Second Department of Neurology, 'Attikon' University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens.
Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece.
Curr Opin Neurol. 2019 Feb;32(1):3-12. doi: 10.1097/WCO.0000000000000633.
To summarize available evidence on the potential utility of pretreatment with intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO) who are treated with mechanical thrombectomy.
Despite theoretical concerns of a higher bleeding risk with IVT pretreatment, there are no data showing increased risk of symptomatic intracerebral hemorrhage (sICH) in patients with LVO receiving bridging therapy (IVT and mechanical thrombectomy) compared with direct mechanical thrombectomy (dMT). Additionally, evidence from observational studies suggest lower rates of infarctions in previously unaffected territories and higher rates of successful reperfusion, with lower number of device passes, in patients receiving bridging therapy. There are substantial discrepancies in studies comparing clinical outcomes between dMT and bridging therapy that are directly related to the inclusion of patients with contraindications to IVT in the dMT group. Ongoing clinical trials will provide definitive answers on the potential additional benefit of IVT in LVO patients receiving mechanical thrombectomy.
IVT and mechanical thrombectomy are two effective reperfusion therapies that should be used in a swift and noncompeting fashion in AIS patients. AIS patients with LVO and no contraindications for IVT should receive promptly rt-PA bolus followed by immediate initiation of mechanical thrombectomy as indicated by current international recommendations, unless future randomized controlled trials provide evidence to proceed differently.
总结目前关于大血管闭塞（LVO）急性缺血性卒中（AIS）患者在接受机械取栓治疗前应用重组组织型纤溶酶原激活剂（rt-PA）静脉溶栓（IVT）的潜在益处的证据。
尽管存在 IVT 预处理后出血风险增加的理论担忧，但尚无数据表明 LVO 患者接受桥接治疗（IVT 和机械取栓）与直接机械取栓（dMT）相比，症状性颅内出血（sICH）风险增加。此外，来自观察性研究的证据表明，与接受直接机械取栓治疗的患者相比，接受桥接治疗的患者在未受影响的区域梗死发生率较低，再灌注成功率较高，器械通过次数较少。在比较直接机械取栓和桥接治疗的临床结局的研究中存在着很大的差异，这直接与将有 IVT 禁忌证的患者纳入 dMT 组有关。正在进行的临床试验将为接受机械取栓的 LVO 患者 IVT 的潜在额外益处提供明确的答案。
IVT 和机械取栓是两种有效的再灌注治疗方法，在 AIS 患者中应迅速且非竞争性地使用。LVO 且无 IVT 禁忌证的 AIS 患者应尽快给予 rt-PA 推注，然后根据当前国际建议立即开始机械取栓，除非未来的随机对照试验提供不同的证据。
