治疗中风的新标准


  Nov. 26, 2002─根据11月份神经外科期刊报导,那些不适用标准剂量血栓溶解治疗的中风患者,现在不但可以改用低剂量动脉内导入血栓溶解治疗,也可采用药物结合机械性方式来破坏血块。
  
  纽约州立大学Adnan I. Qureshi博士表示,这个临床试验开启了一个新的中风治疗标准,因为在治疗中风患者的过程中,最让人担心的便是病情持续恶化,而在这个初步研究中,却没有任何一位患者发生出血的危险情况。
  
  这个前瞻性研究一共纳入了19位中风患者,这些患者可能不适用静脉注射血栓溶解剂alteplase的治疗方式,或即使静脉注射血栓溶解剂也不见改善。他们的平均年龄为64.3 ± 16.2岁,其中有10位为男性。治疗前,他们的国家卫生研究院(NIH)脑中风评量表分数为11至42;此外,栓塞的位置有9位发生于中大脑动脉,7位在颈部内颈动脉,2位在基底动脉,1位在颅内内颈动脉;药物治疗约持续1至9小时之间。
  
  一开始先以超选择导管将1U reteplase导入动脉内,剂量最高可达4U,若起始剂量无法让血管重新畅通,就让患者在近端阻塞的地方进行机械性的血管成形术,或在远端阻塞之处利用圈套器处理(snare manipulation);若要加强血管的畅通,可再投予维持剂量的血栓溶解剂。最后在全部19位患者中,有5位仅进行血栓溶解剂的治疗;而除了基本的血栓溶解剂治疗外,有11位还做了血管成形术,5位做了圈套器处理。
  
  有12位患者因为血管成形术而使血流恢复畅通,或修正后的心肌梗塞性血栓(modified TIMI)等级为4;4位患者的血流几乎完全恢复(modified TIMI等级为3),1位患者达到最小的反应(modified TIMI等级为1),2位患者对于治疗完全没有反应(modified TIMI等级为0)。24小时候,7位患者在神经生理学方面获得改善(NIH脑中风评量表分数至少下降4分),其它5位患者则在后续7 ~ 10天获得更进一步的改善,所有患者都未发生血管破裂、剥离,或症状性的颅内出血。
  
  之后再追踪1至3个月,除了有一位患者在治疗后马上死亡之外,其它死亡的10位患者中,6位死于严重的二次中风,1位死于心肌梗塞,3位死于并发性肺炎;另外还有2位患者因为中风而导致残疾,但在19位患者中,有7位患者仍然保持正常的生理功能。
  
  Quereshi博士说,原本大家并不认为这些患者会得到多大的改善,但实际上在这19位患者中,超过1/3的人已拥有不错的生活能力,对于这些受试的患者来说,能够有这样的改善成果也已让他们受宠若惊,但他不讳言,这还需要进行前瞻性的随机临床试验,来做更进一步的确认。
  
  
  

'New Horizon' for Stroke Treat

By Laurie Barclay, MD
Medscape Medical News

Nov. 26, 2002 — Patients ineligible for standard-dose thrombolytic therapy for stroke may respond either to low-dose intra-arterial thrombolytic therapy or a combination of drugs plus mechanical disruption of the clot, according to a report in the November issue of Neurosurgery.

"This trial opens up a new horizon for stroke treatment," lead author Adnan I. Qureshi, MD, from the State University of New York, Buffalo, says in a news release. "The biggest fear in stroke treatment is that the situation can be made worse. In this pilot study, none of the patients experienced damaging hemorrhages."

This prospective study treated 19 consecutive patients who were considered poor candidates for intravenous alteplase therapy or who did not improve after intravenous thrombolysis. Mean age was 64.3 ± 16.2 years, and there were 10 men. Initial National Institutes of Health (NIH) Stroke Scale scores ranged from 11 to 42. Occlusion sites were in the middle cerebral artery in nine patients, the cervical internal carotid in seven, the basilar in two, and the intracranial internal carotid in one. Time from onset to treatment ranged from one to nine hours.

Treatment began with intra-arterial reteplase in 1-U increments via superselective catheterization to a maximum total dose of 4 U. If the initial doses did not result in recanalization, patients underwent mechanical angioplasty for proximal occlusion or snare manipulation for distal occlusion. The remaining doses of thrombolytics were then given as needed for further recanalization. Of the 19 patients, five had thrombolysis alone, 11 had angioplasty, and five had snare maneuvers.

Complete angiographic restoration of blood flow, or modified Thrombolysis in Myocardial Infarction (TIMI) criteria grade 4, was observed in 12 patients. Four patients had near-complete restoration of flow (modified TIMI grade 3), one had minimal response (modified TIMI grade 1), and two had no response (modified TIMI grade 0). At 24 hours, seven patients had neurologic improvement (reflected in decline of at least four points in NIH Stroke Scale score), and five other patients had further improvement at seven to 10 days. No vessel rupture, dissection, or symptomatic intracranial hemorrhages were observed.

At one- to three-month follow-up, 10 patients had died, one soon after treatment, six of a massive second stroke, one of a myocardial infarction, and three of complications of pneumonia. Two patients developed disability related to the stroke, but seven of the original 19 patients were functionally independent.

"Almost all of these patients would be expected to do really poorly," Quereshi says. "More than one-third now are able to live with good functional capacity.... Given the selection of patients, this is an impressive result."

Comments accompanying the article stress the need for a prospective, randomized clinical trial.

Neurosurgery. 2002;251(5):1319-1329

Reviewed by Gary D. Vogin, MD

    
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