急性脑梗死出血转化的临床及康复预后分析

目的:探讨临床氯吡格雷联合拜阿司匹林治疗(双抗治疗)脑梗死并发出血转化(HT)患者的风险是否增高,以及尽早康复治疗对其预后的影响。方法:收集急性脑梗死患者654例,描述性分析HT发生率,观察双抗治疗是否增加HT发生的风险;在所有发生HT的55例患者中选取病情程度及年龄相当的对照组和观察组各15例,观察组患者经康复治疗,比较2组入院前及治疗14d后美国国立卫生研究院卒中量表(NIHSS)、改良的Rankin量表(mRS)评分。结果:在654例患者中,并发HT的患者共55例(8.41%),双抗的使用并不显著增加HT发生风险。康复治疗后,2组NIHSS评分均较治疗前明显降低(P<0.05),2组间比较差异无统计学意义。mRS评分比较,观察组较治疗前及对照组治疗后显著降低(P<0.05),而对照组较治疗前差异无统计学意义。结论:急性脑梗死中HT为急性脑梗死常见并可能影响预后的并发症之一,康复治疗对神经功能的恢复有一定积极意义。     

氯吡格雷联合阿司匹林治疗进展性缺血性脑卒中的临床疗效和安全性

目的探讨短期氯吡格雷联合阿司匹林在治疗进展性缺血性脑卒中的临床疗效和安全性。方法回顾性分析本院近3年来收治的90例进展性缺血性脑卒中患者的临床资料,根据治疗方法不同分为治疗组和对照组,各45例,其中治疗组患者采用氯吡格雷联合阿司匹林治疗,对照组患者仅给予阿司匹林治疗,观察30 d治疗变化,分别于治疗前及治疗后7、14、30d对患者进行美国国立卫生研究院卒中量表评分（NIHSS）、日常生活能力评分（ADL）,以及治疗14、30 d NIHSS和ADL绝对分值变化作为主要临床疗效判断标准,同时检测治疗前后血清高敏C反应蛋白（hs-CRP）,动态复查颅脑CT和（或）MRI,观察有无颅内出血及消化系统不良反应。结果治疗前患者的NIHSS、ADL分值及hs-CRP水平差异均无统计学意义（P〉0.05）。治疗后7、14、30d,治疗组NIHSS分值、血清hs-CRP水平下降和ADL分值升高明显,治疗7、14d差异有统计学意义（P〈0.05）,治疗30 d后ADL分值比较,差异有统计学意义（P〈0.01）;同时,2组均未出现明显药物不良反应,未发生致死性出血现象。结论短期氯吡格雷联合阿司匹林治疗进展性缺血性脑卒中安全有效,能显著改善临床症状,降低血清hs-CRP水平,临床疗效氯吡格雷联合阿司匹林组比单用阿司匹林组显著。     

Antiplatelet therapy for secondary prevention of acute coronary syndrome, transient ischemic attack, and noncardioembolic stroke in an era of cost containment

Physicians are aware of the profound impact of oral antiplatelet therapy for secondary prevention of acute coronary syndrome (ACS), transient ischemic attack, and noncardioembolic stroke. Numerous clinical studies have compared the benefits of aspirin (ASA) alone with those of combination therapy with extended-release dipyridamole or with those of clopidogrel, with or without ASA, for secondary stroke prevention; and of ASA monotherapy compared with ASA plus clopidogrel combination therapy for secondary prevention in various ACS populations. More recently, ASA plus prasugrel has been compared with ASA plus clopidogrel in a high-risk ACS population. However, given the different treatment modalities and methods used in the various trials, it is difficult to make generalizations as to which therapy is most effective with the lowest risk of bleeding. Further complicating physician's decision making are cost considerations, particularly with the newer oral antiplatelet agents, which are considerably more expensive than ASA. This review provides a brief overview of the clinical data on each of the currently marketed oral antiplatelet agents and the available data on cost-effectiveness for the secondary prevention of ACS, transient ischemic attack, and noncardioembolic stroke.     

