Hemiplegia in posterior cerebral artery strokes

Hemiplegia is an unusual presenting feature of posterior circulation strokes. We report five cases who presented with hemiplegia and in whom CT scans revealed evidence of infarcts in posterior cerebral artery territory.     

Reasons to withhold intra-arterial thrombolysis in clinical practice

Background In selected stroke centers intra-arterial thrombolysis (IAT) is used for the treatment of acute stroke patients presenting within 6 hours of symptom onset. However, data about eligibility of acute stroke patients for IAT in clinical practice are very scarce. Methods We collected prospectively data on indications advising for or against IAT of 230 consecutive stroke patients in a tertiary stroke center. Results 76 patients (33.0%) presented within 3 hours, 69 (30%) between 3 and 6 hours of symptom onset and 85 (37%) later than 6 hours. Arteriography was performed in 71 patients (31%) and IAT in 46 (20%). In 11 patients no or only peripheral branch occlusions were seen on arteriography and therefore IAT was not performed. In 9 patients the ICA was occluded and barred IAT and in five anatomical or technical difficulties made IAT impossible. 72 patients presenting within 6 hours did not undergo arteriography and thrombolysis, mostly because of mild (n = 44) or rapidly improving neurological deficits (n = 13). Other reasons to withhold IAT were CT and/or clinical findings suggesting lacunar stroke due to small vessel occlusion (n = 7), limiting comorbidty (n = 7) and baseline international normalized ratio > 1.7 (n = 1). Conclusions A third of the patients underwent diagnostic arteriography and one fifth received IAT. The most important reasons to withhold thrombolysis were presentation beyond the 6 hours time window and mild or rapidly improving symptoms. Received in revised form: 23 July 2005     

Translating research into practice: Lessons from trials of thrombolysis in acute stroke

There exist individual, institutional and national barriers to change, none more so than when introducing new therapies into medical practice especially those that involve organizational change. This paper, presented as an address to the joint meeting of the Association of British Neurologists and the Indian Academy of Neurology in October 2007, explores these barriers in the context of the instruction of thrombolytic therapy for patients with acute ischaemic stroke and suggests how they might be overcome using evidence from relevant clinical trials and observational studies.     

Effect of hypothermia and delayed thrombolysis in a rat embolic stroke model

Effect of hypothermia on cerebral infarcts was studied in rats embolized in the right carotid territory. Thirty-four served as normothermic controls receiving saline infusion only. In 16 rats hypothermia of 32°C was induced by cooling with a fan, followed by embolization. The rats were kept hypothermic for the following 3 h before body temperature was raised to 37°C. In 26 rats, treatment with human recombinant tissue plasminogen activator (20 mg/kg i.v. during 45 min), started 2 h after embolization. Finally, 14 rats were treated similarly with hypothermia for 3 h followed by additional rt-PA treatment starting after 2 h. Thrombolytic therapy reduced median infarct volume from 19.5% of affected hemisphere among controls to 4.6% (p = 0.006) in the treated group. Three hours of hypothermia reduced infarct volume to 1.6% (p = 0.0007). Additional rt-PA could not demonstrate further improvement in this experimental setting.     

Influence of antiplatelet pre‐treatment on the risk of intracranial haemorrhage in acute ischaemic stroke after intravenous thrombolysis

