临床荟萃 ›› 2021, Vol. 36 ›› Issue (11): 1052-1056.doi: 10.3969/j.issn.1004-583X.2021.11.018
• 综述 • 上一篇
收稿日期:
2021-05-17
出版日期:
2021-11-20
发布日期:
2021-12-01
通讯作者:
高阳
E-mail:499967644@qq.com
Received:
2021-05-17
Online:
2021-11-20
Published:
2021-12-01
摘要:
虽然脑血管指南不断更新,但临床医生在缺血性卒中静脉溶栓治疗方面仍存在很多困惑。本文通过参考相关文献,结合临床工作经验在判断是否为缺血性卒中,能否溶栓,如何权衡溶栓治疗的获益和风险,静脉溶栓后24小时内早期神经功能恶化如何处理等方面进行了深入探讨,力求为临床医生提供相应的解决方案和诊疗思路。
中图分类号:
高阳. 急性缺血性卒中静脉溶栓治疗中需要思考的几个问题[J]. 临床荟萃, 2021, 36(11): 1052-1056.
[1] | 王拥军, 李子孝, 谷鸿秋, 等. 中国卒中报告2019(中文版)(1)[J]. 中国卒中杂志, 2020, 15(10):1037-1043. |
[2] |
Wang W, Jiang B, Sun H, et al. Prevalence, incidence, and mortality of stroke in China: Results from a nationwide population-based survey of 480 687 adults[J]. Circulation, 2017, 135(8):759-771.
doi: 10.1161/CIRCULATIONAHA.116.025250 URL |
[3] | 王陇德, 刘建民, 杨弋, 等. 《中国脑卒中防治报告2017》概要[J]. 中国脑血管病杂志, 2018, 15(11):611-617. |
[4] |
Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials[J]. Lancet, 2010, 375(9727):1695-1703.
doi: 10.1016/S0140-6736(10)60491-6 URL |
[5] |
Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: An updated systematic review and meta-analysis[J]. Lancet, 2012, 379(9834):2364-2372.
doi: 10.1016/S0140-6736(12)60738-7 pmid: 22632907 |
[6] |
Liu L, Wang D, Wong KS, et al. Stroke and stroke care in China: Huge burden, significant workload, and a national priority[J]. Stroke, 2011, 42(12):3651-3654.
doi: 10.1161/STROKEAHA.111.635755 URL |
[7] | 《中国脑卒中防治报告2019》概要[J]. 中国脑血管病杂志, 2020, 17(5):272-281. |
[8] | 刘丽萍, 陈玮琪, 段婉莹, 等. 中国脑血管病临床管理指南(节选版)——缺血性脑血管病临床管理[J]. 中国卒中杂志, 2019, 14(7):709-726. |
[9] | 董士豪, 周立春. 以孤立性眩晕为首发症状的急性脑梗死患者10例[J]. 脑与神经疾病杂志, 2019, 27(5):300-304. |
[10] | 丁友建, 黄海良. 低血糖症误诊为脑卒中32例临床分析[J]. 临床误诊误治, 2014, 27(1):18-19. |
[11] | 陈彬, 王瑞金, 周春来, 等. 散发性偏瘫性偏头痛误诊为进展性脑卒中1例[J]. 神经损伤与功能重建, 2012, 7(6):461. |
[12] | 急性缺血性卒中静脉溶栓:中国卒中学会科学声明[J]. 实用心脑肺血管病杂志, 2017, 25(10):58. |
[13] |
Smith EE, Fonarow GC, Reeves MJ, et al. Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: Findings from Get With The Guidelines-Stroke[J]. Stroke, 2011, 42(11):3110-3115.
doi: 10.1161/STROKEAHA.111.613208 pmid: 21903949 |
[14] |
Nedeltchev K, Schwegler B, Haefeli T, et al. Outcome of stroke with mild or rapidly improving symptoms[J]. Stroke, 2007, 38(9):2531-2535.
doi: 10.1161/STROKEAHA.107.482554 pmid: 17673713 |
[15] |
Smith EE, Abdullah AR, Petkovska I, et al. Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke[J]. Stroke, 2005, 36(11):2497-2499.
