rt-PA静脉溶栓治疗50例急性脑梗死疗效及安全性分析

目的探讨重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗急性脑梗死的临床效果及安全性。方法选择发病在4.5h内,平均2.86±0.8h内急性脑梗死患者73例,分为两组,溶栓组50例患者给予rt-PA 0.9mg·kg-1·d-1静脉溶栓,常规治疗组23例患者采用抗血小板聚集药物等治疗,比较溶栓和常规治疗后24h、7d及14d美国国立卫生研究院卒中量表(NIHSS)评分并记录不良反应。结果溶栓组治疗后24h、7d及14d时,NIHSS评分较溶栓前及对照组均明显减少,差异有统计学意义(P<0.05);溶栓后头颅MRI/CT及临床表现提示未出现症状性脑出血。结论 rt-PA静脉溶栓治疗发病4.5h内脑梗死是安全有效的。     

Use of the Trellis™ Peripheral Infusion System for Enhancement of rt-PA Thrombolysis in Acute Lower Limb Ischemia

The Trellis Peripheral Infusion System is an over-the-wire 0.035 guidewire compatible device, designed to isolate a region of the peripheral vasculature to allow for lytic drug infusion and dispersion. We used it successfully through a percutaneous approach in two cases of acute thrombosis of a native lower limb artery. The total amount of rt-PA used was 12 and 9 mg, respectively and was delivered through bolus injections obviating the need for a supplementary continuous infusion of the agent. The time for dissolution of thrombus was 45 and 35 minutes, respectively. No complications were observed.     

Intracranial Dural Sinus Thrombosis: Novel Use of a Mechanical Thrombectomy Catheter and Review of Management Strategies

Management of intracranial dural sinus thrombosis with involvement of multiple sinuses is complex, often involving not only the primary problem (thrombosis) but acute adverse events consequent to the disease. We highlight the novel use of an endovascular device (typically for suction thrombectomy in the peripheral vascular system) used in our patient with a life-threatening multi-sinus thrombosis. As there is no standard treatment yet for cranial sinus thrombosis, our review of the literature highlights some effective management strategies. A 35-year-old woman developed associated complications of cranial sinus thrombosis that included intracranial hypertension caused by an expanding intracranial hematoma, pulmonary embolism treated by placement of filters in superior and inferior vena cava to eliminate intra- and extracranial sources of emboli, and procedure-related retroperitoneal hematoma that necessitated peripheral vascular intervention. After failure of several common devices during mechanical thrombolysis, a thrombectomy catheter (typically for peripheral vascular intervention to aide in the clot removal) was used. Our case highlights the fine balance of anticoagulation and thrombolysis and the proactive, aggressive approach used by our multispecialty team to manage concurrent factors.     

治疗深静脉血栓形成过程中活化蛋白C和D-二聚体的改变

目的观察深静脉血栓形成(DVT)发病时和两种治疗[尿激酶和重组组织型纤溶酶原激活剂 (rt-PA)]过程中活化蛋白C(APC)和D-二聚体(D-D)的变化及其意义。方法确诊的30例DVT随机分为:A组(15例),用尿激酶治疗;B组(15例),用rt-PA治疗。治疗过程中4次采血观察血浆APC和D-D水平。普通住院术前患者为对照组(10例),不采用药物治疗,入院时采血观察血浆APC和D-D水平。结果治疗前A、B组血浆APC水平与照组相比明显降低(P<0．01),血浆D-D水平则明显升高(P<0．01)。治疗过程中,A、B组血浆APC水平均明显升高;A组血浆D-D含量无明显变化(P>0．05),B组D-D含量明显降低(P<0．05),A组和B组之间的疗效无明显差异(P>0．05)。不同的发病时间其治疗效果有明显差异(P<0．05)。结论 APC和D-D对DVT有早期诊断价值;APC可能提示病情的严重程度,D-D无此作用。用常规剂量尿激酶和rt-PA治疗DVT的疗效无差异;治疗效果好的患者发病时间一般较短。     

