Fisher M, Jonas S, Sacco R L, Jones S [corrected to Jonas S ]
Medical Center of Central Massachusetts, Worcester 01605.
Stroke. 1994 May;25(5):1075-80. doi: 10.1161/01.str.25.5.1075.
Treatments for acute ischemic stroke have evolved as knowledge about the pathophysiology of ischemic brain injury has advanced. Treatment strategies under development are aimed at offering neuroprotection acutely after focal cerebral ischemic injury, but delayed initiation of therapy may reduce efficacy. Pretreatment before ischemia begins could offer distinct advantages in patient groups at high risk for ischemic stroke.
If a neuroprotective drug were available orally, safe, and relatively inexpensive, it could be considered for prophylactic use in high-risk populations. Prophylactic neuroprotection would include (1) short-term neuroprotection before and after high-stroke risk procedures, (2) long-term neuroprotection for primary and secondary intervention in populations at high risk for stroke, and (3) concomitant neuroprotection with agents that have multiple treatment effects. Patients undergoing procedures such as cardiac surgery, endarterectomy, or endovascular therapy, which have a risk of cerebral ischemic events during a defined period, might be considered for short-term, periprocedure prophylactic neuroprotection. Several populations at high long-term risk for initial ischemic stroke have been identified and include those with combinations of vascular risk factors, transient ischemic attacks, atrial fibrillation, and asymptomatic carotid stenosis. Such people, as well as those at risk for stroke recurrence after minor strokes, are readily identifiable and perhaps appropriate for long-term prophylactic neuroprotection. Patients with hypertension and cerebrovascular atherosclerosis have a high stroke risk, and therapies directed at these underlying disorders are available that also have concomitant neuroprotective effects. An ideal drug for trials in these patient groups has not yet been developed, and establishing its efficacy may prove to be an arduous and lengthy task.
The possibility of ameliorating the consequences of an acute ischemic stroke by pretreating high-risk patients with appropriate neuroprotective agents needs to be explored. Several types of high-risk population for prophylactic neuroprotection can be envisioned and then studied in clinical trials.
随着对缺血性脑损伤病理生理学认识的不断深入，急性缺血性中风的治疗方法也在不断发展。正在研发的治疗策略旨在局灶性脑缺血损伤后急性提供神经保护作用，但治疗开始延迟可能会降低疗效。在缺血开始前进行预处理可能会给缺血性中风高危患者群体带来明显优势。
如果有一种神经保护药物可以口服、安全且相对便宜，那么可以考虑在高危人群中进行预防性使用。预防性神经保护将包括：（1）在高中风风险手术前后的短期神经保护；（2）对中风高危人群进行一级和二级干预的长期神经保护；（3）与具有多种治疗作用的药物同时进行神经保护。在特定时期有发生脑缺血事件风险的心脏手术、动脉内膜切除术或血管内治疗等手术的患者，可考虑在围手术期进行短期预防性神经保护。已确定了几个初始缺血性中风长期高危人群，包括那些具有多种血管危险因素、短暂性脑缺血发作、心房颤动和无症状颈动脉狭窄的人群。这些人以及轻度中风后有中风复发风险的人很容易识别，可能适合长期预防性神经保护。高血压和脑血管动脉粥样硬化患者中风风险高，针对这些潜在疾病的治疗方法也具有伴随的神经保护作用。尚未开发出适用于这些患者群体试验的理想药物，证明其疗效可能是一项艰巨而漫长的任务。
需要探索用适当的神经保护剂对高危患者进行预处理以改善急性缺血性中风后果的可能性。可以设想几种预防性神经保护的高危人群类型，然后在临床试验中进行研究。
