卒中后癎性发作

卒中后癎性发作常见,根据其发生时间分为早发性和迟发性癎性发作,前者与卒中后病理生理学改变有关,后者与胶质细胞增生有关.卒中后癎性发作与卒中类型、病因、病灶部位和大小及神经功能缺损情况等有关.临床上,大部分卒中后癎性发作表现为部分性发作或部分性发作继发全面性发作,部分患者发展为癫癎持续状态.根据卒中病史、癎性发作临床表现、脑电图和神经影像学,卒中后癎性发作的诊断一般并不困难,但需与其他发作性疾病鉴别.卒中后反复癎性发作者应予抗癫癎药物治疗,同时还应注意药物之间的相互作用,无需预防性用药.其与预后的关系尚存争议.     

缺血性卒中的抗血小板治疗30年循证历程的回顾与展望

抗血小板药是在缺血性卒中预防和治疗的众多药物中研究最充分、证据最多的一类药物。抗血小板药主要包括血栓素A2抑制剂(阿司匹林)、ADP受体拮抗剂(氯吡格雷和噻氯匹定)、磷酸二酯酶抑制剂(双嘧达莫)、糖蛋白(GP)Ⅱb/Ⅲa受体阻滞剂(阿昔单抗等)。其中,对阿司匹林的研究最早、证据最充分、也最成熟。近年来对氯吡格雷、噻氯匹定和双嘧达莫的研究也相当活跃。GPⅡb/Ⅲa受体阻滞剂和其他抗血小板药物正在研究之中。现就主要的抗血小板临床试验证据做一回顾,希望能从抗血小板药防治卒中的漫长循证历程中得到关于卒中防治研究的有用启示。1抗…     

三联抗血小板治疗无法改善急性卒中患者的转归

根据2017年国际卒中会议(International Stroke Conference,ISC)上提交的一项研究,与基于现行指南进行的治疗相比,对急性卒中或短暂性脑缺血发作(transient ischemic attack,TIA)患者进行强化抗血小板治疗不能提供任何更多的益处. 三联抗血小板治疗减少缺血性卒中生活依赖(Triple Antiplatelets for Reducing Dependency in Ischemic Stroke,TARDIS)试验包括来自英国、丹麦、格鲁吉亚和新西兰的3 096例非心源性卒中或TIA患者,其中2 143例被诊断为缺血性卒中,953例被诊断为TIA.     

不同年龄段的妊娠相关卒中风险存在差异

根据 JAMA Neurology 发表一项的研究,与年龄相匹配的对照组相比,年龄较轻的孕妇(包括分娩后6 周内的产后期)的卒中风险显著增高,而年龄较大的孕妇则不然. 美国哥伦比亚大学的Miller 等使用2003 至2012 年期间纽约州的所有卒中住院数据来确定妊娠相关性卒中(pregnancy-associated stroke, PAS)相对于非妊娠相关性卒中(nonpregnancy -associated stroke, NPAS)的年龄特异性发病率风险比.     

缺血性卒中或短暂性脑缺血发作患者的卒中预防指南美国心脏协会/美国卒中协会卒中委员会向医疗卫生专业人员的声明心血管放射学与介入委员会共同倡导

这份新声明旨在为缺血性卒中或短暂性脑缺血发作存活者的缺血性卒中预防提供全面和及时的循证推荐.循证推荐包括对危险因素的控制、动脉粥样硬化性疾病的干预措施、心源性栓塞的抗栓治疗以及非心源性栓塞性卒中抗血小板药的应用.另外,还为其他多种特殊情况下复发性卒中的预防提供了推荐,包括动脉夹层分离、卵圆孔未闭、高同型半胱氨酸血症、高凝状态、镰状细胞病、脑静脉窦血栓形成、女性卒中(特别是与妊娠和绝经后激素替代治疗相关卒中)、脑出血后抗凝药的应用,以及该指南在高危人群中执行和应用的特殊措施.     

抗血小板治疗预防无卒中或TIA病史的非瓣膜性心房颤动患者的卒中

背景:心房颤动(AF)会增加卒中的危险性,业已证实抗血小板治疗可有效地预防其他情况下的卒中。 目的:评估抗血小板治疗在慢性非瓣膜性AF患者的卒中预防中的效果和安全性。 检索策略:检索了Cochrane卒中组试验资料库、Medline数据库(1999年7月)和Antithrombotic Trialists Collaboration数据库以及相关论文的参考文献。 选择标准:所有比较无卒中或TIA病史的非瓣膜性AF患者的抗血小板治疗与安慰剂效果的随机试验。     

