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。     

急性肺栓塞二次溶栓治疗的疗效及安全性评价

目的 评价急性肺栓塞二次溶栓治疗的疗效及安全性.方法 回顾分析2002年7月～2010年10月在我院住院的12例需溶栓的急性肺栓塞病人,予重组组织型纤溶酶原激活剂(rt-PA)50 mg静脉输注,24小时后复查CT肺动脉造影(CTPA)、心脏超声,血栓部分溶解且心脏超声示右心室室壁运动功能异常,再次予重组组织型纤溶酶原激活剂40mg静脉输注行二次溶栓治疗.结果 有效率100％.1例病人出现生殖道出血,无颅脑出血等危及生命的不良反应.结论 急性肺栓塞首次予重组组织型纤溶酶原激活剂50 mg静脉溶栓,血栓部分溶解且心脏超声示右心室室壁运动功能异常者二次溶栓疗效确切,安全性好.     

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.     

Complete Lysis of Left Ventricular Giant Thrombus with Fibrinolytic Therapy in Clopidogrel Resistant Patient

Sixty-year-old woman admitted with dyspnea and cough. Three weeks ago she underwent primary stenting for acute anterior myocardial infarction and recieved antiplatelet therapy (clopidogrel). Echocardiography and left ventriculography revealed left ventricular segmental dysfunction at anterolateral-apical region but no thrombus. On last admission, despite the clopidogrel therapy, echocardiography showed giant-partly mobil thrombus obliterated half of the left ventricle. Slow infusion of thrombolytic therapy was given and complete lysis occurred with uneventful course. Disclosure of such a rapidly evolving giant left ventricular thrombus in the clopidogrel non-responder is a rare clinical problem with potentially catastrophic consequences. Slow infusion of thrombolytic therapy may be effective and life saving.     

Efficacy of Thrombolytic (rt-PA) Therapy in Old Stroke Patients: The Perugia Stroke Unit Experience

The use of intravenous recombinant tissue plasminogen activator (rt-PA) administered within 3 hrs from symptom onset is beneficial in selected patients independent of age; although oldest patients (≥80 years) are excluded a priori. We report an experience relative to rt-PA treatment in the oldest patients including outcome at 3 months. Data were from the hospital-based Perugia Stroke Registry. Seventy-two consecutive acute stroke patients, fulfilling NINDS and EUSI-criteria were treated with rt-PA Of these 23 patients (30.5%) were ≥80 years. The median and mean age were, respectively, 72.5 and 71.1 ± 12.7 years (range 35–94). The proportion of favorable outcome at 3-months did not differ between groups (55% elderly versus 51.1% of younger patients). Proportions of unfavorable outcome and death from baseline were similar in both groups of patients. Age did not influence prognosis in patients treated with rt-PA. The oldest stroke patients should not be excluded from rt-PA treatment on the basis of age per se.     

Full colour reproduction of figures originally submitted in colour

Case reports on three patients who underwent vitrectomy assisted t-PA injection for the management of branch retinal vein occlusion. Three-port, 20-gauge vitrectomy was performed under local anesthesia. After posterior vitreous detachment and fluid-air exchange, 50 μ g t-PA/0.5 ml were injected in the eye. All patients were instructed for strict supine position for 6 hours. Main outcome measure was visual acuity. Three patients with branch vein occlusion (BVO) were studied, with duration of symptoms less than 25 days, and mean follow-up period of 18.8 months. Although no intraoperative complications were noticed, no one showed any significant improvement of vision. One patient required a second operation for the management of intravitreal hemorrhage, and another developed an epiretinal membrane. Vitrectomy assisted t-PA injection does not seem to improve the course of branch retinal vein occlusion in this small case series. Future research on intravitreal thrombolysis needs to be focused on additional mechanical approaches and modalities that can facilitate the access of the drug into the vascular lumen.     

rt-PA 静脉溶栓后颅内出血转化相关机制的研究进展

急性缺血性脑卒中是最常见的脑卒中类型,重组组织型纤溶酶原激活剂(Recombinant Tissue Plasminogen Activator,rt-PA)静脉溶栓是急性缺血性脑卒中有效的治疗方法,具有明确的循证学依据,美国国立神经疾病与卒中研究所(NINDS)、欧洲急性卒中协作研究(ECASS)及中国2014中国急性缺血性脑卒中诊治相关指南均加以推荐使用.rt-PA静脉溶栓后部分类型颅内出血,严重影响患者预后,增加患者的死亡及伤残率,是阻碍静脉溶栓实施的重要因素.因此,探讨rt-PA静脉溶栓后颅内出血转化的发病机制,具有重要意义.本文就溶栓后颅内出血转化的分类、rt-PA药理作用、不同类型出血转化发病机制加以综述.     

