动脉内溶栓治疗36例急性缺血性脑梗死临床分析

目的探讨急性脑梗死行局部动脉内溶栓治疗的临床疗效及安全性。方法选择36例起病至溶栓时间在4～24h之内的急性缺血性脑梗死患者,经股动脉插管行全脑血管造影术发现闭塞血管后,用注射泵缓慢注射尿激酶行局部溶栓治疗,并通过导引导管造影,了解闭塞再通情况。结果36例中治愈16例,显效13例,有效6例,无效1例,显效率80.5%,总有效率97.2%。结论动脉插管接触性溶栓治疗急性脑梗死疗效确切,是治疗脑梗死有效的治疗手段。     

支架取栓术治疗大脑中动脉M2段闭塞的临床效果

正对急性脑梗死患者,早期开通血管与预后密切相关~([1])。超早期使用重组组织型纤溶酶原激活剂(recombinant tissue plasminogen activator,rt-PA)进行溶栓是目前急性脑梗死最有效的治疗方法之一,但闭塞大血管再通率仅为13%～18%~([2])。2015年美国心脏协会(American Heart Association,AHA)/美国卒中协会(American Stroke Association,ASA)发布的《急性缺血性卒中治疗指南》~([3])推荐,对发病6h内的颈内动脉或近端大脑中动脉闭塞患者可行血管内支     

动脉内溶栓治疗急性缺血性脑梗死:时间窗选择

目的 评价尿激酶动脉内溶栓治疗急性脑梗死的安全性和疗效。方法217例急性脑梗死患者接受动脉内尿激酶溶栓治疗，患者发病时间3～36h，6h以内23例(10．6％)。结果脑血管造影示颈内动脉系统闭塞119例(54．83％)，椎基动脉系统闭塞43例(19．82％)；无血管闭塞55例(25．35％)。溶栓后成功再通103例(63．58％)，不成功再通59例(36．42％)。3个月后恢复良好56例(25．80％)，轻度伤残51例(23．50％)，重度伤残59例(27．19％)，植物状态22例(10．14％)，死亡29例(13．36％)。并发颅内出血8例(3．69％)、再灌注损伤73例(33．64％)、再栓塞6例(2．76％)。结论经动脉尿激酶溶栓治疗急性缺血性脑梗死安全有效；急性脑梗死溶栓治疗时间窗可适当延长。     

介入疗法在急性肢体动脉闭塞治疗中的应用价值

目的探讨介入疗法在急性肢体动脉闭塞治疗中的应用价值。方法回顾性总结28例急性肢体动脉闭塞介入治疗经验。采用经皮血管腔内成形术和动脉内溶栓术治疗上肢动脉闭塞5例、腹主动脉下段闭塞1例、下肢动脉闭塞22例。结果经术后4个月~9年临床观察,急性单段动脉闭塞血管再通率为100%(8/8例)、多段动脉闭塞血管再通率为80%(16/20例),总血管再通率为85.71%(24/28例)。结论介入疗法是治疗急性肢体动脉闭塞的一种有效方法,值得推广应用。     

不同方法治疗急性大脑中动脉M2段闭塞效果

目的对比常规治疗、经静脉溶栓和血管内治疗对急性大脑中动脉M2段(MCA-M2)闭塞的临床疗效。方法76例急性MCA-M2闭塞患者分别接受常规治疗(常规组,n=31)、静脉溶栓治疗(溶栓组,n=27)和血管内治疗(血管内组,n=18),比较3组疗效相关指标。结果治疗后24 h,血管内组美国国立卫生研究院卒中量表(NIHSS)评分较基线下降≥4分者占比(83.33%)显著高于常规组(48.15%,校正前及校正后P均<0.01)。随访90天,相比常规组,溶栓组和血管内组良好预后率均提高、死亡率均降低,非症状性颅内出血发病率增加(校正前P均<0.05);经年龄、基线NIHSS评分、发病至入院时间校正后差异均无统计学意义(P均>0.05)。溶栓组1例出现症状性颅内出血。血管内组血管再通率94.44%。结论对于MCA-M2闭塞性急性脑梗死患者,急诊血管内治疗安全、有效,可早期快速改善神经功能。     

