Clinical implication of hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator

To determine the clinical implications of hemorrhagic transformation (HT) after thrombolysis, 241 eligible patients receiving alteplase for acute ischemic stroke were studied. HT was classified, according to the European Cooperative Acute Stroke Study criteria, as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH). Symptomatic intracranial hemorrhage (SICH) was defined according to the National Institute of Neurological Disorders and Stroke study. A novel classification, clinically significant intracranial hemorrhage (CSICH) was defined as HTs associated with an unfavorable clinical outcome (modified Rankin Scale 5–6) at 3 months. For all subtypes of HT, we found that patients receiving alteplase were more often in the standard-dose group (0.90 ± 0.02 mg/kg) than in the lower dose group (0.72 ± 0.07 mg/kg). PH and SICH were related to an unfavorable clinical outcome, while HI was not. There was a positive trend between age and CSICH in patients receiving the standard dose (P = 0.0101), and between alteplase dose and CSICH in patients ≥70 years old (P = 0.0228). All PHs (including asymptomatic PHs) and symptomatic HIs have been found to be associated with unfavorable outcome, and for this reason defined as CSICH. Independent predictors of CSICH were age ≥70 years and the standard dose of alteplase. Further studies of thrombolysis for ischemic stroke with different doses of alteplase are warranted.     

Arterial reocclusion in stroke patients treated with intravenous tissue plasminogen activator

BACKGROUND: Arterial reocclusion has not been systematically studied despite the fact that 13% of patients in the National Institute of Neurological Diseases and Stroke rt-PA Trial deteriorated following initial improvement, suggesting that reocclusion might be responsible for poor clinical outcome in some of these patients. METHODS: Consecutive stroke patients treated with IV tissue plasminogen activator (TPA) within 3 hours and an M1 or M2 middle cerebral artery (MCA) occlusion on pre-TPA transcranial Doppler (TCD) were monitored up to 2 hours after TPA bolus. Reocclusion was defined as the Thrombolysis in Brain Ischemia flow decrease by >/=1 grades and no hemorrhage on repeat CT. The NIH Stroke Scale (NIHSS) and modified Rankin Scores (mRS) were obtained by a neurologist independently of TCD. RESULTS: Sixty patients with median prebolus NIHSS score of 16 (range 6 to 28, 90% with >/=10 points) had TPA bolus at 130 +/- 32 minutes (median 120 minutes, 58% within the first 2 hours). Recanalization was complete in 18 (30%), partial in 29 (48%), and none in 13 (22%) patients. Reocclusion occurred in 34% of patients with any initial recanalization (16/47): in 4 of 16 patients with complete recanalization (22%), and in 12 of 29 patients with partial recanalization (41%). Reocclusion was detected in four patients (25%) before TPA bolus, in three (19%) by 30 minutes after bolus, in three (19%) by the end of infusion, and in six (37%) by 60 to 120 minutes. Before reocclusion, those patients had earlier median timing of recanalization: 130 versus 180 minutes after stroke onset compared with those who recanalized without reocclusion (p = 0.01). Median prebolus NIHSS score in the reocclusion group was 13.5 versus 17 (rest, NS), whereas at 2 and 24 hours, their NIHSS scores were higher: 14 versus 9 and 16 versus 6 points (p /=4 NIHSS points occurred in 8 of 16 (50%) patients with reocclusion versus 10% (rest) (p < 0.05). In-hospital mortality was 25 versus 3% (p < 0.0001). At 3 months, good outcome (mRS score of 0 to 1) was achieved by 8% of patients with no recanalization, by 33% of patients with reocclusion, and by 50% of patients with stable recanalization (p 相似文献   

急性脑梗死患者阿替普酶静脉溶栓的疗效及出血性转化影响因素分析

目的研究阿替普酶(rt-PA)静脉溶栓治疗急性脑梗死(ACI)的疗效,并分析静脉溶栓后出血性转化(HT)的影响因素。方法选择发病在6h以内的ACI患者174例,根据治疗方法的不同分为静脉溶栓和常规治疗两组,比较两组治疗前和治疗后24h、14d美国国立卫生研究院卒中量表(NIHSS)评分,90d后改良Rankin量表(m RS)评分的变化,并记录不良反应;比较静脉溶栓组有无出血并发症患者之间的影响因素,多因素回归分析确定溶栓后HT的独立危险因素。结果 1静脉溶栓组溶栓后24h、14d NIHSS评分较溶栓前明显降低(P0.05),常规治疗组治疗后24 h、14 d NHISS评分与溶栓前比较,差异无统计学意义(P0.05),治疗后同一时间点比较静脉溶栓组的NHISS评分均低于常规治疗组(P0.05);2静脉溶栓组患者90d后预后良好率高于常规治疗组(58.4%vs42.3%,2=4.423,P0.05)。两组之间死亡率差异没有统计学意义(12.5%vs19.2%,2=1.487,P0.05;3多因素回归分析显示治疗前NHISS评分(OR:1.517,1.2142.261,P0.05)、心房颤动病史(OR:1.431,1.2792.041,P0.05)是溶栓后HT的独立危险因素。结论rt-PA静脉溶栓对发病6h内的ACI患者的疗效优于常规治疗;治疗前NHISS评分、有心房颤动病史是影响溶栓后HT的独立危险因素。     

