rt-PA治疗急性脑梗死的近期临床疗效及其影响因素分析

目的:探讨重组组织型纤溶酶原激活剂(recombinant tissue plasminogen activator,rt-PA)溶栓治疗急性脑梗死的近期临床疗效及其影响因素。方法:回顾性分析2013年8月至2015年1月于我院神经内科接受rt-PA溶栓治疗的88例急性脑梗死患者的临床资料,分析患者入院及发病24h的美国国立卫生研究院卒中量表(NIHSS)评分,以评分的差值作为结局变量,分为预后良好的观察组(NIHSS差值≥4分或≥50%)及预后不良的对照组(NIHSS差值4分或50%)。选取溶栓前临床及实验室资料,筛选不良预后的可能影响因素,并进行单因素及多因素分析。结果:88例患者溶栓治疗后近期预后良好者46例(52.27%),预后不良者42例(47.73%)。4.5 h内接受溶栓者好转率为57.14%(36/63),4.5 h接受溶栓者好转率为32.00%(8/25),显著低于4.5h内接受溶栓者,差异具有统计学意义(P0.05)。单因素分析结果显示糖尿病史、高密度脂蛋白、血糖、溶栓时间窗、NIHSS评分变量是影响rt-PA溶栓疗效的因素,进一步多因素分析结果显示溶栓时间窗、血糖、NIHSS评分是影响rt-PA溶栓疗效的因素。结论:rt-PA静脉溶栓治疗急性脑梗死的近期疗效有明显的时间依赖性,且血糖、NIHSS评分为早期预后的影响因素。     

重组组织型纤溶酶原激活剂静脉溶栓治疗发病4.5小时内急性脑梗死近期疗效的回顾性研究

目的:研究发病4.5小时内的急性脑梗死患者早期应用重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗的临床效果。方法:回顾性分析2018年07月1日到2020年10月31日我院神经内科收治的发病在4.5小时内的652例急性脑梗死患者的临床资料,其中使用rt-PA静脉溶栓治疗的患者285例为溶栓组,未溶栓仅使用抗血小板聚集、他汀类降脂、脑保护等常规治疗的患者367例为对照组。记录两组患者治疗前及治疗后24小时、7天、14天的美国国立卫生研究院卒中量表(NIHSS)评分和治疗3个月后的改良Rankin量表(mRS)评分。对于有吞咽障碍的患者,收集洼田饮水试验结果。统计两组患者出血情况和死亡率。结果:溶栓组治疗后24小时、7天、14天的NIHSS评分以及治疗后3个月的mRS评分改善明显,与对照组相比,差异有统计学意义(P<0.05);对于有吞咽障碍的患者,溶栓组的治疗有效率高于对照组(P<0.05);溶栓组轻微出血的概率大于对照组(P<0.05);两组在症状性及致死性脑出血方面的差异无统计学意义(P>0.05);溶栓后大量及致死性脑出血部位多在梗死的中心区、出血量多大于10 mL,患者临床NIHSS评分≥24分。溶栓组死亡率较对照组下降(P<0.05)。结论:发病4.5小时内的急性脑梗死患者接受rt-PA静脉溶栓治疗的近期治疗效果良好,轻微出血风险较高,但是死亡率下降。临床神经功能缺损重、NIHSS评分≥24分、出血风险大的患者预后不良,不推荐溶栓治疗。     

影响尿激酶静脉溶栓治疗急性脑梗死预后因素的初步分析

目的:对影响急性缺血性脑卒中患者应用尿激酶溶栓治疗预后的相关危险因素进行初步分析及研究,为今后选择适宜应用尿激酶溶栓的患者打下基础。方法:以2015年1月1日至2015年10月31日入院且应用尿激酶静脉溶栓的38例急性缺血性脑卒中患者,根据治疗3个月后的预后情况将患者分为A组(24例,预后良好)和B组(14例,预后不良),对两组患者的预后影响因素进行分析。结果:预后良好组患者的溶栓前NIHSS评分低于预后不良组,差异具有统计学意义(P0.05)。多因素的Logistic回归分析显示,吸烟和HINSS评分与急性脑梗死尿激酶溶栓预后不良有关,差异具有统计学意义(P0.05),且NIHSS评分是预后的独立预测因素。结论:尿激酶静脉溶栓治疗脑梗死的患者,溶栓前较高的NIHSS评分可能与溶栓预后不良有关。吸烟的患者溶栓后出现预后不良的几率是不吸烟患者溶栓后预后不良的8.83倍,溶栓前NIHSS评分每增加1分,溶栓预后不良的几率增加1.76倍。     

