Broderick Joseph P
Department of Neurology, 260 Stetson St, Suite 2300, University of Cincinnati Medical Center, PO Box, Cincinnati, OH, USA.
Stroke. 2009 Mar;40(3 Suppl):S103-6. doi: 10.1161/STROKEAHA.108.533067. Epub 2008 Dec 8.
To review advances in endovascular therapy for acute ischemic stroke.
Data from primate studies, randomized studies of intravenous recombinant tissue-type plasminogen activator, and nonrandomized and randomized studies of endovascular therapy were reviewed.
Clinical trial data demonstrate the superiority of endovascular treatment with thrombolytic medication or mechanical methods to reopen arteries compared with control patients from the PROACT II Trial treated with heparin alone. However, these same clinical trials, as well as preclinical primate models, indicate that recanalization, whether by endovascular approaches or standard-dose recombinant tissue-type plasminogen activator, is unlikely to improve clinical outcome after a certain time point. Although the threshold beyond which reperfusion has no or little benefit has yet to be conclusively defined, accumulated data to this point indicate an overall threshold of approximately 6 to 7 hours. In addition, although the risk of symptomatic intracerebral hemorrhage is similar in trials of intravenous lytics and endovascular approaches, endovascular approaches have distinctive risk profiles that can impact outcome.
The treatment of acute ischemic stroke is evolving with new tools to reopen arteries and salvage the ischemic brain. Ongoing randomized trials of these new approaches are prerequisite next steps to demonstrate whether reperfusion translates into clinical effectiveness. Physiologic time to reperfusion will remain critical no matter which tools prove most effective and safest.
回顾急性缺血性卒中血管内治疗的进展。
回顾了来自灵长类动物研究、静脉注射重组组织型纤溶酶原激活剂的随机研究以及血管内治疗的非随机和随机研究的数据。
临床试验数据表明，与仅接受肝素治疗的PROACT II试验中的对照患者相比，使用溶栓药物或机械方法进行血管内治疗以重新开通动脉具有优越性。然而，这些相同的临床试验以及临床前灵长类动物模型表明，无论是通过血管内方法还是标准剂量的重组组织型纤溶酶原激活剂实现再通，在某个时间点之后不太可能改善临床结局。尽管尚未最终确定再灌注无益处或益处不大的阈值，但截至目前积累的数据表明总体阈值约为6至7小时。此外，尽管静脉溶栓和血管内治疗试验中症状性脑出血的风险相似，但血管内治疗方法具有独特的风险特征，可能会影响结局。
急性缺血性卒中的治疗正在随着重新开通动脉和挽救缺血脑组织的新工具而不断发展。这些新方法正在进行的随机试验是证明再灌注是否转化为临床疗效的必要下一步。无论哪种工具被证明最有效和最安全，再灌注的生理时间仍将至关重要。
