颈内动脉系统脑梗死3～6 h静脉溶栓与动脉溶栓的比较

目的 观察颈内动脉系统梗死患者3～6 h时间窗内静脉溶栓和动脉溶栓治疗的疗效.方法 对34例发病3～4.5 h和18例发病4.5～6 h颈内动脉系统梗死患者,根据头颅磁共振灌注加权成像(PWI)/弥散加权成像(DWI)≥20%,分别行静脉和动脉内超选择性重组组织型纤溶酶原激活剂(rt-PA)溶栓治疗.治疗前后进行卒中量表(NIHSS)评分,并观察血管再通率、出血率,治疗后90 d用修正Raikin量表(MRS)评价临床预后.结果 溶栓后2组患者NIHSS评分较治疗前明显改善(P＜0.05),2组间NIHSS的改善程度差异无统计学意义(P＞0.05).治疗后90 d预后良好率:静脉溶栓组55.9%,动脉溶栓组61.1%,2组间比较差异无统计学意义(P＞0.05).血管再通率:静脉溶栓组47.1%、动脉溶栓组77.8%,2组间比较差异有统计学意义(P＜0.05).出血率:静脉溶栓组17.6%,动脉溶栓组33.3%,2组比较差异无统计学意义(P＞0.05).结论 在头颅MR PWI/DWI不匹配时,颈内动脉系统脑梗死发生3~4.5 h内静脉溶栓与4.5~6 h内动脉溶栓治疗安全有效,两者的效果相当.     

经颅多普勒超声脑缺血溶栓分级与阿替普酶静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死预后相关性研究

目的探讨分析经颅多普勒超声脑缺血溶栓分级与静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死患者血管再通评价与预后的相关性研究。方法选择急性前循环大动脉闭塞性脑梗死患者,对符合静脉溶栓者给予阿替普酶静脉溶栓治疗,分别于溶栓前及溶栓后24 h行床旁经颅多普勒超声(transcranial Doppler,TCD)检查并记录脑缺血溶栓分级(thrombolysis in brain ischemia,TIBI)。采用美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分记录患者临床神经功能缺损,3个月随访时采用改良Rankin量表(modified Rankin Scale,m RS)评分评估患者预后,分析前循环不同大血管闭塞性脑梗死患者静脉溶栓前后血管再通情况及患者3个月预后。结果共入选46例患者,其中颈内动脉(internal carotid artery,ICA)闭塞患者19例,大脑中动脉(middle cerebral artery,MCA)闭塞患者27例。溶栓前与溶栓后24 h TCD监测TIBI分级提示血管再通者,ICA闭塞组5.26%,MCA闭塞组55.56%。ICA闭塞组与MCA闭塞组比较,MCA闭塞组90 d随访生活自理及良好预后的比例均高于ICA闭塞组,死亡率低于ICA闭塞组,而两组间溶栓后的症状性颅内出血发生率差异无显著性。结论急性前循环大动脉闭塞性脑梗死经静脉溶栓治疗后可获得血管再通,尤其是MCA闭塞患者;溶栓前后TIBI血流分级变化可反映大动脉血管再通情况,且有助于判断患者临床预后。     

MR灌注影像指导下大脑中动脉供血区急性脑梗死的r-tPA静脉溶栓治疗研究

目的 观察在MR灌注影像指导下,重组组织型纤溶酶原激活剂(r-tPA)静脉内溶栓治疗大脑中动脉供血区急性脑梗死的时效及并发症.方法 分别对15 例发病后3 h和12例3～6 h内头颅MR PWI/DWI不匹配≥20%的急性缺血性脑梗死患者行静脉内r-tPA(0.9 mg/kg)溶栓治疗,治疗前后NIHSS评定神经功能恢复状况,治疗后和随访期用Barthel指数(BI)评价临床疗效.结果 不同时间窗内的t-rPA溶栓静脉治疗后NIHSS的评分均有明显改善,临床疗效明显,分别有1例出现皮下淤斑和梗死区渗血.结论 在MR的PWI/DWI不匹配≥20%的情况下,急性大脑中动脉脑梗死3 h内和3～6 h内两个时间窗,用r-tPA静脉溶栓均安全有效.     

