Department of Neurology, University of Texas in Houston, Houston, Texas 77030, USA.
Stroke. 2010 Sep;41(9):2038-43. doi: 10.1161/STROKEAHA.110.586511. Epub 2010 Jul 22.
Clinical trials are assessing the efficacy of fibrinolysis in extended time windows for acute ischemic stroke.
An Internet-based survey was sent to 400 US vascular neurologists affiliated with a university to assess whether there are consensus opinions on how they treat patients beyond 3 hours from symptom onset and which patients they are willing to enroll into clinical trials of fibrinolysis for acute ischemic stroke.
We received 161 responses; 81% were male. Ninety-three percent of respondents treat patients with intravenous tissue plasminogen activator beyond 3 hours. More than 80% were treated beyond 3 hours with intra-arterial therapy (IAT). When asked if IAT improves stroke outcome, >50% selected the choice of "yes for middle cerebral artery and basilar occlusions" and only 2% selected the choice that "IAT does not improve outcome." Over half believe that imaging could be used to approximate the penumbra but with improvements to better identify salvageable tissue. Eighty-seven percent were willing to enroll patients into a placebo-controlled intravenous thrombolysis beyond 3 hours. For IAT trials, >80% would randomize beyond 3 hours with or without prior intravenous treatment.
Vascular neurologists have been treating acute ischemic stroke beyond 3 hours with intravenous tissue plasminogen activator even before the American Heart Association guidelines supported extending the therapeutic window. There is a paradox among the respondents willing to enroll patients into trials involving IAT given that a majority is offering IAT as part of their practice. These results suggest that clinical practice may impair enrollment into trials testing reperfusion therapies for acute ischemic stroke.
临床试验正在评估溶栓治疗在急性缺血性脑卒中延长时间窗内的疗效。
我们向 400 名美国大学附属医院的血管神经科医生发送了一份在线调查，以评估他们在发病后 3 小时以上如何治疗患者，以及他们愿意将哪些患者纳入急性缺血性脑卒中溶栓临床试验。
我们共收到 161 份回复，其中 81%为男性。93%的受访者会对发病 3 小时后的患者使用静脉组织型纤溶酶原激活剂进行治疗。超过 80%的患者会接受动脉内治疗（IAT），治疗时间超过 3 小时。当被问及 IAT 是否能改善卒中预后时，超过 50%的人选择了“对大脑中动脉和基底动脉闭塞有效”，只有 2%的人选择了“IAT 不能改善预后”。超过一半的人认为影像学可以用来估计半暗带，但需要改进以更好地识别可挽救的组织。87%的人愿意在发病 3 小时后纳入静脉溶栓的安慰剂对照试验。对于 IAT 试验，超过 80%的人会在发病 3 小时后进行随机分组，无论是否有前期静脉治疗。
血管神经科医生在《美国心脏协会指南》支持延长治疗窗之前，就已经开始对发病 3 小时后的急性缺血性脑卒中患者使用静脉组织型纤溶酶原激活剂进行治疗。尽管大多数人在提供 IAT 作为治疗的一部分，但愿意将患者纳入涉及 IAT 的试验，这一现象存在矛盾。这些结果表明，临床实践可能会影响急性缺血性脑卒中再灌注治疗试验的入组。
