MRI-guided therapy in acute stroke

Stroke is the third leading cause of death after myocardial infarction and cancer and the leading cause of permanent disability and of disability-adjusted loss of independent life-years in Western countries. Thrombolysis is the treatment of choice for acute stroke within 3 h after onset of symptoms. Treatment beyond the 3-h time window has not been shown to be effective in any single trial, however, meta-analyses suggest a somewhat less but still significant effect within 3 to 6 h after stroke. It seems reasonable to apply improved selection criteria that allow the differentiation of patients with a relevant indication for thrombolytic therapy from those who have not. An overview of a diagnostic approach to acute stroke management that allows patient management individualization based on pathophysiological reasoning and not rigid time windows, established by randomized controlled trials is presented. Therefore, this review concentrates in the first part on giving the reader an integrated knowledge of the current status of thrombolytic therapy in stroke, and in the second part, develops a treatment algorithm based on pathophysiological information rendered by a multiparametric stroke magnetic resonance imaging protocol.     

MRI-guided therapy in acute stroke

Stroke is the third leading cause of death after myocardial infarction and cancer and the leading cause of permanent disability and of disability-adjusted loss of independent life-years in Western countries. Thrombolysis is the treatment of choice for acute stroke within 3 h after onset of symptoms. Treatment beyond the 3-h time window has not been shown to be effective in any single trial, however, meta-analyses suggest a somewhat less but still significant effect within 3 to 6 h after stroke. It seems reasonable to apply improved selection criteria that allow the differentiation of patients with a relevant indication for thrombolytic therapy from those who have not. An overview of a diagnostic approach to acute stroke management that allows patient management individualization based on pathophysiological reasoning and not rigid time windows, established by randomized controlled trials is presented. Therefore, this review concentrates in the first part on giving the reader an integrated knowledge of the current status of thrombolytic therapy in stroke, and in the second part, develops a treatment algorithm based on pathophysiological information rendered by a multiparametric stroke magnetic resonance imaging protocol.     

中危（次大面积）急性肺栓塞患者是否需要溶栓治疗

中危（次大面积）急性肺栓塞患者是否需要溶栓治疗已经争论了很多年。中危肺栓塞患者具有较高的死亡风险。因此,有人建议给予中危肺栓塞患者溶栓治疗,溶栓治疗可以更快地溶解血栓,从而降低中危肺栓塞患者的病死率。但也有研究表明,与单纯抗凝治疗比较,溶栓治疗不能进一步降低中危急性肺栓塞患者的病死率和复发率,且并发出血率较高。该文就中危急性肺栓塞溶栓治疗的有效性及安全性作一综述。     

介入溶栓治疗胸腔镜下肺癌根治术后高危肺栓塞的经验分析

目的 探讨不同介入溶栓方式治疗胸腔镜下肺癌根治术后高危肺栓塞(PE)的价值.方法 选取2018年就诊于河南大学第一附属医院的3例胸腔镜下肺癌根治术后发生高危PE的患者作为研究对象,其中1例接受单纯静脉溶栓治疗,1例接受单纯动脉介入溶栓治疗,1例接受静脉肺动脉联合介入溶栓治疗,分析3例患者住院治疗方式、溶栓治疗效果和术后...     

核素肺灌注显像对血压正常伴右室功能不全的急性肺栓塞症溶栓疗效的评价

目的：运用核素肺灌注显像对血压正常伴右室功能不全的急性肺栓塞患者溶栓治疗前后肺血流灌注进行观察和定量分析．为临床疗效评价提供准确和直观的客观依据。方法：36例急性肺栓塞患者分为溶栓组和抗凝组。在治疗前后均行肺灌注显像。应用半定量法计算全肺灌注缺损百分数（percentage of pulmonary defect score，PPDs）和灌注改善百分数（percentage of pulmonary improve score，PPIs）。治疗前、治疗后7～10d及25—30d的PPDs分别记为PPDsD0、PPDsD10和PPDsD30。各组PPDsD0与PPDsD30之差、PPDsD0与PPDsD10之差、PPDsD10与PPDsD30之差分别记为PPIs、PPIsI1、PPIsI2。结果：溶栓组、抗凝组PPDs在治疗后均随时间显著降低（P〈0．001）；溶栓组PPIsI1明显大于抗凝组；两组PPIsI2无明显差异。在整个观察期间（治疗后1个月），溶栓组PPIs明显大于抗凝组。结论：溶栓治疗较单抗凝治疗能够更加迅速而持续地改善肺栓塞患者的肺血流灌注，应用肺灌注显像可以准确地评价患者治疗前后的肺血流变化     

Is thrombolytic therapy effective for pulmonary embolism?