选择性动脉溶栓治疗急性脑梗死87例临床分析

目的探讨急性缺血性脑血管病选择性动脉溶栓治疗的适应证,以期提高动脉溶栓疗效,减少死亡率。方法87例急性缺血性脑血管病患者行选择性动脉溶栓治疗,ICA系统49例,发病多在6h内;VBA系统38例,发病多在12h以内。血管再通程度根据"急性心肌梗死溶栓标准"(TIMI)分类。临床结果评价在溶栓后30d进行,根据改良的Rank(MRS)评分,0～3分为好结果、4～6分为差结果。结果DSA造影结果,ICA完全闭塞20例,MCA的M1或M2段闭塞16例;溶栓后24例再通,12例未通。椎-基底动脉(VBA)系统,完全闭塞24例,溶栓后11例再通,13例未通。严重狭窄7例,溶栓后狭窄未见明显缓解。20例未见明显闭塞,结合临床症状及CT或MR检查考虑大脑中动脉或基底动脉深穿支闭塞。欧洲卒中评分(ESS):术前37.5±8.1,术后24h 50.6±11.6,术后2周58.2±12.4。痊愈35例(40.2%)、显效18例(20.7%)、有效11例(12.6%),未愈及死亡23例(26.5%)。发病2周以内死亡20例(ICA 3例,VBA 17例),脑出血和上消化道出血各死亡1例外,其余均死于脑梗死。溶栓术后30d,ICA系统30例(61.2%)患者为好结果(MRS 0～3),19例(38.8%)为差结果(MRS 4～6),其中4例(8.2%)死亡。V-BA系统12例(31.6%)患者为好结果(MRS 0～3),26例(68.4%)为差结果(MRS 4～6),其中19例(50%)死亡。结论急性期动脉溶栓治疗是安全有效的;术后24h的恢复程度与远期预后直接相关;动脉严重狭窄所致低灌注性脑梗死溶栓效果不佳;患者死亡的最主要原因是脑梗死及其并发症,极少数死于脑出血和消化道出血。     

时间窗超过3h急性缺血性卒中患者动脉溶栓治疗观察

目的 评价时间窗超过3 h的急性缺血性卒中患者动脉溶栓治疗的疗效及影响因素.方法 选择法国南锡大学中心医院神经影像科自2008年1月至2009年1月收治的16例急性缺血性卒中患者(时间窗均达到或超过3 h,颈内动脉系统卒中时间窗不超过6 h,椎基底动脉系统卒中时间窗不超过24h.昏迷不超过6 h),行动脉内药物联合机械溶栓治疗,分析不同因素对疗效的影响.结果 7例患者闭塞血管达到完全再通,7例达到部分再通,另有2例闭塞血管未再通,再通率为87.5%.患者动脉溶栓后与溶栓前NIHSS评分比较明显降低.时间窗大于5 h的前循环系统闭塞患者溶栓前后NIHSS评分无改善,与时间窗较短患者相比较,出院时mRS评分明显较高.5例颈内动脉闭塞患者溶栓前后NIHSS评分无改善,与9例大脑中动脉闭塞患者、2例基底动脉闭塞患者相比预后较差.4例患者溶栓后24h出现症状性颅内出血,3例为颈内动脉闭塞,1例死亡.1例溶栓后发生血管再闭,但因侧支循环血流丰富,最终临床预后仍较好.结论 对于时间窗超过3 h大脑中动脉和基底动脉闭塞急性缺血性卒中患者,动脉溶栓可使闭塞血管达到较高的再通率,短期内使临床神经功能恢复,改善临床结局.临床应用动脉溶栓时应注意个体化选择性治疗,评价其疗效需结合时间窗、血管闭塞部位、侧支循环、并发症等因素,避免出血等并发症.     

时间窗超过3h急性缺血性卒中患者动脉溶栓治疗观察

目的 评价时间窗超过3 h的急性缺血性卒中患者动脉溶栓治疗的疗效及影响因素.方法 选择法国南锡大学中心医院神经影像科自2008年1月至2009年1月收治的16例急性缺血性卒中患者(时间窗均达到或超过3 h,颈内动脉系统卒中时间窗不超过6 h,椎基底动脉系统卒中时间窗不超过24h.昏迷不超过6 h),行动脉内药物联合机械溶栓治疗,分析不同因素对疗效的影响.结果 7例患者闭塞血管达到完全再通,7例达到部分再通,另有2例闭塞血管未再通,再通率为87.5%.患者动脉溶栓后与溶栓前NIHSS评分比较明显降低.时间窗大于5 h的前循环系统闭塞患者溶栓前后NIHSS评分无改善,与时间窗较短患者相比较,出院时mRS评分明显较高.5例颈内动脉闭塞患者溶栓前后NIHSS评分无改善,与9例大脑中动脉闭塞患者、2例基底动脉闭塞患者相比预后较差.4例患者溶栓后24h出现症状性颅内出血,3例为颈内动脉闭塞,1例死亡.1例溶栓后发生血管再闭,但因侧支循环血流丰富,最终临床预后仍较好.结论 对于时间窗超过3 h大脑中动脉和基底动脉闭塞急性缺血性卒中患者,动脉溶栓可使闭塞血管达到较高的再通率,短期内使临床神经功能恢复,改善临床结局.临床应用动脉溶栓时应注意个体化选择性治疗,评价其疗效需结合时间窗、血管闭塞部位、侧支循环、并发症等因素,避免出血等并发症.     