急性冠脉综合征患者接受经皮冠状动脉介入治疗前后抗凝策略探讨

急性冠脉综合征,包括ST段与非ST段抬高型心肌梗死以及不稳定型心绞痛等。急性冠脉综合征治疗主要包括抗凝与抗血小板两大部分;强效抗凝与抗血小板药物的使用,对急性冠脉综合征患者缺血事件的减少有着很大作用;但急性冠脉综合征患者接受PCI(经皮冠状动脉介入治疗),使用抗凝与抗血小板药物,导致围手术期的出血机率提高,且出血过度又会导致死亡、卒中、心肌梗死等发生。因此改变急性冠脉综合征患者PCI治疗前后的抗凝方案,对降低并发症的发生与疗效的提高均有重大的作用。     

西洛他唑双重抗血小板治疗在腔隙性卒中二级预防中的安全性和有效性

在腔隙性卒中患者中进行长期双重抗血小板治疗(dual antiplatelet therapy, DAPT)对预防复发性卒中的有效性尚不清楚。因此, 日本医科大学的Nishiyama等针对西洛他唑联合抗血小板卒中预防研究(Cilostazol Stroke Prevention Study for Antiplatelet Combination, CSPS.com)进行了一项亚分析, 旨在比较DAPT和单药抗血小板治疗(single antiplatelet therapy, SAPT)预防慢性腔隙性卒中复发的安全性和有效性。     

缺血性卒中的抗血小板治疗——30年循证历程的回顾与展望

抗血小板药是在缺血性卒中预防和治疗的众多药物中研究最充分、证据最多的一类药物。抗血小板药主要包括血栓素A2抑制剂(阿司匹林)、ADP受体拮抗剂(氯吡格雷和噻氯匹定)、磷酸二酯酶抑制剂(双嘧达莫)、糖蛋白(GP)Ⅱb／Ⅲa受体阻滞剂(阿昔单抗等)。     

缺血性卒中或短暂性脑缺血发作患者抗血小板药治疗期间血小板高反应性

抗血小板药是指南推荐的缺血性卒中/短暂性脑缺血发作(transient ischemic attack, TIA)长期治疗及二级预防的基石, 用于降低复发性卒中及其他心血管事件风险。然而, 某些缺血性卒中/TIA患者在抗血小板治疗期间仍会出现缺血性事件, 称为治疗期间血小板高反应性(high on-treatment platelet reactivity, HTPR), 通常发生在服用阿司匹林或氯吡格雷的患者中。文章阐述了缺血性卒中/TIA患者中HTPR的发生率、危险因素和常用评价方法, 阐述HTPR在缺血性卒中/TIA患者中的临床意义, 并探讨HTPR患者的抗血小板治疗方案。     

11例妊娠或产褥期重症结核病患者的临床治疗效果分析

目的 探讨妊娠或产褥期重症结核病的临床特点和治疗结局。 方法 回顾性分析2017年9月至2019年9月长沙市中心医院(长沙市肺科医院)结核重症科收治的11例妊娠或产褥期重症结核病患者,其中妊娠期患者9例,产褥期患者2例,总结其临床特征及母婴治疗转归。 结果 早期妊娠患者共2例,均于适当时间终止妊娠;中期妊娠患者共4例,1例继续妊娠并足月分娩,1例于适当时间终止妊娠,1例在治疗过程中流产,1例病情进展迅速,孕妇与胎儿均死亡;晚期妊娠患者共3例,1例坚持妊娠并足月分娩,2例坚持妊娠并早产;成功分娩的6例患者(包括入院前分娩2例,入院后分娩4例)均与新生儿隔离治疗。11例患者均予以积极的抗结核药物及相应的辅助支持治疗,其中10例好转并出院,1例死亡;11例患者共成功分娩6名新生儿,其中足月分娩2名,早产4名,新生儿均无结核感染表现,均未行母乳喂养。 结论 妊娠或产褥期重症结核病对母婴健康危害极大,加强对该病临床特点的认识,采取合理的治疗方案,可获得较为理想的治疗效果。     

Echocardiographically guided closure of a patent foramen ovale during pregnancy after recurrent strokes

BACKGROUND: Stroke during pregnancy and puerperium is a severe complication that causes high morbidity and mortality. A patent foramen ovale (PFO) allowing paradoxical embolism is one identified risk factor. CASE: A 25-year-old pregnant woman with PFO suffered from recurrent cerebral embolism. To prevent recurrent cerebral embolism during pregnancy, delivery, and puerperium, interventional closure of the PFO was performed without fluoroscopy under echocardiographic guidance. The postinterventional course was uneventful. CONCLUSION: Percutaneous transvenous closure of a PFO during pregnancy is feasible without the use of fluoroscopy.     

