Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Curr Opin Neurol. 2023 Apr 1;36(2):147-154. doi: 10.1097/WCO.0000000000001136. Epub 2023 Feb 7.
This review aims to summarize the therapeutic advances and evidence in the medical management of acute ischemic stroke (AIS). Recent evidence comparing the efficacy and safety of tenecteplase (TNK) with alteplase for intravenous thrombolysis (IVT) in AIS will be highlighted. Recent advances and evidence on improving micro-circulation following endovascular procedures and neuroprotection will be reviewed.
A significant number of randomized control studies now support the use of tenecteplase for IVT in AIS. TNK 0.25 mg/kg single bolus is as effective and well tolerated as alteplase 0.9 mg/kg infusion for IVT in AIS. Evidence from randomized control trials (RCTs) has shown effective and well tolerated expansion of the therapeutic window of IVT in the wake-up stroke and up to 9 h after last seen well, using advanced neuroimaging with computed tomography perfusion/MRI. Early evidence suggests that intra-arterial alteplase may help improve microcirculation in patients with large vessel occlusion following successful thrombectomy. However, more trials are required to confirm the results. Similarly, early evidence from a recent RCT showed that remote ischemic conditioning confers potential neuroprotection and improves outcomes in AIS.
Converging evidence has demonstrated that for patients with ischemic stroke presenting at under 4.5 h from the onset, TNK is comparable to alteplase. These data along with the practical advantages of TNK have resulted in a shift to replace intravenous TNK as the standard for thrombolysis. Ongoing studies of IVT with TNK are focussed on defining the optimal dose, expanding the time window with multimodal imaging and defining the role of thrombolysis for bridging patients with stroke due to large vessel occlusion.
本综述旨在总结急性缺血性脑卒中（AIS）的医学治疗进展和证据。将重点介绍比较替奈普酶（TNK）与阿替普酶静脉溶栓（IVT）治疗 AIS 的疗效和安全性的最新证据。还将回顾血管内治疗后改善微循环和神经保护的最新进展和证据。
大量随机对照研究现在支持替奈普酶用于 AIS 的 IVT。TNK 0.25mg/kg 单次推注与阿替普酶 0.9mg/kg 输注用于 AIS 的 IVT 一样有效且耐受性良好。随机对照试验（RCT）的证据表明，使用 CT 灌注/MRI 等先进神经影像学技术，在唤醒性脑卒中患者和最后一次看到正常后 9 小时内，IVT 的治疗窗口可以有效且耐受性良好地扩大。早期证据表明，在成功取栓后，动脉内阿替普酶可能有助于改善大血管闭塞患者的微循环。然而，还需要更多的试验来证实这些结果。同样，最近一项 RCT 的早期证据表明，远程缺血预处理可潜在地保护神经并改善 AIS 的结局。
越来越多的证据表明，对于发病 4.5 小时内的缺血性脑卒中患者，TNK 可与阿替普酶相媲美。这些数据以及 TNK 的实际优势导致了用静脉 TNK 替代阿替普酶成为溶栓的标准。目前正在进行的 TNK IVT 研究侧重于确定最佳剂量、使用多模态成像扩大时间窗以及确定溶栓在治疗因大血管闭塞导致的脑卒中患者中的作用。
