Department of Neurology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH.
Ann Neurol. 2013 Sep;74(3):363-72. doi: 10.1002/ana.23993.
We review recent advances in the treatment and prevention of acute ischemic stroke, including the current state of endovascular therapy, in light of 5 randomized controlled trials published this past year. Although no benefit of endovascular therapy over intravenous (IV) recombinant tissue plasminogen activator (rt-PA) has been demonstrated, endovascular therapy is an appropriate treatment for acute ischemic stroke patients within the t-PA window who are ineligible for IV t-PA but have a large vascular occlusion. These trials reveal promises and current limitations of endovascular therapy, and comparison of reperfusion therapies remains an important area of research. One common theme is the strong association between a faster time to reperfusion, improved outcome, and reduced mortality. Primary and secondary stroke prevention trials emphasize the importance of aggressive management of medical risk factors as part of any preventative strategy. New oral anticoagulants, for example, offer cost-effective risk reduction in patients with atrial fibrillation, and may represent an opportunity for those with cryptogenic stroke. We highlight areas of unmet need and promising research in stroke, including the need to deliver proven therapies to more patients, and the need to recruit patients into clinical trials that better define the role of endovascular and other stroke therapies. Finally, improvement in strategies to recover speech, cognition, and motor function has the potential to benefit far more stroke patients than any acute stroke therapy, and represents the greatest opportunity for research in the coming century.
我们回顾了过去一年发表的 5 项随机对照试验，讨论了急性缺血性脑卒中治疗和预防方面的最新进展，包括目前的血管内治疗状况。尽管没有证据表明血管内治疗比静脉内（IV）重组组织型纤溶酶原激活剂（rt-PA）更有效，但对于在 t-PA 时间窗内、不适合接受 IV t-PA 治疗但存在大血管闭塞的急性缺血性脑卒中患者，血管内治疗是一种合理的治疗方法。这些试验揭示了血管内治疗的前景和当前局限性，再灌注治疗的比较仍然是一个重要的研究领域。一个共同的主题是再灌注时间更快、预后改善和死亡率降低之间的强相关性。一级和二级卒中预防试验强调了积极管理医疗风险因素作为任何预防策略的一部分的重要性。例如，新型口服抗凝剂可降低房颤患者的风险，并且可能为隐源性卒中患者提供机会。我们强调了卒中领域未满足的需求和有前途的研究领域，包括将已证实的治疗方法推广应用于更多患者的需求，以及招募患者参与临床试验以更好地确定血管内和其他卒中治疗方法的作用的需求。最后，提高恢复言语、认知和运动功能的策略有可能使比任何急性卒中治疗都更多的卒中患者受益，这代表了未来一个世纪研究的最大机会。
