Evaluation of modified hemodilution combined therapy in the treatment of acute ischemic stroke in the elderly

BACKGROUND: Thrombolysis therapy is not suitable for the elderly patients with acute ischemic stroke who delayed to be diagnosed for more than 3 hours, but traditional medicine is also not very ideal.OBJECTIVE: To observe the clinical therapeutic effect of modified hemodilution combined therapy applied in elderly patients with acute cerebral thrombosis and analyze the mechanism of this therapeutic method.DESIGN: 1:1 paired grouping according to gender and controlled observation.SETTING: Department of Internal Medicine, Chengzhanyuan District, First Hospital Affiliated to Zhejiang University.PARTICIPANTS Totally 90 elderly patients with acute ischemic stroke who received the treatment in the Cadre Ward and Mental Ward, Department of Internal Medicine, Chengzhanyuan District, First Hospital Affiliated to Zhejiang University from March 1996 to June 2004 were recruited. They all met the diagnosis criteria revised by the Fourth Academic Conference of National Cerebrovascular Diseases in 1995 and were diagnosed as acute ischemic stroke by skull CT. They were informed of therapeutic plan and detected items.According to 1:1 paired principle in gender, 90 enrolled patients were assigned into treated group (n=45)and control group (n=45). There were 39 male and 6 female in the treatment group, and they were aged (76±6)years, ranging from 71 to 84 years, and hospitalized at the 14th to 76th hours after onset. There were 39 male and 6 female in the control group, and they were aged (76±6)years , ranging from 70 to 82years, and hospitalized at the 16th to 72th hours after onset.METHODS: Therapeutic method: Patients of treated group received modified hemodilution combined therapy.200 mL whole blood of patients was exchanged with 500 mL dextran-40 (including 20 mL danshen parenteral solution and 32 mg heparin) at the beginning of therapy; From the 2nd day, compound huangqi tea bag (Huangqi mainly, including danshen, honghua, chuanxiong, shishao and a little acetyl salicylic acid) was made, twice a day, 1 bag once. At the same time, the above-mentioned dextran-40 liquid of 500 mL was intravenously injected, once a day, 14 days in total; On the 6th day after therapy, the above-mentioned aseptic autoblood stored in refrigerator at 4 ℃ was transfused back into the patients following pre-treatment of high-concentration oxygenation and ultraviolet irradiation by light quantum instrument. Patients of control group were intravenously injected of 0.4 g venoruton(Traditional Chinese medicine compound parenteral solution for promoting blood circulation and removing blood stasis ) and 50 g/L glucose of 500 mL, 75 mg coagulation index, change of platelet aggregation rate and change of hemorrheology of patients in two groups were monitored before and after therapy. The level of blood lipid of patients in two groups was measured with American Beckman automatic biochemistry analyzer. Blood flow rate of middle cerebral artery of resting electrocardiogram were measured with American HP SONOS 2500 sonoscope. Neuro-dysfunction score revised in the national conference (1995) was used to evaluate the recovery of neurological function effect were observed at the same time.effect of drug.RESULTS: Totally 90 patients were enrolled in the experiment. One patient from treated group died of hyperosmolar nonketotic diabetic coma of complicated diabetes mellitus. One patient from control group died ulation index and platelet aggregation rate: prothrombin time (PT), activated partial thromboplastin time (APTT) and thrombin time (TT) of patients after therapy were significantly longer than those before therapy in the treated group and those after therapy in control group [After therapy in treated group: (18.4±1.9),(41.8±2.1), (19.7±1.7)s, Before therapy in treated group: (13.4±1.3), (35.8±1.3), (12.5±0.9)s, After therapy in control group: (16.9±1.5), (39.1±1.1), (11.9±2.1) s, P ＜ 0.05] ;Concentration of fibrinogen (Fbg) after therapy was significantly lower than that before therapy in the treated group and that after therapy in control group[After therapy in treated group: (3.4±0.4) g/L; Before therapy in treated group: (4.3±0.7) g/L;After therapy in control group:(4.0±0.6) g/L; P ＜ 0.05]. Platelet aggregation rate decreased from (37.92of total cholesterol (TC), triacylglycerol(TG) and Iow density lipoprotein cholesterol (LDL-C) of patients after therapy were significantly lower than those before therapy in treated group and those after therapy in control group [After therapy in treated group: (5.2±0.9), (1.9±0.9), (2.08±1.1) mmol/L, before therapy in treated group:(5.9±1.2), (2.8±0.9), (3.94±0.5) mmol/L, After therapy in control group: (6.0±1.1), (2.6±0.8), (3.84±0.9) mmol/L,after therapy than before therapy [Before therapy: (43.84±4.55)% ;After therapy: (40.48±4.02)% ;P ＜ 0.05].cantly lower than of control group 14 days after therapy. The total effective rate after therapy was signifiadverse effect.CONCLUSION: Modified hemodilution combined therapy can improve hemorheology, decrease hematocrit,increase blood flow rate of middle cerebral artery, so as to improve the impaired clinical neurological function of elderly patients with acute cerebral thrombosis through anticoagulation and antiplatelet aggregative activity as well as regulating blood lipid.BACKGROUND: Thrombolysis therapy is not suitable for the elderly patients with acute ischemic stroke who delayed to be diagnosed for more than 3 hours, but traditional medicine is also not very ideal.OBJECTIVE: To observe the clinical therapeutic effect of modified hemodilution combined therapy applied in elderly patients with acute cerebral thrombosis and analyze the mechanism of this therapeutic method.DESIGN: 1:1 paired grouping according to gender and controlled