时间窗超过3h急性缺血性卒中患者动脉溶栓治疗观察

目的 评价时间窗超过3 h的急性缺血性卒中患者动脉溶栓治疗的疗效及影响因素.方法 选择法国南锡大学中心医院神经影像科自2008年1月至2009年1月收治的16例急性缺血性卒中患者(时间窗均达到或超过3 h,颈内动脉系统卒中时间窗不超过6 h,椎基底动脉系统卒中时间窗不超过24h.昏迷不超过6 h),行动脉内药物联合机械溶栓治疗,分析不同因素对疗效的影响.结果 7例患者闭塞血管达到完全再通,7例达到部分再通,另有2例闭塞血管未再通,再通率为87.5%.患者动脉溶栓后与溶栓前NIHSS评分比较明显降低.时间窗大于5 h的前循环系统闭塞患者溶栓前后NIHSS评分无改善,与时间窗较短患者相比较,出院时mRS评分明显较高.5例颈内动脉闭塞患者溶栓前后NIHSS评分无改善,与9例大脑中动脉闭塞患者、2例基底动脉闭塞患者相比预后较差.4例患者溶栓后24h出现症状性颅内出血,3例为颈内动脉闭塞,1例死亡.1例溶栓后发生血管再闭,但因侧支循环血流丰富,最终临床预后仍较好.结论 对于时间窗超过3 h大脑中动脉和基底动脉闭塞急性缺血性卒中患者,动脉溶栓可使闭塞血管达到较高的再通率,短期内使临床神经功能恢复,改善临床结局.临床应用动脉溶栓时应注意个体化选择性治疗,评价其疗效需结合时间窗、血管闭塞部位、侧支循环、并发症等因素,避免出血等并发症.

Abstract：

Objective To evaluate the efficacy of intra-arterial hrombolytic therapy in patients with acute ischemic stroke having their time window over 3 h and analyze its influencing factors.Methods Sixteen patients with acute ischemic stroke having their time window over 3 h, admitted to Department of Neuroradiology of Central Hospital of Nancy University from January 2008 to January 2009, were treated by intra-arterial thrombolysis using chemical (rt-PA) and mechanical technique. These patients had carotid stroke for less than 3 h, vertebrobasilar stroke for less than 24 h or coma for less than 6 h. According to the images of DSA, the recanalization after thrombolysis was evaluated by thrombolysis in cerebral infarction (TICI) grades. CT scans 24 h after thrombolysis were operated to detect the hemorrhage complications. NIHSS at baseline and 24 h after thrombolysis and modified Rankin Scale (mRS) were recorded to evaluate the clinical efficacy. Results After intra-arterial thrombolysis, 7 (43.75%) in 16 patients got totally recanalization (TICI grade 3), another 7 partial recanalization (TICI grade 2), and the left 2 patients failed in recanalization (TICI grade 1); the total recanalization rate was 87.5%. A significant reduction of NIHSS scores after the thrombolysis was noted as compared with that before the thrombolysis. The atients with occlusion of anterior ciculation having time window over 5 h enjoyed no reduction of NIHSS scores after thrombolysis; mRS scores in patients having time window over 5 h were ignificantly higher as compared with those in patients having time window less than 5 h.The patients having ICA occlusion (n=5) had no reduction of NIHSS scores after thrombolysis, and enjoyed poorer prognosis as compared with whose occlusion lay in the middle cerebral artery (MCA,n=9) and basilar artery (BA, n=2). By CT scan 24 h after thrombolysis, 4 patients were detected with symptomatic intra cerebral hemorrhage (ICH, 25%) and all of them with occlusion in the internal carotid artery system: 1 patient with occlusion in MCA died of cerebral hernia causing by the large hematoma;the other 3 were all occlusion in ICA. Although reocclusion after thrombolysis occurred, 1 patient was benefitted from the affluent collateral perfusion and got a good prognosis. Conclusion For patientswith BA and MCA occlusion having time window over 3 h, intra-arterial thrombolytic therapy is effective and selective resulting from their high recanalization rate, improvement of neurological function and clinical end. The therapy should be individually chosen; mutiple factors as time window of stroke,location of stroke, ompensatory circulation and complications should be considered in evaluating the efficacy; and the hemorrhage complications should be avoided.     