Pulmonary embolism is a disorder that is associated with significant morbidity and mortality. Right-sided heart failure and recurrent pulmonary embolism are the main causes of death associated with pulmonary embolism in the first two weeks after the embolic event. Thrombolysis is a potentially lifesaving therapy when used in conjunction with standard anticoagulation. However, it has significant side effects and must therefore be used with caution. Indications for thrombolysis are not well defined and are thus controversial. The only current absolute indication is massive pulmonary embolism with hypotension. Other potential indications include right heart dysfunction, recurrent pulmonary embolism and the prevention of pulmonary hypertension. However, no evidence exists to show benefit of thrombolytic therapy over standard anticoagulation therapy for recurrent pulmonary embolism, mortality or chronic complications. Bleeding is the most common complication of thrombolysis and may be fatal.     

Mechanical circulatory assist for pulmonary embolism

Optimal management of acute pulmonary embolism remains controversial, despite advances in thrombolytic therapy. Haemodynamic instability and, in particular, right ventricular dysfunction is associated with poor outcomes. Urgent surgical embolectomy has been the treatment of choice in this category of patients. We present two cases in which percutaneous cardiopulmonary support (PCPS) was used as an adjunct to thrombolytic therapy for progressive circulatory collapse secondary to massive acute pulmonary embolism. This experience suggests that PCPS may offer an attractive option for a condition which continues to carry significant morbidity and mortality.     

Hemorrhagic disorders associated with thrombolytic therapy

Thrombolytic treatment for AMI, acute ischemic stroke, and massive pulmonary embolism has shown significant benefit. Along with the potential increase in perfusion and decrease in cell death, however, comes potential complications. Bleeding is the most common complication associated with thrombolytic therapy regardless of the particular agent and can range from minor bleeding from an i.v. site to a life-threatening hemorrhage, such as GI bleeding. Expert assessment and management of patients who develop bleeding complications is critical to desired patient outcomes. Knowledge of the diagnosis for which a thrombolytic agent is used, pathophysiology, hemodynamic changes, and symptoms of complications associated with bleeding, all present a challenge to nurses. Research-based algorithms, protocols, or standardized treatment plans and a multidisciplinary approach to thrombolytic therapy provide the best opportunity for success, reducing the risk and enhancing early intervention of complications. Although thrombolytic therapy creates its own set of challenges, the alternative--failure to restore perfusion to the myocardium, brain, or pulmonary vasculature--presents both a different set of challenges and a dismal outcome.     

50例急性肺栓塞2周后小剂量溶栓和单纯抗凝疗效观察

目的：观察急性肺栓塞病程2周以后，溶栓加抗凝和单纯抗凝临床效果比较。方法：将50例肺栓塞病程〉2周的病人分为A、B两组。A组用250ml。生理盐水加尿激酶200000～500000u，低分子肝素钙5000u皮下注射，1次／12h，连用7d，于停用低分子肝素钙前3d开始口服华法令，疗程6个月；B组仅应用低分子肝素钙及华法令，方法同A组。观察临床症状、体征、心脏彩超、肺通气灌注显像及螺旋CT检查的变化。结果：A组总有效率为50％，B组总有效率为40％，两者比较P〉0．05。结论：急性肺栓塞病程〉2周，小剂量溶栓加抗凝与单纯抗凝无显著差别，为减少出血风险选择单纯抗凝治疗。     

Endovascular interventions for acute pulmonary embolism

Massive pulmonary embolism (PE) is a highly lethal condition with clinical manifestations of hemodynamic instability, acute right ventricular (RV) failure, and cardiogenic shock. Submassive PE, as defined by RV failure or troponin elevation, can result in life-threatening sequelae if treatment is not initiated promptly. Current treatment paradigm in patients with massive PE mandates prompt risk stratification with aggressive therapeutic strategies. With the advent of endovascular technologies, various catheter-based thrombectomy and thrombolytic devices are available to treat patients with massive or submassive PE. In this article, a variety of endovascular treatment strategies for PE are analyzed. The authors' institutional experience with ultrasound-accelerated thrombolytic therapy as well as catheter-directed thrombolytic therapy in patients with acute massive PE during a recent 10-year period is discussed. Finally, clinical evidence on the utilization of catheter-based interventions in patients with massive and submassive PE is also analyzed.     