observation.SETTING: Department of Internal Medicine, Chengzhanyuan District, First Hospital Affiliated to Zhejiang University.PARTICIPANTS:Totally 90 elderly patients with acute ischemic stroke who received the treatment in the Cadre Ward and Mental Ward, Department of Internal Medicine, Chengzhanyuan District, First Hospital Affiliated to Zhejiang University from March 1996 to June 2004 were recruited. They all met the diagnosis criteria revised by the Fourth Academic Conference of National Cerebrovascular Diseases in 1995 and were diagnosed as acute ischemic stroke by skull CT. They were informed of therapeutic plan and detected items.According to 1:1 paired principle in gender, 90 enrolled patients were assigned into treated group (n=45)and control group (n=45). There were 39 male and 6 female in the treatment group, and they were aged (76±6)years, ranging from 71 to 84 years, and hospitalized at the 14th to 76th hours after onset. There were 39 male and 6 female in the control group, and they were aged (76±6)years , ranging from 70 to 82years, and hospitalized at the 16th to 72th hours after onset.METHODS: Therapeutic method: Patients of treated group received modified hemodilution combined therapy.200 mL whole blood of patients was exchanged with 500 mL dextran-40 (including 20 mL danshen parenteral solution and 32 mg heparin) at the beginning of therapy; From the 2nd day, compound huangqi tea bag (Huangqi mainly, including danshen, honghua, chuanxiong, shishao and a little acetyl salicylic acid) was made, twice a day, 1 bag once. At the same time, the above-mentioned dextran-40 liquid of 500 mL was intravenously injected, once a day, 14 days in total; On the 6th day after therapy, the above-mentioned aseptic autoblood stored in refrigerator at 4 ℃ was transfused back into the patients following pre-treatment of high-concentration oxygenation and ultraviolet irradiation by light quantum instrument. Patients of control group were intravenously injected of 0.4 g venoruton(Traditional Chinese medicine compound parenteral solution for promoting blood circulation and removing blood stasis ) and 50 g/L glucose of 500 mL, 75 mg acetosal was taken orally, once a day, 14 days in total. ② Measurement and observation of index: Blood coagulation index, change of platelet aggregation rate and change of hemorrheology of patients in two groups were monitored before and after therapy. The level of blood lipid of patients in two groups was measured with American Beckman automatic biochemistry analyzer. Blood flow rate of middle cerebral artery of resting electrocardiogram were measured with American HP SONOS 2500 sonoscope. Neuro-dysfunction score revised in the national conference (1995) was used to evaluate the recovery of neurological function of the patients in two groups at the 3rd, 5th, 7th and 14th days after therapy. ③Therapeutic effect and adverse effect were observed at the same time.MAIN OUTCOME MEASURES: ① Changes of coagulation index, blood lipid level and hemorheology; ② Blood flow rate of middle cerebral artery and NDS of patients with acute ischemic stroke in two groups; ③Adverse effect of drug.RESULTS: Totally 90 patients were enrolled in the experiment. One patient from treated group died of hyperosmolar nonketotic diabetic coma of complicated diabetes mellitus. One patient from control group died of severe pulmonary infection. The rest 88 patients entered the stage of result analysis. ① Change of coagulation index and platelet aggregation rate: prothrombin time (PT), activated partial thromboplastin time (APTT) and thrombin time (TT) of patients after therapy were significantly longer than those before therapy in the treated group and those after therapy in control group [After therapy in treated group: (18.4±1.9),(41.8±2.1), (19.7±1.7)s, Before therapy in treated group: (13.4±1.3), (35.8±1.3), (12.5±0.9)s, After therapy in control group: (16.9±1.5), (39.1±1.1), (11.9±2.1) s, P ＜ 0.05] ;Concentration of fibrinogen (Fbg) after therapy was significantly lower than that before therapy in the treated group and that after therapy in control group[After therapy in treated group: (3.4±0.4) g/L; Before therapy in treated group: (4.3±0.7) g/L;After therapy in control group:(4.0±0.6) g/L; P ＜ 0.05]. Platelet aggregation rate decreased from (37.92±0.85)% before therapy to (26.42±1.01)% after therapy (P ＜ 0.01). ②Change of blood lipid level: Levels of total cholesterol (TC), triacylglycerol(TG) and Iow density lipoprotein cholesterol (LDL-C) of patients after therapy were significantly lower than those before therapy in treated group and those after therapy in control group [After therapy in treated group: (5.2±0.9), (1.9±0.9), (2.08±1.1) mmol/L, before therapy in treated group:(5.9±1.2), (2.8±0.9), (3.94±0.5) mmol/L, After therapy in control group: (6.0±1.1), (2.6±0.8), (3.84±0.9) mmol/L,P ＜ 0.05]. ③ Change of hemorheology index: Hematocrit of patients of treated group was significantly lower after therapy than before therapy [Before therapy: (43.84±4.55)% ;After therapy: (40.48±4.02)% ;P ＜ 0.05].④ Blood flow rate of middle cerebral artery of patients of treated group was significantly lower before therapy than after therapy [(90±1.2), (97±2.1) cm/s,P ＜ 0.01]. ⑤ NDS of patients in treated group was significantly lower than of control group 14 days after therapy. The total effective rate after therapy was significantly higher in the treated group than in the control group (93%,78%, P ＜ 0.05). ⑥There was no obvious adverse effect.CONCLUSION: Modified hemodilution combined therapy can improve hemorheology, decrease hematocrit,increase blood flow rate of middle cerebral artery, so as to improve the impaired clinical neurological function of elderly patients with acute cerebral thrombosis through anticoagulation and antiplatelet aggregative activity as well as regulating blood lipid.     