不同年龄急性缺血性脑卒中患者阿替普酶静脉溶栓的风险获益分析

目的： 探讨不同年龄段急性缺血性脑卒中患者静脉溶栓治疗的安全性和有效性。方法： 回顾性收集扬州市江都人民医院2017年7月至2020年3月神经内科收治的静脉溶栓患者共126例作为研究对象。按照患者年龄分为4组（<60岁,60~69岁,70~79岁,≥ 80岁）,患者发病时间均小于4.5 h,采用阿替普酶静脉溶栓治疗,并通过χ²检验比较患者溶栓前的一般资料,根据溶栓前后美国国立卫生研究院卒中量表（NIH stroke scale,NIHSS）评分改善情况进行有效性分析,患者出血情况及其他不良反应进行安全性分析。结果： （1）年龄≥ 80岁组患者房颤比例较高,Toast分型中（cardio embolism,CE）型比例较高,与其他组有显著差异。其余基线资料无统计学差异。（2）4组患者NIHSS评分降低无显著差异,24 h恢复良好率、NIHSS评分改善情况无显著差异;（3）4组患者出血发生率、非直接不良反应发生率、出院死亡率无显著差异;年龄≥ 80岁组患者颅内出血风险显著增加。结论： 对于发病4.5 h的高龄（≥ 80岁）急性缺血性卒中患者,静脉溶栓治疗获益与<80岁患者相同,出血风险也并未增加,但是对于年龄超过80岁且伴有房颤患者,NIHSS评分较高时,选择是否溶栓要慎重。     

重组组织型纤溶酶原激活剂动脉溶栓联合血管内治疗对早期急性脑梗死的疗效观察

目的 探析重组组织型纤溶酶原激活剂（rt-PA）动脉溶栓联合血管内治疗发病时间6 h内急性脑梗死（ACI）的临床疗效。方法 选取2017年2月—2019年3月徐州医科大学第二附属医院收治的发病<6?h ACI患者160例,按照患者及家属对治疗方案的选择意愿分组,观察组采取rt-PA+血管内支架成形术治疗,对照组采取rt-PA动脉溶栓,每组80例。比较两组术前、术后24?h、7?d、3个月NIHSS评分、ADL评分,观察患者血管再通情况,记录不良反应及临床预后。结果 两组不同时间点的NIHSS评分和ADL评分有差异（P?<0.05）,两组的NIHSS评分和ADL评分有差异（P?<0.05）,两组的NIHSS评分和ADL评分变化趋势有差异（P?<0.05）。观察组血管再通率为100%（完全再通76例,部分再通5例）,对照组血管再通率为95%（完全再通62例,部分再通14例,未通4例）,两组血管再通率比较差异有统计学意义（P?<0.05）。观察组术后仅2例再发脑梗死,未出现死亡病例,对照组术后12例再发脑梗死,且4例因脑梗死伴脑疝死亡,两组预后比较差异有统计学意义（P?<0.05）。结论 ACI发病6?h内采取rt-PA联合血管内支架成形术治疗可提高溶栓效果,促进神经功能恢复,改善预后,安全性良好。但受血管内介入治疗技术及术前准备耗时等因素的影响,可能会延长溶栓处理时间,抵消早期动脉溶栓的优势,建议视患者病情制订个体化溶栓治疗方案。     

Neuroprotection afforded by a combination of eliprodil and a thrombolytic agent, rt-PA, in a rat thromboembolic stroke model

In the present study, we have assessed the efficacy of eliprodil, a neuroprotective agent which blocks both the modulatory polyamine site of the NMDA receptor and neuronal voltage-sensitive calcium channels, alone or in combination with the thrombolytic agent, rt-PA, in a rat embolic stroke model using a neurological score and the volume of the infarct as endpoints. Embolization was induced by intracarotid injection of an arterial blood clot. Eliprodil, administered at the dose of 1 mg/kg, iv, 10 min and 2 h 30 after embolization, reduced the neurological deficit by 54% (P<0.01) and the total volume of the brain lesion by 49%. Thrombolysis with rt-PA (2.5 mg/kg, as a 30 min iv infusion beginning 1 h after embolization) decreased the neurological deficit by 48% (P<0.05) and the size of the total infarct by 55% (P<0.05). Combined therapy greatly improved the degree of neuroprotection as assessed by neurological and histological outcomes (70% (P<0.001) and 89% (P<0.01) neuroprotection, respectively). These results demonstrate that the administration of a neuroprotective drug (eliprodil) or a thrombolytic agent (rt-PA) similarly reduce the volume of brain damage and the neurological deficit in a rat embolic stroke model. Combined cytoprotective therapy and thrombolysis markedly improved the degree of neuroprotection and may, thus, represent a valuable approach for the treatment of stroke in humans.