重组组织型纤溶酶原激活物静脉溶栓治疗超时间窗急性缺血性卒中的Meta分析

目的系统评价超时间窗(4.50~6.00 h)的急性缺血性卒中患者行重组组织型纤溶酶原激活物(rt-PA)静脉溶栓治疗的有效性和安全性。方法分别以缺血性卒中/脑梗死/脑梗塞、溶栓治疗、延长时间窗,以及acute ischemic stroke、thrombolytic therapy、beyond 4.5 hours等中英文词组为检索词,计算机检索1980年1月-2015年8月美国国立医学图书馆生物医学信息检索系统、Cochrane图书馆、中国知网中国知识基础设施工程、万方数据库等收录的rt-PA静脉溶栓治疗超时间窗(4.50~6.00 h)急性缺血性卒中随机对照临床试验;Jadad量表和Rev Man 5.3统计软件进行文献质量评价和Meta分析。结果共获得681篇文献,经剔除重复和不符合纳入标准者,最终纳入3项随机对照临床试验计2033例急性缺血性卒中(发病6 h)患者(rt-PA静脉溶栓组1029例、安慰剂组1004例)。Meta分析显示:rt-PA静脉溶栓与安慰剂对改善患者神经功能(RR=1.070,95%CI:0.940~1.220;P=0.310)和日常生活活动能力(RR=1.040,95%CI:0.940~1.160;P=0.430)、降低病死率(RR=1.260,95%CI:0.990~1.610;P=0.060)差异无统计学意义,但rt-PA静脉溶栓组患者脑出血发生率高于安慰剂组(RR=1.550,95%CI:1.030~2.340;P=0.030)。结论 rt-PA静脉溶栓治疗超时间窗(4.50~6.00 h)急性缺血性卒中无明显疗效且可能增加脑出血风险,高质量证据尚待大样本多中心随机对照临床试验加以验证。     

急性缺血性卒中的抗血小板治疗

急性缺血性卒中患者血小板被激活，抗血小板治疗可减少早期脑梗死的复发，减轻脑损伤的体积，降低早期死亡和改善存活者的长期预后。但抗血小板治疗增加非致死性或症状性颅内出血的发生率。阿司匹林是证据最充分且得到各国指南推荐的治疗急性缺血性卒中的抗血小板药物，对未溶栓治疗的急性缺血性卒中患者应尽早开始阿司匹林治疗。氯吡格雷、血小板糖蛋白Ⅱb/IIIa受体抑制剂、双嘧达莫、西洛他唑等单药用于治疗急性缺血性卒中的安全性和疗效目前尚无足够的证据。抗血小板药物联合应用的疗效和可能的风险尚需进一步研究。     

替格瑞洛的神经科应用：未来路在何方？——急性非致残性脑血管事件高危人群血小板反应性研究的启示

正抗血小板聚集药物在神经科具有广泛的临床应用。阿司匹林作为抗血小板聚集治疗的元老级药物,多项临床研究已经明确其在预防缺血性脑血管病领域的有效性及安全性。氯吡格雷则是继阿司匹林后又一重磅药物,对于神经内科缺血性卒中患者安全有效。除阿司匹林及氯吡格雷外,近年来还有替格瑞洛、西洛他唑、普拉格雷、双嘧达莫、阿西单抗和替罗非班等     

急性缺血性卒中经颅多普勒超声微栓子信号监测临床研究

目的探讨大脑中动脉微栓子信号与急性缺血性卒中的相关性,以及单联和双联抗血小板治疗效果。方法采用经颅多普勒超声(TCD)监测129例急性缺血性卒中患者大脑中动脉微栓子信号,单因素和多因素前进法Logistic回归分析筛查微栓子信号阳性危险因素,阿司匹林单药或联合氯吡格雷双联抗血小板治疗,评价药物疗效和预后。结果 129例患者中42例(32.56%)微栓子信号阳性。Logistic回归分析显示,高脂血症是微栓子信号阳性的独立危险因素(OR=0.335,95%CI:0.147~0.764;P=0.009)。经抗血小板治疗后,双抗组患者微栓子信号消失率高于单抗组(χ~2=16.701,P=0.000);与治疗前相比,两组患者治疗后NIHSS评分减少(P=0.000),与单抗组相比,双抗组患者治疗后NIHSS评分亦减少(P=0.025),表明抗血小板治疗有效且双联抗血小板治疗效果优于单抗治疗。结论高脂血症是TCD监测微栓子信号阳性的独立危险因素,双联抗血小板治疗可以阻止微栓子信号形成并改善患者近期预后。     