小剂量阿替普酶治疗急性脑梗死患者的临床疗效及安全性评价

目的:探讨急性脑梗死患者静脉溶栓使用小剂量(0.6 mg/kg)阿替普酶的临床疗效及安全性。方法:将2016年1月至2019年12月我院神经内科收治的溶栓时间窗内40例急性脑梗死患者随机分为标准剂量组(0.9 mg/kg)和小剂量组(0.6 mg/kg),每组20例,分别在溶栓前、溶栓后1小时对患者进行美国国立卫生研究院卒中量表(NIHSS)评分,溶栓前和溶栓后24小时做头颅CT排除脑出血,密切监测不良反应。结果:标准剂量组有效率为80.00%,小剂量组有效率为75.00%,两组比较差异无统计学意义(P0.05)。治疗前两组NIHSS评分比较差异无统计学意义(P0.05),治疗后两组NIHSS评分均降低,与治疗前相比差异有统计学意义(P0.05),治疗后两组NIHSS评分差异无统计学意义(P0.05)。标准剂量组总不良反应发生率为40.00%,高于小剂量组的20.00%,差异无统计学意义(P0.05)。结论:阿替普酶可有效改善急性脑梗死患者的神经功能,小剂量(0.6 mg/kg)与标准剂量(0.9 mg/kg)溶栓效果相当,安全性较好,出血事件发生率较低,可根据患者情况酌情选用小剂量。     

用SITSSICH风险评分预测脑梗死rt-PA静脉溶栓后症状性颅内出血风险的临床研究

目的：探索SITSSICH风险评分预测中国急性脑梗死患者rt．PA静脉溶栓（时间窗为4．5h,rt．PA剂量0．9mg／kg体重）治疗后症状性颅内出血（SICH）风险的效果,为使用SITSSICH风险评分指导溶栓治疗积累临床经验。方法：对86名进行rt-PA静脉溶栓（剂量0．9mg／kg体重）的急性脑梗死患者,进行SITSSICH风险评分,并记录总分及风险水平分层结果,按总分0、1、2、3、4、5、6、7、8、≥9分,分为10组,再按风险水平低危、平均、中危、高危分为4组,记录各组患者溶栓后有颅内出血（包括SICH）的比例,各组间进行比较。结果：SITSSICH风险评分0．5分、6分、7分、8分、≥9分各组SICH的比例分别为0．0％、8．3％、10．0％、25％和50．0％,卡方检验得x2=64．38,P〈0．001（线性趋势检验）,提示随着SITSSICH风险评分值的增加SICH的比例也在增加,存在统计学上的差异。SITSSICH风险评分风险水平低危及平均组的SICH比率为0％,中危、高危组的SICH比率分别11．5％,50％,卡方检验得xZ=-59．52,P〈0．001（线性趋势检验）,提示SITSSICH风险水平越高,SICH的比例也越高,存在统计学上的差异。另外,将SITSSICH风险评分风险水平分层和出血类型做spearman等级相关分析,得到spearman相关系数0．422,P〈0．001;说明SITSSICH风险评分风险水平分层和S1CH呈正相关。结论：对于经标准的rt—PA静脉溶栓方案（时间窗为4．5h,rt-PA剂量0．9mg／kg体重）治疗中国急性脑梗死患者,SITSSICH风险评分分值的增加与SICH风险的增加呈正相关,SITSSICH风险评分是一个能够预测rt-PA静脉溶栓后sICH风险的简单易行的实用的I临床工具。     

