急性缺血性卒中溶栓治疗

试验状态 :从 2 0 0 3年 10月开始 ,已经募集 3例患者。试验目的 :比较动脉内rtPA溶栓与静脉rtPA溶栓的疗效。试验设计 :多中心剂量开放随机对照试验 ,采用盲法随访。纳入标准 :大脑中动脉 (MCA)缺血性卒中发病 3h内的患者。排除标准 :卒中发病前已有残疾 ,发病时昏迷 ,神经功能缺损迅速改善 ,发病时出现癫 ,对比增强剂过敏 ,分娩期或哺乳期 ,未经控制的高血压 ,颅内出血 ,溶栓治疗的禁忌证或存在其他有可能增加患者危险的任何情况。患者处理 :患者随机分为静脉溶栓组和动脉内溶栓组 ,静脉溶栓组患者 (rtPA 0 9mg/kg ,最大剂量 90mg)…     

缺血性脑卒中的溶栓治疗

急性缺血性脑卒中(AIS)又称脑梗死,是由于局部脑血流突然中断引起局部脑组织缺血坏死而致的相应神经功能缺损。它威胁着上千万人的生命,是工业化国家第3死亡原因,仅次于心肌梗死和癌症,同时它也是造成终身残疾的首要原因[1]。在脑卒中发生后脑血管造影显示80%病人有动脉闭塞,如     

急性缺血性卒中的溶栓治疗策略

溶栓治疗是急性缺血性卒中的主要治疗方法.组织型纤溶酶原激活剂是美国食品药品管理局唯一批准的卒中治疗药物,但由于治疗时间窗狭窄和存在出血并发症风险等原因限制了其临床应用.为了解决这个问题,大量的临床试验开始致力于动脉溶栓、机械溶栓和超声溶栓治疗的研究.     

卒中的溶栓治疗

1引言1.1背景业已证实,溶栓治疗对经过选择的缺血性卒中患者是有益的.8项应用不同溶栓药物、剂量和时间窗的大规模Ⅲ期静脉溶栓治疗试验的完成为指导临床实践提供了一个丰富的数据库.     

Medical therapy for acute ischemic stroke

Over the past decade, there has been an explosion in data related to the treatment of patients with acute ischemic stroke. Thrombolytic therapy with intravenous tissue plasminogen activator has revolutionized the approach to stroke treatment. Intra-arterial administration of thrombolytic agents is also being investigated and is now being used on a compassionate basis. Medical management can have a large impact on stroke-related outcomes, even in patients who do not receive thrombolytic therapy.     

Thrombolytic treatment of acute stroke

Ischemic stroke is a medical emergency and must be treated as quickly as possible according to the "time-is-brain" concept. At present, intravenous administration of recombinant tissue plasminogen activator (rt-PA) within the first 4.5 h from stroke onset is the only effective treatment but is currently still only approved within the first 3 h from onset of symptoms (0.9 mg/kg body weight, maximum dose 90 mg, 10% of the cumulative dose as bolus, remaining 90% subsequently infused within 60 min). The therapeutic effect of magnetic resonance imaging (MRI) based thrombolytic therapy beyond the 4.5 h time window remains to be proven. Proximal occlusions of the middle cerebral artery can be treated successfully within the first 6 h from stroke onset by catheter-based intra-arterial administration of plasminogen activator leading to a significant improvement of outcome. Acute basilar artery occlusion should be treated in specialized centres using intra-arterial application of urokinase, rt-PA or mechanical recanalization but intravenous thrombolysis beyond the 3 h window is an acceptable alternative.     

