动脉内局部溶栓治疗急性缺血性卒中

动脉内局部溶栓对包括心源性栓塞在内的急性缺血性卒中均有较好的疗效,动静脉联合溶栓的安全性较高。最近的研究表明,急诊动脉内局部溶栓联合血管成形术在急性缺血性卒中的治疗中起重要作用。     

急性缺血性卒中的经颅多普勒辅助溶栓

在脑血管病的临床诊断方面,经颅多普勒（TCD）作为一种成熟的技术已在临床应用了20余年。近年来的研究表明,在急性缺血性卒中的治疗中,TCD可以增强溶栓治疗的效果。这引起了学者们的极大关注,并进行了一系列的相关研究。     

Current and Future Use of Intravenous Thrombolysis for Acute Ischemic Stroke

Stroke is a common and disabling condition. Intravenous tissue plasminogen activator (tPA) administered within 3 h of symptom onset is the standard therapy for eligible patients with acute ischemic stroke. Unfortunately, because of the time limitation, very few patients with ischemic stroke actually receive this treatment. In order to increase the number of patients who may benefit from acute treatment, recent research has focused on expanding the time window for thrombolysis and improving its efficacy to ultimately improve patient outcome.     

Thrombolysis for Stroke in the Elderly

Introduction. Systemic thrombolysis with intravenous recombinant tissue plasminogen activator (rtPA) for acute ischemic stroke had been licensed for patients up to 75 years in age in many European countries and was recently extended to 80 years. This age restriction results from the potential higher risk of cerebral bleeding in the elderly. The major rtPA trials included only 42 patients above 80 years showing a potential benefit from treatment. Further data is still rare.Methods. Using our stroke database we identified all patients beyond 75 years with middle cerebral artery ischemia treated with intravenous rtPA in our stroke unit from 02/1999 until 07/2004. Clinical course and outcome until day 5 in addition to mortality after 3 and 6 months were analysed.Results. Twenty-nine patients (80.8 ± 4 years, 16 of them over 80 years old) met the inclusion criteria representing 21.2% of those receiving thrombolytic therapy. The median NIH-SS score on admission was 14 points. On day 5 after thrombolysis, 13/29 showed a good recovery (NIH-SS improvement ≥4 pts). The remaining exhibited only small or no benefit (n = 11), deterioration (n = 3) or died (n = 2). A total of 3/29 patients developed non-symptomatic parenchymal hemorrhage or hemorrhagic transformation. One patient died due to space-occupying cerebral hemorrhage. Extracerebral bleeding was found in 3/29 requiring substitution in one. One other died for primary cardiac reasons. Median NIH-SS on day 5 was 10 points. Mortality after 3 and 6 months was 20.7%. We did not find factors predicting clinical outcome. Most importantly, there was no significant difference regarding outcome in patients 76–80 vs. 81–87 years old.Discussion. Intravenous rtPA resulted in good neurological in-hospital outcome in almost 45% and six-months survival of almost 80% of the patients beyond 75 years. In 10.3% non-symptomatic and in 3.4% symptomatic cerebral bleeding was found. Thus, seniors beyond 75 and even beyond 80 years in good medical condition may benefit from systemic treatment with rtPA. Prospective studies are needed to clarify which part of the senior population might be most eligible for systemic thrombolysis.     

急性缺血性卒中患者尿激酶动脉溶栓治疗的临床观察

目的:评价尿激酶选择性动脉溶栓治疗急性脑梗死的疗效和安全性.方法:38例急性脑梗死患者在发病后6 h内进行尿激酶选择性动脉溶栓治疗,术后即刻和24 h分别行头颅CT检查了解有无颅内出血.采用Barthel指数(BI)和美国国立卫生研究院卒中量表(NIHSS)评分对患者6个月时的生活状态和功能转归进行评价.结果:38例患者中,21例完全再通,8例部分再通,3例发生有症状颅内出血,1例死亡.术后90 d时,22例功能转归良好(BI≥90分),11例较好(50分≤BI＜90分),4例较差(BI＜50分);术后6个月时,24例功能转归良好,9例较好,4例较差.术后14 d时的NIHSS评分显著优于术前水平(12.68±7.43对15.38±4.32,P＜0.01).结论:尿激酶动脉溶栓能使闭塞血管再通,改善患者急性期临床症状和远期预后.     

