采用EKOS系统行血管内超声溶解血栓的安全性和有效性

颅内或颈部动脉急性闭塞是缺血性卒中最常见的病因。血管造影或超声显像的研究提示,有71％-80％的缺血性卒中患者在发病3h内出现颅内血管的闭塞。血管闭塞后自发再通的发生率很低,且通常在疾病后期出现,不利于神经元的存活。再灌注治疗是目前急性卒中最有效的治疗方法,而超声血栓溶解则是血管再通的新方法。自20世纪70年代以来,体外实验、动物模型和临床研究已证实,超声波作用可加快血栓溶解。这些研究采用不同的能量（0．2～2．0W／cm^2）和频率（0．02-2MHz）。     

静脉溶栓桥接治疗急性缺血性卒中

静脉溶栓是治疗急性缺血性卒中的首选方法,但在大血管闭塞性卒中患者中的血管再通率较低.以血管内机械血栓切除术为代表的血管内治疗能有效使缺血性卒中患者闭塞血管再通和改善转归.文章对静脉溶栓桥接治疗的现状和发展方向进行了综述.     

急性缺血性卒中血管再通前神经保护治疗研究进展

卒中是我国成人首位致死、致残性疾病,其中缺血性卒中是最主要的类型,尽早行静脉溶栓或血管内介入治疗,开通闭塞血管是公认的有效治疗手段,但患者的临床预后不甚理想。在血管再通基础上进行有效的神经保护治疗有望进一步改善患者预后,但对于神经保护治疗的启动时机和方法尚无定论。作者分析了缺血性卒中血管再通治疗不同阶段的病理生理变化,论述了血管再通前进行神经保护治疗的必要性和可行性,并对相关临床研究进行分析总结,以期为未来血管再通联合神经保护治疗的相关研究和临床应用提供参考。     

缺血性卒中的神经保护治疗:梦园30年

卒中是影响人类健康的主要疾病,居中国死因顺位的首位,而缺血性卒中占了卒中的绝大多数.缺血性卒中的预防和治疗是临床神经病学最为重要的课题.缺血性卒中的发病基础是供应脑部的血管发生急性闭塞,引起供血区域脑组织缺血坏死,而早期治疗的关键措施是开通血管,即再灌注治疗.     

急性脑梗死静脉溶栓/桥接治疗24 h内血小板活化的研究进展

急性脑梗死目前最理想的治疗是尽快使闭塞的血管再通,静脉溶栓治疗是急性脑梗死确证有效的开通闭塞动脉的急救措施,桥接治疗提高了闭塞血管的再通机率,但仍有一部分患者存在残余血管狭窄。已知血小板在急性脑梗死的发生和发展中起着重要作用。溶栓/桥接治疗后导致血管再通后再闭塞的关键因素之一是溶栓后24 h内禁止抗血小板聚集药物的使用,血小板的聚集与活化使一部分残余动脉狭窄患者发生了动脉再闭塞。本文针对血小板活化机制及近年来关于急性脑梗死静脉溶栓/桥接治疗后血小板活化状态及抗血小板治疗联合静脉溶栓/桥接治疗的研究进行综述,以探讨在静脉溶栓/桥接治疗后24 h内使用抗血小板聚集药物的可行性及安全性,从而改善患者的预后。     

前循环血管闭塞所致致残性与非致残性轻型卒中的再灌注治疗

在血管内血栓切除术可靶向血管闭塞(endovascular thrombectomy-targetable vessel occlusion, EVT-tVO;包括前循环大血管和中型血管闭塞)所致的轻型急性缺血性卒中患者中, 区分致残性与非致残性神经功能缺损的益处尚不清楚。意大利ASST Grande Ospedale Metropolitano Niguada医院的Schwarz等进行了一项研究, 对急性再灌注治疗在致残性和非致残性轻型EVT-tVO患者中的安全性和有效性进行了比较。     

急性缺血性卒中患者再灌注治疗后出血性转化风险的预测

再灌注治疗(包括静脉溶栓和血管内治疗)是急性缺血性卒中的有效治疗方法。作为再灌注治疗后的常见并发症, 出血性转化与患者转归不良密切相关。早期通过临床特征、影像学和血液生物标志物进行评估可预测出血性转化风险, 从而更好地指导急性缺血性卒中患者的再灌注治疗。     