pmid: 16210552 |
[16] |
Tsivgoulis G, Alexandrov AV, Chang J, et al. Safety and outcomes of intravenous thrombolysis in stroke mimics: A 6-year, single-care center study and a pooled analysis of reported series[J]. Stroke, 2011, 42(6):1771-1774.
doi: 10.1161/STROKEAHA.110.609339 pmid: 21493900 |
[17] |
Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force:, Levine SR, Khatri P, Broderick JP, et al. Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: Part 1: Rapidly improving stroke symptoms[J]. Stroke, 2013, 44(9):2500-2505.
doi: 10.1161/STROKEAHA.113.000878 URL |
[18] |
Fischer U, Baumgartner A, Arnold M, et al. What is a minor stroke?[J]. Stroke, 2010, 41(4):661-666.
doi: 10.1161/STROKEAHA.109.572883 pmid: 20185781 |
[19] | 彭斌, 吴波. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志, 2018, 51(9):666-682. |
[20] | 2018年急性缺血性卒中患者早期管理指南[J]. 国际脑血管病杂志, 2018, 26(2):81-113. |
[21] | Berge E, Whiteley W, Audebert H, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke[J]. Eur Stroke J, 2021, 6(1):I-LXII. |
[22] |
Carandang R, Seshadri S, Beiser A, et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years[J]. JAMA, 2006, 296(24):2939-2946.
pmid: 17190894 |
[23] |
Wolf PA, D'Agostino RB, O'Neal MA, et al. Secular trends in stroke incidence and mortality. The Framingham Study[J]. Stroke, 1992, 23(11):1551-1555.
pmid: 1440701 |
[24] |
Fonarow GC, Reeves MJ, Smith EE, et al. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke[J]. Circ Cardiovasc Qual Outcomes, 2010, 3(3):291-302.
doi: 10.1161/CIRCOUTCOMES.109.921858 URL |
[25] |
Fonarow GC, Reeves MJ, Zhao X, et al. Age-related differences in characteristics, performance measures, treatment trends, and outcomes in patients with ischemic stroke[J]. Circulation, 2010, 121(7):879-891.
doi: 10.1161/CIRCULATIONAHA.109.892497 pmid: 20142445 |
[26] |
Bhatnagar P, Sinha D, Parker RA, et al. Intravenous thrombolysis in acute ischaemic stroke: A systematic review and meta-analysis to aid decision making in patients over 80 years of age[J]. J Neurol Neurosurg Psychiatry, 2011, 82(7):712-717.
doi: 10.1136/jnnp.2010.223149 pmid: 21292789 |
[27] |
Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials[J]. Lancet, 2014, 384(9958):1929-1935.
doi: 10.1016/S0140-6736(14)60584-5 URL |
[28] |
Mazya MV, Lees KR, Collas D, et al. IV thrombolysis in very severe and severe ischemic stroke: Results from the SITS-ISTR Registry[J]. Neurology, 2015, 85(24):2098-2106.
doi: 10.1212/WNL.0000000000002199 URL |
[29] |
Generalized efficacy of t-PA for acute stroke. Subgroup analysis of the NINDS t-PA Stroke Trial[J]. Stroke, 1997, 28(11):2119-2125.
doi: 10.1161/01.STR.28.11.2119 URL |
[30] |
Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-guided thrombolysis for stroke with unknown time of onset[J]. N Engl J Med, 2018, 379(7):611-622.
doi: 10.1056/NEJMoa1804355 URL |
[31] |
Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators[J]. Lancet, 1998, 352(9136):1245-1251.
doi: 10.1016/s0140-6736(98)08020-9 pmid: 9788453 |
[32] |
Nordt TK, Moser M, Kohler B, et al. Augmented platelet aggregation as predictor of reocclusion after thrombolysis in acute myocardial infarction[J]. Thromb Haemost, 1998, 80(6):881-886.
