重點
tPA風險. 2.8% 發生腦出血(未施打tPA腦出血機率 0.2%), 但死亡率沒增加.
血管內取栓術並不會增加 tPA 風險
建議若符合 tPA 施打條件. 先打 tPA. 之後再根據CT angiography(血管攝影)找出血栓部位. 再取栓(取栓)
由於 CT angiography 需要時間(3D影像重組比檢查更花時間). 打顯影劑可能造成腎功能急性惡化. 但指引建議. 由於中風取栓有明顯效益. 高於顯影劑造成急性腎衰竭的風險 . 不需要等抽血報告可直接打顯影劑(但應先告知病患/家屬存在急性惡化需急洗腎風險) (一般發生在慢性腎病患者. acute on chronic failure)
應先做 BRAIN CT without contrast 評估是否腦出血. 到院45分鐘內CT判讀完成若符合 tPA 施打適應症.先打 IV tPA.
參考資料 AHA/ASA Current Treatment Approachesfor Acute Ischemic Stroke
下面第二項. 即使考慮做血栓移除術. 仍建議使用 tPA 治療
下面第二項. 即使考慮做血栓移除術. 仍建議使用 tPA 治療
1. Emergency non enhanced CT imaging of the brain is recommended before any
specific treatment for acute stroke.
2. Eligible patients should receive Alteplase intravenous r-tPA even if endovascular treatments are being
considered.
3. Noninvasive intracranial vascular imaging should be obtained as quickly as possible after IV r-tPA.
4. Patients should receive endovascular therapy with a stent retriever if they meet all the criteria.
5. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible and
within 6 hours of stroke onset.
參考資料 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment. Powers WJ, Derdeyn CP,
Biller J, et al. Stroke 2015;46):3020-3035.
Inclusion Criteria
Diagnosis of ischemic stroke causing measurable neurological deficit
Treatment within 4.5 hours (IV r-tPA between 3 & 4.5 hours is not FDA-approved)
Exclusion Criteria
Current intracranial hemorrhage
Subarachnoid hemorrhage
Active internal bleeding
Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma, presence of intracranial
conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations,
or aneurysms)
Bleeding diathesis
Current severe uncontrolled hypertension
Additional exclusion criteria Between 3 and 4.5 hours:
Additional exclusion criteria Between 3 and 4.5 hours:
Age >80 years
Severe stroke (NIHSS > 25)
History of diabetes and prior stroke
Taking an oral anticoagulant regardless of INR
Alteplase (IV r-tPA) within 4.5 hours of stroke onset remains the standard of care for most ischemic stroke patients.
施打tPA之後. 腦血管前循環大動脈阻塞. 考慮血管內取栓術. 最好使用支架取栓器 stent retriever.
After the patient is administered Alteplase (IV r-tPA), and the cause is deemed to be occlusion of a large cerebral
artery in the anterior circulation, considered endovascular therapy, best accomplished with a stent retriever. Criteria for Endovascular Therapy:
Within 6 hours of stroke onset
Pre-stroke modified Rankin Score (mRs0-1)
Acute ischemic stroke receiving Alteplase (IV r-tPA) within 4.5 hours of onset
according to guidelines from professional medical societies (prior administration
of r-tPA is not required)
內頸動脈或中大腦動脈第一段 M1 阻塞引起的中風
Causative occlusion of the internal carotid artery or proximal Middle Cerebral
Artery (M1)
Age 18 years or older
National Institutes of Health Stroke Scale (NIHSS) score of ≥6
Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6
Treatment can be initiated (groin puncture) within 6 hours of symptom onset.
施打tPA效益
預後較佳(43% vs 未施打tPA 32%)
能回復到日常生活 53% (未施打32%)
一年後無中風後遺症或很輕微後遺症 39% (未施打tPA第三個月26%)
3-4.5小時施打 tPA
90天無殘障(或輕微殘障) 52.4% (未施打 45.2%)
tPA及血管內取栓術風險
tPA風險
2.8%腦出血(未打tPA 0.2%)
死亡率未增加
Risks Of Alteplase (IV r-tPA)
Bleeding: 2.8% (vs. 0.2% without r-tPA) intracerebral bleeding in patients treated in the 3-4.5 hour window
(ECASS III Study)
Mortality: No increase from placebo groups
取栓術風險
主要是取栓過程可能發生血管破裂
Risks of Endovascular Treatment with Stent Retriever at 0-6 Hours:
The major risk is intracranial hemorrhage due to: vessel perforation (ripping the blood vessel) or stent retriever
device perforating a vessel while attempting to remove the blood clot from the artery.
Systemic bleeding
Bleeding at the site of catheter introduction
Catheter infection
Death
90天無殘障或輕微殘障比例; 血管內取栓術 47%. 未取栓 28%
取栓術能增加20%良好預後
modified Rankin score
0分代表無殘障
2分代表輕微殘障
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