Acute myocardial infarction in the puerperium.

The authors describe the case of a forty-two-year-old patient with acute myocardial infarction (MI) on the third day of puerperium, who underwent direct angioplasty. The authors review the main physiological cardiovascular and hemostatic changes in pregnancy, which are usually well tolerated but which increase the probability of cardiovascular events when risk factors or previous cardiac disease are associated. Blood volume and cardiac output increase by around 50% during pregnancy, hemoglobin concentration falls, and reduced peripheral vascular resistance leads to a fall in arterial blood pressure during the first half of pregnancy. End-diastolic pressure, stroke volume and cardiac output increase in the immediate puerperium, and cardiovascular risk is highest in the perinatal period. The incidence of MI during pregnancy and puerperium is low; however, it is on the increase due to the growing number of pregnancies in women close to the end of their reproductive age.     

INCREASED RATE OF LUPUS FLARE DURING PREGNANCY AND THE PUERPERIUM: A PROSPECTIVE STUDY OF 78 PREGNANCIES

The objective was to determine whether the frequency of flarein systemic lupus erythematosus (SLE) patients is increasedduring pregnancy and the puerperium. Seventy-eight pregnanciesin 68 SLE patients attending the lupus pregnancy clinic, atSt Thomas' Hospital, during the last 5 yr were included. Thepregnancy period and 8 weeks post-delivery were considered.This group was compared with a control group of 50 consecutive,non-pregnant, age-matched SLE patients attending our weeklylupus clinic. Additionally, 43 of the pregnant patients carriedon attending the lupus clinic for the year after puerperium,and their course was compared with themselves during pregnancy.SLE activity was assessed using the Lupus Activity Index (LAI)score. An increase     

Catastrophic antiphospholipid syndrome during pregnancy and puerperium: maternal and fetal characteristics of 15 cases

BACKGROUND: The catastrophic variant of the antiphospholipid syndrome (APS) is a life-threatening form of presentation of this syndrome that can be triggered by several factors. AIM: To describe the characteristics of patients who developed catastrophic APS triggered during pregnancy and puerperium. METHODS: A review of the first 255 cases collected in the website-based "CAPS Registry" was undertaken. Three new and unpublished cases of catastrophic APS developed during pregnancy and puerperium were added. RESULTS: Fifteen cases were identified. The mean (range) age was 27 (17-38) years. Most patients had a previous unsuccessful obstetric history. In 7 of 14 (50%) cases with available medical history, the catastrophic APS appeared during pregnancy, in 6 (43%) during the puerperium and in 1 (7%) after curettage for a fetal death. The main clinical and serological characteristics were similar to those patients with catastrophic APS triggered by other factors, except for a history of a higher prevalence of previous abortions (p<0.01). Several specific features were found, including the HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome in 8 (53%) patients, placental infarctions in 4 (27%) patients, and pelvic vein thrombosis and myometrium thrombotic microangiopathy in 1 (7%) patient each. Mortality rate was high for the mothers (46%), and for the babies (54%). CONCLUSIONS: It is important to consider the possibility of the development of catastrophic APS in those patients with signs of HELLP syndrome and multiorgan failure during pregnancy or puerperium, especially in those patients with previous history of abortions and/or thrombosis.     

Thrombophilia and pregnancy

The risk of venous thromboembolism (VTE) increases up to 5-10-fold during pregnancy and VTE represents the first cause of maternal mortality. The annual incidence of VTE is 0.97 per 1000 women during pregnancy and 7.19 per 1000 in the puerperium. The risk is higher in carriers of inherited thrombophilia. Prophylaxis of VTE during pregnancy in thrombophilic women, is still controversial, whereas there is agreement on the used of LMWH or oral anticoagulants during puerperium. LMWH is suggested during pregnancy in antithrombin deficient women, compound heterozygotes for prothrombin G20210A and factor V Leiden, and homozygotes for these conditions, with no prior VTE. In heterozygotes for F V Leiden or prothrombin G20210A with no prior VTE surveillance is preferred during pregnancy and LMWH or OA during puerperium. For patients with APLAs and no prior VTE or fetal loss, one of the following approaches is suggested: prophylactic LMWH and/or low-dose aspirin, mini dose heparin, surveillance (7 degrees ACCP). Patients with APLAs and a history of thrombosis should receive therapeutic-dose LMWH or UH plus low-dose aspirin during pregnancy and long term OA postpartum. In women with prior VTE and inherited thrombophilia, prophylactic or intermediate-dose LMWH is recommended during pregnancy plus post-partum OA. Intermediate-dose LMWH during pregnancy is suggested in antithrombin-deficient women, compound heterozygotes for prothrombin G20210A and factor V Leiden, and homozygotes for these conditions.     