氯吡格雷/阿司匹林双抗预防非心源性缺血性脑卒中的效果观察

目的观察氯吡格雷联合阿司匹林双抗防治非心源性缺血性脑卒中的临床效果。方法选取2011-05—2014-05收治的非心源性缺血性脑卒中患者114例,随机分为观察组与对照组,2组均常规卒中治疗,在此基础上对照组单纯应用阿司匹林,观察组使用氯吡格雷联合阿司匹林治疗,观察2组临床效果。结果观察组3个月、1a内复发率均明显低于对照组,总不良反应率低于对照组,差异均有统计学意义(P0.05)。结论对非心源性缺血性脑卒中患者使用氯吡格雷联合阿司匹林进行双抗防治,能够有效降低其卒中复发率,减少不良反应,在临床防治中有较理想的效果。     

西洛他唑治疗动脉瘤性蛛网膜下腔出血后脑血管痉挛的Meta分析

目的系统评价西洛他唑治疗动脉瘤性蛛网膜下腔出血后脑血管痉挛的有效性以及安全性。方法检索PubMed、Cochrane Library、EMBASE、中国生物医学文献、维普及万方数据库,检索时间从建库至2018年09月,收集西洛他唑治疗动脉瘤性患者的临床对照试验。由2名研究者严格制定纳入标准、筛选文献,提取资料,评价质量并用Rev Man5. 3软件进行Meta分析。结果最终纳入临床研究6项,共618例动脉瘤性蛛网膜下腔出血患者。Meta分析结果显示西洛他唑在以下方面优于常规治疗,且差异有统计学意义(P 0. 05),西洛他唑能降低症状性脑血管痉挛(OR=0. 31,95%CI:0. 21-0. 48),重度脑血管痉挛(OR=0. 47,95%CI:0. 31-0. 69),迟发性脑梗塞(OR=0. 32,95%CI:0. 20-0. 52)的发生率,且能够改善患者预后(OR=2. 65,95%CI:1. 66-4. 21)。结论西洛他唑可以降低动脉瘤性蛛网膜下腔出血所致脑血管痉挛的发生率,并对改善预后有一定帮助。     

强化控制血压治疗脑出血有效性和安全性的Meta分析

目的评价强化控制血压治疗脑出血的有效性和安全性。方法以intracerebralhemorrhage、ICH、blood pressure、intensive、acute等英文检索词,计算机检索1980年1月1日-2015年9月30日美国国立医学图书馆生物医学信息检索系统、荷兰医学文摘、Cochrane图书馆等数据库收录的关于强化控制血压治疗脑出血的随机对照临床试验,采用Jadad量表和Rev Man 5.3统计软件进行文献质量评价和Meta分析。结果共获得3322篇文献,经剔除重复和不符合纳入标准者,最终纳入4项较高质量(Jadad评分≥4分)的临床试验共3360例脑出血病例。Meta分析显示:强化控制血压早期并不能减少发病24 h内血肿体积增加1/3的病例数(RR=0.910,95%CI:0.750~1.090;P=0.310),亦不增加治疗90 d时改良Rankin量表评分≤2分的病例数(RR=1.070,95%CI:0.990~1.150;P=0.090)和美国国立卫生研究院卒中量表评分(RR=0.950,95%CI:0.800~1.120;P=0.530)以及循环系统不良事件(RR=0.910,95%CI:0.610~1.370;P=0.660)和严重低血压(RR=0.840,95%CI:0.370~1.940;P=0.690)发生率。结论强化控制血压治疗脑出血并不能在短期内减少血肿增加,但有可能改善患者远期预后,降低病残率和病死率;不增加神经系统损害症状,以及循环系统不良事件和严重低血压发生率。     