Background: Pre‐treatment with antiplatelet agents (AP) is present amongst 30% of acute stroke patients. Previous studies have shown conflicting results on the effect of these drugs regarding haemorrhagic transformation after thrombolytic therapy. The hypothesis that pre‐treatment with AP may increase the risk of cerebral haemorrhage (ICH) after intravenous tissue plasminogen activator (tPA) was assessed. Methods: Retrospective study of consecutive prospectively registered patients with acute ischaemic stroke treated with iv tPA (n = 235) in the last 5 years. Baseline characteristics and prior AP therapy were registered on admission. Computed tomography (CT) scan was performed on admission and 24–36 h after tPA. ICH was classified according to the ECASS II criteria into haemorrhagic infarction and parenchymal haematoma (PH). Symptomatic intracerebral haemorrhage (SICH) was defined as a worsening of ≥ 4 points in the NIHSS score during the first 36 h in any haemorrhage subtype. Results: Seventy‐two (30.6%) patients were pre‐treated with AP (55 aspirin, 14 clopidogrel, 2 aspirin + clopidogrel, 1 triflusal). PH was observed in 33 (14.1%) patients (PH1 13, PH2 12, PHr 8) of whom 16 were symptomatic. Male gender (78.8% vs. 21.2%, P = 0.036), prior AP therapy (54.5% vs. 26.9%, P = 0.001), stroke severity (median NIHSS, 17 vs. 12, P = 0.005) and early CT signs of infarction (12.5% vs. 2.1%, P = 0.004) were associated with PH. The adjusted odds ratios of PH for patients pre‐treated with AP therapy was 3.5 (1.5–7.8, P = 0.002) and for SICH 1.9 (0.6–5.9, P = 0.2). Conclusions: Pre‐treatment with AP is associated with an increased risk of PH after intravenous thrombolysis in patients with acute ischaemic stroke.     

机械取栓治疗兔急性栓塞性脑梗死的实验研究

目的探讨机械取栓治疗兔急性栓塞性脑梗死的效果。方法将30只新西兰大白兔应用血流阻断加注射凝血酶方法制作兔右颈总动脉栓塞模型,然后将其随机分为取栓组、溶栓组和对照组,每组10只。造模成功后3h,取栓组行机械取栓治疗,溶栓组应用重组组织型纤溶酶原激活剂行动脉内溶栓治疗,对照组不治疗。取、溶栓前后行DSA了解血管再通情况;比较取、溶栓前后大脑中动脉流速（Vmca）及各组栓塞后3、6、8、12、24h磁共振弥散系数（ADC）值的差异;比较各组24h神经功能评分。结果取栓组和溶栓组血管再通率分别是80％和20％,差异有统计学意义（P〈0．05）。取栓组和溶栓组治疗后Vmca显著增快（P〈0．05）,取栓组增加更显著（P〈0．05）。取栓组和溶栓组24hADC值、神经功能评分较治疗前显著改善（P〈0．05）,取栓组改善更显著（P〈0．05）。结论取栓治疗急性栓塞性脑梗死安全、有效,疗效优于血管内溶栓治疗。     

Thrombolytic and anticoagulation treatment in a rat embolic stroke model

OBJECTIVES: The effects of pentasaccharide (PENTA), given alone or combined with thrombolysis using recombinant tissue plasminogen activator (rt-PA), on infarct size and clinical outcome were evaluated in a rat embolic stroke model. MATERIALS AND METHODS: Ninety-two rats were embolized unilaterally and assigned to: (i). controls, (ii). rt-PA 6 mg/kg, (iii). PENTA 0.5 mg/kg, (iv). PENTA 0.5 mg/kg and rt-PA 6 mg/kg. After 2 days animals were killed, the brains removed and evaluated microscopically. RESULTS: The median infarct size measured in percentage of the affected hemisphere was 25% in the control group, 4% (P < 0.01, Mann Whitney) in group 2, 19% (n.s.) in group 3, and 10% (P < 0.05) in group 4. rt-PA, and rt-PA combined with PENTA also promoted functional recovery. CONCLUSION: The present study found no effect of 0.5 mg/kg PENTA treatment. Compared with rt-PA treatment alone, 0.5 mg/kg PENTA alone or combined with rt-PA did not significantly increase mortality or tendency for hemorrhage.     