IL-23 and IL-17 in acute ischemic stroke: Correlation with stroke scales and prognostic value

Background and PurposeInflammation plays a crucial role in brain damage following stroke. Here, we evaluate interleukin 23 (IL-23) and interleukin 17 (IL-17) in the inflammatory process and its relations with neurological findings of patients with acute ischemic stroke (AIS).Material and MethodsFifty consecutive patients with AIS admitted to our hospital within 24 h of stroke onset were enrolled in a prospective cohort study. Serum IL-23 and IL-17 were measured in the first, third and fifth day after the stroke. Neurological stroke severity were determined with the National Institutes of Health Stroke Scale (NIHSS) and with the modified Rankin Scale (mRS) within 24 h of the acute event, on the third and fifth day after the stroke, and at the time of hospital discharge.ResultsBoth neurological scores for stroke outcome at hospital discharge were related to IL-23 protein within 24 h and on the fifth day, but with low stroke outcome predictive values. The other measurements did not show predictive capacity for stroke outcome. There was a significant increase in median serum concentrations of IL-23 on the fifth day (p < 0.001) and in IL-17 median levels on the third day compared to the first 24 h after the acute injury (p < 0.001). However, there was no correlation between IL-23 and IL-17 levels with neurological outcomes at hospital discharge or after four years.ConclusionIL-23 and IL-17 increase after stroke, but had no sufficient discriminative capacity to be of clinical use as outcome stroke predictors.     

急性缺血性卒中血管内机械再通的研究现状与展望

急性缺血性卒中如今已成为我国人口死亡的常见原因,静脉溶栓对大血管闭塞尤其是颈内动脉闭塞的患者再通率低,治疗效果有限。血管内机械再通作为一种新的治疗手段,现已成为急性缺血性卒中的重要治疗方法和研究热点。本文就近年来国际上大型的多中心血管内机械再通试验进行综述。     

银杏内酯注射液用于急性缺血性脑卒中溶栓治疗中对炎性因子及Lp-PLA2、NSE、Hcy水平的影响

目的探讨银杏内酯注射液用于急性缺血性脑卒中溶栓治疗中对炎性因子及周围血脂蛋白磷脂酶A2(Lp-PLA2)、神经元特异性稀醇化酶(NSE)、同型半胱氨酸(Hcy)水平的影响。方法选取2017年3月至2020年3月收治的100例急性缺血性脑卒中患者为研究对象,随机将其分为对照组和观察组,各50例。对照组采用阿替普酶静脉溶栓治疗,观察组在对照组治疗基础上加以银杏内酯注射液治疗,比较两组的治疗结果。结果治疗后,观察组NIHSS评分低于对照组,MAS评分高于对照组(P<0.05);治疗后,观察组的IL-6、hs-CRP及TNF-α水平均低于对照组(P<0.05);治疗后,观察组的Lp-PLA2、NSE及Hcy水平均低于对照组(P<0.05)。结论急性缺血性脑卒中溶栓治疗中,联合应用银杏内酯注射液能够有效提高患者神经、运动功能改善效果,减轻炎性反应,也能降低Lp-PLA2、NSE及Hcy水平,值得推广。     

Efficacy and safety of human urinary kallidinogenase for acute ischemic stroke: a meta-analysis