超选择性动脉溶栓治疗急性大脑中动脉脑梗死的疗效和安全性评价

目的:探讨超选择性动脉溶栓治疗急性大脑中动脉脑梗死的疗效和安全性。方法:收集我院就诊或住院治疗的120例急性大脑中动脉脑梗死患者,随机分为实验组和对照组,每组60例。两组患者入院后均给予相应的治疗措施,对照组患者给予静脉溶栓;实验组患者给予超选择动脉溶栓,观察并比较两组患者治疗前后神经功能缺损评分(NIHSS)以及患者治疗后临床疗效和并发症发生率。结果:与治疗前相比,两组患者治疗后的NIHSS水平均下显著降差异具有统计学意义(P0.05);与对照组相比,实验组患者的NIHSS水平、并发症的发生率和病死率较低而治疗有效率较高差异均具有统计学意义(P0.05)。结论:超选择性动脉溶栓治疗急性大脑中动脉脑梗死的临床疗效以及安全性较静脉溶栓更好。     

银杏达莫注射液联合rt-PA静脉溶栓对急性脑梗死患者神经功能、血液流变学及血清NSE、S100B水平的影响

目的:探讨银杏达莫注射液联合重组人组织型纤溶酶原激活物(rt-PA)静脉溶栓对急性脑梗死患者神经功能、血液流变学及血清神经元特异性烯醇化酶(NSE)、S100B蛋白(S100B)水平的影响。方法:采用随机数字表法将2017年1月-2018年12月本院收治的160例急性脑梗死患者分为两组,对照组(80例)患者接受常规治疗+rt-PA静脉溶栓,研究组(80例)患者接受常规治疗+rt-PA静脉溶栓+银杏达莫注射液。治疗后对比两组患者的近期疗效、美国国立卫生研究院卒中量表(NIHSS)评分、改良RANKIN量表(m RS)评分、血液流变学指标[全血比黏度、血浆比黏度、红细胞比容(HCT)]、NSE、S100B水平的差异。结果:研究组患者的总有效率高于对照组患者(P0.05);研究组患者治疗后的NIHSS、m RS评分低于对照组患者(P0.05);研究组患者治疗后的全血比黏度、血浆比黏度、HCT水平低于对照组患者(P0.05);研究组患者治疗后的的血清NSE、S100B水平低于对照组患者(P0.05)。治疗期间,两组患者均无明显药物相关不良反应发生。结论:银杏达莫注射液联合rt-PA静脉溶栓治疗的疗效满意,可改善急性脑梗死患者神经功能,优化血液流变学状态,并降低血清NSE、S100B水平,且安全性好。     

尤瑞克林联合静脉溶栓治疗急性脑梗塞的临床疗效及对血浆血小板、D-D、Fg水平的影响

目的:探讨尤瑞克林联合静脉溶栓治疗急性脑梗塞的临床疗效及对血浆血小板、D-二聚体(D-D)、纤维蛋白原(Fg)水平的影响。方法:选择2015年5月至2018年5月我院接诊的急性脑梗塞患者65例作为研究对象,根据随机数表法分为观察组(n=35)和对照组(n=30)。对照组采用静脉溶栓治疗,观察组采用尤瑞克林联合静脉溶栓治疗。比较两组治疗后的临床疗效,治疗前后血浆血小板、D-D、Fg、美国国立卫生研究院卒中量表(NIHSS)评分、改良Barthel指数评定量表(MBI)水平的变化及不良反应的发生情况。结果:治疗后,观察组临床疗效总有效率为94.29%,显著高于对照组(73.33%,P0.05)。两组患者治疗前血浆血小板、D-D、Fg水平、NIHSS、MBI评分比较差异均无统计学意义(P0.05);治疗后,两组患者血浆血小板、D-D、Fg水平及NIHSS评分均较治疗前明显降低,且观察组患者以上指标均显著低于对照组(P0.05);两组患者治疗治疗后MBI评分均较治疗前显著升高,且观察组MBI评分显著高于对照组(P0.05)。两组患者不良反应总发生率分别为2.86%、13.33%,组间比较差异无统计学意义(P0.05)。结论:尤瑞克林联合静脉溶栓治疗急性脑梗塞患者的临床效果显著优于单用静脉溶栓治疗,这可能与其更有效改善改善患者血浆血小板、D-D、Fg水平有关。     