Evaluation of long-term outcome and safety after hemodilution therapy in acute ischemic stroke.

BACKGROUND AND PURPOSE: In a previous single-center, randomized controlled trial including 102 patients treated in a stroke unit, we showed that rapid, modest hemodilution improved short-term clinical outcome in ischemic stroke patients. I now evaluate the long-term outcome and potential risks of this combined venesection/dextran 40 therapy in the same 52 treated and 50 control patients. METHODS: Mortality, need for institutional care, and recurrent strokes were registered during 1 year following inclusion in the trial, and a final evaluation of functional outcome was performed at 12 months after the stroke. Cerebrospinal fluid was analyzed for protein content and hemorrhagic admixture at two occasions during the acute phase. RESULTS: Thirty-six hemodiluted and 30 control patients survived the first year following the stroke (difference not significant). One year after the stroke, persistent neurological deficits were less frequent among the hemodiluted patients and a larger proportion of hemodiluted survivors was independent in walking (92% versus 73%, p less than 0.05). Two hemodiluted patients (6%) and nine control patients (30%) were totally dependent in the activities of daily living (p less than 0.05). Three hemodiluted patients (8%) and eight control patients (27%) remained hospitalized 1 year after the stroke (p less than 0.05). With the possible exception of patients with a medical history of congestive heart failure, subset analyses revealed a tendency toward improved outcome for hemodiluted patients in all clinically important subgroups compared with the controls. When analyzing cerebrospinal fluid, signs of blood-brain barrier breakdown and hemorrhagic admixture to the cerebrospinal fluid during the acute phase were less frequent in the hemodiluted subjects. CONCLUSIONS: These results suggest that, when applied in a stroke unit, the combination of venesection and dextran 40 administration is a clinically safe, therapeutic regimen in the treatment of acute cerebral infarction that improves long-term clinical outcome.     

