Ho James P, Powers William J
Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA; email:
Annu Rev Med. 2025 Jan;76(1):417-429. doi: 10.1146/annurev-med-050823-094312. Epub 2025 Jan 16.
In the past decade, adding mechanical thrombectomy (MT) of intracranial arterial occlusions to intravenous (IV) thrombolysis has revolutionized the treatment of acute ischemic stroke (AIS) by expanding the therapeutic window to 24 h. Treatment decisions require establishing a high probability of AIS; confirming time since last known well (LKW); assessing severity of the neurological deficit; determining any contraindications to IV thrombolysis; and performing neuroimaging, usually noncontrast computed tomography (NCCT), to exclude intracerebral hemorrhage. If time since LKW is less than 4.5 h, patients with disabling stroke without contraindications can proceed immediately to IV thrombolysis while the decision about MT is under way. For some patients, the MT decision can be made on the basis of clinical assessment, NCCT, and CT angiography showing a large vessel occlusion. Others may require additional neuroimaging. Patients who are not candidates for IV thrombolysis within 4.5 h or MT should be immediately evaluated for eligibility for extended-window IV thrombolysis or early antiplatelet treatment.
在过去十年中，将颅内动脉闭塞的机械取栓术（MT）与静脉溶栓（IV）相结合，通过将治疗窗口延长至24小时，彻底改变了急性缺血性卒中（AIS）的治疗方式。治疗决策需要确定AIS的高可能性；确认距最后已知正常状态（LKW）的时间；评估神经功能缺损的严重程度；确定IV溶栓的任何禁忌症；并进行神经影像学检查，通常是平扫计算机断层扫描（NCCT），以排除脑出血。如果距LKW的时间少于4.5小时，无禁忌症的致残性卒中患者可在进行MT决策的同时立即进行IV溶栓。对于一些患者，MT决策可基于临床评估、NCCT和显示大血管闭塞的CT血管造影做出。其他患者可能需要额外的神经影像学检查。在4.5小时内不适合IV溶栓或MT的患者应立即评估是否适合延长窗口IV溶栓或早期抗血小板治疗。