Multiparametric ISODATA analysis of embolic stroke and rt-PA intervention in rat

To increase the sensitivity of MRI parameters to detect tissue damage of ischemic stroke, an unsupervised analysis method, Iterative Self-Organizing Data Analysis Technique Algorithm (ISODATA), was applied to analyze the temporal evolution of ischemic damage in a focal embolic cerebral ischemia model in rat with and without recombinant tissue plasminogen activator (rt-PA) treatment. Male Wistar rats subjected to embolic stroke were investigated using a 7-T MRI system. Rats were randomized into control (n=9) and treated (n=9) groups. The treated rats received rt-PA via a femoral vein at 4 h after onset of embolic ischemia. ISODATA analysis employed parametric maps or weighted images (T1, T2, and diffusion). ISODATA results with parametric maps are superior to ISODATA with weighted images, and both of them were highly correlated with the infarction size measured from the corresponding histological section. At 24 h after embolic stroke, the average map ISODATA lesion sizes were 37.7+/-7.0 and 39.2+/-5.6 mm2 for the treated and the control group, respectively. Average histological infarction areas were 37.9+/-7.4 mm2 for treated rats and 39.4+/-6.1 mm2 for controls. The R2 values of the linear correlation between map ISODATA and histological data were 0.98 and 0.96 for treated and control rats, respectively. Both histological and map ISODATA data suggest that there is no significant difference in infarction area between non-treated and rt-PA-treated rats when treatment was administered 4 h after the onset of embolic stroke. The ISODATA lesion size analysis was also sensitive to changes of lesion size during acute and subacute stages of stroke. Our data demonstrate that the multiparameter map ISODATA approach provides a more sensitive quantitation of the ischemic lesion at all time points than image ISODATA and single MRI parametric analysis using T1, T2 or ADCw.     

急性缺血性脑卒中治疗的成本效果评价

目的：比较应用溶栓、降纤和抗凝三种治疗急性缺血性脑卒中的成本效果。方法：283例CI病人根据治疗药物分为抗凝、降纤和溶栓组,溶栓组再根据溶栓方法分为静脉溶栓和动脉介入溶栓组。对四组病人进行NIHSS、ADL、QIL评分,同时调查治疗费用,治疗费用分为直接费用和间接费用。追踪时间为一年。结果：四种治疗方法不但影响费用而且影响治疗效果,进一步影响成本-效果比。结论：动脉介入溶栓治疗CI比内科治疗效果好,虽然手术费用高,但成本效果比好。     

爱通立溶栓治疗急性脑梗死伴出血

目的评价和分析rt-PA治疗6 h内急性脑梗死合并出血的临床意义及相关因素。方法将符合入选标准的患者随机分为A组(rt-PA 0．9 mg/kg)、B组(rt-PA 0．7 mg/kg)、C组(对照组),并将三组又分别分为克赛亚组(A1、B1、C1)和非克赛亚组(A2、B2、C2)。采用CSS及Barthel指数评定溶栓前、溶栓后24 h、3 d、7 d、90 d的疗效。结果各组的总出血发生率、48 h脑出血率、14 d脑出血发生率,A、B 组高于C组,差异有显著性。症状性脑出血率A组、B组与C组差异无显著性。90 d显效率与90 d痊愈率 A、B组高于C组,差异有显著性。90 d病死率A、B组低于C组,差异有显著性。以上各观察结果A与B 组差异无显著性,克赛亚组与非克赛亚组差异无显著性。结论rt-PA静脉溶栓6 h以内急性脑梗死会增加出血机会,但能提高疗效,降低病死率,因此,rt-PA 6 h内静脉溶栓治疗急性脑梗死是安全、显效的,剂量以0．7 mg/kg更符合国人。     

