Sugiura S, Iwaisako K, Toyota S, Takimoto H
Department of Neurosurgery, Osaka Neurological Institute, Osaka, Japan.
AJNR Am J Neuroradiol. 2008 Jun;29(6):1061-6. doi: 10.3174/ajnr.A1012. Epub 2008 Mar 27.
Because intravenous (IV) recombinant tissue plasminogen activator (rtPA) does not always lead to a good outcome in a considerable proportion of patients, combined IV rtPA and rescue endovascular therapy (ET) have been performed in several recent studies. However, rescue therapy after completion of IV rtPA often results in late ineffective recanalization. We examined the efficacy and safety of combined IV rtPA and simultaneous ET as primary rather than rescue therapy for hyperacute middle cerebral artery (MCA) occlusion.
A total of 29 patients eligible for IV rtPA, who were diagnosed as having MCA (M1 or M2) occlusion within 3 hours of onset, underwent thrombolysis. In the combined group, patients were treated by IV rtPA (0.6 mg/kg for 60 minutes) and simultaneous ET (intra-arterial rtPA, mechanical thrombus disruption with microguidewire, and balloon angioplasty) initiated as soon as possible. In the IV group, patients were treated by IV rtPA only.
The improvement of the National Institutes of Health Stroke Scale (NIHSS) score at 24 hours was 11 +/- 4.8 in the combined group versus 5 +/- 4.3 in the IV group (P < .001). In the combined group, successful recanalization was observed in 14 (88%) of 16 patients with no symptomatic intracranial hemorrhage, and 10 (63%) of 16 patients had favorable outcomes (modified Rankin Scale [mRS] 0, 1) at 3 months.
Aggressive combined therapy with IV rtPA and simultaneous ET markedly improved the clinical outcome of hyperacute MCA occlusion without significant adverse effect. Additional randomized study is needed to confirm our results.
由于静脉注射重组组织型纤溶酶原激活剂(rtPA)在相当一部分患者中并非总能带来良好的预后,近期的多项研究采用了静脉注射rtPA联合挽救性血管内治疗(ET)的方法。然而,静脉注射rtPA完成后的挽救性治疗常常导致再通延迟且效果不佳。我们研究了静脉注射rtPA联合同步ET作为超急性大脑中动脉(MCA)闭塞的主要治疗而非挽救性治疗的有效性和安全性。
共有29例符合静脉注射rtPA条件、在发病3小时内被诊断为MCA(M1或M2)闭塞的患者接受了溶栓治疗。在联合治疗组中,患者接受静脉注射rtPA(0.6mg/kg,持续60分钟)并尽快启动同步ET(动脉内rtPA、用微导丝进行机械性血栓破碎以及球囊血管成形术)。在静脉注射组中,患者仅接受静脉注射rtPA治疗。
联合治疗组在24小时时美国国立卫生研究院卒中量表(NIHSS)评分的改善为11±4.8,而静脉注射组为5±4.3(P<0.001)。在联合治疗组中,16例无症状颅内出血患者中有14例(88%)实现了成功再通,16例患者中有10例(63%)在3个月时获得了良好预后(改良Rankin量表[mRS]为0、1)。
静脉注射rtPA联合同步ET的积极联合治疗显著改善了超急性MCA闭塞的临床预后,且无明显不良反应。需要进一步的随机研究来证实我们的结果。