doi: 10.1055/s-0037-1615382 URL |
[33] | 张洁茵, 官全生. 老年急性脑梗死患者脑白质疏松病变与静脉溶栓后出血转化的关系研究[J]. 中国医药科学, 2017, 7(7):159-161. |
[34] | 孙威, 马舒贝, 陈忠军, 等. 脑白质疏松程度与急性脑梗死患者静脉溶栓治疗后症状性脑出血转化的相关性研究[J]. 临床神经病学杂志, 2016, 29(5):329-332. |
[35] | 戴永锋, 刘民泽. 脑白质疏松对急性脑梗死患者静脉溶栓后症状性脑出血及短期预后的影响[J]. 卒中与神经疾病, 2020, 27(1):85-88. |
[36] | 舒秀琼, 肖劲松. 脑白质疏松对急性脑梗死患者溶栓治疗后症状性颅内出血及预后影响的meta分析[J]. 临床神经病学杂志, 2019, 32(4):263-267. |
[37] | 刘雪云, 李坦, 王濯, 等. 脑小血管病总体负荷与急性缺血性卒中静脉溶栓后出血转化的关系[J]. 中华神经科杂志, 2019(3):209-215. |
[38] |
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): A randomised controlled trial[J]. Lancet, 2012, 379(9834):2352-2363.
doi: 10.1016/S0140-6736(12)60768-5 pmid: 22632908 |
[39] | 陈祖芝, 梅文丽, 任志霞, 等. 急性脑梗死静脉溶栓后症状性脑出血的危险因素研究进展[J]. 中国实用神经疾病杂志, 2017, 20(2):119-121. |
[40] | 刘春梅, 周俊山, 施洪超, 等. 阿替普酶静脉溶栓治疗急性缺血性脑卒中后出血性转化的影响因素分析[J]. 中国神经免疫学和神经病学杂志, 2018, 25(3):188-192. |
[41] | 鲁文先, 苏毅鹏, 陈金波. 急性脑梗死患者阿替普酶静脉溶栓的疗效及出血性转化影响因素分析[J]. 脑与神经疾病杂志, 2017, 25(1):29-33. |
[42] | 李美英, 凤兆海, 苏建华, 等. 心房颤动相关性脑梗死超早期rt-PA静脉溶栓治疗临床研究[J]. 中国实用神经疾病杂志, 2018, 21(18):1991-1997. |
[43] |
Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: A meta-analysis[J]. Stroke, 2007, 38(3):967-973.
doi: 10.1161/01.STR.0000258112.14918.24 URL |
[44] |
Alexandrov AV, Grotta JC. Arterial reocclusion in stroke patients treated with intravenous tissue plasminogen activator[J]. Neurology, 2002, 59(6):862-867.
doi: 10.1212/wnl.59.6.862 pmid: 12297567 |
[45] |
Rubiera M, Alvarez-Sabín J, Ribo M, et al. Predictors of early arterial reocclusion after tissue plasminogen activator-induced recanalization in acute ischemic stroke[J]. Stroke, 2005, 36(7):1452-1456.
doi: 10.1161/01.STR.0000170711.43405.81 pmid: 15947260 |
[46] | 崔颖, 佟旭, 王伊龙, 等. 阿替普酶静脉溶栓后发生早期神经功能恶化的研究进展[J]. 中国卒中杂志, 2017, 12(2):192-198. |
[47] | 卢桃利, 张蓓. 1例脑梗死静脉溶栓病例的思考[J]. 中国卒中杂志, 2018, 13(6):612-615. |
[48] | 龚汉贤, 李飞, 罗丽霞, 等. 轻型缺血性脑卒中静脉溶栓后24h内抗血小板聚集治疗的研究[J]. 卒中与神经疾病, 2019, 26(1):43-46. |
[49] | Amaro S, Llull L, Urra X, et al. Risks and benefits of early antithrombotic therapy after thrombolytic treatment in patients with acute stroke[J/OL]. PLoS One, 2013, 8(8):e71132. |
[50] | 替罗非班在动脉粥样硬化性脑血管疾病中的临床应用专家共识[J]. 中国卒中杂志, 2019, 14(10):1034-1044. |
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