ObjectiveHuman urinary kallidinogenase (HUK) is a glycoprotein extracted from human urine that is used to treat stroke by triggering positive regulation of the kallikrein–kinin system. Our aim was to evaluate the efficacy and safety of HUK treatment for acute ischemic stroke.MethodsWe searched the online databases PubMed, Embase, Cochrane Library, Google Scholar, and China National Knowledge Infrastructure (CNKI) for papers published between January 2015 and December 2019. The quality of each trial was assessed using the Cochrane Reviewers’ Handbook. Randomized controlled trials of HUK in patients with acute ischemic stroke were included.ResultsSixteen trials with 1326 participants were included. The HUK injection groups had more neurological improvement than the control groups in National Institutes of Health Stroke Scale scores (mean difference, –1.65; 95% confidence interval [CI], –2.12 to –1.71) and clinical efficacy (1.30; 95% CI, 1.21 to 1.41). Subgroup analysis indicated that age may influence heterogeneity. Eleven trials reported adverse effects and there were no significant differences between the control and HUK groups (risk difference, 0.01; 95% CI, –0.02 to 0.04).ConclusionsHUK ameliorates neurological symptoms in stroke patients with few adverse effects. Further high-quality, large-scale randomized trials are needed to confirm these results.     

丹参类中药注射剂治疗急性缺血性脑卒中有效性和安全性的网状Meta分析

目的系统评价丹参类中药注射剂治疗急性缺血性脑卒中的有效性和安全性。方法计算机检索PubMed、EMbase、The Cochrane Library、Web of Science、VIP、WanFang Data和CNKI数据库,搜集有关丹参类中药注射剂治疗急性缺血性脑卒中有效性和安全性的随机对照试验(RCT),检索时限均为建库至2021年2月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Stata 16.0软件和RevMan 5.3软件进行网状Meta分析。结果共纳入160个RCT,包括8种治疗措施(7种中药注射剂):丹红注射剂联合常规治疗(DH+CT)、丹参注射剂联合常规治疗(DS+CT)、丹参川芎嗪注射剂联合常规治疗(DSCXQ+CT)、注射用丹参多酚酸联合常规治疗(DSDFS+CT)、复方丹参注射剂联合常规治疗(FFDS+CT)、注射用丹参多酚酸盐联合常规治疗(SI+CT)、丹参酮ⅡA磺酸钠注射剂联合常规治疗(STS+CT)和常规治疗(CT)。网状Meta分析结果显示:(1)在总有效率方面,累积概率排序为:DSDFS+CT(93.0%)>DH+CT(80.5%)>STS+CT(66.7%)>DSCXQ+CT(66.4%)>SI+CT(50.0%)>DS+CT(26.7%)>FFDS+CT(16.7%)>CT(0.1%)。(2)在NIHSS评分方面,累积概率排序为:STS+CT(95.5%)>DH+CT(80.9%)>DSCXQ+CT(70.1%)>SI+CT(64.7%)>DSDFS+CT(42.0%)>FFDS+CT(24.4%)>DS+CT(20.1%)>CT(2.4%)。(3)在Barthel指数方面,累积概率排序为:DH+CT(76.2%)>DSCXQ+CT(74.3%)>STS+CT(64.1%)>DSDFS+CT(62.2%)>FFDS+CT(51.8%)>SI+CT(46.0%)>DS+CT(21.7%)>CT(3.8%)。结论当前证据显示,丹参多酚酸注射液+常规治疗的总有效率最高,丹参酮ⅡA磺酸钠注射液和丹红注射液分别在改善NIHSS评分和Barthel指数方面有优势。受纳入研究数量和质量的限制,上述结论尚待更多高质量研究予以验证。     

Longitudinal change of Th1, Th2, and Th17 cells and their relationship between cognitive impairment,stroke recurrence,and mortality among acute ischemic stroke patients

