rt-PA溶栓时机对急性缺血性脑卒中伴心房颤动患者的溶栓效果及安全性的影响

目的 探讨rt-PA溶栓时机对急性缺血性脑卒中伴心房颤动患者的溶栓效果及安全性的影响。方法 选取本院2015年4月-2017年8月收治急性缺血性脑卒中伴心房颤动患者共124例,其中发病后3～4.5 h行rt-PA溶栓共64例设为对照组,发病后3 h内行rt-PA溶栓共60例设为观察组; 比较2组患者溶栓有效率、治疗前后NIHSS评分、随访mRS评分及严重出血事件发生率。结果 观察组患者溶栓有效率显著高于对照组(P<0.05); 2组患者治疗后1和7d NIHSS评分均显著低于治疗前(P<0.05); 观察组患者治疗后1 d NIHSS评分显著低于对照组(P<0.05); 2组患者治疗后7d NIHSS评分比较差异无显著性(P>0.05); 2组患者随访mRS评分分级情况比较差异无显著性(P>0.05); 2组患者出血性脑梗死和脑部症状性出血发生率比较差异无显著性(P>0.05); 观察组患者治疗后脑实质出血发生率显著低于对照组(P<0.05)。结论 急性缺血性脑卒中伴心房颤动患者在发病后3 h内行rt-PA溶栓在可提高溶栓效果和促进受损神经功能恢复方面较发病后3～4.5 h溶栓具有明显优势,但在远期疗效和严重出血事件发生风险方面两者接近。     

Intravenous rt-PA for acute ischemic stroke: 69 consecutive patients managed in an emergency stroke centre

INTRODUCTION: After the 2002 European agreement on the use of rt-PA for fibrinolysis within less than 3 hours after ischemic stroke, we designed a specific patient management scheme for patients referred to our center. METHODS: We report the activity of the "stroke emergency" pathway in the Purpan Hospital (Toulouse) for 4 years. We wanted to evaluate our daily practice and to confirm that the results obtained in the randomized clinical trials with rt-PA can be reproduced in routine practice. RESULTS: Among all stroke patients treated in the Neurology Department, 10.2 per cent were managed via this new pathway, in order to receive a fibrinolytic treatment. Amongst these, 25.6 per cent were treated with rt-PA (2.6 per cent of all ischemic and hemorrhagic strokes, with an average NIHSS score of 15.8 at admission [5; 25]. In 90 per cent of the cases, potential patients for thrombolysis were selected by CT-scan. Time from onset to treatment averaged 2 h 25 min, whilst door-to-treatment time averaged 40 minutes. Two patients (3 percent) showed a symptomatic intra-cerebral hemorrhage. Death rate was 18.8 per cent. After 3 months, 53.5 per cent of patients were regarded as functionally "independent" (Rankin scale<3). CONCLUSION: These results in our unit confirm the feasibility, reproducibility, efficacy and safety of the rt-PA fibrinolytic treatment for ischemic stroke of less than 3 hours. A "Stroke emergency" pathway appears to be a helpful option to treat as many patients as possible with the shortest possible lead times.     

Pre-hospital delay in the use of intravenous rt-PA for acute ischemic stroke in Japan

In this study we investigated the factors associated with pre-hospital delay to treat acute ischemic stroke and transient attack with intravenous recombinant tissue-plasminogen activator (rt-PA) in Japan. In 625 patients, we investigated the pathways and times of their arrival to our hospital, and the significant and independent factors in the patients' clinical backgrounds associated with delayed arrival (>2 h after notice). In total, 287 patients arrived at our hospital directly via EMS, 113 came by themselves, and 225 transferred from other institutes. Delayed arrivals occurred in 423 patients (68%). Multivariate analyses showed that staying in another hospital at notice, a worsened course, and referral from other institutes were positively related, and evening onset, having a witness at onset, loss of consciousness, and using EMS were negatively related to delayed arrival; a worsened course was positively related, and staying in other hospital at notice, having a witness at onset, loss of consciousness, and a high NIHSS on admission were negatively related to delayed alert; hypercholesterolemia and onset in a nursing home were positively related, and staying in other hospital at notice, loss of consciousness, and a high NIHSS on admission were negatively related to not using EMS. A lack of knowledge concerning stroke emergency by medical staff as well as the general public may be responsible for some stroke patients losing the chance for rt-PA treatment.     