血管内再通结合短时间极低温生理盐水颈动脉灌注治疗大脑中动脉急性闭塞的对照研究

目的比较大脑中动脉急性闭塞行血管内再通与血管内再通结合短时间极低温生理盐水颈动脉灌注2种治疗方法的安全性和效果。方法选择大脑中动脉急性闭塞患者20例,根据入选标准及患者家属意愿分为常规治疗组4例、常温组8例(单纯血管内再通治疗)和低温组8例(血管内再通结合短时间极低温生理盐水颈动脉灌注治疗)。对比分析各组患者手术前后各项指标(体温、心率、血压、红细胞压积及血小板计数)和术前、术后1、7、15d患者美国国立卫生研究院卒中量表评分动态变化及发病24h梗死体积。结果 3组不同时间点各项指标无明显变化,临床上未有不良反应发生。低温组术后1、7、14d神经功能缺损评分较常规治疗组和常温组明显降低,低温组发病24h梗死体积[(6.41±3.28)cm3 vs(13.65±5.27)cm3,(9.15±4.12)cm3]较常规治疗组和常温组明显减小,差异有统计学意义(P<0.05)。结论血管内再通结合短时间极低温生理盐水颈动脉灌注是一种安全的治疗手段,比单纯血管内再通治疗大脑中动脉急性闭塞在术后的神经功能缺损评分和梗死体积均有明显改善。     

替奈普酶治疗与早期再灌注相关的血栓特征

颅内动脉闭塞部位、对比剂渗透和血栓负荷是影响阿替普酶相关再灌注的血栓特征。澳大利亚墨尔本大学皇家墨尔本医院的Yogendrakumar等对缺血性卒中血管内治疗前替奈普酶与阿替普酶对比(Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke, EXTEND-IA TNK)试验进行了一项合并分析, 旨在基于上述特征的患者亚组中对替奈普酶和阿替普酶的再灌注效果进行比较。     

急性心肌梗死介入再灌注治疗的进展

急性心肌梗死 (ＡＭＩ)发病后 6～ 12ｈ内给予静脉溶栓治疗 ,可以降低住院病死率 ,改善患者的预后 ,但静脉溶栓治疗临床再通率为 6 0 %～ 70 % ,90ｍｉｎ冠状动脉 (冠脉 )造影心肌梗死血流分级 (ＴＩＭＩ) 3级者仅 5 0 %左右 ,早期再闭塞率约 5 %～ 10 % ,晚期再闭塞率 30 % ,颅内出血及卒中等并发症限制了溶栓治疗的使用。直接经皮冠脉介入 (ＰＣＩ)治疗ＡＭＩ是对胸痛症状发作 6～ 12ｈ内的患者直接进行冠状动脉造影 ,通过经皮穿刺冠脉血管成形术 (ＰＴＣＡ)或同时置入支架将闭塞的冠脉开通 ,恢复血流灌注 ,初步临床研究结果令人满意 ,它…     

机械取栓装置在缺血性卒中患者治疗中的应用

目前,在发病4．5h内进行静脉溶栓仍然是治疗急性缺血性卒中患者的最有效方法。对于不符合静脉溶栓治疗标准、静脉溶栓后症状无明显改善甚至恶化的患者,血管内介入治疗是一种安全的替代治疗方法。经动脉机械取栓装置能实现迅速和完全的血管再通,为急性缺血性卒中患者提供了更多的治疗选择。文章对近年来机械取栓装置相关的技术演变和临床试验进行了综述。     

Treatment of acute ischemic stroke: recent progress

Intravenous thrombolysis with tissue plasminogen activator is currently the most effective treatment of acute ischemic stroke if administerd within 3 hours after symptom onset. Intraarterial thrombolysis by prourokinase is the another choise if the middle cerebral artery is occluded and within less than 6 hours after onset. Although heparin especially a moderate dose is not proved to be effective, a randomized, placebo-controlled trial to determine the safety and efficacy of argatroban (a selective thrombin inhibitor) in patients with acute ischemic stroke was started in USA. Aspirin provides some benefit to patients with acute stroke. However, its effect is not fully satisfactory. Although reports of numerous trials for neuroprotective drugs have been disappointing, edaravone (free radical scavenger) was approved for the treatment of acute ischemic stroke in Japan. In the future, thrombolytic and neuroprotective drugs will be used in combination.     

Prähospitalversorgung und Akuttherapie des ischämischen Schlaganfalls

An acute ischemic stroke (AIS) is always a life threatening medical emergency. The possibility and success of applying an effective acute therapy depends mainly on a fast decision-making process within the pre-clinical phase of patient care. Systemic thrombolysis using recombinant tissue plasminogen activator (rtPA) is an effective treatment for AIS, but is restricted to the first 3 h after symptom onset and is most effective the earlier the treatment is applied. Thus, avoiding delays until treatment is the main challenge in the acute care of stroke patients. Time to treatment consists of two distinct segments, each having its own special problems and challenges: the pre-hospital phase and the early in-hospital treatment. However, for optimized stroke care, both parts need to be closely coordinated. In this article, specifics and problems of pre- and in-hospital care of acute stroke patients are discussed.     

