Powers William J
From the Department of Neurology, University of North Carolina at Chapel Hill.
South Med J. 2014 Feb;107(2):101-6. doi: 10.1097/SMJ.0000000000000054.
Intravenous tissue plasminogen activator (IV tPA, alteplase) provides a statistically and clinically significant improvement in clinical outcome for carefully selected patients with acute ischemic stroke when administered within 4.5 hours of onset; however, even within the 4.5-hour window, outcome is poor for some eligible patients, including those with occlusions of large arteries (internal carotid, middle cerebral, and basilar) and many patients do not meet the stringent eligibility criteria, especially the time requirement. Intraarterial (also known as endovascular or neurointerventional) therapies have been developed to address these needs. This review summarizes the current evidence for the efficacy of endovascular treatments in acute ischemic stroke. Randomized controlled clinical trials of acute ischemic stroke do not show any added clinical benefit of endovascular treatment over IV tPA alone in IV tPA-eligible patients, even in patients with persistent large-artery occlusion, nor have these trials provided evidence of clinical benefit in patients ineligible for IV tPA because they are >4.5 hours from onset, even if selected by sophisticated neuroimaging. The new stent retrievers, however, were rarely used in these trials. It remains to be determined from trials with direct head-to-head comparisons whether these new devices are superior to standard nonendovascular therapy. If there is a role for endovascular treatment of acute ischemic stroke, it is for patients who can be treated under 4.5 hours but who are ineligible for IV tPA because of increased hemorrhage risk from systemic thrombolytic drug effects, although this remains unproven.
对于在发病4.5小时内接受治疗的精心挑选的急性缺血性中风患者，静脉注射组织型纤溶酶原激活剂（IV tPA，阿替普酶）在临床结局方面具有统计学和临床意义上的显著改善；然而，即使在4.5小时的时间窗内，一些符合条件的患者，包括那些大动脉（颈内动脉、大脑中动脉和基底动脉）闭塞的患者，预后仍然很差，而且许多患者不符合严格的入选标准，尤其是时间要求。动脉内（也称为血管内或神经介入）治疗已被开发出来以满足这些需求。本综述总结了目前血管内治疗急性缺血性中风疗效的证据。急性缺血性中风的随机对照临床试验未显示血管内治疗相对于单独使用IV tPA在符合IV tPA治疗条件的患者中具有任何额外的临床益处，即使是在持续性大动脉闭塞的患者中也是如此，这些试验也未提供在因发病时间超过4.5小时而不符合IV tPA治疗条件的患者中具有临床益处的证据，即使这些患者是通过先进的神经影像学检查挑选出来的。然而，这些试验中很少使用新型支架取栓器。直接头对头比较的试验仍有待确定这些新设备是否优于标准的非血管内治疗。如果血管内治疗对急性缺血性中风有作用，那也是针对那些在4.5小时内可以接受治疗但因全身溶栓药物作用导致出血风险增加而不符合IV tPA治疗条件的患者，尽管这一点仍未得到证实。