颅内动脉溶栓联合机械碎栓治疗急性脑梗死患者的护理

对9例急性脑梗死患者实施动脉内尿激酶溶栓联合机械性碎栓介入治疗。结果基本治愈5例,显效2例,有效1例,无效1例。提出超选择局域性动脉内尿激酶溶栓联合机械碎栓治疗6h内急性脑梗死,能使闭塞的血管尽快开通;建立溶栓患者绿色通道,积极为溶栓争取时间,术后严密观察病情变化,积极发现及预防并发症,做好心理护理是其护理重点。     

颅内动脉溶栓联合机械碎栓治疗急性脑梗死患者的护理

对9例急性脑梗死患者实施动脉内尿激酶溶栓联合机械性碎栓介入治疗。结果基本治愈5例,显效2例,有效1例,无效1例。提出超选择局域性动脉内尿激酶溶栓联合机械碎栓治疗6h内急性脑梗死,能使闭塞的血管尽快开通;建立溶栓患者绿色通道,积极为溶栓争取时间,术后严密观察病情变化,积极发现及预防并发症,做好心理护理是其护理重点。     

下肢动脉硬化闭塞症治疗后再闭塞的处理

目的 总结下肢动脉硬化闭塞症治疗后再闭塞的治疗经验.方法 回顾性分析2007年1月至2011年12月70例患者的临床资料,其中30例单纯股-腘动脉旁路术、15例单纯腔内成形术、25例联合治疗后下肢单侧动脉再次闭塞.70例患者共发生98次动脉闭塞.10例次在发生末次闭塞时保守治疗(组),余88例次行手术治疗[包括单纯股或人工血管取栓15例次(单纯取栓组),取栓+局部动脉微导管置入(组)抗凝溶栓13例次,取栓+远端动脉成形+微导管置入抗凝溶栓60例次].结果 保守治疗组膝上截肢5例,失访2例.单纯取栓组膝上、下截肢各1例,失访2例.取栓+微导管置入组膝下截肢1例,死亡2例.取栓+动脉成形+微导管置入组急性肾衰转透析后失访1例.本组63例患者获得随访,随访时间8～60个月,平均(24±5)个月.其中44例血管通畅,通畅率69.8％.8例患者血管闭塞后截肢,总截肢率为12.7％.结论 对于动脉硬化闭塞症治疗后再闭塞的患者,取栓+腔内血管成形+微导管置入局部抗凝溶栓近期效果较好.     

急性下肢动脉缺血溶栓治疗的临床研究

目的 总结溶栓治疗对急性下肢动脉缺血的疗效及其安全性.方法 回顾性分析2009年1月～201 1年12月收治43例急性下肢动脉缺血患者的临床资料,均进行动脉腔内溶栓治疗,其中27例进行导管直接溶栓,6例导管直接溶栓前行血管内球囊扩张,7例导管直接溶栓后进行血管内球囊扩张和支架置入,溶栓前后均进行球囊扩张有3例.腔内溶栓治疗无效转而手术取栓13例.结果 30例(69.8％)患者血管再通及肢体保存,但其中1例因出血并发症死亡,发生脑梗死1例.8例(18.6％)截肢,均为移植物血栓形成.1例肢体坏死但未行截肢.4例溶栓无效但肢体未坏死而最终采取药物保守治疗.结论 溶栓治疗对急性下肢动脉缺血总体安全有效,可优先考虑,根据病情的需要采取综合治疗方案.     