BackgroundT‐helper (Th) cells regulate immunity and inflammation, and modulate cognitive impairment in both cardio‐cerebrovascular and neurological diseases. This study aimed to explore the correlation of longitudinal change of Th1/2/17 cells with cognitive impairment and prognosis in acute ischemic stroke (AIS).MethodsTh1/2/17 cells were detected by flow cytometry in peripheral blood samples from 150 AIS patients at admission (baseline), Day (D)1, D3, and D7 after admission, and from 30 controls. Mini‐Mental State Examination (MMSE) score among AIS patients at discharge was assessed. Stroke recurrence and mortality were evaluated.ResultsTh1 (p = 0.013) and Th17 cells (p < 0.001) but not Th2 cells (p = 0.105) were elevated in AIS patients versus controls. Th1 cells (p = 0.027) and Th17 cells (p < 0.001) but not Th2 cells (p = 0.227) were positively correlated with NIHSS score in AIS patients. Furthermore, Th1 and Th17 cells elevated from baseline to D3 and then decreased on D7 after AIS onset, while Th2 cells illustrated an opposite trend (all p < 0.001). Th17 cells on D1 (p = 0.011), D3 (p = 0.014), and D7 (p < 0.001) were correlated with lower MMSE score, and their levels on D3 (p = 0.033) and D7 (p = 0.004) were related to elevated cognitive impairment. Th1 and Th2 cells were not related to cognitive function (all p > 0.05). Additionally, Th17 cells at baseline, D1, D3, and D7 (all p < 0.05) were increased in recurrent patients versus non‐recurrent patients, and in survived patients versus dead patients, but Th1 or Th2 cells did not vary (all p > 0.05).ConclusionTh17 cells correlate with increased cognitive impairment, stroke recurrence, and mortality among AIS patients.     

Clinical role of serum histone deacetylase 4 measurement in acute ischemic stroke: Relation to disease risk,severity, and prognosis

ObjectiveHistone deacetylase 4 (HDAC4) is engaged in the pathophysiology of acute ischemic stroke (AIS) through modulating atherosclerosis, inflammation and neurocyte death. This study aimed to investigate the clinical role of HDAC4 in AIS.MethodsSerum samples were collected from 176 AIS patients and 80 controls for HDAC4 detection by enzyme‐linked immunosorbent assay (ELISA). In AIS patients, disease severity was assessed by National Institute of Health Stroke Scale (NIHSS) score and their recurrence‐free survival (RFS) and overall survival (OS) were calculated, inflammatory cytokines and adhesion molecules were detected by ELISA.ResultsHDAC4 was declined in AIS patients vs. controls (p < 0.001), it also had certain ability of distinguishing AIS patients from controls with an area under curve of 0.748 (95% confidence interval: 0.689–0.806). Among AIS patients, HDAC4 was negatively linked with NIHSS score (p < 0.001) but no other clinical features (all p > 0.05). Moreover, HDAC4 was negatively related to interleukin (IL)‐17 (p = 0.010) and tumor necrosis factor alpha (p = 0.001), while it was not correlated with IL‐1β (p = 0.081) or IL‐6 (p = 0.074). Furthermore, HDAC4 was negatively associated with intercellular cell adhesion molecule‐1 (p < 0.001) and vascular cell adhesion molecule‐1 (p = 0.003). During a median follow‐up of 19.0 months, 17 (9.7%) patients had recurrence and 10 (5.7%) patients died. Additionally, high HDAC4 was linked with prolonged RFS (p = 0.044) but not OS (p = 0.079).ConclusionHDAC4 possesses the potential to monitor disease risk, inflammation and estimate recurrence of AIS, while further study with larger scale is needed to verify our findings.     

Survival and functional outcome following endovascular thrombectomy for anterior circulation acute ischemic stroke caused by large vessel occlusion in Sweden 2017–2019–a nationwide,prospective, observational study

BackgroundEndovascular thrombectomy (EVT) is standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), but data on nationwide performance in routine healthcare are sparse. The study aims were to describe EVT patients with LVO AIS, analyze mortality and functional outcome, and compare results with randomized controlled trials (RCTs).MethodsData from the Riksstroke and the Swedish Endovascular Treatment of Acute Stroke Registry (RSEVAS) on pre-stroke independent patients, with LVO AIS in 2017–2019, defined as occlusion of the intracranial internal carotid artery, or the M1 or M2 segments of the middle cerebral artery, and groin puncture <6 h of onset, were compared to aggregated HERMES collaboration RCT data. We assessed 90-day survival and function, defined by the modified Rankin Scale. Specific analyzes were stratified by occlusion location.ResultsIn all, 1011/2560 of RSEVAS patients matched RCT inclusion criteria. Compared with RCT data, patients were older (73 vs. 68), fewer received intravenous thrombolysis (63.1% vs. 83%), and M2 occlusions were more common (24.5% vs. 8%). 90-day survival in RSEVAS was 85.3%, 42.8% achieved good outcome and 5% had symptomatic intracerebral hemorrhage (sICH). Corresponding outcomes in RCT data were 84.7% survival, 46% good outcome, and 4.4% sICH. Functional outcome was most favorable following M2 occlusions.ConclusionsEVT patients from our large real-world national dataset differed from RCT patients in several baseline factors including distribution of vascular occlusion site. However, the overall outcome of EVT in our Swedish cohort appeared to well match the pivotal trial findings.     