急性脑梗死重组组织型纤溶酶原激活物静脉溶栓后严重出血性转化研究进展

严重出血性转化是静脉溶栓治疗最危险的并发症。本文对近年来有关静脉溶栓后严重出血性转化的定义、临床表现、影像学特征以及相关危险因素的研究进展进行综述。对具有严重出血性转化高风险的急性脑梗死患者可以选择低剂量重组组织型纤溶酶原激活物(recombinant tissue plasminogen activator,rtPA)静脉溶栓治疗,以降低症状性颅内出血的发生风险。     

脑白质T2高信号与缺血性卒中静脉溶栓后出血转化及神经功能的关系

目的 明确脑白质高信号(WMHs)的严重程度与急性缺血性卒中患者静脉重组组织型纤溶酶原激活剂(rt-PA)溶栓后的出血转化以及3个月后神经功能结局之间的关系.方法 连续收集就诊于我科并接受静脉rt-PA溶栓治疗的急性缺血性卒中患者144例,分析其临床资料,利用改良Schelten量表评定脑白质高信号严重程度,出血转化根据欧洲协作性急性卒中研究Ⅲ(ECASSⅢ)标准评定,改良Rankin评分≥2分定义为神经功能结局不利.结果 144例接受静脉rt-PA溶栓治疗的患者年龄为(66.6±12.6)岁,女性46例(31.9％),发病至溶栓时间为(241.9 ±88.4) min,溶栓前NIHSS为(12.31±5.98)分,脑白质高信号评分为(7.81±4.93)分.共28例(19.4％)影像学表现为溶栓后出血转化,其中18例(12.5％)为出血性梗死(HI)型,10例(6.9％)为脑实质出血(PH)型.经多元Logistic回归分析提示,WMHs严重程度不增加HI型风险(OR=1.017,95％ CI0.919 ～1.126,P =0.744),对PH型风险亦无增加(OR=1.025,95％CI0.895 ～1.175,P=0.716).二元Logistic回归分析提示,脑白质高信号严重程度是神经功能结局不利的独立危险因素(OR=1.135,95％ CI1.036 ～1.244,P=0.007).结论 严重WMHs不增加急性缺血性卒中静脉rt-PA溶栓后的出血转化风险,但与卒中后不利神经功能结局有关.     

Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator

OBJECTIVE: To evaluate clinical, biological, and pretreatment imaging variables for predictors of tissue plasminogen activator (tPA) related intracerebral haemorrhage (ICH) in stroke patients. METHODS: 48 consecutive patients with hemispheric stroke were given intravenous tPA within seven hours of symptom onset, after computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Baseline diffusion weighted (DWI) and perfusion weighted (PWI) imaging volumes, time to peak, mean transit time, regional cerebral blood flow index, and regional cerebral blood volume were evaluated. The distribution of apparent diffusion coefficient (ADC) values was determined within each DWI lesion. RESULTS: The symptomatic ICH rate was 8.3% (four of 48); the rate for any ICH was 43.8% (21 of 48). Univariate analysis showed that age, weight, history of hyperlipidaemia, baseline NIHSS score, glucose level, red blood cell count, and lacunar state on MRI were associated with ICH. However, mean 24 hour systolic blood pressure and a hyperdense artery sign on pretreatment CT were the only independent predictors of ICH. Patients with a hyperdense artery sign had larger pretreatment PWI and DWI lesion volumes and a higher NIHSS score. Analysis of the distribution of ADC values within DWI lesions showed that a greater percentage of pixels had lower ADCs (< 400 x 10(-6) mm(2)/s) in patients who experienced ICH than in those who did not. CONCLUSION: Key clinical and biological variables, pretreatment CT signs, and MRI indices are associated with tPA related intracerebral haemorrhage.     

血浆中PAI-1和TAFI水平与溶栓后出血性转化相关性研究

目的探索PAI及TAFI对急性脑梗死静脉溶栓后出血性转化的预警作用。方法前瞻性的将溶栓患者分为出血转化组和无出血转化组,对两组患者溶栓前及溶栓后静脉血浆PAI及TAFI浓度进行对比及统计学分析。结果溶栓前两组基线PAI-1水平差异有明显统计学意义(P=0.037)。溶栓后次日复查晨血PAI-1水平出血转化组明显较无出血转化组值更低(P=0.035)。溶栓前出血转化组的基线TAFI水平较无出血转化组比较TAFI值更低(P=0.024)。溶栓后次日复查晨血出血转化组TAFI值同样低于无出血转化组(P=0.042)。结论血浆中PAI-1和TAFI水平与溶栓后出血性转化相关性较高。当溶栓前及溶栓后PAI-1及TAFI的低水平表达均可增加溶栓后出血性转化的风险。     

