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STROKE:脑梗vs.心梗:早期再灌注治疗的比较

2012-12-11 我要评论0

       最近在线发表于《卒中》杂志的一项对比分析研究表明,与心肌梗死早期开展血管再灌注治疗,且完全再灌注率高相比,脑梗死的再灌注治疗起步晚,完全再灌注率低。缺血性脑卒中的再灌注治疗需要我们更进一步的努力和研究。


(与心肌梗死相比,脑梗患者部分及完全再灌注率均较低)

       研究者在文中指出,早期再灌注对急性脑缺血和急性心肌缺血都是最有效的治疗方法。但是头颈部较为复杂的血管循环对脑血流再通的干预提出了更大的挑战。而对于再灌注治疗的发展史之前还没有做过系统性比较。

       该研究采用Medline数据库搜索确定所有关于急性心肌梗死冠脉再通的多臂对照研究和急性缺血性卒中脑血管再灌注的多中心研究中有报道血管成像检查再灌注率的文献。
最终纳入了37个冠状脉再灌注治疗研究,纳入10908例从1983年-2009年的患者;10个脑血管再灌注治疗试验,纳入从1992年-2009年的1064例患者。

       所有冠脉再灌注治疗试验包括:10个单用静脉内溶栓治疗的试验、8个联合静脉内溶栓和经皮血管内冠状动脉成形术(用或不用支架)试验、3个动脉内溶栓试验、16个经皮血管内冠脉成形术试验(用或不用支架)。

       脑血管再灌注治疗试验包括:1个单用静脉内溶栓的研究、3个动脉内溶栓试验、3个单用血管内装置和3个血管内治疗(有些联合动脉内溶栓)。

       研究结果表明,在再灌注成功率方面,血管内治疗优于外周使用溶栓药物。在冠脉试验组,1980年代再灌注率已达到较高水平,随后的30年有缓慢提高。在脑血管实验组,1990年代,再灌注率水平达到中等,随后缓慢提高。

       2005-2009年,心脏血管再灌注率远远超过脑血管再灌注率,部分再灌注方面,前者为86.1%,后者为61.1%,而在完全再灌注方面,差异更显著,前者为78.6%,后者为23.4%。

       因此,脑梗相比心梗,再灌注治疗发展更慢,效果也更差。需要为临床医生们进一步研究脑循环专用技术,使其能够像治疗心脏缺血一样安全地为缺血脑组织重建血流。



Background and Purpose
Early reperfusion is the most effective therapy for both acute brain and cardiac ischemia. However, the cervicocephalic circulatory bed offers more challenges to recanalization interventions. The historical development of reperfusion interventions has not previously been systematically compared.
Methods
Medline search identified all multi-arm, controlled trials of coronary revascularization for acute myocardial infarction and multicenter trials of cerebral revascularization for acute ischemic stroke reporting angiographic reperfusion rates.
Results
Thirty-seven trials of coronary reperfusion enrolled 10 908 patients from 1983 to 2009, and 10 trials of cerebral reperfusion enrolled 1064 patients from 1992 to 2009. Coronary reperfusion trials included 10 of intravenous fibrinolysis alone, 8 combined intravenous fibrinolysis and percutaneous transluminal coronary angioplasty with or without stenting, 3 intra-arterial fibrinolysis, and 16 percutaneous transluminal coronary angioplasty with or without stenting. Cerebral reperfusion trials included 1 of intravenous fibrinolysis alone, 3 intra-arterial fibrinolysis, 3 endovascular device alone, and 3 of endovascular treatment ± intravenous fibrinolysis. In both circulatory beds, endovascular treatments were more efficacious at achieving reperfusion than peripherally administered fibrinolytics. In the coronary bed, rates of achieved reperfusion began at high levels in the 1980s and improved modestly over the subsequent 3 decades. In the cerebral bed, reperfusion rates began at modest levels in the early 1990s and increased more slowly. Most recently, in 2005 to 2009, cardiac reperfusion rates substantially exceeded cerebral, partial reperfusion 86.1% versus 61.1%, complete reperfusion 78.6% versus 23.4%.
Conclusions
Reperfusion therapies developed more slowly and remain less effective for cerebral than cardiac ischemia. Further, cerebral circulation–specific technical advances are required for physicians to become as capable at safely restoring blood flow to the ischemic brain as the ischemic heart.



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