急性肺栓塞的临床特点及诊治方法

【目的】分析总结急性肺栓塞的临床特点,提高对该病的认识,减少漏诊率、误诊率和病死率。【方法】对本院39例诊治为急性肺栓塞的临床表现、诊断和治疗方法进行回顾性分析。【结果】肺栓塞缺乏临床特异性表现,常被误诊为冠心病、慢性阻塞性肺疾病、肺炎等。D-二聚体大于500μg／L者占92．3％,血气分析P02〈80mmHg占89．7％,螺旋CT肺段动脉以上动脉血栓者占79．5％。溶栓加抗凝治疗组有效率为81％,单纯抗凝治疗组有效率为66．7％。【结论】肺栓塞易漏诊和误诊,血气分析、D-二聚体、UCG可作为急性肺栓塞的初筛检查指标,溶栓加抗凝疗法治疗PE优于单纯抗凝疗法。     

Catheter intervention for pulmonary embolism

Thrombolysis is generally accepted in patients with acute massive pulmonary embolism, however, thrombolytic agents could not be fully administrated for cases with a high risk of bleeding. On the other hand, catheter intervention is an optimal treatment for massive pulmonary embolism patients having contraindications for thrombolysis, and is a minimally invasive alternative to surgical embolectomy. It can be performed with a minimum dose of thrombolytic agents or without, and can be combined various procedures including catheter fragmentation or embolectomy in accordance with the extent of thrombus on pulmonary angiogram. Hybrid catheter intervention for massive pulmonary embolism can reduce rapidly heart rate and pulmonary artery pressure, and can improve the gas exchange indices and outcomes.     

Thrombolytic therapy for acute myocardial infarction: the elderly population.

Coronary artery disease is the most common cause of death in persons older than 65 years. More than half of all patients hospitalized for acute myocardial infarction (AMI) are now older than 65, with this percentage expected to increase significantly in subsequent years. The current evidence regarding the treatment of AMI indicates that early thrombolytic therapy can limit the extent of myocardial necrosis, preserve left ventricular function, decrease the incidence of congestive heart failure, and reduce mortality in patients with AMI. Most studies have adhered to empiric recommendations to exclude elderly patients, based on the assumption that in the elderly the risks of serious hemorrhagic complications after thrombolytic therapy outweigh the potential benefits of early reperfusion. This article reviews the current literature regarding use of thrombolytic agents in treating AMI in the elderly population with some guidelines for protocol formation.     

Echocardiographic visualization of acute pulmonary embolus and thrombolysis in the ED

Echocardiography has been used to diagnose acute right-sided dysfunction arising from pulmonary embolism (PE). Rarely, it can visualize the embolic material in the right heart cavities. We report a case of acute PE that was seen in the right ventricle and right pulmonary artery using bedside transthoracic echocardiography in the ED. As a result of the prompt diagnosis of a massive embolus and associated right ventricular dysfunction, the patient was treated with thrombolytics. Serial echocardiographs confirmed the response to therapy and the dissolution of thrombi. In this report, echocardiographic findings of acute PE and indications of thrombolytics in PE are also reviewed from the literature. Based on available evidence, those patients who present with cardiogenic shock from PE, and young patients with acute PE leading to right ventricular dysfunction benefit the most from early thrombolytic therapy.     

Thrombolytic therapy and outcome of patients with an acute symptomatic pulmonary embolism

Background:  While the primary therapy for most patients with a pulmonary embolism (PE) consists of anticoagulation, the efficacy of thrombolysis relative to standard therapy remains unclear. Methods:  In this retrospective cohort study of 15 944 patients with an objectively confirmed symptomatic acute PE, identified from the multicenter, international, prospective, Registro Informatizado de la Enfermedad TromboEmbólica (RIETE registry), we aimed to assess the association between thrombolytic therapy and all‐cause mortality during the first 3 months after the diagnosis of a PE. After creating two subgroups, stratified by systolic blood pressure (SBP) (< 100 mm Hg vs. other), we used propensity score‐matching for a comparison of patients who received thrombolysis to those who did not in each subgroup. Results:  Patients who received thrombolysis were younger, had fewer comorbid diseases and more signs of clinical severity compared with those who did not receive it. In the subgroup with systolic hypotension, analysis of propensity score‐matched pairs (n = 94 pairs) showed a non‐statistically significant but clinically relevant lower risk of death for thrombolysis compared with no thrombolysis (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.36–1.46; P = 0.37). In the normotensive subgroup, analysis of propensity score‐matched pairs (n = 217 pairs) showed a statistically significant and clinically meaningful increased risk of death for thrombolysis compared with no thrombolysis (OR 2.32; 95% CI, 1.15–4.68; P = 0.018). When we imputed data for missing values for echocardiography and troponin tests in the group of normotensive patients, we no longer detected the increased risk of death associated with thrombolytic therapy. Conclusions:  In normotensive patients with acute symptomatic PE, thrombolytic therapy is associated with a higher risk of death than no thrombolytic therapy. In hemodynamically unstable patients, thrombolytic therapy is possibly associated with a lower risk of death than no thrombolytic therapy. However, study design limitations do not imply a causal relationship between thrombolytics and outcome.     