高龄急性脑梗死患者时间窗内rt-PA静脉溶栓治疗的对照研究

目的观察临床高龄急性脑梗死患者时间窗内重组组织型纤溶酶原激活剂（rt-PA）静脉溶栓治疗的效果。方法选取本院2009年2月～2012年12月收治的45例高龄急性脑梗死患者按患者或家属溶栓治疗意愿分为溶栓组20例,非溶栓组25例。非溶栓组给予常规抗血小板聚集等治疗,溶栓组在常规治疗的基础上应用rt-PA溶栓剂进行治疗,比较两组患者溶栓前后美国国立卫生院卒中量表（NIHSS）评分及溶栓后3个月日常生活能力（ADL）评分。结果治疗前两组患者的NIHSS评分比较,差异无统计学意义（P〉0.05）,治疗后两组患者的NIHSS评分比较,差异有统计学意义（P〈0.01）;溶栓后3个月的ADL比较,溶栓组评分优于非溶栓组,差异有统计学意义（P〈0.01）;两组患者均有颅内出血现象发生,溶栓组发生率高于非溶栓组,差异有统计学意义（P〈0.01）;两组死亡率比较,差异无统计学意义（P〉0.05）。结论高龄急性脑梗死患者时间窗内rt-PA静脉溶栓治疗是改善患者预后的有效方法,但颅内出血可能性增大。     

Thrombolytic therapy in pregnancy

Pregnancy due to its physiological changes is a procoagulant state. The rate of cardiac valve prosthesis thrombosis, deep venous thrombosis and pulmonary embolism are all increased. Thrombolytic therapy with tissue plasminogen activator (rt-PA) is an approved therapy for ischemic stroke, myocardial infarction, pulmonary embolism and thrombosis of cardiac valve prosthesis. However, there are no data from controlled randomized trials in pregnant patients. Thrombolytic therapy has been rarely used in pregnancy with only 28 cases of rt-PA thrombolysis reported in the literature so far. Indications for rt-PA thrombolysis were stroke (n = 10), thrombosis of cardiac valve prosthesis (n = 7), pulmonary embolism (n = 7), deep venous thrombosis (n = 3), and myocardial infarction (n = 1). Remarkably, all thrombosis of cardiac valve prostheses occurred after switching from warfarin to heparin in order to prevent teratogenicity and fetal loss. Two patients died (7%) and three suffered from complications that were managed conservatively (11%). In another three patients thrombolysis was not successful. Thrombolysis complication rates were similar compared to non-pregnant patients for the above mentioned indications. Six out of the 26 fetus from surviving mothers died (23%), three of them after induced abortion for maternal reasons (12%). A likely causal relation to the prior thrombolysis could only be established in two fetal fatalities (8%). None of the live born children suffered a permanent deficit. Considering that rt-PA does not cross the placenta and taking into account that the complication rates do not exceed those of large randomised controlled trials thrombolytic therapy should not be withheld in pregnant patients in case of life-threatening or potentially debilitating thrombembolic disease.     

Factors influencing nonadministration of thrombolytic therapy in early arrival strokes in a university hospital in Hyderabad,India

Background:It is a well-known fact that very few patients of stroke arrive at the hospital within the window period of thrombolysis. Even among those who do, not all receive thrombolytic therapy.Objective:The objectives of this study were to determine the proportion of early arrival ischemic strokes (within 6 h of stroke onset) in our hospital and to evaluate the causes of nonadministration of intravenous and/or intraarterial thrombolysis in them.Results:Out of 2,593 stroke patients, only 145 (5.6%) patients presented within 6 h of stroke onset and among them 118 (81.4%) patients had ischemic stroke and 27 (18.6%) patients had hemorrhagic stroke. A total of 89/118 (75.4%) patients were thrombolyzed. The reasons for nonadministration of thrombolysis in the remaining 29 patients were analyzed, which included unavoidable factors in 8/29 patients [massive infarct (N = 4), hemorrhagic infarct (N = 1), gastrointestinal bleed (N = 1), oral anticoagulant usage with prolonged international normalized ratio (INR) (N = 1), and recent cataract surgery (N = 1)]. Avoidable factors were found for 21/29 patients, include nonaffordability (N = 7), fear of bleed (N = 4), rapidly improving symptoms (N = 4), mild stroke (N = 2), delayed neurologist referral within the hospital (N = 2), and logistic difficulty in organizing endovascular treatment (N = 2).Conclusion:One-fourth of early ischemic stroke patients in our study were not thrombolyzed even though they arrived within the window period. The majority of the reasons for nonadministration of thrombolysis were potentially preventable, such as nonaffordability, intrahospital delay, and nonavailability of newer endovascular interventions.     

