中国急性缺血性卒中早期血管内介入诊疗指南对比分析

doi:10.3969/j.issn.1004-583X.2022.11.014

摘要/Abstract

摘要：

脑血管病在我国发病率很高,其中以急性缺血性卒中最为常见,其脑组织缺血缺氧引起的神经功能损伤及并发症对现代人的生活质量造成了严重影响。目前关于急性缺血性卒中介入治疗的临床研究在适用范围、治疗理念及技术层面等方面有新一步进展。中华医学会神经病学分会分别于2018年、2022年组织制定了《中国急性缺血性卒中早期血管内介入诊疗指南》,对认识和诊疗急性缺血性卒中具有非常重要的临床意义。本文将2018年指南及2022年指南内容进行对比及分析,明确缺血性卒中早期血管内介入诊疗变化,以利于临床诊治。

关键词: 缺血性卒中, 早期血管内介入诊疗, 指南, 对比

Abstract:

Cerebrovascular disease has a high incidence rate in my country, among which acute ischemic stroke (AIS) is the most common. The cerebral ischemia-induced brain injury and its complications seriously affect the quality-of-life of modern people. At present, clinical research regarding AIS interventional treatment have made new progress in terms of applicable scope, medical perspective, treatment technology. The Neurology Branch of the Chinese Medical Association organized and formulated the "Chinese guidelines for the endovascular treatment of acute ischemic stroke" in 2018 and 2022, which have great clinical significance for understanding and diagnosis of AIS. In this article, A comparative analysis will be performed in 2018 and 2022 guidelines to clarify the changes in early endovascular interventional, which might be beneficial to clinical diagnosis and treatment.

Key words: ischemic stroke, early endovascular intervention, guideline, comparison

中图分类号:

R743.3

唐秋燕, 韦小凤, 冯茜, 杨慧中, 杨旭红. 中国急性缺血性卒中早期血管内介入诊疗指南对比分析[J]. 临床荟萃, 2022, 37(11): 1037-1043.

Tang Qiuyan, Wei Xiaofeng, Feng Qian, Yang Huizhong, Yang Xuhong. Comparative analysis of Chinese guidelines for the endovascular treatment of acute ischemic stroke[J]. Clinical Focus, 2022, 37(11): 1037-1043.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2022.11.014

https://huicui.hebmu.edu.cn/CN/Y2022/V37/I11/1037

图/表 8

参考文献 28

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年份		相同点	不同点
适应证	2018年指南	①影像学检查证实为大动脉闭塞;②CT排除颅内出血;③前循环闭塞和后循环闭塞发病时间内治疗方式一致。	①CT排除蛛网膜下腔出血;②年龄在18岁以上。
适应证	2022年指南	①影像学检查证实为大动脉闭塞;②CT排除颅内出血;③前循环闭塞和后循环闭塞发病时间内治疗方式一致。	高龄患者(年龄大于85岁)、低龄患者(最小年龄为7岁)及妊娠妇女不是血管介入治疗的绝对禁忌证。
禁忌证	2018年指南	①严重活动性出血或已知有明显出血倾向者;②严重心、肝、肾等脏器功能不全。	①若进行动脉溶栓,参考静脉溶栓禁忌证标准;②血糖<2.7 mmol/L或>22.2 mmol/L;③药物无法控制的严重高血压。
禁忌证	2022年指南	①严重活动性出血或已知有明显出血倾向者;②严重心、肝、肾等脏器功能不全。	未明确提出低血糖和高血糖范围及严重高血压(药物无法控制),仅在术前评估的其他辅助检查里面提及需在术前排除低血糖。

年份		相同点	不同点
适应证	2018年指南	①影像学检查证实为大动脉闭塞;②CT排除颅内出血;③前循环闭塞和后循环闭塞发病时间内治疗方式一致。	①CT排除蛛网膜下腔出血;②年龄在18岁以上。
适应证	2022年指南	①影像学检查证实为大动脉闭塞;②CT排除颅内出血;③前循环闭塞和后循环闭塞发病时间内治疗方式一致。	高龄患者(年龄大于85岁)、低龄患者(最小年龄为7岁)及妊娠妇女不是血管介入治疗的绝对禁忌证。
禁忌证	2018年指南	①严重活动性出血或已知有明显出血倾向者;②严重心、肝、肾等脏器功能不全。	①若进行动脉溶栓,参考静脉溶栓禁忌证标准;②血糖<2.7 mmol/L或>22.2 mmol/L;③药物无法控制的严重高血压。
禁忌证	2022年指南	①严重活动性出血或已知有明显出血倾向者;②严重心、肝、肾等脏器功能不全。	未明确提出低血糖和高血糖范围及严重高血压(药物无法控制),仅在术前评估的其他辅助检查里面提及需在术前排除低血糖。

