溶栓评估及再通选择课件

急性脑梗死诊治热点：

溶栓出血预测及血管再通方法选择

血管再通方法

MethodsinrecanalizationIntravenousrtPAthrombolysis(IVT)Intra-arterialthrombolysis(IAT)CombinationofIVTandIAT/MechanicaldevicesMechanicalendovascularrecanalizationSono-thrombolysisAcuteangioplastyandstenting

BarM,etal.JNeuralTransm(2011)118:1131–1138AHAacuteischemicstrokeguideline.Stroke.2013;44:870-947Limitationsofiv.rtPALimitedto<4.5hoursOnlyaminorityofstrokepatientsbeeligibleforthistreatmentLowrecanalizationrates(6%-44%)IncreasedriskofsymptomaticICH(6.4%vs0.6%)AlexandrovAV.JInternMed2010;267:209–219溶栓后症状性颅内出血预测量表研究

HAT

SPAN-100

SITS

THRIVE

LouM,SafdarA,MehdirattaM,KumarS,SchlaugG,CaplanL,SearlsD,SelimM.The

HAT

Score:asimplegradingscaleforpredicting

hemorrhage

after

thrombolysis.

Neurology.2008;71(18):1417-23.HAT

(HemorrhageAfterThrombolysis)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(strokeprognosticationusingageandNIHStrokeScale-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SaposnikG,GuzikAK,ReevesM,OvbiageleB,JohnstonSC.StrokePrognosticationusingAgeandNIHStrokeScale:SPAN-100.

Neurology,

2013;80(1):21-8.SITS量表(SafeImplementationofThrombolysisinStroke)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MazyaMV,AhmedN,FordGA,HobohmC,MikulikR,NunesAP,WahlgrenN.RemoteorExtraischemicIntracerebralHemorrhage-AnUncommonComplicationof

Stroke

Thrombolysis:ResultsFromthe

Safe

Implementation

ofTreatmentsin

StrokeInternational

Stroke

ThrombolysisRegister.Stroke

2014;45(6):1657-1663THRIVE(TotaledHealthRisksinVascularEvents)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FlintAC,FaigelesBS,CullenSP,etal.THRIVE

score

predicts

ischemic

stroke

outcomes

and

thrombolytichemorrhage

risk

inVISTA.Stroke

2013;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心源性脑梗死非心源性脑梗死THRIVE0-2n=196THRIVE3-5n=256THRIVE6-9n=53PValueTHRIVE0-2n=2434THRIVE3-5n=848THRIVE6-9n=92PValue出血转化30(15.3)69(27.0)15(28.3)0.004100(4.1)73(8.6)11(11.9)<0.001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%CI1.03to1.30,P=0.003)，非心源性脑梗死患者的出血风险增加1.29倍(95%CI1.17to1.40,P<0.001)动脉溶栓

Intra-arteralthrombolysisPotentialadvantagesLowertotaldose/higherlocaldoseofagents(减少出血）GreaterrecanalizationratesMayhavewidertimewindowPotentialdisadvantagesCathetermanipulationandNeedskilledpersonsDelayininitiationofthrombolysis围手术期镇静手术并发症ExpensiveWhatabouttheEvidence?FirstRCT:PROACTIITrialr-pro-UK+heparinvsIVheparinwithin6h.180patients,M1orM2MCAocclusion.NIHSS>/=4(Average17)MediantimetoIAthrombolysis5.7hoursFurlanA,etal.JAMA,1999Dec1;282(21):2003-11PROACTIITrial结果mRS<2:40%VS25%(P=0.043)Recanalisationat2h:66%vs18%Symptomatichemorrhage:10%vs2%(P=0.06)Nodifferenceinmortality(25%VS.27%)FurlanA,etal.JAMA,1999Dec1;282(21):2003-11WhatabouttheEvidence?SR:5RCTswith395participants(40-180)Timewindow:3forMCA:<6hours1forICAorMCA:<6hours1forBAorVA:<24hoursFibrinolyticagents:

Pro-urokinase;urokinase;t-PALeeM,etal.Stroke,2010;41:932-937Meta-analysisofRCTsIAfibrinolysiswasassociatedwithincreasedgoodandexcellentoutcomesLeeM,etal.Stroke,2010;41:932-937

桥接(Bridging)

