急性卒中患者的缺血半暗带评价

卒中的发病率、致残率和死亡率均很高.缺血半暗带评价对于指导临床治疗和评估预后具有非常重要的意义.目前,可采用MRI、CT、正电子发射体层摄影和单光子发射计算机体层摄影等影像学技术评价缺血半暗带.     

Imaging of acute stroke

Acute stroke patients represent an important diagnostic and therapeutic challenge. Patients with brain damage in the ischemic, but not yet infarcted, phase have the greatest potential for recovery. Here we review the most commonly employed diagnostic tools that are currently used before stroke therapy. While computed tomography is pertinent to differentiate ischemic from hemorrhagic stroke, this technique cannot be used as an etiological screening too. The ischemic origin of symptoms can be confirmed with magnetic resonance imaging which also contributes to for therapeutic decision making, prognosis assessment and etiological screening.     

急性脑梗死患者影像学缺血半暗带的临床评价策略

缺血性卒中再灌注治疗近年来取得了重大进展,治疗前快速精准评估缺血半暗带是临床诊治的紧迫需求.目前,影像学是显示缺血半暗带最直观、有效的方法,该方法通过利用组织窗筛选出能够从再灌注治疗中获益的患者,并预估风险和预后.作者介绍了急性脑梗死影像学缺血半暗带的临床评估模式,并对不同发病时间、拟进行再灌注治疗患者的缺血半暗带评价...     

Blood pressure in acute stroke

Elevated systolic blood pressure levels (> or =160 mmHg) are a common complication of acute stroke, affecting up to 60% of patients, and providing an immediate management dilemma in the 40% of acute stroke patients on pre-existing antihypertensive therapy. There are theoretical reasons for both lowering blood pressure in the acute stroke situation, as well as leaving raised levels untreated. Furthermore, low systolic blood pressure levels (< or =140 mmHg), though a less common problem affecting approximately 20% of patients, may also be associated with increased morbidity and mortality. However, limited data exists from randomised, placebo-controlled trials to inform as to the optimum management of acute stroke blood pressure. This review will consider the evidence for and against the therapeutic manipulation of acute stroke blood pressure, and discuss the information currently available from observational and therapeutic intervention trials, as well as consider the ongoing clinical trials in this area.     

Clock drawing in acute stroke

We studied 118 elderly subjects with first-ever stroke free of severe cognitive impairment and able to write. Within 14 days of stroke we measured clock drawing, ability to copy drawings of dual pentagons and a house, line bisection, Mini-Mental State score, homonymous hemianopia and visual and tactile extinction. Thirty subjects had impaired clock drawing. When compared with the remaining 88 subjects with normal clock drawing the impaired group had similar pre-stroke characteristics but had significantly more severe stroke deficits. Hospital stay was significantly longer in the impaired group and a much greater proportion of subjects were discharged to long-term hospitals rather than home. Barthel ADL scores at days 7, 30, 60 and maximal recovery were significantly lower. Using a multivariate generalized linear model, clock drawing was a significant independent predictor of maximal Barthel ADL after accounting for other significant predictors such as Barthel score at day 7, limb power, visual extinction, line bisection error and Mini-Mental State score. Impaired clock drawing can reflect either cognitive impairment or spatial neglect.     

急性卒中的机械溶栓

1引言 在美国,静脉内(IV)组织型纤溶酶原激活物(tPA)是目前惟一获得批准的一种卒中疗法.在美国国立神经病和卒中研究所(NINDS)的试验中,尽管接受tPA治疗的患者约有一半得到完全恢复,但其亚组分析表明,较严重的卒中患者用tPA治疗取得明显改善的几率只有8%.这些患者的不良转归促使我们寻找更有效的急性卒中治疗措施.     

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目的探讨急性脑卒中患者肺部感染的高发因素及并发肺部感染对预后的影响,寻求降低肺部感染率的方法。方法分析1996-2003年间上海同济大学附属同济医院神经内科急性脑卒中患者391例,采用卡方检验法分析肺部感染率与患者年龄、病种、病情、基础疾病及预后的关系。结果高龄、病情重、原有糖尿病、心脏病、肿瘤、免疫系统疾病及中风史患者,其肺部感染率明显升高,并发肺部感染的脑卒中患者病死率明显升高。结论控制院内肺部感染可有效提高脑卒中救治成功率。     