下肢动脉硬化闭塞症术后再闭塞的治疗

目的评价导管溶栓联合球囊扩张或支架血管成形术在下肢动脉硬化闭塞症(ASO)术后再闭塞的治疗效果。方法 2012年1月至2013年10月对35例治疗后再闭塞的ASO患者先采用溶栓导管动脉内接触性溶栓,再选择性联合血管形成术治疗。11例患者近膝关节处股浅动脉或腘动脉病变,应用VIABAHN覆膜支架治疗。观察溶栓效果和动脉再通情况。结果本组溶栓总有效率达92.3%,治疗后皮肤温度回升,静息痛消失,无垃圾脚发生,但有1例轻度脑栓塞。踝肱指数由术前的0.18±0.07升高至0.82±0.05,手术前后比较差异有统计学意义(P0.01)。11例患者使用VIABAHN覆膜支架,术后3个月复查均通畅,术后6个月1例再闭塞,予支架内球囊扩张后血流通畅。结论动脉内溶栓导管接触性溶栓,能够溶解大部分血栓,暴露真实病变,减少支架数目、缩短支架长度,结合新型覆膜支架VIABAHN动脉成形术,降低血管再狭窄风险,提高保肢率。     

Angioplasty of intracranial occlusion resistant to thrombolysis in acute ischemic stroke

OBJECTIVE: Thrombolysis has been demonstrated to improve revascularization and outcome in patients with acute ischemic stroke. Many centers now apply thrombolytic therapy locally via intra-arterial infusion. One therapeutic benefit is the ability to cross soft clots with a guidewire and to perform mechanical thrombolysis. In some instances, reopened arteries reocclude as a result of either thrombosis or vasospasm. We report the use of balloon angioplasty during thrombolysis for acute stroke. METHODS: From June 1995 through June 1999, 49 patients underwent intra-arterial therapy for acute stroke. In this group, nine patients (seven men and two women) were treated with balloon angioplasty after inadequate recanalization with thrombolytic infusion. The mean age of these patients was 67.9 years. Nine matched control patients who underwent thrombolysis alone without angioplasty were chosen for comparison. RESULTS: In the group of nine patients who had angioplasty, the mean National Institutes of Health Stroke Scale score at presentation was 21.8 +/- 5.4. Four patients had residual distal occlusion after angioplasty, and one patient had a hemorrhagic conversion. Of the five patients in which recanalization was successful, none had reocclusion of the balloon-dilated vessel. The mean score at 30 days for the five survivors was 12.6 +/- 14.9, for an improvement of 7.0 +/- 14.2. Among the nine control patients, the mean score at presentation was 20.3 +/- 5.2; the mean score at 30 days for the five survivors was 19.4 +/- 7.7, for an improvement of 4.2 +/- 7.8. CONCLUSION: In our experience, balloon angioplasty is a safe, effective adjuvant therapy in patients who are resistant to intra-arterial thrombolysis. The use of balloon angioplasty may prevent reocclusion in a stenotic artery and permit distal infusion of thrombolytic agents.     

Intra-arterial revascularization therapy for basilar artery occlusion—a systematic review and analysis

Acute basilar artery occlusion has been managed aggressively with various modalities due to its potentially debilitating outcome. While intra-arterial mechanical thrombectomy with stentriever has established clear evidence for anterior circulation stroke with large vessel occlusion as an adjunct to intravenous thrombolysis or the sole modality in intravenous thrombolysis ineligible patients, similar high-level evidence was not available for intra-arterial mechanical thrombectomy of posterior circulation stroke with acute basilar artery occlusion. We hence perform a systematic review of current literature to compare intra-arterial pharmacological thrombolysis (IA-P) and intra-arterial mechanical thrombectomy (IA-MT) for acute basilar artery occlusion. Forty-one studies published between 1996 and 2015 were compared and studied by odds ratio analysis using Mantel-Haenszel risk ratio estimation, and time trend analysis using meta-regression. Patients in the IA-MT group were older, presented with more severe stroke, and more likely received treatment more than 12 h since onset of stroke. At 3 months, survival and clinical outcome were superior in the IA-MT group than the IA-P group, associated with higher recanalization rate. There were no difference between proportion of dependent survivors, and rate of symptomatic intracerebral hemorrhage across groups. Intra-arterial thrombolysis with mechanical devices led to improved survival, better short-term clinical outcome and higher recanalization rate than intra-arterial pharmacological thrombolysis.     

Advances in treatment of acute ischemic stroke

Opinion statement 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.     

