Schellinger P D, Fiebach J B, Mohr A, Ringleb P A, Jansen O, Hacke W
Department of Neurology, University of Heidelberg, Heidelberg, Germany.
Crit Care Med. 2001 Sep;29(9):1819-25. doi: 10.1097/00003246-200109000-00028.
Intra-arterial thrombolytic therapy for carotid and vertebrobasilar stroke may result in a more rapid clot lysis and higher recanalization rates than can be achieved with intravenous thrombolysis and thus may warrant the more invasive and time-consuming therapeutic approach. We present an overview of all hitherto completed trials of intra-arterial thrombolytic therapy for carotid and vertebrobasilar artery stroke including recommendations for therapy and a meta-analysis. Furthermore, new imaging techniques such as diffusion- and perfusion-weighted magnetic resonance imaging and their impact on patient selection are discussed. Finally, phase IV trials of thrombolysis in general and cost efficacy analyses are presented.
We performed an extensive literature search not only to identify the larger and well-known randomized trials but also to identify smaller pilot studies and case series. Trials included in this review, among others, are the PROACT I and PROACT II studies and the Cochrane Library report.
Intra-arterial thrombolytic therapy of acute M1 and M2 occlusions with 9 mg/2 hrs pro-urokinase significantly improves outcome if administered within 6 hrs after stroke onset. Seven patients need to be treated to prevent one patient from death or dependence. Vertebrobasilar occlusion has a grim prognosis and intra-arterial thrombolytic therapy to date is the only life-saving therapy that has demonstrated benefit with regard to mortality and outcome, albeit not in a randomized trial. New magnetic resonance imaging techniques may facilitate and improve the selection of patients for thrombolytic therapy. Presently, thrombolytic therapy is still underutilized because of problems with clinical and time criteria, and lack of public and professional education to regard stroke as a treatable emergency. If applied more widely, thrombolytic therapy may result in profound cost savings in health care and reduction of long-term disability of stroke patients.
与静脉溶栓相比，颈动脉和椎基底动脉卒中的动脉内溶栓治疗可能导致血栓更快溶解，再通率更高，因此可能需要采用更具侵入性且耗时的治疗方法。我们对迄今为止所有已完成的颈动脉和椎基底动脉卒中动脉内溶栓治疗试验进行了综述，包括治疗建议和荟萃分析。此外，还讨论了诸如弥散加权磁共振成像和灌注加权磁共振成像等新的成像技术及其对患者选择的影响。最后，介绍了溶栓治疗的IV期试验及成本效益分析。
我们进行了广泛的文献检索，不仅旨在识别较大且知名的随机试验，还旨在识别较小的试点研究和病例系列。本综述纳入的试验包括PROACT I和PROACT II研究以及Cochrane图书馆报告等。
急性M1和M2段闭塞采用9mg/2小时的尿激酶原进行动脉内溶栓治疗，若在卒中发作后6小时内给药，可显著改善预后。需要治疗7名患者才能预防1名患者死亡或依赖。椎基底动脉闭塞预后严峻，迄今为止，动脉内溶栓治疗是唯一在死亡率和预后方面显示出益处的挽救生命的治疗方法，尽管尚未进行随机试验。新的磁共振成像技术可能有助于并改善溶栓治疗患者的选择。目前，由于临床和时间标准问题以及缺乏公众和专业教育，将卒中视为可治疗的急症，溶栓治疗仍未得到充分利用。如果更广泛地应用，溶栓治疗可能会在医疗保健方面大幅节省成本，并减少卒中患者的长期残疾。