外周血白细胞与急性缺血性卒中的相关性研究

目的探讨外周血早期白细胞及其亚型与急性缺血性卒中(AIS)发生、发展的关系。方法连续收集AIS住院患者588例,性别和年龄匹配的非脑卒中患者630例,比较2组患者的临床资料并进行多元Logistic回归分析。根据头颅CT或MRI梗死面积大小将AIS患者分为腔隙性AIS组151例和非腔隙性AIS组437例,比较2组白细胞参数并进行多元Logistic回归分析。结果 AIS组白细胞、中性粒细胞及中性粒细胞/淋巴细胞比值(NLR)高于对照组,差异有统计学意义(P0.05);Logistic回归分析显示,白细胞计数(OR=1.073,95%CI:1.017~1.132,P=0.009)和中性粒细胞计数(OR=1.068,95%CI:1.001~1.139,P=0.046)进入回归方程。非腔隙性AIS组白细胞计数高于腔隙性AIS组,差异有统计学意义(P0.05);Logistic回归分析显示,白细胞计数(OR=0.898,95%CI:0.811~0.995,P=0.040)进入回归方程。结论白细胞和中性粒细胞升高是AIS的独立危险因素,低白细胞计数为腔隙性AIS的危险因素,白细胞计数对AIS的发生及梗死面积具有一定的预测价值。     

进展性缺血性脑卒中影响因素的前瞻性研究

目的 探讨进展性缺血性脑卒中的危险因素.方法 前瞻性登记急性缺血性脑卒中患者并收集其临床资料.依据欧洲进展性卒中诊断标准将患者分组,对可能影响卒中进展的因素进行比较及多因素Logistic逐步回归分析.结果 共有569例患者纳入研究,其中127例归入进展性卒中组,442例归入非进展性卒中组.进展性卒中组患者的病程、伴糖尿病、心房纤颤史及脑卒中史、入院时发热、高血糖、合并并发症、入院时美国国立卫生研究院卒中量表及格拉斯哥昏迷量表评分与非进展性卒中组比较差异有统计学意义(均P<0.1).多因素Logistic逐步回归分析显示,糖尿病(RR=2.625,95%CI:1.422～4.844)、发热(RR=0.192,95%CI:0.075～0.491)、合并并发症(RR=2.442,95%CI:1.394～4.279)、神经功能缺损中度(RR=5.602,95%(CI:2.789～11.251)及重度(RR=24.734,95%CI:4.218～145.052)是进展性卒中的独立危险因素.结论 糖尿病、发热、合并并发症、中及重度神经功能缺损是缺血性脑卒中进展的独立危险因素.     

抗血小板药物抵抗与复发性缺血性脑卒中

缺血性脑卒中在抗血小板治疗期间1/3~1/2的患者卒中复发。卒中复发有多种原因,多认为病人的不依从性是实验室抗血小板药物抵抗的最常见原因,但需要正确识别卒中的原因和发病机制。目前还没有良好指征用于缺血性卒中抗血小板药物抵抗的检测,或根据检测结果调整药物剂量的方法。选择预防卒中复发的抗血小板药物取决于卒中发作的时间,轻度缺血性卒中在发病3个月内选用阿司匹林联合氯吡格雷优于单一的抗血小板药物,但对长期二级预防来说,联合应用抗血小板治疗不仅无益处,且有增加出血的风险。     

Cilostazol combined with aspirin prevents early neurological deterioration in patients with acute ischemic stroke: a pilot study

Recent randomized trials have shown that cilostazol is superior to aspirin for secondary stroke prevention. We hypothesized that combining cilostazol with aspirin is more effective than aspirin alone in patients with acute ischemic stroke. This randomized study compared the effects of oral aspirin alone to aspirin plus cilostazol in patients with non-cardioembolic ischemic stroke within 48 h of stroke onset. NIH Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores were checked before and after 14 days and 6 months of drug administration. The primary and secondary endpoints were neurological deterioration or stroke recurrence (NIHSS score ≥ 1) within 14 days and 6 months, respectively. For statistical analysis, on-treatment analysis was conducted. Seventy-six patients were enrolled in the study. The primary endpoint was significantly higher in the aspirin group than in the aspirin plus cilostazol group (28% vs. 6%, relative risk (RR): 0.21, 95% confidence intervals (CI): 0.05-0.87, p=0.013). Among the patients who did not reach these endpoints, the mean improvement in the NIHSS score at day 14 tended to be better (-1.8 ± 1.2 vs. -1.2 ± 1.0, p=0.078) and the frequency of the favorable functional status of mRS 0-1 at month 6 was significantly higher (RR: 1.48, 95% CI: 1.07-2.06, p=0.0048) in the aspirin plus cilostazol group than in the aspirin group. Patients treated with aspirin plus cilostazol during the acute phase of stroke had less neurological deterioration and more favorable functional status than those treated with aspirin alone.     