急性缺血性卒中重组组织型纤溶酶原激活剂静脉溶栓致出血性转化及其预后的危险因素分析

目的 探讨急性缺血性卒中重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓后发生出血性转化(HT)的可能危险因素以及这些危险因素对患者预后的影响.方法 128例急性缺血性卒中患者发病6h内接受rt-PA静脉溶栓治疗,选取溶栓前临床和实验室资料,通过比较HT组与非HT组之间的差异,筛选与HT相关的可能危险因素,并进一步通过Logistic回归分析影响HT及其预后的独立危险因素.结果 128例溶栓患者有29例继发HT(22.66％),其中16例为症状性脑出血(12.50％),死亡2例,占HT的6.90％.Logistic回归分析表明房颤(OR=1.293,95％ CIl.224 ～1.589,P=0.00l)、早期CT改变(OR=2.452,95％ CI 1.132～3.309,P=0.034)、基线舒张压≥100 mm Hg(1 mm Hg=0.133 kPa,OR=9.265,95％ CI 1.435 ～ 59.836,P=0.019)、基线血糖≥11.1 mmol/L(OR=3.037,95％ CI0.252 ～ 57.593,P=0.047)、NIHSS评分＞15分(OR=8.752,95％CI 1.035 ～30.285,P=0.023)和溶栓时间窗＞3h(OR=98.74,95％CI 5.067 ～ 186.120,P=0.002)6项为HT独立危险因素,其中基线血糖≥11.1 mmol/L(OR=3.265,95％ CI 0.435 ～ 59.863,P=0.045)、NIHSS评分＞15分(OR=10.453,95％ CI 5.647～38.185,P=0.003)和溶栓时间窗＞3h(OR =2.541,95％CI 1.098 ～51.086,P=0.017)影响了HT患者的预后.结论 溶栓前的舒张压、血糖水平、神经功能缺损程度、CT低密度改变或水肿占位效应、房颤和溶栓时间窗是HT的独立危险因素,其中基线血糖水平、神经功能缺损程度和溶栓时间窗影响了溶栓后HT患者的预后.     

T2*-weighted MRI in diagnosis of multiple system atrophy

Abstract Background Putaminal iron deposition is a histopathological feature of multiple system atrophy (MSA), which is not observed in patients with idiopathic Parkinson's disease (PD). T2*-weighted magnetic resonance imaging (MRI) gradient echo (GE) sequences are sensitive for paramagnetic susceptibility changes and therefore may support the clinical differential diagnosis between MSA and PD. Methods We evaluated putaminal signal intensities on 1.0 Tesla scans of 52 MSA patients, 88 patients with PD and 29 healthy control subjects. Results The typical finding in T2* GE sequences of MSA patients was a signal loss of the dorsolateral putamen, which showed a high specificity (>0.91), but was present in only a subpopulation of patients (sensitivity 0.64–0.69). The combination of the latter with additional presence of a hyperintense lateral rim in fluid attenuated inversion recovery (FLAIR) sequences increased the specificity to 0.97. Using a quantitative evaluation of putaminal signal intensities in defined regions of interest MSA and PD could be discriminated with a diagnostic accuracy (r) of up to 0.82. Conclusion Although the separation of groups remains incomplete, the use of T2*-weighted GE sequences combined with FLAIR may be helpful for the differential diagnosis of MSA versus PD considering its fast application, easy evaluation, broad availability, the specificity of findings and the presence of putaminal signal loss already at early disease stages.     

Influence of pretreatment MRI parameters on clinical outcome, recanalization and infarct size in 49 stroke patients treated by intravenous tissue plasminogen activator

We hypothesized that pretreatment magnetic resonance imaging (MRI) parameters might predict clinical outcome, recanalization and final infarct size in acute ischemic stroke patients treated by intravenous recombinant tissue plasminogen activator (rt-PA). MRI was performed prior to thrombolysis and at day 1 with the following sequences: magnetic resonance angiography (MRA), T2*-gradient echo (GE) imaging, diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI). Final infarct size was assessed at day 60 by T2-weighted imaging (T2-WI). The National Institutes of Health Stroke Scale (NIHSS) score was assessed prior to rt-PA therapy and the modified Rankin Scale (m-RS) score was assessed at day 60. A poor outcome was defined as a day 60 m-RS score >2. Univariate and multivariate logistic regression analyses were used to identify the predictors of clinical outcome, recanalization and infarct size. Forty-nine patients fulfilled the inclusion criteria. Baseline NIHSS score was the best independent indicator of clinical outcome (p=0.002). A worse clinical outcome was observed in patients with tandem internal carotid artery (ICA)+middle cerebral artery (MCA) occlusion versus other sites of arterial occlusion (p=0.009), and in patients with larger pretreatment PWI (p=0.001) and DWI (p=0.01) lesion volumes. Two factors predict a low rate of recanalization: a proximal site of arterial occlusion (p=0.02) and a delayed time to peak (TTP) on pretreatment PWI (p=0.05). The final infarct size was correlated with pretreatment DWI lesion volume (p=0.025). Recanalization was associated with a lower final infarct size (p=0.003). In conclusion, a severe baseline NIHSS score, a critical level of pretreatment DWI/PWI parameters and a proximal site of occlusion are predictive of a worse outcome after IV rt-PA for acute ischemic stroke.