基于MRI和DSA的ICA、MCA狭窄或闭塞患者发生不同供血区脑梗死的对比分析

目的 探讨颈内动脉(ICA)、大脑中动脉(MCA)狭窄或闭塞引发脑梗死的部位及特点。方法 选取2013年1月～2016年2月本院诊治的98例经头颅磁共振加权成像(DWI)和数字减影血管造影(DSA)确诊的ICA或MCA狭窄或闭塞引发脑梗死患者进行回顾性研究,根据患者起病1周内的DWI确诊梗死部位,对比ICA和MCA狭窄或闭塞引发脑梗死的部位和特点。结果 ICA组患者的完全性前循环脑梗死率(36.00%)显著高于MCA组的12.50%(P<0.05); ICA组的腔隙性脑梗死发生率(26.00%)显著低于MCA组的52.08%(P<0.05); ICA组和MCA组患者的PI、PAI、LTI供血区脑梗死发生率无明显差异(P>0.05); MCA组患者的BZI供血区脑梗死发生率(62.50%)显著高于ICA组的26.00%(P<0.05); ICA组患者的单发性脑梗死发生率(70.00%)显著高于MCA组患者的(47.92%)(P<0.05)。结论 ICA狭窄以单发性脑梗死多见,MCA以多发性脑梗死多见,MCA狭窄或闭塞患者的分水岭梗死发生率高于ICA狭窄或闭塞患者。     

颈内和大脑中动脉重度狭窄或闭塞的分水岭梗死类型与机制的研究

目的研究单侧动脉粥样硬化性大脑中动脉(MCA)及颈内动脉(ICA)重度狭窄或闭塞所致急性缺血性脑卒中患者分水岭梗死(WI)类型及发病机制。方法起病48h内DWI诊断的急性分水岭梗死伴有动脉粥样硬化性MCA/ICA重度狭窄与闭塞的患者102例,其中MCA组38例,ICA组64例,有潜在心源性栓子患者除外。急性期DWI上分水岭梗死病灶分为:(1)单纯分水岭梗死病灶;(2)含分水岭梗死的多发梗死病灶。结果 ICA组单纯分水岭梗死病灶较多,其中前+内分水岭梗死的例数最多,与MCA组比较具差异有统计学意义(P<0.05);ICA组复合梗死病灶中,出现最多的梗死类型为穿支动脉伴分水岭梗死,与MCA组比较差异具有统计学意义。MCA组以穿支动脉伴皮层支梗死伴分水岭梗死最多,且与ICA组比较,差异具有统计学意义(P<0.05)。结论颈内和大脑中动脉重度狭窄与闭塞所致分水岭梗死的类型有明显的不同,提示有着不同的发病机制。     

不同时间窗rt-PA静脉溶栓治疗椎-基底动脉系统脑梗死的疗效观察

目的探讨不同时间窗rt-PA静脉溶栓治疗椎-基底动脉系统脑梗死的临床疗效。方法选取2016年8月~2017年8月我院收治的70例椎-基底动脉系统脑梗死患者为研究对象,所有患者均经多模式MRI证实且行rt-PA静脉溶栓治疗,根据患者溶栓治疗时间窗不同,将其分为4.5 h组(35例)和4.5~9 h组(35例),比较两组神经功能缺损量表(national institutes of health stroke scale,NIHSS)评分、Barthel指数(Barthel index,BI)评分及改良Rankin量表(modified Rankin scale,mRS)评分,观察两组脑出血发生情况。结果与治疗前比较,4.5 h组和4.5~9 h组患者溶栓后24 h、14 d、30 d及90 d的NIHSS评分显著降低(P0.05),BI评分显著升高(P0.05),而两组患者在rt-PA静脉溶栓治疗后的NIHSS评分及BI评分比较,差异无统计学意义(P0.05);两组rtPA静脉溶栓后90 d的mRS评分及预后良好率比较均无明显差异(P0.05)。3 m随访期内,4.5 h组脑出血发生率为5.71%,4.5~9 h组脑出血发生率为8.57%,两组比较差异无统计学意义(P0.05)。结论 I扩大时间窗至9 h对椎-基底动脉系统脑梗死行rt-PA静脉溶栓治疗安全有效,因此,对于治疗时间窗为4.5 h~9 h的椎-基底动脉系统脑梗死也可行rt-PA静脉溶栓治疗。     

How do you provide treatment if different people need different things at different times?