Fibrinolytic therapy in acute stroke

Acute ischemic stroke is a major cause of morbidity and mortality in Europe, North America, and Asia. Its treatment has completely changed over the past decade with different interventional approaches, such as intravenous trials, intra-arterial trials, combined intravenous/intra-arterial trials, and newer devices to mechanically remove the clot from intracranial arteries. Intravenous thrombolysis with tissue plaminogen activator (tPA) within 4.5 hours of symptoms onset significantly improved clinical outcomes in patients with acute ischemic stroke. Pharmacological intra-arterial thrombolysis has been shown effective until 6 hours after middle cerebral artery occlusion and offers a higher rate of recanalization compared with intravenous thrombolysis, whereas combined intravenous/ intra-arterial thrombolysis seems to be as safe as isolated intravenous thrombolysis. The more recent advances in reperfusion therapies have been done in mechanical embolus disruption or removal. Merci Retriever and Penumbra System have been approved for clot removal in brain arteries, but not as a therapeutic modality for acute ischemic stroke since it is no clear whether mechanical thrombectomy improves clinical outcome in acute stroke. However, mechanical devices are being used in clinical practice for patients who are ineligible for tPA or who have failed to respond to intravenous tPA. We summarize the results of the major thrombolytic trials and the latest neurointerventional approaches to ischemic stroke.     

Functional neuroimaging in acute stroke

To the present day, the first and most widespread diagnostic approach in the assessment of acute stroke remains CT scan. Its sensitivity is very high (nearly 100%) in detecting intracerebral hemorrhage in the acute period, but its capability of revealing ischemic injury in the very first hours from symptom onset is relatively poor. Since the efficacy of thrombolytic treatment in acute stroke has been suggested by the ECASS and NINDS rt-PA trials, functional neuroimaging able to distinguish potentially salvageable tissue from irreversibly injured areas has acquired primary importance. The possibility to correctly identify the tissue of the ischemic penumbra within the first hours from symptom onset is essential for correct patient selection for thrombolitic treatment. Different imaging strategies are available for the definition of perfusion deficits within the acute time window; among these are positron emission tomography (PET), single photon emission computed tomography (SPECT), Xenon CT (XeCT), dynamic CT perfusion imaging (CTP), diffusion weighted magnetic resonance imaging (DW-MRI), and perfusion weighted magnetic resonance imaging (PW-MRI). Though each technique has its advantages and limitations to present day functional MRI remains the most widespread imaging technique in the assessment of acute stroke being more accessible than both SPECT and PET, and capable of giving information on both perfusion and tissue functional status in a single imaging session. In this paper we discuss the role of functional neuroimaging in acute stroke.     

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.     

Innovative strategies in the management of acute stroke

Advances in acute stroke therapy are rapidly changing our approach to management of patients with ischemic stroke. Intravenous tissue-plasminogen activator (tPA) was the first treatment demonstrated in a randomized controlled trial to improve outcome if given within the first 3 hours of stroke onset. Subsequent trials failed to extend the time window for intravenous therapy beyond 3 hours. Intra-arterial thrombolysis provides an alternative approach, with several advantages over intravenous therapy. The major drawback is the additional time needed for the interventional procedure, and the equipment and personnel requirements. New strategies aimed at reducing the total time from stroke onset to recanalization of occluded arteries include a combined intravenous/ intra-arterial delivery of thrombolysis and mechanical devices. For the millions of stroke survivors, investigations are now underway into the possibility of improvement of function through neuronal transplantation.     

Intravenous heparin for the prevention of stroke progression in acute partial stable stroke

In a double-blind, placebo-controlled trial, 225 patients with acute partial stable thrombotic stroke were randomly assigned to receive continuous intravenous heparin therapy or placebo for 7 days for the prevention of stroke progression or death. No statistically significant difference between the two groups was found in degree of neurologic change; incidence of stroke progression after 7 days; or functional activity level of survivors at 7 days, 3 months and at 1 year after treatment. Compared with controls, a statistically significant greater number of patients in the group receiving heparin died in the year after the stroke. These deaths occurred 3 to 12 months after the initial stroke and probably were not related to treatment. Results of this study do not support the use of intravenous heparin to treat patients who have had acute partial stroke.     

急性卒中后谵妄

谵妄是急性卒中的一种常见并发症,通常提示患者转归不良、病死率较高、住院时间较长以及痴呆风险增高.因此,急性卒中后谵妄的早期发现和干预具有重要意义.文章从卒中后谵妄的发病机制、危险因素、诊断评估、治疗和转归等方面进行了综述.     

Thrombolysis for acute stroke

Thrombolysis for acute stroke is effective if administered according to the approved protocol. Since the initial report of success in 1995, a number of subsequent reports confirmed the safety and efficacy of this treatment. There is no particular subgroup of patients at increased likelihood of benefit or hemorrhage that can be identified at baseline. Unlike many expensive therapies, thrombolysis for acute stroke saves the health care system considerable long-term costs. The search for even safer and more effective thrombolytics continues.