急性脑梗死静脉溶栓89533演示.pptVIP

作者认为，NIHSS25者与NIHSS为15-25分者相比没有过度增加脑出血的风险，提示欧洲把NIHSS25分作为静脉tPA溶栓禁忌症是没有根据的。 NIHSS25者较高的死亡率以及较低的功能独立是由于卒中严重性、后循环缺血导致意识受损以及时间的延迟造成的。 NIHSS25分者出血风险较低的原因，作者认为与高比例的后循环卒中有关。 当前26页，共53页，星期二。 症状迅速缓解 发病时表现为中到重度神经功能缺失，早期迅速缓解，但缓解后仍然具有中度神经功能缺失，并且由医生判断是潜在的致残性卒中患者，给予静脉溶栓是合理的(Class IIa, Level of Evidence A) “时间就是大脑”，因此不推荐推迟溶栓，观察病情是否继续缓解(Class III, Level of Evidence C) 当前27页，共53页，星期二。 10%由于症状轻而未溶栓者出现早期神经功能恶化 20%结局差的原因是大动脉闭塞 当前28页，共53页，星期二。 溶栓治疗的组织管理 溶栓治疗的临床标准化操作 溶栓治疗并发症的处理及风险管理 Contents 指南推荐的溶栓治疗及现况 当前29页，共53页，星期二。 溶栓的获益—来自时间 NNT NNH 0 – 90 mins 3.6 65 91 – 180 mins 4.3 38 181 – 270 mins 5.9 30 271 – 360 mins 19.3 14 Stroke 2009;40:2079-2084 0 2 4 6 30 20 10 0 Time (hours) Benefit Harm 当前30页，共53页，星期二。 缩短延误措施 当前31页，共53页，星期二。 溶栓前的准备：积极改善内环境 当前32页，共53页，星期二。 溶栓患者症状性脑出血的发生率 症状性脑出血 研究 对照组 溶栓组 P NINDS 3.5% 7.9% 0.006 ECASS II 0.2% 2.4% 0.008 ECASS III 2.2% 5.3% 0.023 SITS-MOST 0.2% 1.9% 0.022 IST-3 1.0% 7.0% 0.0001 ECASS III definition – Symptomatic cerebral haemorrhage was defined as any blood in the brain or intracranially associated with a clinical deterioration of ≥ 4 points of the NIHSS for which the haemorrhage has been identified as the dominating cause of the neurologic deterioration. ECASS II definition – Any intracranial bleed and 4 points or more worsening on the NIHSS score from baseline or the lowest value in the first 7 days, or any haemorrhage leading to death. NINDS definition – A haemorrhage was considered symptomatic if it was not seen on a previous CT scan and there had subsequently been either a suspicion of haemorrhage or any decline in neurologic status. To detect intracranial haemorrhage, CT scans were required at 24 hours and 7 to 10 days after the onset of stroke and when clinical finding suggested haemorrhage. SITS-MOST definition – Local or remote parenchymal haematoma type 2 on the 22- to 36-hour post-treatment imaging scan, combined with a neurologic deterioration of 4 points or more on the NIHSS from baseline, or from the lowest NIHSS valu