Thrombolytic therapy in acute myocardial infarction

The effect of thrombolysis in acute myocardial infarction on infarct size, left ventricular function, clinical course and patient survival was studied in a randomized trial comparing thrombolysis (269 patients) with conventional treatment (264 control patients). All 533 patients were admitted to the coronary care unit within 4 hours after the onset of symptoms related to the infarction. Baseline characteristics were similar in both groups. Informed consent was requested only of patients allocated to thrombolysis; no angiography was performed in 35. The infarct-related artery was patent in 65 patients and occluded in 169. Recanalization was achieved in 133 patients. The median time to angiographic documentation of vessel patency was 200 minutes after the onset of symptoms. The clinical course in the coronary care unit was more favorable after thrombolysis. Infarct size, estimated from myocardial enzyme release, was 30% lower after thrombolysis. In patients admitted within 1 hour after the onset of symptoms the reduction of infarct size was 51%, in those admitted between 1 and 2 hours it was 31% and in those admitted later than 2 hours it was 13%. Left ventricular function measured by radionuclide angiography before hospital discharge was better after thrombolysis (ejection fraction 48 ± 15%) than in control patients (44 ± 15%). Similar improvement was observed in patients with a first infarct only (thrombolysis 50 ± 14%, control subjects 46 ± 15%), in patients with anterior infarction (thrombolysis 44 ± 16%, control subjects 35 ± 14%) and in those with inferior infarction (thrombolysis 52 ± 12%, control subjects 49 ± 12%). Similar results were obtained by contrast angiography. Mortality was lower after thrombolysis. After 28 days 16 patients allocated to thrombolysis and 31 control patients had died. One year survival rates were 91 and 84%, respectively. On the other hand, nonfatal reinfarction occurred more frequently after thrombolysis (36 patients) than in control subjects (16 patients). Early thrombolysis by intracoronary streptokinase leads to a smaller infarct size estimated by enzyme release, preserves left ventricular function at the second week and leads to improved 1 year survival.

Originally published in the Journal of the American College of Cardiology, April 1986.     

急性心肌梗死的溶栓治疗

80年前 ,美国Ｈｅｒｒｉｃｋ和苏联Ｏｂｒａｓｔｚｏｗ和Ｓｔｒａｓｃｈｅｓｋｏ首次描述了冠状动脉突然闭塞的临床特征。但是 ,直到上个世纪 80年代初 ,通过对急性心肌梗死 (ＡＭＩ)发病机制的深入研究 ,人们才逐步认识到 :冠状动脉粥样硬化斑块破裂基础上的血栓形成、冠状动脉急性闭塞是ＡＭＩ发生的根本原因。之后Ｒｅｎｔｒｏｐ在国际上首次报道了链激酶 (ＳＫ)冠状动脉内溶栓治疗 ,从此 ,ＡＭＩ的治疗进入了再灌注治疗的新时期。现今 ,静脉内溶栓已被广泛用于ＡＭＩ的治疗。尽管如此 ,溶栓治疗本身以及在实际临床应用过程中 ,仍有诸多…     

Stroke intervention: catheter-based therapy for acute ischemic stroke

The majority (>80%) of the three-quarters of a million strokes that will occur in the United States this year are ischemic in nature. The treatment of acute ischemic stroke is very similar to acute myocardial infarction, which requires timely reperfusion therapy for optimal results. The majority of patients with acute ischemic stroke do not receive any form of reperfusion therapy, unlike patients with acute myocardial infarction. Improving outcomes for acute stroke will require patient education to encourage early presentation, an aggressive expansion of qualified hospitals, and willing providers and early imaging strategies to match patients with their best options for reperfusion therapy to minimize complications.     

Problems related to short-term antihypertensive therapy in acute ischemic stroke

Hypertension is a common early finding after an acute ischemic stroke, even in previously normotensive patients. But its significance and proper management are a matter of debate, because of the lack of adequately powered randomized clinical trials. A close analysis of observational and interventional trials, published so far, fails to convince that an early antihypertensive therapy is needed and beneficial. During the first 24-48 hr after ischemic stroke, only blood pressure values repeatedly higher than 220/120 mmHg require antihypertensive treatment to keep blood pressure levels in the range of 180-220 mmHg systolic and 100-120 diastolic. Blood pressure reduction should be cautious with the aim of keeping the pressure at relatively high values (180/100-105 in previously hypertensive patients and 160-180/90-100 in previously normotensive patients). The usefulness of increasing blood pressure with vasopressive agents in selected patients with ischemic stroke deserves adequate testing with randomized clinical trials.     

急性缺血性卒中再灌注治疗后血管再闭塞

急性缺血性卒中是最常见的卒中类型,在发病4.5 h内进行静脉溶栓仍是目前最有效的治疗方法.其他再灌注治疗,如血管内血栓切除术也显示出其安全性和有效性.然而,部分接受再灌注治疗的患者会出现血管再闭塞,且与转归不良相关.文章对再灌注后血管再闭塞的发生机制和可能防治措施进行了综述.