急性脑梗死患者重组组织型纤溶酶原激活剂静脉溶栓前后的血液动力学改变

目的 观察急性脑梗死患者重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator,rt-PA）超早期静脉溶栓治疗后脑血液动力学变化及临床转归。方法 2002年9月至2006年4月发病3h以内的急性脑梗死患者,符合美国国家神经疾病和卒中研究National Institute of Neurological Disorders and Stroke,NINDS）溶栓入选标准,用rt-PA 0.9 mg/kg（最大剂量不超过90 mg）溶栓治疗。同时用经颅多普勒超声（TCD）于患者溶栓前、溶栓中、溶栓后24 h、3 d、2周和1个月分别监测其病变血管血液动力学变化。结果 18例患者进行了脑血液动力学监测。男15例、女3例,平均年龄（65±9）岁。溶栓前美国国立卫生院卒中量表（National Institures of Health Stroke Scale,NIHSS）评分6～16分,平均（11.4±2.8）分。溶栓前TCD检查TIBI 0级1例,1级3例,2级8例,3级3例,4级2例（大脑中动脉严重狭窄）,5级1例（腔隙性脑梗死）。从发病至开始溶栓的时间2～3 h,平均（2.80±0.20）h。闭塞动脉在溶栓过程中再通2例,溶栓后1 h内再通1例,24 h内再通4例,溶栓再通4 h后再闭塞1例,其余无变化。溶栓前与溶栓后24 h、3 d、2周、1个月的NIHSS评分及TIBI分级均有统计学差异,NIHSS评分与TIBI存在明显的负相关关系。结论 溶栓前后脑血液动力学改变与神经功能变化明显相关,脑血液动力学监测有助于深入了解卒中的发病机制和溶栓疗效。     

注射用鼠神经生长因子联合rt-PA静脉溶栓对急性脑梗死患者神经功能及血清NGF、MBP水平的影响

目的 探讨注射用鼠神经生长因子联合重组组织型纤维蛋白溶酶原激活剂(rt-PA)静脉溶栓治疗急性脑梗死(ACI)的临床价值。方法 按照治疗方案不同将本院178例ACI患者(2014年8月-2018年9月)分为观察组与对照组,每组各89例; 在常规及对症治疗基础上对照组给予rt-PA静脉溶栓,观察组给予rt-PA静脉溶栓+注射用鼠神经生长因子治疗; 对比2组治疗前及治疗后不同时段(治疗1、2周后)神经功能(NIHSS评分)变化、治疗前及治疗2周后血清神经生长因子(Nerve growth factor,NGF)、髓鞘碱性蛋白(Myelin basic protein,MBP)水平变化、治疗期间不良反应发生率,治疗结束后随访3个月对比2组不良事件发生率及肢体运动功能(FMA评分)、生活自理能力(ADL评分)改善情况。结果(1)神经功能:治疗1、2周后2组NIHSS评分均较治疗前下降,且观察组下降幅度>对照组(P<0.05);(2)血清学指标:治疗2周后2组血清NGF、MBP水平均较治疗前改善(P<0.05),且观察组血清NGF水平高于对照组,MBP水平低于对照组(P<0.05);(3)安全性:治疗期间观察组不良反应发生率12.36%(11/89),与对照组8.99%(8/89)比较无显著差异(P>0.05);(4)不良事件:随访3个月观察组不良事件发生率3.37%(3/89),低于对照组11.24%(10/89)(P<0.05);(5)肢体运动功能及生活自理能力:随访3个月后2组FMA评分及ADL评分均较治疗前提高(P<0.05),且观察组优于对照组(P<0.05)。结论 注射用鼠神经生长因子联合rt-PA静脉溶栓治疗ACI效果显著,可有效促进患者神经功能恢复,调节血清NGF、MBP表达水平,有利于降低不良事件发生风险,改善患者肢体运动功能及生活自理能力,且有较好的安全性。     

急性脑梗死超早期重组组织型纤溶酶原激活物溶栓治疗的临床研究

目的:探讨发病6h内急性脑梗死给予重组组织型纤溶酶原激活物(rt-PA)溶栓治疗的疗效及并发症,并分析预后相关因素。方法:共收集本院2001-2005年70例溶栓治疗的急性脑梗死病例,其中52例静脉溶栓,18例动脉溶栓,分析比较两组病例溶栓前后及3个月随访的ESS评分及Barthel指数结果;同时分析与预后相关的因素。结果:静脉和动脉溶栓组溶栓前及溶栓30min后ESS评分及Barthel指数迅速增加,溶栓前后分值有显著差异。1个月内颅内出血率为5.77%(静脉组)和16.67%(动脉组)。3个月时ESS评分及Barthel指数较溶栓后30min的评分有显著改善。结论:6h内动脉、静脉溶栓治疗均安全有效。