CombinedIVandIAthrombolysis

SR:15studies(Non-RCT)included559strokepatientstreatedwithacombinedIV/IAapproachThepooledestimateforrecanalizationratewas69.6%(95%CI,63.9%–75.0%)Theshortermeantimetointravenoustreatment,thegreatertherecanalizationrate(per10-minutedecrease:OR,1.24;95%CI,1.02–1.51)andthelowermortalityrate(per10-minutedecrease:OR,0.75;95%CI,0.60–0.94)MazighiM,etal.Stroke,2012;43:1302-08Combined(Bridging)TherapyBridgingtherapywasassociatedwithafavorableoutcome(mRS:0-2)MazighiM,etal.Stroke,2012;43:1302-08BridgingTherapyAlthoughthesepositiveefficacyandsafetyfindingsfavorthebridgingtherapyapproach,thereisnodatafromRCTsRandomizedtrial--InterventionalManagementofStrokeIII(IMS-III)TargetN=900

IvrtPAalone(0.9mg/kg)vscombinedIV/IA(0.6mg/kgover30minfollowedbyimmediateangiography.Ifclotisdemonstrated,theneuro-interventionalistwillthenchoosefromcurrentlyavailablebuttrialdefinedintra-arterialtreatmentapproaches.IATwillbegivenatmaximum2mgbolusand10mg/hr,max22mg)usingstandardmicrocathether.The

Interventional

Management

of

Stroke

(IMS-III

trial)Thepatientswhohadreceivedintravenoust-PAwithin3hoursaftersymptomonsetwererandomlyassignedtoreceiveadditionalendovasculartherapyorintravenoust-PAalone,ina2:1ratioTheprimaryoutcomemeasure:amodifiedRankinscalescoreof2orlessat90daysBroderickJP,etal.NEnglJMed,2013;368:893-903血管内治疗VS静脉溶栓endovasculartherapy:

-Intra-arterialthrombolysis-mechanicalendovascularrecanalization(clotdisruption/extraction)-orcombination血管内治疗优于静脉溶栓吗？CicconeA,etal.NEnglJMed,2013;368:904-13(The

SYNTHESISExpansionInvestigators)结果：At3months,55patientsintheendovascular-therapygroup(30.4%)and63intheintravenoust-PAgroup(34.8%)werealivewithoutdisability(OR,0.71;95%CI,0.44to1.14;P=0.16)Theendovasculartherapyisnotsuperiortostandardtreatmentwithintravenoust-PAinpatientswithacuteischemicstroke后循环（Posteriorcirculation）?ThevastmajorityofthedataonreperfusionwereobtainedintheanteriorcirculationwithlimitedevidenceintheposteriorcirculationAsinglelargeprospectiveregistry,theBasilarArteryInternationalCooperationStudy(BASICS)register592patientsSchonewilleWJ,etal.LancetNeurol2009;8:724–30Patientsweredividedintothreetherapeuticalgroups:1、Antithrombotictherapy;2、i.v.thrombolysis;3、EndovasculartherapyInthiscohortofpatients,endovasculartherapydidnotshowsuperiorityoverIVthrombolysisintermsofmortalityordependencyPatientshadanincreasedriskofpoorfunctionaloutcomeastimetorecanalizationtherapybecamelonger:

≦3hours:62%3to6hours:67%（RR,1.06;0.91–1.25）

6to9hours:77%（RR,1.26;1.06–1.51）>9hours:85%（RR,1.47;1.26–1.72）Asignificantincreasedchanceofapooroutcomewhenrecanalizationtherapyisstarted6hoursafterestimatedtimeofBAO.PublishedonlineSeptember18,2012再通（中间指标）=临床效果（终点）吗？Recanalization=favorableoutcome?Higherrecanalizationratesatanextendedtimeframedonotnecessarilyleadtobetterclinicaloutcomesat3monthsAlexandrovAV.JInternMed2010;267:209–19Thelikelihoodofgoodoutcomeisdependentprimarilyon:1.Goodpremorbidstatusandrelativelysmalldeficitatpresentation;2.Smallinfarct;3.Short-timeintervalbetweenimagingandrecanalization;4.LowcomplicationraterelatedtotheinterventionUSFDAapproved4systemsCurrently,FDAapproveddevicesforendovascularclotremovalaretheMERCIRetrievalSystem,

thePenumbrasystem,SolitaireFR,andTrevo.AlexandrovAV.JInternMed2010;267:209–219AHAGuideline2013,Stroke;44:870-947RelatedGuidelinesEndovasculartherapyofacuteischemicstroke:reportoftheStandardsofPracticeCommitteeoftheSocietyofNeuro-InterventionalSurgery(Surgery)

BlackhamKAetal.JNeuroInterventSurg2012;87-93IndicationsforthePerformanceofIntracranialEndovascularNeurointerventionalProcedures(AHA)