Cardiocenter, Third Faculty of Medicine, Charles University Prague, Ruska 87, 100 00 Prague 10, Czech Republic.
Eur Heart J. 2014 Jan;35(3):147-55. doi: 10.1093/eurheartj/eht409. Epub 2013 Oct 3.
The evolution of reperfusion therapy in acute myocardial infarction and acute ischaemic stroke has many similarities: thrombolysis is superior to placebo, intra-arterial thrombolysis is not superior to intravenous (i.v.), facilitated intervention is of questionable value, and direct mechanical recanalization without thrombolysis is proven (myocardial infarction) or promising (stroke) to be superior to thrombolysis-but only when started with no or minimal delay. However, there are also substantial differences. Direct catheter-based thrombectomy in acute ischaemic stroke is more difficult than primary angioplasty (in ST-elevation myocardial infarction [STEMI]) in many ways: complex pre-intervention diagnostic workup, shorter time window for clinically effective reperfusion, need for an emergent multidisciplinary approach from the first medical contact, vessel tortuosity, vessel fragility, no evidence available about dosage and combination of peri-procedural antithrombotic drugs, risk of intracranial bleeding, unclear respective roles of thrombolysis and mechanical intervention, lower number of suitable patients, and thus longer learning curves of the staff. Thus, starting acute stroke interventional programme requires a lot of learning, discipline, and humility. Randomized trials comparing different reperfusion strategies provided similar results in acute ischaemic stroke as in STEMI. Thus, it might be expected that also a future randomized trial comparing direct (primary) catheter-based thrombectomy vs. i.v. thrombolysis could show superiority of the mechanical intervention if it would be initiated without delay. Such randomized trial is needed to define the role of mechanical intervention alone in acute stroke treatment.
溶栓优于安慰剂，动脉内溶栓并不优于静脉内溶栓（i.v.），辅助介入的价值值得怀疑，直接机械再通而不溶栓在心肌梗死中已被证明（或在卒中中有希望）优于溶栓，但仅在无或最小延迟的情况下启动。然而，也存在实质性差异。急性缺血性卒中直接基于导管的血栓切除术在许多方面比直接经皮冠状动脉介入治疗（在 ST 段抬高型心肌梗死 [STEMI] 中）更困难：复杂的介入前诊断工作、更短的临床有效再灌注时间窗口、需要从首次医疗接触开始进行紧急多学科方法、血管迂曲、血管脆弱、缺乏围手术期抗血栓药物剂量和联合的证据、颅内出血风险、溶栓和机械干预各自作用的不明确、适合患者数量较少，以及工作人员的学习曲线更长。因此，启动急性卒中介入治疗项目需要大量的学习、纪律和谦逊。比较不同再灌注策略的随机试验在急性缺血性卒中与 STEMI 中提供了相似的结果。因此，如果能够立即启动，那么人们可能会期望未来一项比较直接（原发性）基于导管的血栓切除术与静脉溶栓的随机试验也能显示出机械干预的优越性。为了明确机械干预在急性卒中治疗中的单独作用，需要进行这样的随机试验。
