HandiStroke: A Handheld Tool for the Emergent Evaluation of Acute Stroke Patients

BACKGROUND: The management of acute stroke is time-sensitive. Clinical decision making requires data not only from laboratory testing and neuroimaging, but also from a detailed history and neurologic examination. The neurologic examination provides baseline information and assists in differentiating acute stroke from its mimickers. There is a need for tools to facilitate the evaluation and decision making in the acute stroke patient to make the correct diagnosis and, when indicated, to properly administer intravenous thrombolytic therapy. OBJECTIVES: The goals of this project were to create a standardized, handheld software program to aid physicians in their evaluation of patients presenting to the emergency department (ED) with acute ischemic stroke, and to create an educational tool with which residents and other health care professionals can gain a level of proficiency in treating these patients. RESULTS: A comprehensive handheld tool was created that incorporates a National Institutes of Health Stroke Scale (NIHSS) calculator, inclusion criteria, absolute contraindications, and relative warnings for thrombolytic use (i.e., recombinant tissue plasminogen activator), and a weight-based dosing calculator that flows in a logical and clinically relevant format. Additionally, the program includes reference materials and guidelines for clinical management to further assist the clinician. CONCLUSIONS: Applications of this program include reformatting for use as a data-gathering tool in future clinical studies investigating the treatment of stroke patients, increasing the use and documentation of the NIHSS within the ED in acute ischemic stroke patients, and improving protocol adherence for rt-PA use.     

重组人组织型纤溶酶原激活剂溶栓后脑出血的脑梗死患者血压、心率、NIHSS评分和GCS评分的分析

目的 脑梗死患者在重组人组织型纤溶酶原激活剂（rt-PA）静脉溶栓后,对并发脑出血的患者进行血压、心率、美国国立卫生研究院卒中量表（national institutes of health stroke scale,NIHSS）评分、Glasgow昏迷评定量表（Glasgow coma scale）GCS评分的护理分析.方法 收集2011年4月至2013年4月,经静脉应用rt-PA溶栓的脑梗死患者共48例.分为2组：第1组为溶栓后未脑出血组共32例;第2组为溶栓后脑出血组共16例.比较2组溶栓前后和2组之间的收缩压、舒张压、心率、NIHSS评分和GCS评分.结果 溶栓后脑出血患者的收缩压、舒张压较自身溶栓前和同期未脑出血患者明显升高,溶栓后未脑出血患者的NIHSS评分较溶栓前明显降低,而溶栓后脑出血患者的NIHSS 评分较溶栓前明显升高.心率和GCS评分在溶栓后脑出血患者和未脑出血患者之间比较差异无统计学意义.结论 收缩压、舒张压的升高和NIHSS评分的升高,有助于我们判断患者溶栓后的早期脑出血.     

CT灌注成像在急性缺血性脑卒中rt-PA溶栓中的指导意义

目的 探讨CT灌注成像(CTP)在rt-PA静脉溶栓治疗急性缺血性脑卒中的价值.方法 25例急性缺血性脑卒中(发病时间<3h)患者行CTP检查组15例:见缺血半晴带应用rt-PA静脉溶栓组(见IP)10例,无缺血半暗带常规治疗组(无IP)5例.未行CTP检查应用rt-PA静脉溶栓组(对照组)10例.评价CTP指导下见IP组、无IP组和对照组患者疗效和预后.结果 见IP组rt-PA静脉溶栓后各时间段NIHSS评分与治疗前相比均有明显改善(P<0.001),而对照组NIHSS评分于24h、7d均无明显变化,直到30d后明显改善(P<0.01),而两组相比于24h后见IP组NIHSS评分明显低于对照组(P<0.05).见IP组未出现颅内出血及死亡病例,且Barthel指数明显高于对照组.对照组颅内出血率44%,死亡率11%.无IP组常规抗栓治疗NIHSS评分于24h、7d均无明显变化,30d后明显改善(P<0.01),与对照组相比无明显差异(P>0.05).结论 急性缺血性脑卒中在发病3h内,经CTP检查见IP者应用rt-PA溶栓安全、效果可靠;无IP者不予溶栓治疗而给予常规抗栓治疗,即能避免盲目溶栓所带来的出血及死亡风险,还能取得较好的远期疗效.     