Detection of decreased response to activated protein C during pregnancy by an endogenous thrombin potential-based assay

Pregnancy has been widely recognized as a predisposing risk factor for deep vein thrombosis (DVT). However, it still remains unclear why pregnant women without a history of familial thrombophilia or antiphospholipid syndrome (APS) have a higher incidence of DVT and pulmonary embolism (PE) during pregnancy and puerperium. We examined the activated protein C (APC) system in healthy pregnant women and in patients with the onset of DVT during puerperium. Sixty unselected Japanese pregnant women without a past or family history of thrombosis or APS and 3 Japanese women with DVT during puerperium were evaluated. Endogenous thrombin potential-ratio (ETP-r) was measured by determination of thrombin-alpha2-macroglobulin complexes in thromboplastin-activated patient plasma. APC sensitivity ratio (APC-sr) was calculated by the determination of ETP-r in patient plasma in the presence and absence of APC (final concentration [conc.] 5.9 nM) to evaluate the functional APC anticoagulant activity. Mean APC-sr was significantly increased at 30 weeks' gestation (2.35 +/- 0.72) and remained high during puerperium compared with the mean APC-sr in nonpregnant women (1.15 +/- 0.63). Mean APC-sr in patients with DVT at the onset was significantly higher (3.57 +/- 0.54) than mean APC-sr during puerperium was, indicating that the sensitivity to APC was reduced in the ETP-based assay. These data suggest a significant reduction in the functional sensitivity to APC associated with an increased risk of venous thrombosis during pregnancy.     

Control del embarazo en pacientes con lupus eritematoso sistémico y síndrome antifosfolípido. Parte 1: Infertilidad,preservación ovárica y valoración preconcepcional. Documento de consenso de la Sociedad Española de Ginecología y Obstetricia (SEGO), Sociedad Española de Medicina Interna (SEMI) y Sociedad Española de Reumatología (SER)

ObjectivePregnancy and puerperium are considered a risk situation in women with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). Therefore, specialized assessment is essential both preconception and during pregnancy and the puerperium. Likewise, it is very important that different specialists in autoimmune diseases and high-risk pregnancies participate in the follow-up of these patients in a coordinated manner. The Spanish Society of Gynaecology and Obstetrics, the Spanish Society of Internal Medicine, and the Spanish Society of Rheumatology have set up a working group for the preparation of three consensus documents.MethodsThe stages of the work were: distribution of work in three groups corresponding to the three periods related to pregnancy (preconception, during pregnancy and childbirth and puerperium), identification of key areas, exhaustive review of the literature and formulation of recommendations.ResultsThis first document includes the 48 recommendations that address aspects related to infertility, the need for and treatments for gonadal preservation and preconception assessment.ConclusionsThese multidisciplinary recommendations are considered decision-making tools for clinicians involved in the care of patients with SLE/APS during pregnancy.     

Recurrent thrombosis of a mitral mechanical heart valve prosthesis during puerperium--a case report

A case of a 27-year-old female with prosthetic mitral valve is presented. Prolonged anticoagulation therapy was continued during pregnancy without complications. During puerperium, the dose of subcutaneous low molecular weight heparin was reduced due to subcutaneous blood effusions. Subsequently, the patient developed acute left ventricular heart failure due to prosthetic valve thrombosis. She underwent urgent surgery with new prosthetic valve implantation. Two weeks later she suffered another episode of acute mitral prosthetic valve thrombosis which was effectively treated with intravenous heparin. Difficulties concerning prolonged anticoagulation during pregnancy and puerperium in patients with prosthetic valves are discussed.     

认知评估量表组合在脑卒中后认知功能损害中的应用

目的探讨认知评估量表组合在脑卒中后认知功能损害患者随访中,应用及进行多中心临床研究时的可行性。方法共有10个中心的197例患者符合入选标准进入本研究基线期,对所有患者在基线期、6个月、12个月进行简易智能状态检查量表、蒙特利尔认知评估量表、临床痴呆量表、电脑干扰记忆试验等多重量表的评估,共154例患者完成所有随访。总结各量表在各随访期的完成情况及在各中心的得分情况、各主要观察指标的变化趋势图,计算各指标在各随访期的差异情况。结果除电脑干扰记忆试验外,各量表在各随访期的完成情况均>95%,各中心的得分亦无显著差异,提示各量表可在脑卒中后认知功能损害患者随访及多中心研究时应用。各观察指标在随访期间均好转,提示所选量表可用于脑卒中后认知功能损害的随访。结论本研究所选量表可以用于多中心临床研究;各量表及其亚项可用于脑卒中后认知功能损害随访的观察指标。