心房颤动对不同时间窗内急性缺血性脑卒中患者静脉溶栓疗效的对比研究

目的:探讨与对比心房颤动对不同时间窗内急性缺血性脑卒中患者静脉溶栓疗效的影响。方法:选择2014年8月到2016年5月在我院进行诊治的急性缺血性脑卒中患者98例,其中卒中前已诊断心房颤动定义为慢性心房颤动组(n=50),入院后诊断心房颤动者为新发心房颤动组(n=48);两组都给予重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗,记录两组预后情况。结果:两组患者的性别、年龄、时间窗、合并疾病、血糖与甘油三酯含量对比无明显差异(P0.05)。慢性心房颤动组与新发心房颤动组的有效率分别为94.0%和95.8%,组间比较差异无统计学意义(P0.05)。慢性心房颤动组与新发心房颤动组治疗后的m RS评分分别为6.22±1.83分和6.29±1.45分,都明显低于治疗前的9.24±1.31分和9.19±1.52分(P0.05),组间对比无明显差异(P0.05)。慢性心房颤动组的症状性脑出血与非症状性脑出血发生率分别为4.0%和2.0%,都明显低于新发心房颤动组的14.6%和12.5%(P0.05)。结论:发病4.5h之内静脉溶栓急性缺血性脑卒中是安全有效的,新发心房颤动不影响患者静脉溶栓后的神经功能结局,但是会增加症状性脑出血与非症状性脑出血,需要加强预防性管理。     

溶栓联合丁苯肽氯化钠治疗急性脑梗死的疗效分析

为了分析溶栓联合丁苯肽氯化钠对急性脑梗死患者的治疗效果和对患者体内血清神经元特异性烯醇化酶、同型半胱氨酸水平变化的影响,本研究回顾性地选取2015年4月至2017年4月我院收治的急性脑梗死患者89例,根据用药不同分为对照组和观察组。对照组患者采用静脉溶栓治疗,观察组患者采用静脉溶栓联合丁苯肽氯化钠治疗。观察两组患者治疗后NIHSS评分、Barthel指数评分、血液流变学指标、NSE、Hcy、血浆N末端B型脑钠肽前体(NT-ProBNP)及内皮素-1(ET-1)水平变化情况。本研究显示两组患者入院7 d和14 d时NIHSS和Barthel指数评分均较入院1 d时改善,且观察组患者入院7 d和14 d时NIHSS和Barthel指数评分均优于同期对照组(p0.05)。两组患者治疗后NSE、Hcy、NT-ProBNP及ET-1水平均较治疗前下降,且观察组患者治疗后NSE、Hcy、NT-ProBNP及ET-1水平均低于对照组(p0.05)。两组患者治疗后观察组全血黏度、血浆黏度及红细胞聚集指数水平均低于对照组,且均较治疗前下降(p0.05)。本研究表明溶栓联合丁苯肽氯化钠治疗急性脑梗死可有效改善患者神经功能,降低患者血清NSE、Hcy、NT-ProBNP水平,提高患者日常生活活动能力。     

Thrombolysis and acute cerebral infarction

Thrombolytic therapy are the most important advance in the management of acute ischemic stroke and has been evaluated in several randomised trials. Thrombolysis with recombinant tissue plasminogen activator (rt-Pa) is effective within 3 h of onset of ischemic stroke and this efficacy is similar between different stroke subtypes. New trials will determine if extension of this time-window can be substantiated. Therapy beyond the 3-hour window, with intra-arterial thrombolysis, appears to improve outcome but are applicable to selected group of patients. Thrombolytic drugs can also carry an important risk (5 % to 10 %) of brain hemorrhage and edema that can prove fatal. The risk of symptomatic intracranial hemorrhage is directly proportional to stroke severity and inversely proportional to time to treatment. There is a growing interest in the use of MRI in acute ischemic stroke. It helps identify location of early cerebral ischemia and provides valuable information not only of the penumbra but also of vessel occlusion. Its use might help in selecting patients who will benefit most from treatment such as thrombolysis. In spite of these results, community use of thrombolytic therapy remains dismally low. Many physicians and medical centers are not presently equipped or willing to give thrombolytic drugs for stroke treatment. Increasing stroke awareness in the community, creating stroke unit and physicians education are necessary to extend the effective use of acute treatment in cerebral infarct to a larger group of patients.     