Catheter-directed ultrasound-accelerated thrombolysis for the treatment of acute pulmonary embolism

Background

Systemic thrombolysis rapidly improves right ventricular (RV) dysfunction in patients with acute pulmonary embolism (PE) but is associated with major bleeding complications in up to 20%. The efficacy of low-dose, catheter-directed ultrasound-accelerated thrombolysis (USAT) on the reversal of RV dysfunction is unknown.

Materials and methods

We performed a retrospective analysis of 24 PE patients (60 ± 16 years) at intermediate (n = 19) or high risk (n = 5) from the East Jefferson General Hospital who were treated with USAT (mean rt-PA dose 33.5 ± 15.5 mg over 19.7 hours) and received multiplanar contrast-enhanced chest computed tomography (CT) scans at baseline and after USAT at 38 ± 14 hours. All CT measurements were performed by an independent core laboratory.

Results

The right-to-left ventricular dimension ratio (RV/LV ratio) from reconstructed CT four-chamber views at baseline of 1.33 ± 0.24 was significantly reduced to 1.00 ± 0.13 at follow-up by repeated-measures analysis of variance (p < 0.001). The CT-angiographic pulmonary clot burden as assessed by the modified Miller score was significantly reduced from 17.8 ± 5.3 to 8.7 ± 5.1 (p < 0.001). All patients were discharged alive, and there were no systemic bleeding complications but four major access site bleeding complications requiring transfusion and one suspected recurrent massive PE event.

Conclusions

In patients with intermediate and high risk PE, low-dose USAT rapidly reverses right ventricular dilatation and pulmonary clot burden.     

急性脑梗死溶栓治疗

目的观察溶栓治疗在时间窗内急性脑梗死的疗效。方法对7例应用溶栓治疗的急性脑梗死患者的临床特点、治疗、预后情况进行分析。结果急性脑梗死溶栓治疗对选择恰当的病人可能是有效的。结论正确地评估溶栓风险,对时问窗内急性脑梗死进行溶栓治疗可能是可行的。     

血浆PAI-1和TAFI的变化对STEMI患者静脉溶栓治疗后血管再通的预测价值

目的 通过检测急性心肌梗死( AMI)患者静脉溶栓前、后2小时内血浆凝血酶激活的纤溶抑制物(TAFI)和纤溶酶原激活物抑制剂-1(PAI-1)的含量,探讨两者的变化是否对溶栓后血管再通具有预测价值.方法2007年1月至2009年3月期间收集广州医学院第二附属医院急诊科16例急性ST段抬高心肌梗死(STEMI)患者溶栓前、后0.5,1,1.5,2h的血浆标本,并以16名健康人作为健康对照组,用ELISA法测定血浆中TAFI和PAI-1的含量.结果 (1)与健康对照组相比,STEMI患者溶栓前的血浆PAI-1水平显著升高(P＜0.01);而TAFI活性与对照组相比差异无统计学意义.(2)与溶栓前相比,溶栓后0.5,1,1.5,2h的血浆TAFI活性较溶栓前比较,差异无统计学意义(P＞0.05);溶栓后1.5,2h的血浆PAI-1显著升高(P＜0.01).(3)溶栓后2h冠脉未通组PAI-1水平显著高于再通组(P＜0.05);而冠脉未通组和再通组TAFI活性差异无统计学意义(P＞0.05).结论 升高的血浆PAI-1在溶栓后2h下降可能对溶栓后血管再通具预测价值,TAFI对血管冉通不具预测价值.     