Addition of cilostazol reduces biological aspirin resistance in aspirin users with ischaemic stroke: a double‐blind randomized clinical trial

Background and purpose: Biological aspirin resistance (AR) has been recognized as an important cause of clinical AR. Recent studies have reported the beneficial effects of cilostazol for the prevention of cardiovascular diseases. This study investigated whether addition of cilostazol to aspirin in ischaemic stroke patients can reduce AR. Methods: In this double‐blind multicenter trial, 244 aspirin users with ischaemic stroke were randomly assigned to receive cilostazol 100 mg twice daily or to placebo. Antiplatelet function was assessed using the VerifyNow? Aspirin system. The primary end‐point was the incidence of AR, which was measured as aspirin resistance unit (ARU) ≥550 after 4‐week treatment. Results: The incidence of AR after treatment in cilostazol group was not significantly different from that in placebo (8.8% vs. 10.9%, P = 0.578). However, AR decreased from 12.8% to 8.8% in cilostazol group, whereas it was not changed in the placebo group. The mean ARU after treatment were also lower in the cilostazol group (456.9 ± 56.0 vs. 470.7 ± 67.2, P = 0.081). Cilostazol addition did not prolong bleeding time. Conclusions: Although this was a negative study, our findings disclosed a trend toward enhanced antiplatelet effects when cilostazol was added to aspirin in ischaemic stroke patients. Combination of aspirin and cilostazol might be a treatment option in the ischaemic stroke patients with AR.     

Treatments for stroke prevention in atrial fibrillation: a network meta-analysis and indirect comparisons versus dabigatran etexilate

Patients with atrial fibrillation at moderate to high risk of stroke are not always anticoagulated despite a lack of contraindications to vitamin K antagonists (VKAs) like warfarin. These patients are treated with aspirin, aspirin-clopidogrel combination therapy or even receive no thromboprophylaxis. The oral direct thrombin inhibitor, dabigatran etexilate 150 mg BID and 110 mg BID, might represent an alternative for these patients; however, no head-to-head clinical trial data exist versus these alternative treatments. A network meta-analysis (NMA) was performed to indirectly compare dabigatran etexilate with antiplatelets and placebo. Compared with placebo, dabigatran etexilate 150 mg BID was estimated to significantly reduce the risk of any stroke (ischaemic and haemorrhagic) by 75% (relative risk [RR] 0.25; 95% confidence interval [CI] 0.12-0.51), ischaemic stroke by 77% (RR 0.23; 95% CI 0.14-0.38), systemic embolism by 83% (RR 0.17; 95% CI 0.05-0.50) and mortality by 36% (RR 0.64; 95% CI 0.45-0.91). Dabigatran etexilate 150 mg BID was estimated to significantly reduce the risk of any stroke compared with aspirin monotherapy by 63% (RR 0.37; 95% CI 0.20-0.69) and aspirin plus clopidogrel by 61% (RR 0.39; 95% CI 0.21-0.72). Trends toward reduced risk with both dabigatran etexilate regimens were found for most clinical outcomes. Relative risk estimates of dabigatran etexilate versus adjusted-dose VKAs within the NMA were consistent with results from the head-to-head randomised trial of these two strategies. Indirect evidence suggests treatment with dabigatran etexilate offers benefit for the prevention of stroke, systemic embolism and mortality over antiplatelets and placebo. There was no indication of increased intracranial or extracranial haemorrhage with dabigatran etexilate compared to antiplatelet agents.     