This chapter emphasizes the need to focus on the individual's process of reintegration. It identifies three key questions that need to be asked of the patient and answered.     

Female command presence: different problems, different powers

Psychoanalytic theory with an understanding of group dynamics provides a means for appreciating and successfully addressing gender-related bias as encountered by a female commander in the military. Vignettes provide specific examples from which conclusions are drawn.     

Submaximal stimuli activate different nerve fiber populations at different sites

Theoretically, the largest and fastest nerve fibers are preferentially stimulated with submaximal stimuli. However, it is also well known that intraneural fascicular topography changes substantially along a proximal to distal axis. Because of this change in fascicular topography, we hypothesized that percutaneous submaximal stimuli applied to a nerve at different locations would stimulate different subpopulations of large fibers. We performed a series of collision studies by stimulating the ulnar nerve submaximally at proximal and distal sites at varying levels of stimulation intensity from motor threshold to supramaximal stimulation. The results suggest that variation in intraneural topography at different sites allows different large diameter nerve fiber subpopulations to be activated at submaximal stimuli, and emphasizes the importance of supramaximal stimulation to determine a valid conduction velocity. © 1994 John Wiley & Sons, Inc.     

Neglect rehabilitation by prism adaptation: different procedures have different impacts

Several studies point to prism adaptation as an effective tool for the rehabilitation of hemispatial neglect. However, some recent reports failed to show a significant amelioration of neglect after prism adaptation as compared to control treatments. This apparent contradiction might reflect important differences in the procedures used for treatment. Here we compare the effects of two treatments (performed for 10 sessions, over 2 weeks) in two groups of patients, based either on a Terminal (TPA) or a Concurrent (CPA) prism adaptation procedure. During TPA only the final part of the pointing movement is visible and prism adaptation relies most strongly on a strategic recalibration of visuomotor eye-hand coordinates. In contrast, during CPA the second half of the pointing movement is visible, and thus adaptation mainly consists of a realignment of proprioceptive coordinates.The present results show that both TPA and CPA treatments induced a greater improvement of neglect as compared to a control treatment of pointing without prisms. However, neglect amelioration was higher for patients treated with TPA than for those treated with CPA. At the same time, the TPA treatment induced a stronger deviation of eye movements toward the left, neglected, field as compared to the CPA treatment. Interestingly, in TPA patients the visuomotor and oculomotor effects of the treatment were directly related to the patients’ ability to compensate for the optical deviation induced by prism during pointing (i.e., Error reduction effect).In summary, prism adaptation seems particularly effective for the recovery of visuo-spatial neglect when conducted with a procedure stressing a correction of visuomotor eye-hand coordinates, i.e., with a TPA procedure. The present observations may help to better understand the mechanisms underlying prism-induced recovery from neglect and the procedural basis for some of the contradictory results obtained when using this rehabilitative strategy.     

The different kinds of group psychotherapy with patients with different diagnoses

Group psychotherapy is a treatment method in which in addition to the therapist(s) the participating individuals are, autocentrically, active in attaining a therapeutic effect. The different kinds of group psychotherapy are described: 1) activity group psychotherapy, 2) analytic group psychotherapy, 3) directive-suggestive-group psychotherapy, 4) psychodrama, 5) accelerating/focal methods of group psychotherapy. Group psychotherapeutic techniques with patients of different diagnoses are discussed, e.g. group psychotherapy with drug dependants and alcoholics, in which it is not possible to use a pure analytic method of group psychotherapy. Their oral tendencies and narcissistic desires of undergoing a fusion with the therapist have to a certain degree to be fulfilled. Schizophrenics should encounter in group psychotherapy an unconditioned emotional response from the therapist. These patients on the one hand expect to be understood in their psychotic experience, but on the other hand they seem to be glad when the measures of the outside reality are maintained in the group. The relatives of schizophrenics wanting to co-operate are taken in a parallel group. Depressives, especially endogenous depressives, need a longer time to be integrated in a therapeutic group than other patients, but if they can be integrated, it helps them to tolerate their sufferings. To the neurotics, group psychotherapy offers insight and a chance to “translate” this insight into a new social behaviour. Analytic self-experience groups with staff members give them an opportunity to recognise from their own experience the conflicts and the behaviour patterns from which their patients suffer.