Treatment of acute stroke: an update

Stroke is the second leading cause of global mortality after coronary heart disease, and a major cause of neurological disability. About 17 million strokes occur worldwide each year. Patients with stroke often require long‐term rehabilitation following the acute phase, with ongoing support from the community and nursing home care. Thus, stroke is a devastating disease and a major economic burden on society. In this overview, we discuss current strategies for specific treatment of stroke in the acute phase, focusing on intravenous thrombolysis and mechanical thrombectomy. We will consider two important issues related to intravenous thrombolysis treatments: (i) how to shorten the delay between stroke onset and treatment and (ii) how to reduce the risk of symptomatic intracerebral haemorrhage. Intravenous thrombolysis has been approved treatment for acute ischaemic stroke in most countries for more than 10 years, with rapid development towards new treatment strategies during that time. Mechanical thrombectomy using a new generation of endovascular tools, stent retrievers, is found to improve functional outcome in combination with pharmacological thrombolysis when indicated. There is an urgent need to increase public awareness of how to recognize a stroke and seek immediate attention from the healthcare system, as well as shorten delays in prehospital and within‐hospital settings.     

No space left for intravenous thrombolysis in acute stroke: CONS

Recent successful clinical trials of endovascular thrombectomy for large artery ischaemic stroke have established the value of this treatment modality as an adjunct to intravenous thrombolysis, not as an alternative: thrombectomy delivery was undertaken in the context of highly efficient networks for acute thrombolysis delivery and the great majority of patients received IV thrombolytic drug treatment. Even for the minority of acute stroke patients for whom thrombectomy is potentially relevant, access will be limited by geography and service infrastructure. Developments in intravenous thrombolysis in the near future will likely produce safer and more effective intravenous treatments. Intravenous thrombolysis will remain the first line of treatment for the great majority of acute stroke patients.     

Thrombolysis for acute stroke in the United Kingdom

The publication of the National Institute of Neurological Disorders and Stroke trial of thrombolysis has not led to the widespread implementation of alteplase for acute ischaemic stroke in the United Kingdom. However, the Cochrane systematic review of thrombolysis for acute ischaemic stroke suggests that alteplase is the most promising treatment for acute ischaemic stroke. Successful implementation of thrombolysis in the United Kingdom will depend on continued investment in acute stroke services, attention to the known barriers to treatment, further data from randomized controlled trials and the licensing of alteplase for this indication.     

Venous thrombolysis: Current perspectives

Opinion statement Venous thromboembolism is a common problem in hospital and community patients and is associated with longer hospital stays, significant morbidity, and mortality. It is the third most common cardiovascular disease after ischemic coronary artery disease and stroke. A quarter of patients with acute myocardial infarction and more than half of patients with acute ischemic stroke may develop venous thromboembolism. The traditional treatment of venous thrombosis has been with anticoagulation, initially with heparin, followed by warfarin long term. The concept of thrombolysis for venous thrombosis is relatively new, but its exact role remains unsettled and largely unexplored. Reports of catheter fragmentation with systemic thrombolysis as well as catheter-directed thrombolysis are promising, and groups of patients who would benefit from thrombolytic therapy as the primary treatment are now being identified.     

合并糖尿病或胰岛素抵抗的缺血性卒中患者的抗血小板治疗

糖尿病是缺血性卒中患者抗血小板治疗后发生血小板高反应性的独立预测因素,而后者与卒中复发风险增高密切相关.糖尿病或胰岛素抵抗患者血小板反应性增高的机制与多种因素有关,一些血液循环分子可作为预测血小板反应性增高的标记物.监测新型抗血小板药治疗后的血小板反应性,可为合并糖尿病或胰岛素抵抗的缺血性卒中患者的个体化抗栓治疗提供依据.     

急性脑梗死患者重组组织型纤溶酶原激活物静脉溶栓后脑出血

重组组织型纤溶酶原激活物(recombinant tissue plasminogen activator,rtPA)静脉溶栓是急性缺血性卒中最有效的治疗手段,其最严重的并发症为有症状脑出血,文献撒道其总体发生率为6%,与血管损伤和通透性增加有关.某些临床特征、影像学和实验室检查可预测脑出血并发症风险.溶栓治疗后发生脑出血并发症的患者病死率和致残率极高,预后很差.文章对溶栓后脑出血的分型、发生率、预测因素和预后进行了综述.     

静脉联合超选择动脉溶栓治疗急性缺血性脑卒中的疗效及安全性

目的观察静脉联合超选择动脉溶栓治疗缺血性脑卒中的疗效及安全性。方法回顾分析2003年8月~2005年8月急性缺血性脑卒中患者67例,随机分为观察组34例和对照组33例,分别给予静脉联合动脉溶栓和单纯动脉溶栓治疗,比较两组患者间疗效。结果观察组与对照组再通率间差异有非常显著性意义(P<0·01);观察组发病3h内与3~6h溶栓患者再通率间差异有显著性意义(P<0·05)。结论静脉联合超选择动脉溶栓治疗缺血性脑卒中能明显提高闭塞血管的再通率,疗效好,见效快,明显改善预后,是治疗急性缺血性脑卒中有效和相对安全的方法。