Thrombolysis for pulmonary embolism

More than 10 years ago, thrombolytic therapy with urokinase and streptokinase for pulmonary embolism was found to have considerable advantages over standard heparin therapy. After the introduction of alteplase, a recombinant tissue plasminogen activator, further studies confirmed this benefit. However, thrombolytic therapy for pulmonary embolism has not gained universal acceptance, even though it now has U.S. Food and Drug Administration approval. Clear advantages of thrombolytic therapy over conventional heparin therapy are improved pulmonary capillary blood volume, accelerated clot lysis and accelerated pulmonary perfusion. Earlier reversal of right-sided heart failure, a lower incidence of recurrent pulmonary embolism, a reduced risk of chronic pulmonary hypertension and reduced mortality have been claimed as advantages, but these have not been adequately proved. A recent survey suggests that about half of all patients with pulmonary embolism are potential candidates for thrombolytic therapy. In a subset of patients with hemodynamic compromise, thrombolysis has definite advantages over heparin therapy.     

肺动脉栓塞不同时相的尿激酶溶栓疗效观察的实验研究

目的探讨肺动脉栓塞不同时相的尿激酶溶栓的疗效。方法成功制作11头小型猪肺动脉栓塞实验模型(另1头死于出血性肺梗死),以尿激酶作为溶栓剂,观察在栓塞不同时相(栓塞术后30min、栓塞术后10天、术后30天)的溶栓治疗效果。结果实验小型猪在肺动脉栓塞急性期(3头次)以尿激酶15×104U溶栓治疗后被栓塞肺动脉恢复通畅;亚急性期(3头次)以30×104U尿激酶后得到同样结果;慢性期(3头次)以50×104U尿激酶溶栓后,肺动脉三级分支内的血栓完全溶解,再追加5×104U尿激酶,肺动脉四级分支内血栓明显减少。结论肺动脉栓塞不同时相的尿激酶溶栓治疗均有一定的疗效,急性期和亚急性期较慢性期的疗效好,不同时相的溶栓治疗所需尿激酶剂量随栓塞时间延长而呈递增趋势。     

肺灌注/通气显像对肺栓塞溶栓疗效的评价

目的 探讨肺灌注/通气显像对评价肺栓塞溶栓治疗的价值. 方法 43例肺栓塞患者在溶栓治疗前和治疗后1周及3个月进行肺灌注/通气显像,评价溶栓治疗效果. 结果 43例患者共观察到421个受损肺段.溶栓治疗后1周复查,199(47.3%)个受损肺段恢复正常;3个月后复查231(54.9%)个受损肺段恢复正常(P<0.05).溶栓前病程≤1周组受损肺段恢复正常数高于病程>1周组(P相似文献   

下腔静脉滤器植入后中西医结合介入治疗急性下肢深静脉血栓的临床应用

目的 探讨下腔静脉滤器植入后中西医结合介入治疗急性下肢深静脉血栓形成的应用价值.方法 收集有明确临床症状、体征,并经彩色多普勒超声或造影证实的下肢深静脉血栓形成患者56例,随机分为治疗组(28例)和对照组(28例),所有急性下肢深静脉血栓患者均在植入下腔静脉滤器后抗凝治疗,治疗组经插管溶栓或经患肢足背静脉溶栓治疗并联合应用中药内服外敷,对照组经插管溶栓或经患肢足背静脉溶栓治疗.结果 按血管通畅度评价,治疗组血管通畅度高于对照组.随访结果显示治疗组治疗的疗效优于对照组治疗(P＜0.01).溶栓治疗过程中未出现肺动脉栓塞症状及出血现象.结论 中西医结合介入治疗方法对急性下肢深静脉血栓形成有良效,结合中医辨证论治综合治疗,可以增强疗效.     

Thrombolysis in cardiopulmonary resuscitation

The prognosis of patients suffering cardiac arrest is still poor. Until today, no drug therapy has shown to improve longterm survival after cardiac arrest. Thrombolysis has been shown to be an effective therapy in patients with acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Since 50-70% of cardiac arrests are caused by AMI or massive PE, the combination of cardiopulmonary resuscitation (CPR) and thrombolytic therapy appears to be sensible. As experimental studies have shown, thrombolytic therapy during CPR may not only be a causal treatment for coronary or pulmonary arterial obstruction by thrombi, but may also improve microcirculatory reperfusion after cardiac arrest. Although numerous small clinical studies have shown the efficacy of thrombolysis during CPR in selected patients, the generalized treatment of patients suffering cardiac arrest with thrombolytics can not be recommended based on current clinical evidence. According to the recent CPR guidelines, thrombolysis may be considered in cardiac arrest patients with suspected massive PE or as a so-called rescue therapy after unsuccessful conventional CPR in patients with a suspected thrombotic cause of cardiac arrest. The risk of severe bleeding complications following thrombolysis during CPR seems to be outweighed by the potential benefit of this therapy in selected patients.