A randomized controlled trial of hemodilution therapy in acute ischemic stroke

Rapid hemodilution in the early phase of ischemic stroke by the combination of venesection (250-650 ml during the first 2 days) and administration of low-molecular weight dextran was evaluated in a prospective controlled trial. Fifty-two patients were randomized to hemodilution therapy and 50 to a control group; the two groups were comparable in important prognostic variables. Mean hemoglobin was reduced from 147 to 127 g/l, hematocrit from 43 to 37% and, in a subsample of patients, whole-blood viscosity at a shear rate of 23 sec-1 from 7.0 to 4.3 cps over the first 2 days. Hemodilution was then maintained by repeated dextran infusions. Of the hemodiluted patients, 85% improved in neurological scoring over the first 10 days as compared to 64% of the control patients (p less than 0.025). The case fatality rate during the first 3 months was little affected by hemodilution. Among the survivors, 8% of the hemodiluted and 31% of the non-hemodiluted patients were unable to walk at 3 months. The proportion of surviving patients still hospitalized at the 3-month follow-up was 13% in the hemodilution group and 39% in the control group (p less than 0.01). The combination of venesection and dextran 40 administration is thus an unsophisticated but effective way to achieve rapid hemodilution in patients with acute cerebral infarction, and it improves the overall clinical outcome over the first 3 months.     

Adjusted hypervolemic hemodilution in acute ischemic stroke.

We prospectively randomized 47 patients with acute ischemic stroke of the middle cerebral artery of less than 24 hours' duration to either adjusted hypervolemic hemodilution or control treatment and followed them up for 90 days. Rapid hemodilution to a target hematocrit of 30-35% as monitored with bedside determinations was achieved by using infusions of dextran 40, venesections, and infusions of additional crystalloid solution when necessary. There was no difference in the death rate between the two treatment groups. Of these 47 patients, 37 (19 in the hemodilution group and 18 in the control group) could be followed up for the entire study period of 3 months. The relative improvement in neurologic function from day 1 to days 8, 21, and 90 was significantly better in the hemodilution group than in the control group. In accordance, special tests for fine motor control of the paretic arm disclosed better performance in the hemodilution group. The frequency of patients with severe disability was significantly lower in the hemodilution group on days 8 and 21. Plasma viscosity (measured in 11 patients) was not affected by infusions of dextran 40. Vigorous hypervolemic hemodilution in patients with acute ischemic stroke is well tolerated and improves early neurologic outcome with an effect lasting at least 3 months.     

Randomized clinical trials of hemodilution in acute ischemic stroke

Abstract– The effects of hemodilution in acute ischemic stroke have been investigated, first in a single-center, then in a multicenter trial. Patients with hematocrit levels of 38–50% were randomized, within 48 h of onset of symptoms, to treatment with repeated venesections (total 250–1000 ml) and concomitant dextran 40 administation, or to a control group. The single-center study, performed in a research-oriented stroke unit, involved 102 patients. Case fatality rate was not grossly affected by hemodilution. In survivors, hemodilution improved neurological outcome. More hemodiluted patients were independent in walking and more were at home 3 months after the stroke. The ensuing multicenter trial involved 383 patients in 15 Scandinavian centers. Three-month case fatality rate was 16% in hemodiluted and 12% in control patients. Neurological scoring and ADL performance at 3 months was not improved by hemodilution. No subgroup with beneficial effects was discerned. It is concluded that the present standardized hemodilution regime cannot be recommended for general use in patients with ischemic stroke.     