溶栓治疗研究中的缺血性卒中模型

缺血性卒中是最常见的脑血管病,超早期溶栓治疗是目前惟一公认有效的治疗方法。建立完善的动物溶栓模型对于研究脑梗死的发病机制、病理生理学变化和溶栓治疗的效果至关重要。文章从模型制备机制的角度对现有缺血性脑血管病溶栓模型做了综述。     

缺血性卒中溶栓治疗中的经颅多普勒监测

经颅多普勒 (TCD)在脑梗死溶栓治疗中应用广泛。溶栓前 ,TCD可判断动脉闭塞部位 ,帮助选择合适的溶栓病例 ;在溶栓中和溶栓后 ,监测血管再通并记录微栓子信号。此外 ,TCD尚具有促进栓子溶解的作用。     

急性脑梗死的动脉溶栓治疗

动脉溶栓是挽救缺血半暗带和治疗急性脑梗死的最有效方法之一，但由于治疗时间窗短、溶栓后出血以及再闭塞等诸多因素的限制，这一技术在广泛开展和应用之前，仍然需要进行更多的临床研究。     

Ultrasound- and Microspheres-Enhanced Thrombolysis for Stroke Treatment: State of the Art

Intravenous administration of recombinant tissue-plasminogen activator (rt-PA) remains the fastest and widely feasible strategy to initiate treatment in acute ischemic stroke. Because it works by inducing recanalization of an occluded vessel, augmentation of this process is desirable and diagnostic transcranial Doppler (TCD) ultrasound can accomplish this safely. A 2-MHz pulsed-wave monitoring can at least double the chance of early complete arterial recanalization at no increase in the risk of symptomatic intracerebral hemorrhage. Gaseous microspheres, initially developed as ultrasound contrast agents, can further increase the effectiveness of rt-PA. A recent microsphere dose-escalation study called TUCSON showed sustained complete recanalization rates of 67% in patients receiving TCD monitoring with a 1.4-mL perflutren-lipid microsphere dose compared with controls receiving rt-PA alone with no increase in hemorrhage rate. In this article, we review the current and emerging applications of ultrasound and microspheres in stroke management including augmentation of systemic thrombolysis and implications for future reperfusion strategies.     

流程改进与智能时间追踪在急性缺血性脑卒中溶栓流程中的作用

目的研究急性缺血性脑卒中流程改进与电子信息智能时间追踪系统对缩短缺血性脑卒中患者从入院到溶栓治疗的时间(door to needle time,DNT)及溶栓率的影响。方法选取我院神经内科收治的2592例急性缺血性脑卒中(acute ischemic stroke,AIS)患者,其中静脉溶栓患者共243例,优化流程前组有106例,优化流程后组有137例。回顾分析开通绿色通道及智能时间追踪前、后两组接受静脉溶栓的AIS患者的临床资料。对两组患者的DNT、DNT≤60分钟的比例,以及时间窗内患者溶栓率及总溶栓率进行分析,比较优化流程并采取智能时间追踪前后上述指标的变化。结果优化流程并利用电子信息系统实时监控后,年龄80岁的患者比例增高(P0.05),DNT显著缩短(P0.01),且时间窗内就诊的AIS患者溶栓率有了明显的提高(P0.01),而总体AIS患者溶栓率虽有提高,但差异无统计学意义(P0.05)。两组患者在症状性出血转化及死亡方面差异无统计学意义(P0.05)。结论启动急性缺血性脑卒中静脉溶栓绿色通道及智能时间追踪系统可显著缩短DNT,提高时间窗内患者溶栓率及总溶栓率,且安全有效。     

Acute Ischemic Stroke Successfully Treated Using Sequenced Intravenous and Intra-Arterial Thrombolysis and Argatroban Anticoagulation: A Case Study

