Fisher M
Department of Neurology, Memorial Health, University of Massachussetts Medical School, Worcester, Massachussetts.
J Thromb Thrombolysis. 1999 Apr;7(2):165-9. doi: 10.1023/a:1008889605137.
Anthithrombotic therapy is widely used as primary and secondary preventative treatment for ischemic cerebrovascular disease. Aspirin modestly reduces the risk for subsequent ischemic stroke after a transient ischemic attack or initial stroke. Adding dipyridamole may enhance this benefit. Ticlopidine confers a small additional benefit, but with more side effects and cost. The best dose of aspirin remains unsettled, but recent studies support the concept of very early initiation of treatment. Intravenous and subcutaneous heparin or low-molecular-weight heparin is not recommended because of enhanced bleeding side effects, unless venous thrombosis in debilitated patients is a concern. Thrombolytic therapy with rt-PA was recently demonstrated to improve outcome in ischemic stroke patients treated within 3 hours of onset. However, the risk-benefit ratio is narrow because of the substantial risk for intracerebral hemorrhage with rt-PA. An enhanced ability to identify patients at risk for bleeding and newer thrombolytic drugs may expand the utility of this therapy, as would extending the time window beyond the current 3-hour period. Clinicians should anticipate continued advances in the fields of antithrombotic and thrombolytic therapy for ischemic stroke over the next few years.
抗栓治疗广泛用作缺血性脑血管病的一级和二级预防治疗。阿司匹林可适度降低短暂性脑缺血发作或首次卒中后后续缺血性卒中的风险。加用双嘧达莫可能会增强这种益处。噻氯匹定有少量额外益处，但副作用更多且费用更高。阿司匹林的最佳剂量尚无定论，但近期研究支持尽早开始治疗的理念。不推荐静脉和皮下使用肝素或低分子肝素，因为出血副作用增加，除非虚弱患者存在静脉血栓形成问题。最近证实，在发病3小时内接受治疗的缺血性卒中患者中，使用重组组织型纤溶酶原激活剂（rt-PA）进行溶栓治疗可改善预后。然而，由于rt-PA导致脑出血的风险很大，其风险效益比很窄。提高识别出血风险患者的能力以及新型溶栓药物可能会扩大这种治疗方法的应用范围，将时间窗延长至目前的3小时以上也会如此。临床医生应预计未来几年缺血性卒中抗栓和溶栓治疗领域会持续取得进展。