Inflammatory responses and CNS injury: implications,prophylaxis, and treatment

EXCERPT: Early detection of perioperative stroke is essential if there is to be any opportunity to improve outcome. If there is suspicion of cerebral embolic stroke, scanning with computerized tomography can rule out acute hemorrhage and demonstrate diagnostic changes in a majority of patients within 5 hours of onset of symptoms. Strategies for reperfusion of ischemic tissue may include intraarterial thrombolysis in select patients with acute ischemic stroke even after recent cardiac operation. In one series, 13 patients with acute ischemic stroke within 12 days of cardiac operation underwent intraarterial thrombolysis within 6 hours of stroke symptom onset. Recanalization was complete in 1 patient and partial in 5, and 7 patients had low flow. Neurologic improvement occurred in 5 patients (38%). One patient needed a chest tube for hemothorax; 2 others received transfusions for low hemoglobin. No operative intervention for bleeding was necessary. In addition to thrombolysis, mechanical clot removal may be attempted. Thromboaspiration requires favorable anatomy and a fresh nonadhesive clot. It reduces the time for recanalization, has no hemorrhagic risk, and may prevent distal clot migration. Thromboaspiration may be attempted as an adjunct or alternative to intraarterial fibrinolysis for basilar artery recanalization. If massive cerebral gas embolism is suspected and hyperbaric facilities are available, confirmation can be obtained by early single-photon emission tomography (SPET) and hyperbaric oxygen therapy instituted. This process was successfully undertaken in a case of paradoxical air embolism in a patient undergoing percutaneous nephrolithotripsy in the prone position and presenting with blindness and neurological deficits 8 hours later. Treatment with hyperbaric oxygen therapy was successful in this case.     

Safety and efficacy of intraarterial thrombolysis for perioperative stroke after cardiac operation

Background. Acute ischemic stroke after cardiac operations is a devastating complication with limited therapeutic options. As clinical trials of thrombolysis for acute ischemic stroke exclude patients with recent major surgery, the safety of intraarterial thrombolysis in this setting is unknown.

Methods. Thirteen patients with acute ischemic stroke within 12 days of cardiac operation underwent intraarterial thrombolysis within 6 hours of stroke symptom onset. The National Institutes of Health Stroke Scale was used to assess neurologic recovery.

Results. The mean age was 69 years (standard deviation ±5 years) and 62% were men. Cardiac procedures included valve operations in 6 patients, coronary artery bypass grafting in 4, valve and coronary artery bypass grafting in 2, and left ventricular assist device in 1 patient. Atrial fibrillation occurred in 5 patients (38%). The mean time from operation to stroke was 4.3 days (standard deviation ± 3 days). Thrombolysis was initiated within 3.6 hours (standard deviation ±1.6 hours) of stroke symptom onset. Recanalization was complete in 1 patient, partial in 5, and 7 patients had low flow. Neurologic improvement occurred in 5 patients (38%). One patient needed a chest tube for hemothorax, 2 others were transfused for low hemoglobin. No operative intervention for bleeding was necessary.

Conclusions. In select patients with acute ischemic stroke after recent cardiac operation, intraarterial thrombolysis appears to be reasonably safe and may lead to neurologic recovery.     

Bivalirudin for endovascular intervention in acute ischemic stroke: case report

OBJECTIVE AND IMPORTANCE: Intra-arterial thrombolysis has been demonstrated to improve recanalization and outcomes among patients with acute ischemic stroke. However, thrombolytic agents have limited effectiveness and are associated with a significant risk of bleeding. Bivalirudin is a direct thrombin inhibitor that has been demonstrated in the cardiology literature to have a more favorable efficacy and bleeding profile than other antithrombotic medications. We report the use of bivalirudin during endovascular treatment of acute stroke, when hemorrhagic complications are not uncommon. CLINICAL PRESENTATION: A 71-year-old woman with atrial fibrillation presented with right hemiparesis and aphasia and was found to have a National Institutes of Health Stroke Scale score of 10. Computed tomographic scans revealed no evidence of intracranial hemorrhage, aneurysm, or ischemic stroke. Cerebral angiography revealed thromboembolic occlusion of the superior division of the left middle cerebral artery. INTERVENTION: For anticoagulation, a loading dose of bivalirudin was intravenously administered before the interventional procedure, followed by continuous infusion. Attempts to remove the clot with an endovascular snare failed to induce recanalization of the vessel. Bivalirudin was then administered intra-arterially. Immediate postprocedural angiography demonstrated restoration of flow in the left middle cerebral artery. Repeat computed tomographic scans demonstrated no intracranial hemorrhage. The patient's hemiparesis and aphasia were nearly resolved and her National Institutes of Health Stroke Scale score was 2 at the time of her discharge 5 days later. CONCLUSION: To our knowledge, this is the first report of the use of bivalirudin for treatment of acute ischemic stroke. Bivalirudin may be a useful agent for intravenous anticoagulation and intra-arterial thrombolysis in this setting.     