Intravenous thrombolysis for acute ischemic stroke--our experiences

Intravenous (i.v.) thrombolysis with recombinant tissue plasminogen activator (rt-PA) is the only available pharmacological therapy to improve the outcome of acute ischemic stroke. We compared 71 patients presenting with ischaemic stroke and given intravenous rt-PA (0.9 mg/kg total dose) within 3 h with 71 patients who present to the hospital more than 3 hours after stroke symptom onset. The primary endpoint was the modified Rankin scale (mRS) at 90 days, dichotomised for favourable and unfavourable (score 2-6). Outcome measures were symptomatic intracerebral haemorrhage within 36 h (haemorrhage associated with National Institutes of Health Stroke Scale [NIHSS] > or = 4 points deterioration), and mortality at 3 months. More patients had favourable outcome with the rt-PA-treated group than with the control group (64.79% vs. 22.54%; p = 0.0001). The greater proportion of patients left with minimal or no deficit 90 days after rt-PA treatment, as compared with the control group. In the treated group symptomatic intracranial hemorrhage occurred in 1 patient who recovered to a level of functional independence, and asymptomatic intracranial hemorrhage was observed in 2 patients. Our experience of an acute stroke thrombolysis service shows that we are able to provide this treatment safely and in accordance with established treatment guidelines. We recommend thrombolytic treatment in acute ischemic stroke for selected population.     

Predictors of Outcome and Hemorrhage in Patients Undergoing Endovascular Therapy with Solitaire Stent for Acute Ischemic Stroke

Background

Endovascular mechanical thrombectomy is emerging as a promising therapeutic approach for acute ischemic stroke and show some advantages. However, the data of predicting clinical outcome after thrombectomy with Solitaire retriever were limited. We attempt to identify prognostic factors of clinical outcome in patients with acute ischemic stroke undergoing thrombectomy with Solitaire retriever.

Methods

We conducted a retrospective analysis of consecutive acute ischemic strokes cases treated between December 2010 and December2013 where the Solitaire stent retriever was used for acute ischemic stroke. We assessed the effect of selected demographic characteristics, clinical factors on poor outcome at 3 months (modified Rankin score 3–6), mortality at 3 months, and hemorrhage within 24 h (symptomatic and asymptomatic). Clinical, imaging and logistic variables were analyzed. A multivariate logistic regression analysis was used to identify variables influencing clinical outcome, based on discharge NIHSS score change and mRS at 3 months.

Results

Eighty nine consecutive patients with acute ischemic stroke underwent mechanical thrombectomy. Multivariate analysis revealed that admission NIHSS score, Serum glucose and endovascular procedure duration were independently associated with clinical outcome. Sex, NIHSS score at admission, diabetes and time of operation were associated with sICH in 1 day. NIHSS score ≥20 (OR 9.38; 95% CI 2.41–36.50), onset to reperfusion >5 hours (OR 5.23; 95% CI1.34,20.41) and symptomatic intracranial hemorrhage (OR 10.19; 95% CI1.80,57.83) were potential predictive factors of mortality at 3 months.

Conclusion

Multiple pre- and intra-procedural factors can be used to predict clinical outcome, symptomatic intracranial hemorrhage and mortality in acute ischemic stroke patients undergoing endovascular therapy. This knowledge is helpful for patients selection for endovascular mechanical thrombectomy.     

Increased Risk of Post-Thrombolysis Intracranial Hemorrhage in Acute Ischemic Stroke Patients with Leukoaraiosis: A Meta-Analysis

BackgroundLeukoaraiosis is common in patients with acute ischemic stroke. The results from many studies investigating the association between leukoaraiosis and intracranial hemorrhage after thrombolysis remain conflicting.MethodsA meta-analysis was performed to compare the risk of post-thrombolytic intracranial hemorrhage in patients with and without leukoaraiosis. Relevant reports were identified by searching PubMed, EmBase, Cochrane Library, and ISI Web of Science through December 2015 using a combination of subjective and random terms. Eligible studies that were original articles with a clear definition of leukoaraiosis and intracranial hemorrhage were selected and analyzed. Funnel plots, Egger’s test, and Begg’s test were conducted to assess the publication bias. Sensitivity analysis was also performed to evaluate the influence of each individual study.ResultsEleven trials that enrolled 6912 participants were included. There was a significantly increased risk for acute ischemic stroke patients with leukoaraiosis (odds ratio: 1.89, 95% confidence interval 1.51–2.37, P<0.001). Low heterogeneity and less publication bias was detected among these studies. The results of both computed tomography and magnetic resonance imaging performed on the subgroups of leukoaraiosis were significant. Furthermore, an association between leukoaraiosis and symptomatic intracranial hemorrhage was also confirmed. The odds ratios remained stable with no obvious variations on the sensitivity analysis. The limitations consisted of types of including trials and not matching some baseline variables.ConclusionsThe results of this meta-analysis show that leukoaraiosis approximately doubles the incidence of intracranial hemorrhage after thrombolytic therapy. However, it does not critically affect decision making regarding thrombolysis for patients with acute ischemic stroke. Additional investigations are required.     