年份	相同点	不同点
2018年指南	院内延误控制方面,对符合血管内介入治疗适应证患者应尽可能控制院内延误治疗的时间。 Ⅰ级推荐,B级证据:在行静脉溶栓桥接机械取栓过程中,不应等待观察静脉溶栓的具体疗效。	Ⅰ级推荐,A级证据:当患者同时符合静脉溶栓与动脉取栓的条件,建议行静脉溶栓-动脉取栓桥接治疗模式,不推荐越过静脉溶栓直接进行血管内处理。
2022年指南		①3个Ⅰ级推荐,A级证据:将符合闭塞血管开通适应证的患者迅速运送至就近卒中中心救治;对于发病时间<4.5 h的急性前循环大血管闭塞卒中,满足条件要求的推荐静脉溶栓-血管内介入的桥接治疗模式;对于发病4.5~24 h的大血管闭塞卒中,经过充分评估后,直接进行血管内治疗; ②两个Ⅱ级推荐,B级证据:绕过能够静脉溶栓的卒中中心直接转运至具备血管内治疗的卒中中心,患者是否获益仍不确定;在能够快速启动血管内治疗的卒中中心,经过充分评估的病例,越过静脉溶栓直接进行血管内治疗是可行的,但临床获益有待于进一步证实。

年份	相同点	不同点
2018年指南	院内延误控制方面,对符合血管内介入治疗适应证患者应尽可能控制院内延误治疗的时间。 Ⅰ级推荐,B级证据:在行静脉溶栓桥接机械取栓过程中,不应等待观察静脉溶栓的具体疗效。	Ⅰ级推荐,A级证据:当患者同时符合静脉溶栓与动脉取栓的条件,建议行静脉溶栓-动脉取栓桥接治疗模式,不推荐越过静脉溶栓直接进行血管内处理。
2022年指南		①3个Ⅰ级推荐,A级证据:将符合闭塞血管开通适应证的患者迅速运送至就近卒中中心救治;对于发病时间<4.5 h的急性前循环大血管闭塞卒中,满足条件要求的推荐静脉溶栓-血管内介入的桥接治疗模式;对于发病4.5~24 h的大血管闭塞卒中,经过充分评估后,直接进行血管内治疗; ②两个Ⅱ级推荐,B级证据:绕过能够静脉溶栓的卒中中心直接转运至具备血管内治疗的卒中中心,患者是否获益仍不确定;在能够快速启动血管内治疗的卒中中心,经过充分评估的病例,越过静脉溶栓直接进行血管内治疗是可行的,但临床获益有待于进一步证实。

年份	相同点	不同点
2018年指南	经影像学明确为前循环大血管闭塞的急性缺血性卒中在6~16 h时间窗治疗方式两版指南看法一致。	Ⅱ级推荐,B级证据:对发病时间在16~24 h同时影像学结果证实为前循环大血管闭塞的急性缺血性脑卒中且符合DAWN标准的患者,建议行血管内介入治疗。
2022年指南	经影像学明确为前循环大血管闭塞的急性缺血性卒中在6~16 h时间窗治疗方式两版指南看法一致。	①Ⅰ级推荐,A级证据:所有疑似卒中患者均应在首次到达医院后行颅脑影像学检查,如头颅CT或MRI; ②Ⅰ级推荐,B级证据:推荐使用卒中评定量表进行评估,如NIHSS;对发病时间为16~24 h经影像学证实为前循环大血管闭塞的急性缺血性脑卒中且符合DAWN标准的患者,推荐采用血管内介入治疗; ③Ⅰ级推荐,C级证据:进行血液常规、血液生化及凝血功能检查以及其他辅助检查,应尽量缩短检查所需时间; ④Ⅱ级推荐,C级证据:人工智能可以在卒中自动化影像学分析、临床辅助决策和预后预测等方面予以应用。