解读AAN发布的《DWI和PWI在缺血性卒中的诊断价值-循证指南》

近期,美国神经病学学会（AAN）治疗与技术评定小组发布了《磁共振扩散加权成像（DWI）和灌注加权成像（PWI）在缺血性卒中的诊断价值一循证指南》（以下简称《指南》）,《指南》以循证医学证据为基础,对相关研究试验进行回顾分析,并得出具有指导意义的6条推荐意见。本文对《指南》的主要内容进行介绍,对其采用的相关循证医学依据进行解读。     

益气活血法治疗缺血性脑卒中恢复期患者的临床疗效及对hs-CRP、Fg、HCY水平的影响

目的探讨益气活血法治疗缺血性脑卒中恢复期患者的临床疗效及其对血清超敏C反应蛋白(hs-CRP),血浆纤维蛋白原(Fg)、血浆同型半胱氨酸(HCY)。方法选取缺血性脑卒中恢复期患者125例,随机分为观察组62例和对照组63例,对照组给予常规治疗,恢复期给予常规康复训练。观察组在对照组的基础上加用益气活血通络方。均以4周为1个疗程。观察2组治疗前后神经功能缺损程度评分、Barthel指数评分、中医血瘀证症状积分,及临床疗效和hs-CRP、Fg、HCY水平。结果2组患者治疗后神经功能缺损程度评分、血瘀证的症状积分均较治疗前显著降低(P0.05或P0.01),Barthel指数评分均较治疗前显著提高(P0.01)。治疗后,观察组神经功能缺损程度评分、血瘀证的症状积分均低于对照组,差异有统计学意义(P0.05或P0.01)。观察组临床总有效率为87.10%,高于对照组的66.67%,差异有统计学意义(P0.01)。在血瘀证症状疗效方面,观察组总有效率为72.58%,高于对照组的42.86%,差异有统计学意义(P0.01)。2组患者治疗后hs-CRP、Fg、HCY水平均较治疗前下降,差异有统计学意义(P0.05或P0.01),观察组治疗后hs-CRP、Fg、HCY水平低于对照组,差异有统计学意义(P0.05或P0.01)。结论益气活血法用于治疗缺血性脑卒中恢复期患者能提高临床疗效,改善神经功能。     

伴心房颤动的急性脑梗死患者静脉溶栓的疗效

目的 观察伴心房颤动的急性脑梗死患者使用重组组织型纤溶酶原激活物(rt-PA)静脉溶栓的疗效.方法 连续收集发病时间＜4.5h的94例应用rt-PA静脉溶栓治疗的急性脑梗死患者,将64例无心房颤动患者作为非心房颤动组,30例伴心房颤动患者作为心房颤动组,并收集同一时段30例未行溶栓治疗的伴有心房颤动的急性脑梗死患者作为对照组,比较3组患者治疗前及治疗后7d的美国国立卫生研究院卒中量表(NIHSS)评分,观察颅内出血(ICH)和症状性颅内出血(SICH)的发生率,采用改良Rankin量表(mRS)对3组患者3个月预后进行分析.结果 心房颤动组和非心房颤动组溶栓后7d的NIHSS评分较溶栓前显著降低(P＜0.05或P＜0.01);对照组治疗前后NIHSS评分比较差异无统计学意义(P＞0.05);心房颤动组的ICH发生率高于非心房颤动组(26.7％vs.9.4％,P＜0.05),而两组之间SICH发生率差异无统计学意义(13.3％vs.6.3％,P＞0.05);心房颤动组、非心房颤动和对照组3个月预后良好的比例分别为40.0％、45.3％和16.7％,心房颤动组和非心房颤动组的3个月预后良好比例差异无统计学意义(P＞0.05),均明显高于对照组(P＜0.05或P＜0.叭);心房颤动组、非心房颤动组和对照组预后极差的比例分别为20.0％、18.8％和33.3％ (P ＞0.05).结论 伴有心房颤动的急性脑梗死患者rt-PA静脉溶栓治疗是安全有效的.     