阿替普酶静脉溶栓治疗急性脑梗死患者的临床疗效及预后的影响因素

目的 探讨阿替普酶（rt-PA）静脉溶栓治疗急性脑梗死（ACI）患者的临床疗效,并对其预后的影响因素进行分析。方法 对我院2015年4月~2017年8月收治的120例ACI患者的临床资料进行回顾性分析,根据不同治疗方式分为对照组与观察组,每组各60例。对照组采取常规溶栓治疗,观察组在常规治疗的基础上实行静滴rt pA09mg/kg（≦50mg）,于1h内滴注完,运用美国的NIHSS及Barthel指数（BI）分别对患者治疗前与治疗后7d、1个月时评分,评价神经功能恢复状况。记录患者临床疗效及不良反应发生情况,分析其影响预后的因素。结果 治疗后两组同一时间点NIHSS评分比较,差异有统计学意义（P＜0.05）,且随着治疗时间变长,NIHSS评分逐渐下降;治疗前,两组BI评分无明显差异（P＞0.05）,治疗后两组同一时间点,观察组BI评分明显高于对照组（P＜0.05）;观察组患者治疗总有效率（98.33％）明显高于对照组（83.33％）（X2=8.107,P=0.004）;观察组不良反应发生率（5.00％）与对照组（3.33％）相比,差异无统计学意义（X2=0.209,P=0.648）;单因素分析显示,年龄及治疗前NIHSS评分、心脏疾病及糖尿病、营养状况等因素对患者的预后有影响（P＜0.05）;进一步Logistic多因素回归分析后表示,治疗前NIHSS评分、心脏病及糖尿病史、营养状况及治疗方式均是影响患者预后治疗的独立危险因素（P＜0.05）。结论 对ACI患者,采取rt-PA静脉溶栓治疗的临床疗效优于常规治疗,可明显地改善患者的神经功能,更具安全性,可更好地保障患者的预后,并且对于栓塞的治疗越早越好,患者的预后与病情轻重、年龄及糖尿病、心脏疾病和营养状况等因素有关。     

急诊rt-PA静脉溶栓治疗急性心肌梗死的护理配合

重组人组织纤维蛋白溶酶原激活剂(rt-PA)属于第二代血栓溶解剂,我院急诊科自2007年11月～2008年3月开始引进rt-PA对急性心肌梗死(AMI)患者行急诊室内静脉溶栓治疗21例,效果满意.现报告如下.     

脑卒中患者静脉溶栓治疗采用纤溶酶原重组组织型激活剂与早期影像学征象改变的相关性研究

研究脑卒中患者CT灌注（CTP）在辅助纤溶酶原重组组织型激活剂（rt-PA）静脉溶栓治疗中的临床意义。方法：选取我科2010年1月至2013年1月因急性脑卒中入院治疗的患者共58例,根据CTP 提示是否存在缺血半暗带（脑血流量CBF比值介于0．2-0．6之间）分为实验组和对照组。对照组予以rt-PA静脉溶栓,实验组在对照组的基础上,予以CTP 辅助溶栓。对比实验组患者溶栓前及溶栓后24h、7d的CTP 各参数。对比两组患者溶栓前及溶栓后24h、7d的NIHSS评分;对比两组患者溶栓后14d时的临床疗效及治疗期间不良反应。结果：实验组患者治疗后24h、7d的CBF、CBV灌注量均显著高于前一时间节点,而CBF、CBV和TTP 面积均显著低于前一时间节点,P＜0．05。实验组患者治疗后24h、7d的rCBF和rCBV均显著高于前一时间点,P＜0．01。两组患者治疗后24h、7d的NIHSS评分均显著低于前一时间节点,P＜0．01;实验组治疗后24h、7d的NIHSS评分均显著低于同一时间节点的对照组,P＜0．01。实验组的临床疗效显著优于对照组,P＜0．05。两组患者不良反应发生率无显著差异,P＞0．05。结论：CTP 辅助静脉溶栓治疗对于脑卒中患者具有一定的临床意义。     

重组组织型纤溶酶原激活剂治疗下肢深静脉血栓形成的临床应用

目的:观察重组人组织纤维蛋白溶酶原激活剂(rt-PA)治疗急性下肢深静脉血栓形成的效果和安全性。方法:对32例下肢深静脉血栓形成患者应用rt-PA进行静脉溶栓治疗,观察治疗前后患肢症状、体征变化,有无不良反应,结合血管多普勒彩超或数字减影血管造影(DSA)评价治疗效果。结果:出院时32例患者症状、体征均获缓解;血管多普勒彩超或DSA显示血栓形成相关血管完全再通3例,部分再通29例。无严重并发症。结论:rt-PA是一种安全有效的溶栓药物,可选择性用于治疗急性下肢深静脉血栓形成。