BACKGROUND: Direct thrombin inhibitors, a class of anticoagulants distinct from heparins, have not been evaluated for immediate use after thrombolytic therapy in acute ischemic stroke. We report a case of ischemic stroke and prothrombotic state treated using sequenced intravenous and intra-arterial thrombolytic therapy and argatroban anticoagulation. CASE DESCRIPTION: A 19-year-old man with a complicated history of recurrent life-threatening thrombosis presented at the emergency department with acute ischemic stroke. The patient received standard-dose intravenous alteplase starting 2.25 hours after symptom onset without change in his global aphasia and right hemiparesis. Five hours after symptom onset, intra-arterial reteplase was administered for treatment of a left internal carotid "T" occlusion, with successful recanalization of the left internal carotid artery, A1 and M1 segments, and right middle cerebral anterior division and with improvement in symptoms. Argatroban therapy was started after completion of intra-arterial thrombolysis, i.e., 8.5 hours after symptom onset, and was maintained for 14 days. Although the patient sustained a small left basal ganglia infarct, he improved significantly over the course of therapy and was discharged to home without bleeding or further thrombotic episodes. CONCLUSIONS: Sequenced intravenous and intra-arterial thrombolytic therapy and argatroban anticoagulation was used successfully to safely treat a patient with ischemic stroke and comorbid prothrombotic state within 8.5 hours of symptom onset.     

急性脑卒中患者静脉血栓栓塞症调查及危险因素探讨

<正>静脉血栓栓塞症(venous thromboembolism,VTE)包括深静脉血栓形成(deep venous thrombosis,DVT)和肺血栓栓塞症(pulmonary thromboembolism,PTE)。脑卒中患者是VTE发生的高危人群,如果不给予任何干预措施,30%~40%的脑卒中患者会发生DVT,严重     

诱导性低温治疗急性卒中

轻度低温的神经保护研究在近20年里不断深入,低温正成为一种治疗急性缺血性和出血性卒 中很有前景的方法。文章介绍了急性卒中治疗现状、低温的作用机制、诱导性低温治疗急性卒中的实 验研究和临床研究、低温的实施方法和并发症的防治。     

急性卒中的低温治疗

低温脑保护作用是目前研究的热点之一。文章综述了目前低温治疗的实施方法及其并发症、低温治疗在急性卒中方面的研究进展以及循证医学对其的评价。     

急性卒中的低温治疗

低温脑保护是目前的研究热点之一,文章综述了发热对卒中患者的危害、低温脑保护的作用机制以及低温治疗急性卒中的临床应用。     

Techniques for Acute Stroke Intervention

Stroke or cerebrovascular accident is the second most common cause of death in Western countries. Although stroke is a treatable disease, the majority of patients do not receive intravenous thrombolysis or catheter-based therapy. The lack of treatment is multifactorial. Several treatments have been studied. Research and development in the area of acute stroke treatment are ongoing.     

急性心肌梗死冠脉内超声溶栓

目的研究冠脉内低频（２０ｋＨｚ）、高强度（４０Ｗ）超声溶栓在急性心肌梗死梗塞相关血管中的应用。方法急性心肌梗死患者１１例（前壁心梗６例,下壁心梗５例）,梗塞相关血管前向血流均为ＴＩＭＩ０级和１级（左前降支６例,左回旋支２例,右冠状动脉３例）,超声溶栓后行急诊经皮腔内冠状动脉成形术（ＰｒｉｍａｒｙＰＴＣＡ）。结果冠脉内超声溶栓对梗塞相关血管的开通率为７３％（血流达ＴＩＭＩ３级）,残余狭窄为（７２±１４）％,１１例全部立即行ＰＴＣＡ,超声溶栓失败的３例经ＰＴＣＡ后血管全部开通,ＰＴＣＡ术后残余狭窄为（２４±１２）％。冠脉内超声溶栓时,因超声探头折断,血管再度闭塞１例,冠脉轻度撕裂１例;无血管痉挛,无远端血管栓塞等并发症,也无室速、室颤等恶性事件发生。结论本研究表明冠脉内低频、高强度超声溶栓是安全、有效的血管开通方式,可应用于临床。