2015急性腦梗死溶栓20年

急性腦梗死溶栓20年回顧與展望,杜萬良北京天壇醫(yī)院神經(jīng)內(nèi)科2015.10.11,20年的試驗,Randomized Trials of Alteplase vs Placebo,Effect of alteplase on good stroke outcome (mRS 01), by treatment delay, age, and stroke severity,Effect of timing of alteplase treatment on good stroke outcome (mRS 01),20年的指南,指南中的治療,1994,AntithromboticHeparinThrombolyticHemodilutionCytoprotectiveNimodipineBarbituratesNaloxoneglutamate antagonistsamphetaminesSurgical Interventionscarotid endarterectomyembolectomy angioplasty,2013,靜脈溶栓rtPA替奈普酶、瑞替普酶、去氨普酶、尿激酶及其他纖溶藥物安克洛酶和其他降纖藥物血管內(nèi)介入動脈溶栓機械取栓血管成形術(shù)和/或支架植入術(shù)抗凝劑普通肝素、低分子肝素及達那肝素阿加曲班或其他凝血酶抑制劑抗血小板藥阿司匹林氯吡格雷替羅非班和依替巴肽擴容、舒張血管及誘導高血壓血管收縮劑白蛋白擴容劑己酮可可堿機械性血流增強神經(jīng)保護劑他汀類亞低溫經(jīng)顱近紅外激光高壓氧其他神經(jīng)保護劑外科干預頸動脈內(nèi)膜切除術(shù),指南中的影像,1994,CTDiagnostic studies aimed at establishing a likely etiology of acute ischemic stroke, including ultrasound or other imaging of intracranial or extracranial vessels, can, in some circumstances, be helpful in making decisions about treatment. However, there is general agreement that these tests should not delay treatment, and their use should be tailored to specific clinical situations.,2013,未緩解者CT或MRICT灌注、MRI灌注和彌散成像CTA或MRA（動脈溶栓或機械取栓）已緩解者（TIA）CTA或MRADSAMRI或CT,指南中的臨床,1994,2013,NIHSS量表詩杜萬良喚醒提問命令遲，（3項，3+2+2=7分）凝望視野面容知；（3項，2+3+3=8分）上下左右協(xié)調(diào)動，（5項，4+4+4+4+2=18分）感覺語音不忽視。（4項，2+3+2+2=9分）,指南中的臨床,1994,The early course can be one of worsening (stepwise or stuttering), gradual deterioration or the immediate appearance of severe deficits, or fluctuations,我的經(jīng)驗,發(fā)病后3小時內(nèi)可以用rtPA治療的患者,發(fā)病后3小時內(nèi)可以用rtPA治療的患者,發(fā)病后3小時內(nèi)可以用rtPA治療的患者,發(fā)病后4.5小時內(nèi)可以用rtPA治療的患者,禁忌癥的發(fā)展,動脈瘤,顱內(nèi)