Grotta James C
Continuum (Minneap Minn). 2023 Apr 1;29(2):425-442. doi: 10.1212/CON.0000000000001207.
This article reviews the history of IV thrombolysis, its current indications and implementation, the duality of the "time is brain" versus "tissue clock" approaches, the impact of endovascular thrombectomy on IV thrombolysis, the emergence of tenecteplase, and future research directions.
The growing use of factor Xa inhibitors has increasingly caused patients with stroke to be excluded from treatment with IV thrombolysis. Important geographic, socioeconomic, sex, race, and ethnic disparities have been identified in the implementation of IV thrombolysis and need to be overcome. IV thrombolysis substantially improves outcomes when provided within the first golden hour after stroke onset in patients treated in mobile stroke units, supporting the "time is brain" concept and encouraging the possible value of more widespread implementation of the mobile stroke unit approach. At the same time, other studies have shown that IV thrombolysis can be successful in patients whose "tissue clock" is still ticking up to 9 hours after stroke onset or in patients who awaken with their stroke, as demonstrated by favorable imaging profiles. These considerations, along with the emergence of endovascular thrombectomy, have fostered examination of our care systems, including the "drip and ship" versus direct to comprehensive or endovascular thrombectomy stroke center approaches, as well as the possibility of skipping IV thrombolysis in certain patients treated with endovascular thrombectomy. Data suggesting that tenecteplase is at least noninferior to alteplase, as well as its more convenient dosing, has led to its increased use. Ongoing studies are evaluating newer thrombolytics and adding antithrombotic therapy to IV thrombolysis.
IV thrombolysis remains the most common acute stroke treatment. Advances in acting faster to treat stroke have increased its efficacy, and advances in imaging have expanded its use. However, implementing these advances and overcoming disparities in IV thrombolysis use remain major challenges.
本文回顾了静脉溶栓的历史、当前的适应证及实施情况、“时间就是大脑”与“组织时钟”方法的二元性、血管内血栓切除术对静脉溶栓的影响、替奈普酶的出现以及未来的研究方向。
Xa因子抑制剂的使用日益增加，越来越多的卒中患者被排除在静脉溶栓治疗之外。在静脉溶栓的实施过程中，已发现重要的地理、社会经济、性别、种族和民族差异，需要加以克服。对于在移动卒中单元接受治疗的患者，在卒中发作后的首个黄金小时内进行静脉溶栓可显著改善预后，这支持了“时间就是大脑”的概念，并凸显了更广泛实施移动卒中单元方法的潜在价值。与此同时，其他研究表明，对于那些“组织时钟”在卒中发作后长达9小时仍在运转的患者，或者卒中发作后醒来的患者，静脉溶栓可能成功，良好的影像学表现证明了这一点。这些考量，再加上血管内血栓切除术的出现，促使人们审视我们的医疗系统，包括“滴注并转运”与直接送往综合或血管内血栓切除术卒中中心的方法，以及在某些接受血管内血栓切除术的患者中跳过静脉溶栓的可能性。有数据表明替奈普酶至少不劣于阿替普酶，且给药更方便，这导致其使用增加。正在进行的研究正在评估更新的溶栓药物，并在静脉溶栓中添加抗栓治疗。
静脉溶栓仍然是最常见的急性卒中治疗方法。更快治疗卒中的进展提高了其疗效，影像学的进展扩大了其应用范围。然而，实施这些进展并克服静脉溶栓使用中的差异仍然是重大挑战。
