Department of Stroke Research, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.
J Vasc Surg. 2011 Sep;54(3):901-7. doi: 10.1016/j.jvs.2011.04.062.
Thrombolysis with intravenous alteplase is the primary therapy for acute ischemic stroke, and is approved in most countries. Early administration improves functional outcome though benefit and risk depend on the time elapsed between stroke onset and initiation of treatment. Randomized controlled trials demonstrated benefit from intravenous thrombolysis when initiated up to 4.5 hours after symptom onset, and pooled analysis of all trials indicates that the sooner that alteplase is given, the greater is the benefit. Treatment carries a risk of bleeding, with symptomatic intracranial hemorrhage (SICH) of around 3%. Initiating treatment after 4.5 hours increases mortality and reverses the risk-benefit balance. Baseline stroke severity, age, diabetes and concomitant stroke are associated with poorer outcome from acute stroke; but secondary analyses and controlled registry data suggest that intravenous alteplase remains effective in most subgroups. Intra-arterial thrombolysis has a less extensive evidence base and is mostly unapproved for acute stroke. Access to thrombolysis remains patchy and involves unacceptable delays: greater awareness of the benefits and time dependency are crucial.
静脉注射阿替普酶溶栓是急性缺血性脑卒中的主要治疗方法，在大多数国家都得到批准。早期给药可改善功能结局，但获益和风险取决于脑卒中发病与治疗开始之间的时间间隔。随机对照试验表明，在症状发作后 4.5 小时内开始静脉溶栓治疗可获益，所有试验的汇总分析表明，阿替普酶越早给药，获益越大。治疗有出血风险，症状性颅内出血（SICH）约为 3%。4.5 小时后开始治疗会增加死亡率并改变风险效益平衡。基线脑卒中严重程度、年龄、糖尿病和并发脑卒中与急性脑卒中的预后较差相关；但二次分析和对照登记数据表明，静脉内阿替普酶在大多数亚组中仍然有效。动脉内溶栓的证据基础较少，大多未批准用于急性脑卒中。溶栓治疗的可及性参差不齐，且存在不可接受的延迟：提高对获益和时间依赖性的认识至关重要。