Ipsilateral Nonstenotic Carotid Disease in Minor Ischemic Stroke: an Exploratory Analysis of The POINT Randomized Clinical Trial

Background and aimIpsilateral nonstenotic carotid disease is increasingly recognized as an etiology of ischemic stroke, however tailored treatment strategies are lacking. We aimed to examine clinical characteristics and treatment effects in patients with minor ischemic stroke associated with ipsilateral nonstenotic carotid disease in the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial.MethodsWe performed an exploratory analysis of the interaction of the treatment effects of aspirin plus clopidogrel versus aspirin monotherapy, stratified by presence of ipsilateral nonstenotic carotid disease in patients with minor ischemic stroke in the POINT trial.ResultsFor this exploratory analysis, 167 patients presenting with ischemic stroke and ipsilateral nonstenotic carotid disease, defined as 1%-49% carotid stenosis ipsilateral to the corresponding territory of ischemic stroke, and 833 patients no carotid disease were included. Compared to patients with no carotid disease, patients with ipsilateral nonstenotic carotid disease were older (68.5 ± 11.3 years versus 61.3 ± 12.8 years; P < 0.001), and had a higher prevalence of hypertension (76.6% versus 59.2%, P < 0.001), ischemic heart disease (13.8% versus 5.4%, P < 0.001), and tobacco use (past: 34.1% versus 25.2%, P = 0.005; present: 27.5% versus 22.8%, P = 0.005). 5.4% of patients with ipsilateral nonstenotic carotid disease had recurrent ischemic stroke within 14 days. Patients receiving dual antiplatelet therapy had a numerical reduction in recurrent ischemic stroke compared to patients receiving aspirin monotherapy, however the exploratory analysis was underpowered to detect a statistically significant difference in treatment effect (HR 0.50, 95% CI 0.18-1.40, P = 0.19).ConclusionPatients with minor ischemic stroke and ipsilateral nonstenotic carotid disease had a high risk of early stroke recurrence in the POINT trial. Dual antiplatelet therapy provided a non-statistically significant reduction in recurrent ischemic stroke with no difference in safety outcomes compared to aspirin monotherapy. Further study is needed to determine if early and short duration dual antiplatelet therapy is beneficial for all patients with ipsilateral nonstenotic carotid disease.     

EBM of cerebral infarction: message from mega-studies]

A meta-analysis by the Antithrombotic Trialists' Collaboration showed significant reduction of vascular events including stroke. MI, and vascular death by antiplatelet therapy in high risk patients with obstructive vascular disease. Low dose aspirin of 75 to 150 mg was most effective and its very low dose below 75 mg was not proven effective. Cilostazol significantly reduced the risk of recurrence in Japanese patients with ischemic stroke, mostly lacunar stroke. Large randomized controlled trials (RCTs) such as MATCH, ACTIVE, and CHARISMA are ongoing to see an effect of aspirin plus clopidogrel. Among patients with non-valvular atrial fibrillation (NVAF), warfarin is recommended in patients at age over 75 years, and those with history of stroke or TIA, hypertension, congestive heart failure, diabetes or coronary heart disease, while aspirin can be alternative in patients without any of these risk factors of stroke. Target INR of 2.0 to 3.0 is recommended in these NVAF patients, although lower INR of 1.6 to 2.5 is recommended to avoid hemorrhagic stroke in elderly patients with NVAF. SPORTIF was conducted to compare ximelagatran, an oral thrombin inhibitor, with warfarin in NVAF patients with risk factors, and the result showed a comparable efficacy and safety of ximelagatran. WARSS did not show any efficacy of warfarin over aspirin in any subtypes of ischemic stroke patients without NVAF, acute MI, left ventricular thrombi, or prosthetic heart valve. PICSS, a substudy of WARSS, also did not show any efficacy of warfarin over aspirin in stroke patients with patent foramen ovale (PFO), although warfarin might be recommended in PFO patients with deep vein thrombosis.     

