静脉和动脉联合溶栓治疗急性缺血性卒中

Combined intravenous and intra-arterial thrombolysis in patients with acute ischemic stroke

目的评估静脉和动脉联合溶栓治疗急性缺血性卒中的有效性和安全性。方法采用前瞻性、开放性临床病例研究，对北京世纪坛医院神经内科自2005年5月至2009年2月收治的发病3h内的40例颈内动脉系统急性缺血性卒中患者使用重组人组织型纤溶酶原激活剂（rt—PA）行静脉和动脉联合溶栓治疗，并就患者预后良好比例、症状性颅内出血发生率、病死率等与国外多个大样本试验研究结果进行比较。结果静脉溶栓治疗后行DSA显示25％（10／401未见血管闭塞，7．5％（3／40）有严重血管狭窄f颈内动脉2例，大脑中动脉1例），67．5％（27／40）发现血管闭塞（颈内动脉9例，大脑中动脉18例）。其中24例于发病后180～390min[平均（304±61）min]开始联合动脉溶栓治疗，血管再通率（TICI分级2或3级1为79．2％（19／24）。再梗死发生率为7．5％（3／40）。3个月时预后良好（mRS评分0～2分）比例为60％（24／40），与NINDS试验安慰剂组[27．2％（85／312]1比较差异有统计学意义（P〈0．05）；预后良好（NIHSS评分≤1）比例为52．5％（21／40），与NINDS试验rt-PA组[31％（97／312）]、安慰剂组[20％（62／312）]和IMS[27．5％（22／80）]比较差异均有统计学意义（P〈0．05）；症状性颅内出血发生率为2．5％（1／40），病死率为10％（4／401，与NINDS试验rt-PA组、安慰剂组、EMS和IMS比较差异均无统计学意义（P〉0．05）。结论静脉和动脉联合溶栓治疗急性缺血性卒中，可提供更高的血管再通率，可明显改善患者的预后，是一种安全、有效的新方法。

Objective To evaluate the efficacy and safety of combined intravenous （IV） and intra-arterial （IA） thrombolysis in patients with acute ischemic stroke. Methods A prospective and open-label trial was performed on 40 patients with acute ischemic stroke in the carotid artery system within 3 hours of symptom onset, admitted to our hospital from May 2005 to February 2009; these patients were treated with recombinant tissue plasminogen activator （rt-PA） by a combined IV and IA thrombolysis approach. The percentage of favorable prognosis, incidence of symptomatic intracranial haemorrhage （SICH） and fatality rate in these patients were compared with those research results from foreigners having large samples. Results According to the results of DSA, recanalization rate （grade-2 or -3 in the Thrombolysis in Cerebral Infarction [TICI] scale） after IV thrombolysis was 25% （10/40）, rate of serious cerebrovascular stenosis was 7.5% （3/40）, including 2 patients with stenosis of the internal carotid artery （ICA） and 1 with stenosis of the middle cerebral artery （MCA）, and rate of vascular occlusion was 67.5% （27/40）, including 9 patients with ICA occlusion and 18 with MCA occlusion. Twenty-four patients adopted combined IV and IA thrombolysis approach after 180-390 min （mean [304±61] min） of stroke onset, and their recanalization rate was 79.2% （19/24）. Re-infarction rate was 7.5% （3/40）. Three months after the thrombolysis, percentage of good fimctional outcomes （modified Rankin Scale [mRS]） scores： 0-2） was 60% （24/40）, which had significant differences as compared with that with NINDS placebo treatment （27.2% [85/312], P〈0.05）; percentage of good functional outcomes （NIHSS score ≤ 1） was 52.5% （21/40）, which had significant differences as compared with that of groups with NINDS rt-PA treatment （31% [97/312]）, NINDS placebo treatment （20% [62/312]） and interventional management of stroke （IMS, 27.5% [22/80]）, P〈0.05）; SICH was noted in 2.5% （1/40） and fatality in 10% （4/40） accepted thrombolysis, and no significant differences were noted as compared with those in groups with NINDS rt-PA treatment, N1NDS placebo treatment, emergency management of stroke EMS and IMS （P〉0.05）. Conclusion Combined IV and IA thrombolysis is an effective and safe new method in treating patients with acute ischemic stroke by providing good vascular recanalization rate and good clinical outcomes.