Neuroprotective therapy for the treatment of acute ischemic stroke]

Following cerebral ischemia, various biochemical reactions are provoked in a stepwise manner leading neuronal cells to ischemic death. The prevention of these biochemical reactions may exert neuroprotective actions and consequently reduce the magnitude of ischemic cerebral injury. On the basis of such a view, numerous neuroprotective drugs have been developed during the last decade. Quite a few drugs were found effective in reducing the infarct volume in experimental studies, and more than 15 of them were subjected to clinical phase III trials to see a therapeutic effectiveness. However, the results of phase III trials were disappointing in the majority drugs. Only three drugs, nicaravene, ebselen and edaravone, all radical scavengers, were judged effective by small-sized trials with a wide therapeutic window, 48-72 hours after stroke, in Japan. The fact suggests that a one-point prevention of biochemical reactions by single drug is unable to rescue ischemic neuronal cells. Ischemic insult causes damages of vascular wall including the endothelium which play an important role in the development of hemorrhagic changes or cerebral edema. Vascular protection is considered as important as neuroprotection in treatment of clinical stroke. Mild hypothermia has neuroprotective and vascular protective actions and hence may be more effective than neuroprotective drugs for the treatment of stroke. The prevention of fever, which often occurs in severe stroke, may exert the similar effect as hypothermia in neuroprotection. Neuroprotective therapy in the future should proceed toward the simultaneous protections of neurons and vessels using combination of multiple drugs.     

Custom-tailored hemodilution with albumin and crystalloids in acute ischemic stroke.

BACKGROUND AND PURPOSE: Hemodilution in the acute phase of ischemic stroke is still controversial. Multicenter studies have failed to demonstrate any benefit. The present study focuses attention on analysis of circulation in stroke and on individual restabilization of circulation. METHODS: The Amsterdam Stroke Study is a prospective, single-center, randomized clinical trial (n = 300). Normovolemic hemodilution is accomplished in a customized procedure by administration of 20% albumin plus crystalloids under hemodynamic and rheological monitoring in the acute phase of stroke. All patients receive general intensive care treatment and monitoring with a pulmonary artery catheter. This custom-tailored fluid therapy is guided on the basis of a target pulmonary capillary wedge pressure (12 +/- 3 mm Hg) and hematocrit (0.32 +/- 0.02). The control group receives only customized rehydration by infusion of crystalloids. RESULTS: We obtained significant (p less than 0.05) reduction in mortality at 3 months (from 27% to 16%) and an increase in independence at home (from 35% to 48%) after viscosity reduction by means of hemodilution with albumin in the subgroup with a hematocrit less than 0.45 (n = 201) (specific viscosity effect). We also obtained a significant (p less than 0.005) reduction in mortality at 3 months (from 27% to 8%) and an increase in independence (from 35% to 59%) after only rehydration with crystalloids in the subgroup with overt dehydration (hematocrit greater than or equal to 0.45; n = 51) as compared with the normal-hematocrit group without signs of dehydration (hematocrit less than 0.45; n = 103) (specific rehydration effect). CONCLUSIONS: This study may provide an explanation for the failures in former hemodilution trials and may re-establish proper hemodilution and rehydration as a valuable therapy in the acute phase of stroke, thus reducing mortality and improving independence after 3 months.     

Thrombolytic therapy for acute ischemic stroke

The treatment of acute stroke changed dramatically since the publication of the NINDS trail for IV rt-PA for acute stroke. While this was not the first trial, it was the first positive trial. Subsequently there has been an explosion in acute treatment modalities since the NINDS trial showed that acute stroke treatment is feasible. The following chapter reviews the thrombolysis trials, the inclusion and exclusion criteria of intravenous and intra-arterial use of pharmacologic and mechanical thrombolysis in acute ischemic stroke. Also discussed are the new pharmacotherapies and mechanical devices that will hopefully expand the treatment window and make thrombolysis safer and more effective.     

Antithrombotic therapy in acute ischemic stroke]

The purpose of antithrombotic therapy is not to recanalyze obstruction but to prevent propagation of thrombus and reocclusion by rethrombosis in the brain arteries. There is no evidence of heparin or heparinoid to improve long-term outcome, although anticoagulant therapy might be indicated for stroke associated with coagulation activation such as progressing stroke, basilar artery thrombosis, cardioembolic stroke at high risk, coagulopathy, and arterial dissection. In patients with nonvalvular atrial fibrillation, there is no evidence of immediate anticoagulation with heparin to improve long-term outcome, which is rather contraindicated for large hemispheric stroke, and it is recommended to start warfarin directly in the safety issue. Aspirin is recommended in the guidelines of many countries, although the efficacy is modest. A clinical trial of the GP IIb/IIIa inhibitor abciximab, which is a more potent antiplatelet agent than aspirin, had recently been conducted, although it was stopped because of the concern on the safety. Clinical trials of dual antiplatelet therapy with aspirin and another antiplatelet agent are ongoing to compare efficacy and safety with aspirin monotherapy in Japan and overseas.     