Stroke prevention with aspirin, warfarin and ximelagatran in patients with non-valvular atrial fibrillation: a systematic review and meta-analysis

OBJECTIVE: To compare the effectiveness of aspirin, warfarin, and ximelagatran as thromboprophylaxis in patients with non-valvular atrial fibrillation (NVAF). METHODS: Systematic review of randomised controlled trials in patients with NVAF treated with adjusted-dose warfarin and aspirin, fixed low-dose (FLD) warfarin, ximelagatran or placebo. Outcome measures studied were ischaemic stroke, systemic embolism, mortality and haemorrhage. Meta-analysis was performed using a fixed effects model. RESULTS: We identified 13 trials (n=14,423 participants) of sufficient quality to be included in the analysis. Adjusted-dose warfarin significantly reduced the risk of ischaemic stroke or systemic embolism compared with aspirin (relative risk [RR] 0.59; 95% confidence interval [CI]: 0.40 to 0.86), FLD warfarin (RR 0.36; 95% CI: 0.23 to 0.58), or placebo (RR 0.33; 95% CI: 0.24 to 0.45). However, aspirin and placebo had a lower risk of major bleeding compared to warfarin (RR 0.58; 95% CI: 0.35 to 0.97 and RR 0.45; 95% CI: 0.25 to 0.82, respectively). The oral direct thrombin inhibitor, ximelagatran was as effective as adjusted-dose warfarin in the prevention of ischaemic strokes or systemic emboli (RR 1.04; 95% CI: 0.77 to 1.40) with less risk of major bleeding (RR 0.74; 95% CI: 0.56 to 0.96). Adjusted-dose warfarin significantly reduced mortality compared to placebo (RR 0.69; 95% CI: 0.53 to 0.89), but not for any of the other comparisons (aspirin: RR 0.87; 95% CI: 0.67 to 1.13; FLD warfarin: RR 1.11; 95% CI: 0.81 to 1.52; ximelagatran: RR 1.04; 95% CI: 0.86 to 1.26). CONCLUSIONS: We have extended previous analyses, making this the largest systematic review and meta-analysis of thromboprophylaxis trial data in AF--and have included recent trials with the new oral direct thrombin inhibitor, ximelagatran. This systematic review confirms the superiority of anticoagulation therapy over aspirin as thromboprophylaxis in patients with NVAF. The new oral direct thrombin inhibitor, ximelagatran, appears as effective as adjusted-dose warfarin for the prevention of thromboembolic events in NVAF, with a lower risk of bleeding.     

Effect of cilostazol on cerebral arteries in secondary prevention of ischemic stroke

Objective

To compare the effects of cilostazol on cerebral arteries and cerebrovascular blood flow in secondary prevention of ischemic stroke, with those of aspirin.

Methods

Sixty-eight patients who had ischemic stroke during the recent 1–6 months were recruited and randomized into cilostazol or aspirin group. Cerebrovascular condition was assessed by magnetic resonance angiography (MRA) and transcranial doppler ultrasonography (TCD) at the beginning of the study and after 12-month medication.

Results

During the clinical follow-up, ischemic stroke recurred in 2 patients in cilostazol group, while in aspirin group, one case of ischemic stroke recurrence and one case of acute myocardial infarction were found. MRA revealed that in aspirin group, the percentages of patients experiencing aggravation and attenuation of cerebrovascular condition were 3.3% and 6.7%, respectively, while in aspirin group, they were 3.3% and 10%, respectively. Moreover, TCD revealed that 26.9% of the patients in aspirin group and 14.3% of the patients in cilostazol group experienced aggravation of cerebrovascular condition. However, the systolic peak flow velocity of the previously abnormal arteries increased by 42.9% after 12-month medication of cilostazol, which was significantly higher than that after aspirin medication (27.5%) (P = 0.04). Furthermore, as a major side effect of antiplatelet therapy, the frequrency of bleeding was much less in cilostazol group (0 case in cilostazol group vs 5 in aspirin, P < 0.05).

Conclusion

Cilostazol is as effective as aspirin in preventing the aggravation of cerebral arteries in secondary prevention of ischemic stroke. Besides, it is more safe. Cilostazol can increase the systolic peak flow velocity of cerebral arteries, which may improve the blood supply of focal ischemia.     

Regional differences in incidence and management of stroke - is there any difference between Western and Japanese guidelines on antiplatelet therapy?

