Ciccone Alfonso, Valvassori Luca, Gasparotti Roberto, Scomazzoni Francesco, Ballabio Elena, Sterzi Roberto
Stroke Unit and Department of Neurology, Niguarda Ca' Granda Hospital, Milan, Italy.
Stroke. 2007 Jul;38(7):2191-5. doi: 10.1161/STROKEAHA.106.465567. Epub 2007 May 31.
Although intravenous (IV) thrombolysis is the standard treatment for patients with ischemic stroke occurring within 3 hours from symptom onset, a few interventional neuroradiologists have been treating this category of patients by an intra-arterial (IA) route for >25 years. However, evidence is still required to support the clinical feeling that IA treatment, which needs longer time and greater complexity, leads to a better outcome. Therefore, the objective of the present review was to analyze beliefs and myths underlying the selection of patients for IA thrombolysis.
We identified and debunked the following myths on IA thrombolysis: (1) IA thrombolysis works better than IV because it achieves higher recanalization rates; (2) IA thrombolysis works better than IV after the 3-hour window; (3) IA thrombolysis works better than IV in vertebrobasilar stroke; (4) carotid duplex, transcranial doppler, CT angiography, or MRA should be used to screen for major vessel occlusion treatable with IA thrombolysis; (5) to be treated with IA thrombolysis, patients should be selected with diffusion/perfusion MRI; (6) IA thrombolysis should be used as a "rescue" therapy for IV thrombolysis; and (7) the efficacy of IA thrombolysis depends on the thrombolytic agent or the device used.
Evidence on acute stroke management with IA thrombolysis is scant. Therefore, neither clinicians nor patients have enough information to make truly informed decisions about the most appropriate treatment. Only randomized controlled trials can clear uncertainties about the possible superiority of IA over IV thrombolysis. Regretfully, case series on IA treatment have limited the organization of such trials and have only favored the spread of myths.
尽管静脉溶栓是症状出现后3小时内发生缺血性卒中患者的标准治疗方法，但一些介入神经放射科医生采用动脉内（IA）途径治疗此类患者已有25年以上。然而，仍需要证据来支持这种临床感觉，即需要更长时间和更高复杂性的IA治疗能带来更好的结果。因此，本综述的目的是分析IA溶栓患者选择背后的观念和误区。
我们识别并揭穿了以下关于IA溶栓的误区：（1）IA溶栓比静脉溶栓效果更好，因为其再通率更高；（2）在3小时时间窗之后，IA溶栓比静脉溶栓效果更好；（3）在椎基底动脉卒中中，IA溶栓比静脉溶栓效果更好；（4）应使用颈动脉双功超声、经颅多普勒、CT血管造影或MRA来筛查可通过IA溶栓治疗的大血管闭塞；（5）要接受IA溶栓治疗，应选择通过弥散/灌注MRI筛选的患者；（6）IA溶栓应用作静脉溶栓的“补救”疗法；（7）IA溶栓的疗效取决于所使用的溶栓剂或设备。
关于IA溶栓治疗急性卒中的证据很少。因此，临床医生和患者都没有足够的信息来就最合适的治疗做出真正明智的决定。只有随机对照试验才能消除关于IA溶栓可能优于静脉溶栓的不确定性。遗憾的是，关于IA治疗的病例系列限制了此类试验的开展，且只助长了误区的传播。