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.     

氯吡格雷联合奥扎格雷钠治疗急性缺血性卒中疗效评价

研究背景抗血小板治疗已经成为缺血性卒中的常规治疗方法,目前对其作用的肯定主要源于临床应用,迄今尚无一项能够准确评价其有效性的实验室指标。有研究证实,血小板活化程度与动脉粥样硬化和缺血性卒中相关,尤其是血小板α颗粒膜糖蛋白CD62p和溶酶体膜糖蛋白CD63均为血小板活化的重要指标。本研究旨在通过观察急性缺血性卒中患者血小板膜表面CD62p和CD63表达变化,探讨以血小板活化程度反映氯吡格雷(75 mg)、奥扎格雷钠(80 mg)与阿司匹林(0.15 g)的疗效差异。方法采用流式细胞术检测急性缺血性卒中患者氯吡格雷(75 mg)联合奥扎格雷钠(80 mg,联合治疗组)及阿司匹林单药(阿司匹林组)治疗前后血小板CD62p和CD63阳性表达率,美国国立卫生研究院卒中量表(NIHSS)评价神经功能改善程度。结果与正常对照组相比,治疗前急性缺血性卒中组患者血小板CD62p和CD63阳性表达率升高(P=0.001,0.032);治疗后CD62p和CD63阳性表达率、NIHSS评分逐步下降(均P=0.000)。与治疗前相比,治疗后联合治疗组和阿司匹林组患者血小板CD62p和CD63阳性表达率、NIHSS评分逐步下降(均P=0.000),但组间差异无统计学意义(均P>0.05)。CD62p和CD63阳性表达率在不同观察时间点与治疗分组之间不存在交互作用(F=1.403,P=0.250;F=2.830,P=0.063),但NIHSS评分在不同观察时间点与治疗分组之间存在交互作用(F=4.518,P=0.013)。结论抗血小板药物治疗急性缺血性卒中有效,但氯吡格雷与奥扎格雷钠联合治疗之疗效与阿司匹林单药治疗并无差异。缺血性卒中急性期测定血小板CD62p阳性表达率可以用于评价抗血小板药物的疗效,但CD63表达的临床价值尚待进一步研究。     

Evaluation of the role of susceptibility-weighted imaging in thrombolytic therapy for acute ischemic stroke

We inspected low-intensity venous signals and microbleeds in patients with acute ischemic stroke (AIS) using susceptibility-weighted imaging (SWI) before and after administration of within-thrombolytic-time-window thrombolytic therapies, and observed their prognosis and safety, in order to guide individualized thrombolytic therapies. Patients with AIS were divided into groups A or B according to the presence of symmetric or asymmetric veins on SWI, and were re-inspected by SWI after intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA). The National Institutes of Health stroke scale (NIHSS) score before treatment and at 1-h and 24-h posttreatment in the two groups were 11.9, 7.3, and 7.1 in group A, 12.4, 8.2, and 7.9 in group B, significant difference was detected between the two groups after treatment. The 90-day mortality rate was 0, and the incidences of cerebral microbleeds (CMBs) and symptomatic cerebral hemorrhage (SCH) were 17.6%, and 0% in group A, 25.6% and 0% in group B, respectively. The incidences of CMBs and SCH in group A were lower than those in group B, but the intergroup differences were not statistically significant (P > 0.05). The 90-day neurological improvement rates in the two groups were 70.2% and 58.1%, respectively, and group A showed a significantly better prognosis than group B (P < 0.05). Thus, low-intensity venous signals in SWI can be used to evaluate a low level of perfusion, post-thrombolytic prognosis, and bleeding indexes, and can therefore be used to guide individualized thrombolytic therapies.     

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.     

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.