PURPOSE: There have not been many discussions on the differences between the guidelines for the management of stroke used in eastern and western countries. The purpose of this paper was to examine whether or not there are substantial differences between western countries and Japan in the prevalence of stroke and the frequencies of stroke subtypes, as well as in the recommended therapy for secondary prevention of ischemic stroke. RESULTS AND CONCLUSIONS: Although there are racial differences and differences in approved drugs between the East and West, the prevalence of stroke and the frequencies of stroke subtypes tend to converge throughout the world. However, the ratio of stroke to ischemic heart disease is still different between the East and West. Comparison of various countries' guidelines shows that recommendations on antiplatelet therapy for secondary prevention of ischemic stroke are fundamentally similar in the East and West, but the recommended doses of antiplatelets, especially aspirin and ticlopidine, are smaller in Japan. Furthermore, Japanese guidelines only recommend the use of antiplatelets (particularly cilostazol) for patients with lacunar infarction with evidence.     

症状性颈内动脉完全闭塞患者的临床干预和随访研究

目的 评价症状性颈内动脉完全闭塞患者介入治疗和药物治疗的效果,观察临床干预后血管事件的随访结果.方法 将自2004年2月至2009年1月在聊城市人民医院和南京军区南京总医院神经内科住院的62例症状性颈内动脉完全闭塞患者意向性分为介入组和药物组,介入组21例给予颈内动脉闭塞血管再通术,药物组41例给予阿司匹林、氯吡格雷及他汀类药物治疗.随访主要终点事件为发病2年时患者功能预后,以改良的Rankins评分(mRS评分)为依据,秩和检验比较组间平均秩次的差异;次要终点事件为血管事件的再发,Kaplan-Meier法及多因素Cox回归分析其中位数时间及独立危险因素.结果 在随访3月、6月、1年及2年时,介入组患者mRS评分平均秩次均明显低于药物组,差异有统计学意义(P＜0.05).介入组和药物组患者再发血管事件的中位数时间分别为(17.42± 1.20)个月和(19.43±1.51)个月,比较差异无统计学意义(P＞0.05).多因素Cox回归分析表明患者再发血管事件的独立危险因素主要包括吸烟(RR=3.189,95％ CI:1.020～9.968,P=0.046)、糖尿病(RR=2.717,95％CI:1.113～6.631,P=0.028)及基线时美国国立卫生研究院卒中量表(NIHSS)评分(RR=2.984,95％CI:1.049～8.485,p=0.040),而治疗方案(介入治疗和药物治疗)不是血管事件再发的独立影响因素(RR=1.191,95％CI:0.430～3.296,P=0.737).结论 对于症状性颈内动脉完全闭塞患者,介入治疗较药物治疗能获得更好的功能预后,但随访2年时未能减少血管事件的发生.吸烟、糖尿病及基线NIHSS评分是其血管事件再发的独立危险因素.     

伴脑出血史的缺血性卒中患者使用抗血小板药物二级预防的调查

目的 通过结局调查分析既往有脑出血史的缺血性卒中患者使用抗血小板药物(antiplatelet drugs,APD)的状况以及使用APD对再发脑出血和再发脑梗死的影响.方法 随访我院既往有过脑出血的脑梗死患者的单中心、回顾性队列研究.统计学方法采用生存曲线及Logistic回归分析APD对既往有过脑出血患者缺血性卒中二级预防结局的影响.结果 既往有过脑出血的缺血性卒中合并心房颤动和心肌梗死的患者在心内科就诊时更易接受服用APD.既往有过脑出血患者缺血性卒中二级预防中APD没有增加再发脑出血(OR=1.149,95%CI0.376～3.513,P=0.808);未良好控制的高血压和脑叶出血是再发脑出血的危险因素;APD的使用能明显降低再发脑梗死的发生(OR=0.410,95%CI0.203～0.826,P=0.013).既往有过脑出血的缺血性卒中患者服用APD再发脑出血间隔时间均值为39个月,未服APD患者为45个月(X2=1.257,P=0.262).既往有过脑出血的缺血性卒中患者服用APD再发脑梗死间隔时间均值为42个月,末服APD患者为22个月(X2=14.315,P=0.001).结论 既往有过脑出血的缺血性卒中患者,通过APD进行缺血性卒中二级预防可获益,再发肭出血未见增多.考虑到本调查中脑叶出血和高血压控制不良容易再发脑出血,使用APD时把血压控制在正常范围并排除既往有过脑叶出血的病例,也许是更为安全的选择.