Chinese herbal medicine Dengzhan Xixin injection for acute ischemic stroke: A systematic review and meta-analysis of randomised controlled trials

ObjectiveTo evaluate the effectiveness and safety of Chinese herbal medicine Dengzhan Xixin (Erigeron breviscapus) injection for acute ischemic stroke.DesignSystematic review and meta-analysis (CRD42016038413, http://www.crd.york.ac.uk/PROSPERO).MethodsSix electronic databases were searched from inception to March 2016 for randomised controlled trials (RCTs) of Dengzhan Xixin (DZXX) injection for acute ischemic stroke. The methodological quality of RCTs was assessed by the Cochrane risk of bias tool.Data synthesiswas performed using RevMan 5.3 and was presented with mean difference (MD) or relative risk (RR) and their 95% confidence interval (CI). A summary of finding table was generated by GRADEpro (version 3.6).ResultsTwenty-five RCTs with 2498 participants were included and all trials adopted conventional therapy (CT) in both arms. Most of the studies had high risk of bias. The addition of DZXX to CT showed no significant benefit on death (RR 0.27, 95% CI 0.05–1.63) within the treatment period (14–35 d), but showed higher Barthel index score (MD 10.20, 95% CI 8.16–12.25), lower neurological function deficit score (MD −3.99, 95% CI −5.68 to −2.30, by NFDS; MD −1.67, 95% CI −2.59 to −0.76, by NIHSS), and lower treatment failure (RR 0.40, 95% CI 0.31–0.52). Thirteen trials (52%) reported the outcome of adverse events, but no serious adverse events were reported.ConclusionLow quality evidence implied that DZXX injection appeared to improve neurological function in patients with acute ischemic stroke. However, this potential benefit should be further studied in large, rigorous trials.     

Influence of coronavirus disease 2019 (COVID-19) on working flow,safety and efficacy outcome of mechanical thrombectomy for acute ischemic stroke with large vessel occlusion

AimThe epidemic of COVID-19 has greatly affect the world health care system, particular measures have been taken not only to provide safety for health care providers but also to maintain the treatment quality. We evaluate the effect of COVID-19 epidemic to acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) received endovascular treatment (EVT) in our institution.MethodsAIS patients with LVO who underwent EVT in the period of January 1st to April 30th between 2015 and 2020 from our stroke center. The baseline characteristics, working flow time, safety and efficacy outcome and the hospitalization status were retrospectively reviewed, compared and analyzed.ResultsThere is significant decline in the number of AIS patients with LVO treated compared with the previous year (36 Vs 72 patients) during the epidemic period. The door to puncture time was significantly prolong (225 minutes versus 115 minutes) as well as the length of hospital stay with increase of the hospitalization costs (P < 0.05 for all). There is no significant difference on the safety and efficacy outcome, such recanalization rate, incidence of intracranial hemorrhage, functional independence and mortality during the epidemic (P > 0.05 for all).ConclusionsProlongation of the working time flow during the COVID-19 epidemic did not influence the safety and efficacy of EVT in AIS patients with LVO. However, special policy and particular measures in this circumstances is still need to evolve to improve the treatment quality.