Carotid endarterectomy and intracranial thrombolysis: simultaneous and staged procedures in ischemic stroke

PURPOSE: The feasibility and safety of combining carotid surgery and thrombolysis for occlusions of the internal carotid artery (ICA) and the middle cerebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. METHODS: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusions of the MCA, was performed between January 1994 and January 1998. Exclusion criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the modified Rankin scale. RESULTS: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the MCA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic stroke (n = 5) or surgical reexploration after elective CEA complicated by perioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embolic occlusions and 10 of 11 ICA occlusions were recanalized successfully (confirmed with angiography or transcranial Doppler studies). Four patients recovered completely (Rankin 0), six patients sustained a minor stroke (Rankin 2/3), two patients had a major stroke (Rankin 4/5), and two patients died. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. CONCLUSION: Combining carotid surgery with thrombolysis (simultaneous or staged procedure) offers a new therapeutic approach in the emergency management of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies.     

Intra-arterial or intravenous thrombolysis for acute ischemic stroke? The SYNTHESIS pilot trial

OBJECTIVE To assess the feasibility, safety and preliminary efficacy of intra-arterial thrombolysis (IAT) compared with standard intravenous thrombolysis (IVT) for acute ischemic stroke. METHODS Eligible patients with ischemic stroke, who were devoid of contraindications, started IVT within 3 h or IAT as soon as possible within 6 h. Patients were randomized within 3 h of onset to receive either intravenous alteplase, in accordance with the current European labeling, or up to 0.9 mg/kg intra-arterial alteplase (maximum 90 mg), over 60 min into the thrombus, if necessary with mechanical clot disruption and/or retrieval. The purpose of the study was to determine the proportion of favorable outcome at 90 days. Safety endpoints included symptomatic intracranial hemorrhage (SICH), death and other serious adverse events. RESULTS 54 patients (25 IAT) were enrolled. Median time from stroke onset to start to treatment was 3 h 15 min for IAT and 2 h 35 min for IVT (p<0.001). Almost twice as many patients on IAT as those on IVT survived without residual disability (12/25 vs 8/29; OR 3.2; 95% CI 0.9 to 11.4; p=0.067). SICH occurred in 2/25 patients on IAT and in 4/29 on IVT (OR 0.5; CI 0.1 to 3.3; p=0.675). Mortality at day 7 was 5/25 (IAT) compared with 4/29 (IVT) (OR 1.6; CI 0.4 to 6.7; p=0.718). There was no significant difference in the rate of other serious adverse events. CONCLUSIONS Rapid initiation of IAT is a safe and feasible alternative to IVT in acute ischemic stroke.     

Anesthetic management of patients with acute stroke

Stroke is a major cause of death and disability. Anesthesiologists are likely to encounter patients with stroke and must be aware of the anesthetic considerations for these patients. Intravenous thrombolysis and intra-arterial thrombolysis are effective treatments for acuteischemic stroke as well as evolving endovascular techniques such as mechanical clot retrieval. Recent retrospective studies have found an association between general anesthesia and poor clinical outcome. The results of these studies have several limitations, and current evidence is inadequate to guide the choice of anesthesia in patients with acute stroke. The choice of anesthesia must be based on individual patient factors until further research is completed.