溶栓药物的基础和临床研究的新进展

溶栓药物的使用是溶栓治疗的一个关键性问题，随着溶栓治疗的发展，许多新的溶栓药物也相继出现，并且展开了许多动物实验和临床的研究，本文就相关的研究进展予以介绍。     

超选择动脉溶栓治疗80岁以上脑梗死的安全性及疗效评估-两中心研究

目的 探讨80岁以上高龄脑梗死患者超选择动脉溶栓治疗的安全性、可行性及治疗效果.方法 回顾性分析86例超选择动脉溶栓治疗的脑梗死患者的临床资料,根据年龄不同分为高龄组(≥180岁,21例)和普通年龄组(<80岁,65例),并设对照组(同时期≥80岁未行动脉溶栓治疗患者,50例).评估患者动脉溶栓术后血管良好再通率、早期临床改善率,以及各组症状性脑出血发生率、较好转归率及死亡率.结果 接受动脉溶栓治疗的两组患者血管良好再通率、早期临床改善率及症状性脑出血发生率比较差异无统计学意义(P=0.528,P=0.102,P=0.353).高龄组症状性脑出血发生率明显高于对照组,比较差异有统计学意义(P=0.034).高龄组较好转归率为42.9%,低于普通年龄组(50.8%),但高于对照组(16%),差异有统计学意义(P=0.042,P=0.017).高龄组死亡率与对照组比较差异无统计学意义(23.8%vs 28%,P=0.816),但高于普通年龄组,差异有统计学意义(23.8%vs 10.8%,P=0.034).结论 80岁以上高龄脑梗死患者超选择动脉溶栓治疗具有较高的安全性、可行性和临床疗效,高龄不是脑梗死动脉溶栓治疗的禁忌因素.

Abstract：

Objective To evaluate the feasibility, safety and efficacy of intra-arterial thrombolytic therapy on elderly patients (≥ 80 years old) with acute ischemic stroke. Methods The clinical data of 86 patients with acute ischemic stroke, received intra-arterial thrombolytic therapy, were retrospectively analyzed; according to age differences, these patients were divided into advanced age group (≥80 years old, n=21) and common age group (<80 years old, n=65); and control group (≥80 years old, not receiving thrombolytic therapy, n=50) was established. The recanalization rate and early clinical improvement rate, and the incidence, recover rate and death rate of symptomatic intracerebral hemorrhage were evaluated in these patients after treatment. Results No significant differences in the favorite recanalization rate and short-term outcome, and the incidence of symptom intracranial hemorrhage were noted between the advanced age group and common age group (P=0.528, P=0.102,P=0.353). The incidence of symptom intracranial hemorrhage in the advanced age group was obviously higher than that in the control group (P=0.034); the recover rate of symptom ntracranial hemorrhage in the advanced age group (42.9%) was obviously lower than that in the common age group (50.8%), but significantly higher than that in the control group (16%, P=0.042, P=0.017). The mortality of the advanced age group was similar to that of the control group (23.8% versus 28%, P=0.816), but higher than that of common age group (23.8% versus 10.8%, P=0.034). Conclusion Relatively high feasibility, safety and efficacy of intra-arterial thrombolytic therapy are noted in elderly patients (≥80 years old) with acute ischemic stroke, demonstrating that the use of intra-arterial thrombolytic therapy in very elderly patients should not be avoided but pursued advisably.     

Intravenous thrombolysis in stroke patients with hyperdense middle cerebral artery sign

Background and purpose:  We assessed the safety and efficacy of intravenous thrombolysis (IVT) in acute stroke patients with hyperdense middle cerebral artery sign (HMCAS).
Patients and methods:  Data from consecutive patients with acute (within 6 h of symptom onset) ischaemic stroke admitted between January 1999 and November 2007, in whom HMCAS was diagnosed on admission CT scan was retrospectively analysed. Seventy-one patients, admitted within the 3-h window, were treated with IVT, whilst further 42, admitted 3–6 h after symptom onset, were not. At 3-month clinical follow-up, outcome, mortality at 3 months and incidence of symptomatic intracranial haemorrhage were evaluated.
Results:  The two groups were comparable concerning age, stroke risk factors, prior antithrombotic treatment and NIHSS scores on admission. Good outcome (mRS score ≤ 1) was observed in 12/71 (17%) patients who were treated with IVT and in 1/42 (2%) patients who were not ( P  = 0.02). IVT treatment was identified as independent predictor of good outcome ( P  = 0.05). Mortality was 20% in patients treated with IVT and 12% in remaining patients ( P  = 0.3). Symptomatic intracranial haemorrhage occurred in 1 patient of each group (2%).
Conclusions:  These findings suggest that IVT in patients with HMCAS results in significantly better outcome, without significantly influencing mortality.     

