溶栓评估及再通选择

急性脑梗死诊治热点：溶栓出血预测及血管再通方法选择,刘 鸣四川大学华西医院神经内科四川大学华西医院脑血管病中心,血管再通方法Methods in recanalization,Intravenous rtPA thrombolysis (IVT)Intra-arterial thrombolysis (IAT)Combination of IVT and IAT/ Mechanical devicesMechanical endovascular recanalizationSono-thrombolysisAcute angioplasty and stenting,Bar M, et al. J Neural Transm (2011) 118:11311138AHA acute ischemic stroke guideline. Stroke. 2013;44:870-947,Fast recanalization and subsequent reperfusion is the main objective to be achieved in acute ischemic stroke with arterial occlusion To date, the most effective therapy for treatment of acute ischemic stroke is intravenous rtPA (4.5hours)Other methods of recanalization became hot topics in recent years because of limitations of iv rtPA.,静脉溶栓仍然是首选,Molina CA. Stroke. 2011;42:S16-S19,Limitations of iv. rtPA,Limited to 25、CT低密度1/3MCA供血区、有卒中+糖尿病史等需要进一步研究（IIb, C),AHA acute ischemic stroke guideline. Stroke. 2013;44:870-947,溶栓后症状性颅内出血预测量表研究 HAT SPAN-100 SITS THRIVE,Lou M, Safdar A, Mehdiratta M, Kumar S, Schlaug G, Caplan L, Searls D, Selim M.TheHATScore: a simple grading scale for predictinghemorrhageafter thrombolysis. Neurology. 2008;71(18):1417-23.,HAT(Hemorrhage After Thrombolysis)量表,总共5分，随着分值增高，症状性颅内出血风险增高,SPAN -100量表(stroke prognostication using age and NIH Stroke Scale-100),年龄+入院时NIHSS评分 以100为分界点，大于100出血风险高 对预测症状性颅内出血的敏感性较低，特异性较高,Saposnik G, Guzik AK, Reeves M, Ovbiagele B, Johnston SC. Stroke Prognostication using Age and NIH Stroke Scale: SPAN-100. Neurology,2013 ;80(1):21-8.,SITS量表(Safe Implementation of Thrombolysis in Stroke),SITS 量表包括9个因素（入院时NIHSS评分、血糖、收缩压、年龄、体重、脑卒中发生后开始治疗时间、阿司匹林或者阿司匹林和氯吡格雷的联合运用、高血压史），总共12分 对症状性颅内出血风险的预测，按照分值高低进行分层,Mazya MV, Ahmed N, Ford GA, Hobohm C, Mikulik R, Nunes AP, Wahlgren N. Remote or Extraischemic Intracerebral Hemorrhage-An Uncommon Complication ofStrokeThrombolysis: Results From theSafeImplementationof Treatments inStroke InternationalStrokeThrombolysis Register. Stroke2014;45(6):1657-1663,THRIVE (Totaled Health Risks in Vascular Events)量表,该量表总共9分，随分值增高，症状性颅内出血风险增高,Flint AC, Faigeles BS, Cullen SP, et al. THRIVEscorepredictsischemicstrokeoutcomesandthrombolytic hemorrhageriskin VISTA. Stroke2013;44(12):3365-9.,THRIVE量表能在亚洲人群（尤其是中国人）预测出血转化风险吗？,雷春艳 吴波 刘鸣等, Stroke.2014;45:1689-1694,本期推荐阅读文章,社论：21世纪预后估计与卒中治疗的艺术,用2分作为分界点评估出血转化的风险（心源性脑梗死：敏感性:62.5%,特异性:73.5%；非心源性脑梗死：敏感性:71.2%,特异性: 65.6%),雷春艳 吴波 刘鸣等,Stroke.2014;45:1689-1694,THRIVE量表预测出血转化的ROC曲线，无论是心源性脑梗死还是非心源性脑梗死其ROC曲线值都大于0.5（心源性脑梗死: ROC=0.602 ；非心源性脑梗死:ROC=0.608 ),雷春艳 吴波 刘鸣等, Stroke， 2014;45:1689-1694.,雷春艳 吴波 刘鸣等, Stroke.2014;45:1689-1694,提示THRIVE量表分值越高，心源性脑梗死和非心源性脑梗死患者发生出血转化的风险越高 lTHRIVE每增加1分，心源性脑梗死患者的出血危险增加1.15倍（95%CI 1.03 to 1.30, P=0.003)，非心源性脑梗死患者的出血风险增加1.29倍 (95%CI 1.17 to 1.40, P/= 4 (Average 17)Median time to IA thrombolysis 5.7 hours,Furlan A, et al. JAMA,1999 Dec 1;282(21):2003-11,PROACT II Trial,结果mRS 2: 40% VS 25% (P=0.043)Recanalisation at 2h: 66% vs 18%Symptomatic hemorrhage: 10% vs 2%(P=0.06)No difference in mortality (25% VS. 27%),Furlan A, et al. JAMA,1999 Dec 1;282(21):2003-11,What about the Evidence?,SR: 5 RCTs with 395 participants (40-180 )Time window: 3 for MCA: 6 hours 1 for ICA or MCA: 6 hours 1 for BA or VA: 9 hours: 85% （RR, 1.47; 1.26 1.72）,A significant increased chance of a poor outcome when recanalization therapy is started 6 hours after estimated time of BAO.,Published online September 18, 2012,再通（中间指标）=临床效果（终点）吗？Recanalization=favorable outcome ?,Higher recanalization rates at an extended timeframe do not necessarily lead to better clinical outcomes at 3 months,Alexandrov AV. J Intern Med 2010; 267: 20919,The likelihood of good outcome is dependent primarily on:1. Good premorbid status and relatively small deficit at presentation;2. Small infarct;3. Short-time interval between imaging and recanalization;4. Low complication rate related to the intervention,US FDA approved 4 systems,Currently , FDA approved devices for endovascular clot removal are the MERCI Retrieval System, the Penumbra system, Solitaire FR, and Trevo.,Alexandrov AV. J Intern Med 2010; 267: 209219AHA Guideline 2013, Stroke;44:870-947,Related Guidelines,Endovascular therapy of acute ischemic stroke: report of the Standards of Practice Committee of the Society of Neuro-Interventional Surgery (Surgery) Blackham KA et al. J NeuroIntervent Surg 2012; 87-93Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures (AHA) Meyers PM, et al. Circulation. 2009;119:2235-2249Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008 (ESO) Cerebrovasc Dis 2008;25:457507,急性期血管内治疗美国指南2013版推荐,即使有条件动脉溶栓也应优先使用静脉溶栓（I; A)动脉溶栓可用于经严格选择的不能静脉溶栓的MCA闭塞较严重的患者，发病在6小时内。(I; B)应尽可能减少时间延误（I；B）动脉溶栓应在有条件的医院和由有资质介入医生进行（I； C)对有静脉溶栓禁忌症的患者考虑动脉溶栓或机械取栓是合理的（IIa; C)对静脉溶栓无效的大动脉闭塞患者进行补救性动脉溶栓或机械取栓（桥接）可能是合理的但需要更多随机对照试验（IIb; B)紧急颅内、外动脉血管成型术或支架的效果尚未证实，需在临床试验的环境中进行（IIb; C), 特殊情况如颈动脉粥样硬化或夹层可考虑但 需更多随机对照试验（IIb; C),AHA acute ischemic st