基层医院阿替普酶在脑梗死4.5h内静脉溶栓的回顾性分析

目的:观察阿替普酶(alteplase,rt-PA)在脑梗死4.5 h内溶栓的有效性及安全性,分析影响静脉溶栓预后因素。方法:回顾2007-2012年台州一院和温州一院96例4.5 h内静脉溶栓患者的资料,以NINDS研究和ECASS-3研究的资料作为本研究的对照。结果:对比经典试验,有统计学差异表明溶栓改善近期及长期预后,24 h改善率达52.1%,3个月预后良好的比例为46.9%,虽然增加了颅内出血风险,但以非症状性颅内出血为主,且不增加总体死亡率。良好预后与基线NIHSS评分≤12和24 h改善率相关。结论:只要严格掌握了溶栓的适应症和禁忌症,阿替普酶4.5 h内静脉溶栓是有效且安全的,特别是轻、中度(NIHSS≤12)卒中患者获益最大;可明显改善脑梗死患者的预后;不良预后与基线卒中病情严重相关。     

用HAT评分预测rt-PA静脉溶栓治疗脑梗死后出血的临床研究

[目的]探索HAT评分(溶栓后出血评分)与使用rt-PA(0.6mg/kg体重)静脉溶栓治疗脑梗死后颅内出血情况的关系,为使用HAT指导溶栓治疗做准备。[方法]对162名进行了重组组织型纤溶酶原激活剂(rt-PA,按0.6mg/kg体重)静脉溶栓的急性前循环脑梗死患者,分别记录HAT评分的各分项评分情况,按HAT0分、1分、2分、3分和≥4分为5组,记录各组患者的溶栓后颅内出血情况(分为非症状性、症状性及致死性颅内出血)和90d后的功能结局(以改良Rankin评分,mRs表示),各组间进行比较。[结果]HAT0分、1分、2分、3分和≥4分各组的总颅内出血的百分比分别为2.7%、10.2%、20.0%、31.2%和50.0%;症状性颅内出血的比例分别为0.0%、2.0%、5.0%、12.6%和50.0%,卡方检验得χ2=28.0,P﹤0.001(Monte Carlo确切概率法),提示HAT分值的增加,颅内出血的比例及严重程度在增加,存在统计学上的差异。另外将HAT和出血类型做spearman等级相关分析,得到spearman相关系数0.306,P﹤0.001;说明HAT得分和出血程度正相关。本研究患者队列的症状性出血比例为3.1%,低于NINDS研究的5.9%。随着HAT评分的增加,取得良好预后(mRs≤2的比例)的可能性越来越小。[结论]对于按0.6mg/kg体重,时间窗为4.5h使用rt-PA进行静脉溶栓的急性脑梗死患者,HAT评分的增加与颅内出血风险的增加正相关。HAT可能作为预测溶栓后颅内出血风险的一个简单易行的实用临床工具。     

Venöse Interventionen – Teil 1: Interventionstechniken und Thrombosen der Bein- und Beckenvenen

Venous thrombosis is one of the most common vascular diseases. Without treatment, pulmonary embolism is a potentially life-threatening complication. Long-term complications are chronic venous insufficiency and post-thrombotic syndrome. Medical anticoagulation is currently the standard therapy, since it prevents appositional thrombus growth although it usually can not prevent the development of post-thrombotic syndrome. The structure of the thrombotic material often leads to partial recanalisation with residual stenosis. Early and sufficient systemic thrombolysis with adequate concentration may achieve disintegration of the thrombus and preservation of venous valve function. Supplementary to conservative therapy, local catheter thrombolysis is possible even in cases with contraindications for a systemic thrombolysis therapy. Additional interventional techniques reduce the required concentration of the thrombolytic. Venous stenosis can be treated by balloon angioplasty and stent implantation. This article reviews the different percutaneous treatment options as well as their application and usefulness in thrombosis of the lower torso.