Sultan Sherif, Acharya Yogesh, Barrett Nora, Hynes Niamh
Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland.
Department of Vascular & Endovascular Surgery, Galway Clinic, Royal College of Surgeons of Ireland/National University of Ireland Affiliated Teaching Hospitals, Doughiska, Galway, Ireland.
Ann Transl Med. 2020 Oct;8(19):1275. doi: 10.21037/atm-2020-cass-14.
An alternative to tissue plasminogen activator (tPA) failure has been a daunting challenge in ischemic stroke management. As tPA is time-dependent, delays can occur in definitive treatment while passively waiting to observe a clinical response to intravenous thrombolysis. Until today, uncertainty exists in the management strategy of wake-up stroke patients or those presenting beyond the therapeutic tPA window. Clinical dilemmas in these situations can prolong the transitional period of inertia, resulting in an adverse neurological outcome. We propose and review an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains-targeted hypothermia, systemic induced hypertension, and barbiturates infusion, to protect the brain during carotid endarterectomy after failed tPA and/or beyond the 24-hour therapeutic mechanical thrombectomy window. This proposal assimilates discussion on the clinical evidence of the individual domains of TNP with our own clinical experience with TNP. Our first TNP was successfully employed in a 55-year-old man in 2015 while performing emergency carotid endarterectomy after he was referred to us 72 hours post tPA failure. The patient had a successful clinical outcome despite being in therapeutic inertia with 90-99% ipsilateral carotid stenosis and contralateral occlusion on presentation. In the last five years, we have safely used TNP in 25 selected cases with favourable clinical outcomes.
在缺血性中风的治疗中，组织型纤溶酶原激活剂（tPA）治疗失败后的替代方案一直是一项艰巨的挑战。由于tPA治疗具有时间依赖性，在等待观察静脉溶栓临床反应的被动过程中，确定性治疗可能会出现延迟。直到今天，对于醒后中风患者或在tPA治疗窗之外就诊的患者的管理策略仍存在不确定性。这些情况下的临床困境会延长惰性过渡期，导致不良的神经学预后。我们提出并回顾一种名为三重神经保护（TNP）的创新方法，该方法涵盖三个技术领域——靶向性低温、全身性诱导高血压和巴比妥酸盐输注，用于在tPA治疗失败后和/或超过24小时治疗性机械取栓窗的颈动脉内膜切除术中保护大脑。本提议将关于TNP各个领域临床证据的讨论与我们自己使用TNP的临床经验相结合。我们的首例TNP于2015年成功应用于一名55岁男性，当时他在tPA治疗失败72小时后被转诊至我们这里并接受紧急颈动脉内膜切除术。尽管患者就诊时存在90 - 99%同侧颈动脉狭窄和对侧闭塞的治疗惰性，但临床结局良好。在过去五年中，我们已在25例选定病例中安全使用TNP，临床结局良好。