体外溶栓试验确定急性脑梗死治疗中尿激酶用量的研究

目的 探讨体外溶栓试验确定尿激酶用量进行急性脑梗死溶栓治疗的效果。方法 对急性脑梗死患者立即应用体外溶栓试验,寻找处于溶柞状态的尿激酶用量进行溶栓,以后持续7d应用尿激酶40万U维持溶枪治疗,在溶栓治疗不同时间进行神经功能缺损程度评分及测定纤维蛋白原（Fbg）浓度、聚合反应速率（FMPV）、最大吸光度（ODmax）、FMPV／ODmax.结果 溶栓治疗组疗效明显高于非溶栓组（P〈0．05）,〈6h治疗纰疗效优于6～24h治疗组,6～24h治疗组优于非溶栓组（均P〈0．05）。Fbg浓度、FMPV、FMPV／ODmax溶栓后开始下降,而于溶栓后24h反弹达到高峰,随后再下降,于第5d再次显著升高,与溶栓后其他时间段相比差异显著性（均P〈0．05）,ODmax无明显变化。溶栓组并发出血1例（2．17％）,非溶栓组无出血患者。结论 应用体外溶栓试验确定尿激酶用量进行急性脑梗死溶栓治疗是安全有效的。     

以脑梗死表现的3例神经梅毒病例分析

目的分析3例被误诊为急性脑梗死接受溶栓治疗的神经梅毒患者的临床资料,提高对神经梅毒的诊断准确率,降低基层医院溶栓误治率。方法回顾性总结收治的3例以急性脑梗死起病并给以rt-PA静脉溶栓治疗神经梅毒患者的临床症状、实验室检查、脑电图及影像学检查结果、诊治过程及预后等资料,采用NIHSS评分进行神经功能评估,m RS评分进行预后评估。结合文献分析以急性脑梗死起病的神经梅毒的临床特征。结果3例以急性脑梗死起病的男性患者,接受rt-PA静脉溶栓治疗,神经功能缺损症状恶化,以往无脑血管病危险因素,影像学检查提示脑缺血和脑萎缩,血及脑脊液梅毒螺旋体明胶凝集试验和甲苯胺红不加热血清学试验阳性明确神经梅毒诊断。早期、大剂量、足疗程青霉素G治疗预后良好,NIHSS及m RS评分降低。结论以急性脑梗死起病的神经梅毒患者,静脉溶栓治疗效果差,尽早进行梅毒血清学和脑脊液检查,降低溶栓误治率,大剂量青霉素G治疗有效。     

Potentiated thrombolysis in a Chandler system using rtPA and lys-plasminogen

The effect of glu/lys-plasminogen on rtPA induced thrombolysis was studied in a Chandler model using rabbit blood. Glu/lys-plasminogen in various concentrations was added to the Chandler loop before or after thrombi were formed from 2 ml of rabbit blood containing ¹²⁵I-labelled rabbit fibrinogen. The thrombolysis was estimated as radioactivity in the supernatant/total radio-activity. Thrombi formed in the presence of extra lys-plasminogen (conc ≥0.025 mg/ml blood) lysed spontaneously to a significantly higher extent than thrombi formed in the presence of glu-plasminogen or saline. If the glu/lys-plasminogen was added to a preformed thrombus no thrombolysis occured. When added together with single-chain rtPA (s.c.rtPA) or two-chain rtPA (t.c.rtPA) the thrombolysis was similar to the one obtained by s.c./t.c.rtPA alone. If on the other hand s.c./t.c.rtPA was added to lys-plasminogen enriched thrombi (>0.01mg/ml blood) a significantly enhanced thrombolysis as compared to the one achieved by s.c./t.c.rtPA alone was obtained. Based on the observation that lys-plasminogen potentiates the lysis of thrombi in a Chandler model a bolus dose administered preoperatively may enhance spontaneous lysis of thrombi formed during surgery.