Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.
Int J Stroke. 2024 Aug;19(7):718-726. doi: 10.1177/17474930241267353.
A decade on from the first positive thrombectomy trials, hyperacute therapies for ischemic stroke continue to rapidly advance. Effective treatments remain limited to reperfusion, although several cytoprotective approaches continue to be investigated. Intravenous fibrinolytics are now demonstrated to be beneficial up to 24 h in patients selected using perfusion imaging, but their role in patients with non-disabling symptoms appears very limited. Tenecteplase is superior to alteplase in meta-analysis of the latest trials, and adjuvant thrombolytics are an area of active investigation. Endovascular thrombectomy is beneficial in a wide range of anterior and posterior circulation large vessel occlusions up to 24 h after onset with the more distal occlusions, mild presentations, and >24 h window being the main frontiers to be tested in ongoing trials. Imaging parameters are prognostic but appear not to modify the relative treatment benefit of thrombectomy versus standard medical care. Therefore, deciding who not to treat with thrombectomy is a key clinical challenge that requires careful but rapid integration of clinical, imaging, and patient preference considerations. Systems of care to accelerate delivery of these highly effective therapies will maximize benefits for the greatest number of patients with stroke.
自首次积极的血栓切除术试验以来的十年间，缺血性脑卒中的超急性期治疗方法继续迅速发展。尽管有几种细胞保护方法仍在继续研究，但有效的治疗方法仍然限于再灌注。现在已经证明，在使用灌注成像选择的患者中，静脉内溶栓治疗在 24 小时内是有益的，但它们在症状不致残的患者中的作用似乎非常有限。在最新试验的荟萃分析中，替奈普酶优于阿替普酶，辅助溶栓是一个活跃的研究领域。血管内血栓切除术在发病后 24 小时内对广泛的前循环和后循环大血管闭塞都有益，对于更远端的闭塞、轻度表现和 >24 小时的时间窗，目前正在进行的试验正在对其进行测试。影像学参数具有预后价值，但似乎不会改变血栓切除术与标准药物治疗的相对治疗益处。因此，决定哪些患者不应接受血栓切除术治疗是一个关键的临床挑战，需要仔细但迅速地综合考虑临床、影像学和患者偏好等因素。加速这些高效治疗方法的护理系统将使最大数量的脑卒中患者受益最大化。
