急性缺血性脑卒中血管成形术(英文).pptVIP

Emergent Revascularization For Acute Ischemic Stroke Rishi Gupta, MD Staff, Cerebrovascular Center The Cleveland Clinic Foundation Introduction Intro (Cont’d) Large Vessel Occlusion Cerebral Blood Flow changes in Acute Ischemic Stroke Tissue outcome following arterial occlusion is determined by cerebral blood flow thresholds below which neuronal integrity and function is differentially affected 1 ISCHEMIC PENUMBRA  ISCHEMIC CORE CT Perfusion Retrospective review of 57 patients treated with Intra-arterial t-PA for MCA occlusion Mean NIHSS = 16 CT Perfusion performed prior to infusion of IA t-PA Patients with lower pre-treatment Cerebral blood volume found to be at increased risk of intracranial hemorrhage - 16 of 19 patient with hemorrhage initial CBV 2.0 mL/100 g LIMITATIONS OF INTRAVENOUS TPA Recanalization rate poor for larger arteries such as ICA or proximal MCA Outcomes for MCA occlusions poor No information regarding site or presence of arterial occlusion Effectiveness beyond 3 hours not established i.v t-PA recanalization at one hour (angiographic data) Intra-arterial Options Intra-arterial (Cont’d) Advantages Maximum delivery of lytic agent Endpoint of clot lysis Not given if spontaneous clot lysis Disadvantages Time necessary to place catheter Requires interventionalist Emergent availability of angiography PROACT II Randomized multicenter controlled trial 9 mg IA r-proUK + IV heparin v. IV heparin alone Randomized 2:1 to treatment v. control 180 pts with M1 or M2 occlusion by angio Treatment started within 6 hours of stroke onset IA r-proUK infused over 2 hours then repeat angio Primary endpoint - mRS ≤ 2 at 90 days PROACT II: 90 DAY OUTCOMES Intent to Treat PROACT II: MCA RECANALIZATION Favorable Outcomeat 3 months (%)* IMS Safety Issues with IA Chemical Lysis Time consuming to dissolve clot May be ineffective with long segments of clot Platelet rich/Plasminogen poor clots resistant to IA thrombolysis Mechanical thrombol