Koudstaal P J, Stibbe J, Vermeulen M
Department of Neurology, Academic Hospital, Dijkzigt, Rotterdam, The Netherlands.
BMJ. 1988 Dec 17;297(6663):1571-4. doi: 10.1136/bmj.297.6663.1571.
Two patients with acute major, disabling cerebral infarction with presumed middle cerebral artery occlusion were treated with the clot specific thrombolytic agent tissue plasminogen activator roughly three and a half hours after the onset of symptoms. Both patients had a normal computed tomography (CT) scan before treatment. No appreciable systemic bleeding complications occurred, apart from bruising. One patient had bleeding into the subarachnoid space from a microscopic angioma, which was found at necropsy. Haematological monitoring of the two patients showed pronounced fibrinogenolysis and alpha 2 antiplasmin consumption in one. One patient showed transient improvement during the infusion. In both cases extensive infarction, partly haemorrhagic in one, with massive concomitant oedema was found on repeated CT. Both patients deteriorated and eventually died as a consequence of transtentorial herniation. In the one patient who came to necropsy a moderate, probably pre-existing smooth stenosis of the ipsilateral carotid artery was found, all cerebral vessels being patent. It is concluded that thrombolytic treatment with a clot specific agent such as tissue plasminogen activator started three to four hours after a major ischaemic stroke may be hazardous, not because of haemorrhagic transformation of the original ischaemia but because early reperfusion may promote massive, potentially fatal cerebral oedema.
两名患有急性严重致残性脑梗死且推测为大脑中动脉闭塞的患者，在症状发作约三个半小时后接受了凝块特异性溶栓剂组织型纤溶酶原激活剂治疗。两名患者在治疗前计算机断层扫描（CT）均正常。除瘀伤外，未发生明显的全身性出血并发症。一名患者因显微镜下血管瘤导致蛛网膜下腔出血，尸检时发现该血管瘤。对两名患者的血液学监测显示，其中一名患者出现明显的纤维蛋白溶解和α2抗纤溶酶消耗。一名患者在输注过程中出现短暂改善。在这两例中，重复CT检查均发现广泛梗死，其中一例部分出血，并伴有大量水肿。两名患者均病情恶化，最终因小脑幕切迹疝死亡。在进行尸检的那名患者中，发现同侧颈动脉有中度、可能为先前存在的平滑狭窄，所有脑血管均通畅。得出的结论是，在重大缺血性中风三到四小时后开始使用凝块特异性药物如组织型纤溶酶原激活剂进行溶栓治疗可能具有危险性，并非因为原始缺血灶的出血性转化，而是因为早期再灌注可能会促进大量潜在致命性脑水肿。