老年颈内动脉系统急性脑梗死动脉溶栓的疗效观察

目的:探讨老年颈内动脉系统急性脑梗死动脉溶栓的疗效。方法:对我院老年科收治的63例老年颈内动脉系统急性脑梗死随机分为股动脉组以及颈动脉组,其中股动脉组患者30例,对其采用经皮股动脉穿刺微导管介入尿激酶溶栓治疗,颈动脉组患者33例,对其采用经皮患侧颈动脉穿刺尿激酶溶栓治疗。结果:对两组患者治疗前、术后2h以及术后30d采用NIHSS评分比较,两组患者NIHSS评分在术后2h及术后30d均较术前有明显改善(P<0.05);对两组患者治疗相关情况比较,股动脉组患者术后2h血管再通率明显高于颈动脉组(P<0.05),两组颅内出血率未显示出统计学差异性;对两组患者术后30d牛津残障OHS评分、BI指数比较,股动脉组患者明显优于颈动脉组(P<0.05)。结论:对老年急性脑梗死患者采用经皮股动脉穿刺微导管介入或采用经皮患侧颈动脉穿刺尿激酶溶栓治疗,均可有效改善患者预后,提高患者的临床疗效,两组相比较,股动脉组更能显示出优良的治疗率。     

脑出血后白质微观结构损伤与血管性认知功能障碍的相关性研究

目的:探讨脑出血后白质微观结构损伤情况和血管性认知功能功能障碍(VCI)的相关性。方法:选择2012年1月至2017年12月我院收治的脑出血患者50例作为研究对象,所有患者按照神经心理学评估结果分为认知功能障碍组(A组)29例和认知正常组(B组)21例,观察和比较两组患者病灶情况和白质微观结构的改变情况。结果:A组患者额区、基底核区病灶数量,病灶直径、白质病变、美国国立卫生院卒中量表(NIHSS)_评分等指标均明显高于B组,改良巴氏指数(MBI)评分低于B组(P0.05);将蒙特利尔认知评估(MoCA)量表评分作为因变量,MBI评分和NIHSS量表评分、病灶直径、病灶数量、白质病变程度等作为自变量进行多元Logistic回归分析,结果显示白质病变程度是脑出血患者VCI独立危险因素(P0.05)。结论:脑出血患者白质缺血性病变程度可能用于评估其发生VCI的风险。     

Knowledge of Thrombolytic Therapy for Acute Ischemic Stroke among Community Residents in Western Urban China

Background and Purpose

Thrombolytic therapy rate for acute ischemic stroke remains low, and improving public awareness of thrombolytic therapy may be helpful to reduce delay and increase chances of thrombolytic therapy. Our purpose was to survey the level of knowledge about thrombolytic therapy for acute ischemic stroke among community residents in Yuzhong district, Chongqing, China.

Methods

In 2011, a population-based face-to-face interview survey was conducted in Yuzhong district, Chongqing. A total of 1500 potential participants aged ≥18 years old were selected using a multi-stage sampling method.

Results

A total of 1101 participants completed the survey. Only 23.3% (95% CI = 20.8 to 25.8) were aware of thrombolytic therapy for acute ischemic stroke, of whom 59.9% (95% CI = 53.9 to 65.9) knew the time window. Awareness of thrombolytic therapy was higher among young people, those with higher levels of education and household income, those with health insurance, and those who knew all 5 stroke warning signs, while awareness of the time window was higher among those aged 75 years or older. Multivariate logistic regression analysis showed that awareness of thrombolytic therapy was independently associated with age, education level, health insurance and knowledge of stroke warning signs (P<0.05).

Conclusions

In this population-based survey the community residents have poor awareness of thrombolytic therapy for acute ischemic stroke.