disruption or retrieval devices to angioplasty and stenting. The tools in the armamentarium of the neuroendovascular interventionalist enable fast, effective revascularization to be offered to a wider population of patients that may otherwise have few therapeutic options available to them. In this paper, we review the current state-of-the-art in neuroendovascular intervention for acute ischemic stroke. Particular emphasis is placed on delineating the indications and outcomes for use of these various technologies.     

Advances in treatment of acute ischemic stroke

Stroke carries a severe toll in terms of loss of life and disability for patients and their families. Until 10 years ago, physicians, and in particular neurologists, had a conservative, nonaggresive approach to this devastating disease. The advent of thrombolytic therapy not only proved that acute ischemic stroke is treatable, but also that early reperfusion can dramatically change the outcome of acute stroke patients. As a result of these trials, intravenous (IV) tissue plasminogen activator (t-PA) has been approved for treatment of acute ischemic stroke within 3 hours after symptom onset in the United States, Canada, Australia, and the European Union. The near future is extremely promising. Imaging modalities, such as diffusion- and perfusion-weighted images, as well as CT perfusion and CT angiography, to better select patients for treatment are now routinely performed in most academic medical centers. Novel IV and intra-arterial (IA) agents have been developed and tested. Emerging therapies will soon be available to increase the therapeutic windows for thrombolysis both by better screening patients using MRI or CT and by new IV and IA treatments. Several multicenter controlled trials in both imaging-guided decisions and therapeutic agents are either completed or being performed. We review data on advancement in imaging and treatment of acute ischemic stroke, in particular focusing on pharmacologic and mechanical IA thrombolysis.     

Advances in treatment of acute ischemic stroke

Stroke carries a severe toll in terms of loss of life and disability for patients and their families. Until 10 years ago, physicians, and in particular neurologists, had a conservative, non-aggressive approach to this devastating disease. The advent of thrombolytic therapy not only proved that acute ischemic stroke is treatable, but also that early reperfusion can dramatically change the outcome of acute stroke patients. As a result of these trials, intravenous (IV) tissue plasminogen activator (t-PA) has been approved for treatment of acute ischemic stroke within 3 hours after symptom onset in the United States, Canada, Australia, and the European Union. The near future is extremely promising. Imaging modalities, such as diffusion- and perfusion-weighted images, as well as CT perfusion and CT angiography, to better select patients for treatment are now routinely performed in most academic medical centers. Novel IV and intra-arterial (IA) agents have been developed and tested. Emerging therapies will soon be available to increase the therapeutic windows for thrombolysis both by better screening patients using MRI or CT and by new IV and IA treatments. Several multicenter controlled trials in both imaging-guided decisions and therapeutic agents are either completed or being performed. We review data on advancement in imaging and treatment of acute ischemic stroke, in particular focusing on pharmacologic and mechanical IA thrombolysis.     

Up-dating in acute ischemic stroke treatment.

Stroke is the second commonest cause of death world-wide, and the loss of quality-adjusted life years caused by stroke globally is bigger than for any other disease. The economic burden will be enormous if the nihilistic attitude that nothing can be done for stroke patients is not replaced by an active attitude. Clinical trials have shown that thrombolysis with rtPA is effective in acute ischemic stroke. A meta-analysis of these trials revealed that thrombolysis decreases the risk of death and dependency. All trials studying neuroprotecting agents have failed in man, although they have been successful in experimental animals. Protocolized intervention during the acute phase of ischemic stroke is proposed to correct physiological variables that have been disturbed in these patients. This intervention has been shown to have evident prognostic benefits. However, many of these measures are empirical and there is no clear evidence of their benefits. Organising the stroke units to be able to provide early thrombolysis for eligible patients will help all stroke patients in future treatments for ischemic stroke.

Neurología 2004;19(Supl 2):28-39

     

Remote ischemic conditioning approach for the treatment of ischemic stroke

Stroke is the leading cause of disability and death in North America.There has been growing interest in identifying neuroprotective strategies to reduce ischemic burden in patients with acute ischemic stroke.However,despite extensive clinical trials,no neuroprotective agent has been found for prevention of ischemic damage.Remote ischemic preconditioning(RIC)is a promising non-invasive strategy that has been proven to provide renal and cardioprotection and has recently found to have a potential broad application in the treatment of neurovascular disease,which has bee linked to its possible effects on the release and activation of endogenous neuroprotective substances against the ischemia/reperfusion injuries in experimental studies.This endogenous neuroprotection might vaccinate neural tissues against effects of acute IR following primary infarction insult.Regardless of the method of RIC administration,through manual or automated blood pressure cuff,RIC procedure is inexpensive and easy to use.Based on the experimental and clinical data,application of RIC avoids possible adverse effects and interactions associated with chemical pharmacological agents.In previous clinical studies RIC was safe and associated with only minor transient adverse effects in few cases,including petechia and minor limb pain,which were mostly resolved shortly after completing the treatment.     

The smoking-thrombolysis paradox and acute ischemic stroke

Smokers with acute myocardial infarction have better outcomes after thrombolysis than nonsmokers. The authors evaluated the independent effect of smoking on short-term outcome following IV thrombolysis for acute ischemic stroke. After adjusting for covariates, recent smokers who received thrombolysis had a significantly greater drop in 24-hour median stroke severity scores from baseline than nonsmokers who received thrombolysis and lower mortality over 1 year.     

Desmoteplase in the treatment of acute ischemic stroke

Desmoteplase, developed by Paion, Forest and Lundbeck, is a novel plasminogen activator that selectively activates fibrin-bound plasminogen and is currently being investigated for the treatment of acute ischemic stroke within the time window of 3-9 h after symptom onset. Desmoteplase is believed to offer pharmacologic advantages over currently approved treatment options. To date, two published Phase II perfusion imaging-based clinical trials have reported the safety and potential efficacy of desmoteplase in ischemic stroke. Results from a recently completed Phase III trial in Europe, Asia and the USA are awaited. This article reviews the available data on desmoteplase, including discussion of its favorable features and potential benefit beyond the 3-h time window in the treatment of ischemic stroke.     

Rescue treatment with abciximab in acute ischemic stroke

In acute ischemic stroke, reocclusion after an initially successful thrombolysis treatment can occur and is associated with increased morbidity and mortality. The authors present the successful use of abciximab, a platelet glycoprotein IIb/IIIa receptor inhibitor, in a patient with a thrombotic occlusion of the proximal middle cerebral artery, which was refractory to combined IV and intra-arterial thrombolysis and percutaneous intracranial balloon angioplasty.     

Advances in revascularization for acute ischemic stroke treatment

Intravenous thrombolysis with recombinant tissue plasminogen activator is the established treatment for acute ischemic stroke patients presenting within 3 h after stroke onset. In a significant number of patients, however, intravenous thrombolysis with recombinant tissue plasminogen activator remains ineffective. New thrombolytic agents, such as reteplase, tenecteplase or desmoteplase, offer pharmacokinetic and dynamic advantages over recombinant tissue plasminogen activator and have been or are currently being tested for safety and efficacy in clinical trials. Endovascular revascularization is an evolving treatment option enabling mechanical clot disruption or extraction in combination with thrombolysis. Several new endovascular devices have been successfully tested for safety in acute ischemic stroke patients and are now being tested for efficacy in larger clinical trials. Continued innovation and refinement of endovascular technology and techniques is expected to increase technical success with a minimal procedure-related morbidity in the treatment of acute ischemic stroke.     

Aphasic discourse analysis: The story so far

This paper provides a critical review of the literature currently available relating to aphasic discourse. It outlines the major approaches which have been taken to analysis, differentiating the structuralist and functionalist frameworks in particular and discusses the resultant gap existing in aphasiology research between microstructural linguistic aspects of discourse and macrostructural/pragmatic aspects. Studies addressing lexical, syntactic, semantic, pragmatic and conversational aspects of discourse, as well as those focusing on specific aspects such as cohesion and text macrostructure are discussed and placed in a theoretical perspective. The different methodologies involved in the various studies are critically examined, with implications for using different elicitation techniques in particular discussed.     

A genetic approach to ischemic stroke therapy

Stroke therapy will undergo a great revolution in the present decade. The knowledge of the human genome, gene interactions and proteomics will permit a new concept of drug development for stroke. Gene therapy by modification of gene expression will be useful to treat atherosclerosis and hypertensive microangiopathy, or in the acute phase, we will manipulate the acute gene expression induced by ischemia or the apoptotic gene program. However, a single abnormal gene, as in monogenic diseases, is easier to replace than several genes in complex multigenic disorders. Gene therapy, stem cell therapy and neurological grafts for stroke are still in the experimental phase, and many hurdles will have to be jumped before the introduction of these therapies into human clinical stroke trials. A more immediate clinical application of genetics to stroke therapy is the development of pharmacogenetics that analyzes the influence of genetic variability of individuals on drug response. A new era of personalized therapy is dawning where specific DNA biochips will help stroke clinicians to decide on the better use of thrombolytics, neuroprotectants, antithrombotics, statins or antihypertensives.     

急性缺血性卒中血管内治疗新技术探讨

卒中包括脑梗死和脑出血,其现已成为中国城市人群死亡原因的第二位,农村人群死亡原因的第一位.据报道,全国约有600万～700万卒中幸存者,每年新发卒中人数约250万～300万,死亡人数约150万.卒中幸存者中有3/4的存在不同程度的神经功能丧失,重残者超过40％.缺血性脑梗死即缺血性卒中,包括动脉血栓形成性脑梗死、脑栓塞、腔隙性梗死和分水岭梗死等.血栓形成、栓子脱落、血管壁斑块形成及血管狭窄等是导致急性缺血性卒中的常见病因.由于缺血性卒中发病原因复杂,导致了血管内治疗技术的多样性和高难度.