Lancet Neurol:HERMES工作组答疑:血管内血栓切除术中尽量避免采取全身麻醉

2018-02-06 杨中华 脑血管病及重症文献导读

多项观察性研究提示,在全身麻醉的情况下进行血管内血栓切除术的患者往往预后不良。然而,非常严重卒中患者或存在合并症患者更常选择全身麻醉,这会降低全身麻醉的益处。

多项观察性研究提示,在全身麻醉的情况下进行血管血栓切除术的患者往往预后不良。然而,非常严重卒中患者或存在合并症患者更常选择全身麻醉,这会降低全身麻醉的益处。

在MR CLEAN试验中,研究者前瞻性制定了他们的麻醉策略,该研究的事后分析发现因为采取全身麻醉,血栓切除术的疗效变得无显着性。基于这个原因,对于烦躁或血管解剖不佳的患者也不愿意把麻醉方式从清醒转为全身麻醉。相反,三项小型单中心随机试验比较了全身麻醉(采取严格方案维持血压)和清醒镇静(采用最低剂量的相同麻醉药物,不气管插管),未发现全身麻醉的坏处,功能独立没有差异或轻微增加。

2018年1月HERMES工作组在Lancet Neurology上发表了他们的meta分析结果,目的在于评价前循环大动脉闭塞性缺血性卒中进行血管内血栓切除术时应该选择全身麻醉?非全身麻醉(合并或不合并镇静)?还是标准治疗(非血栓切除术)?

该meta分析纳入的研究皆为2010年1月到2017年5月31之间发表的随机试验。主要终点为90天mRS顺序分析。最终纳入了7项试验,共1764例患者,其中871例分配至血管内治疗组,893例分配至标准治疗组。因为血管内治疗组的患者实际未进行手术和数据丢失,排除了74例患者。采取血管内治疗的797例患者中,236例(30%)采取了全身麻醉性进行血管内治疗。采取全身麻醉的患者更年轻,卒中发作到随机的时间延误更短,但是治疗前临床严重性相似(vs 非全身麻醉)。无论是全身麻醉,还是未选择全身麻醉,与标准治疗相比血管内治疗都能够改善3个月预后。但是,与全身麻醉者相比,未采取全身麻醉者的预后更好。

最终作者认为血管内血栓切除术的不良预后与全身麻醉有关(调整基线预后变量后)。这个结果提示尽可能避免全身麻醉。不过,即使采用全身麻醉血管内治疗仍然优于标准治疗,这提示需要全身麻醉者也不应该终止血管内治疗。

译者注:

2018 AHA/ASA急性缺血性卒中早期管理指南建议:急性缺血性卒中患者血管内治疗时基于患者的危险因素、手术情况和其它临床特征进行个体化评估以选择麻醉方法可能是合理的。还需要更多随机试验数据支持。(推荐等级II a,证据水平B-R,改编自2015版血管内治疗指南)

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    2018-04-14 yinhl1978
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    2018-11-19 howi
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    2018-02-08 longqijun254

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本研究旨在探究是否麻醉方式(局部麻醉[GA]vs.全身麻醉[CS])对脑卒中血管内治疗时血管造影操作的影响,并将结果发表在Radiology上。

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第二代支架取栓装置能够把闭塞颅内血管再通,改善急性缺血性卒中患者的预后。不过,内皮损伤不可避免,并引起动脉早期再闭塞。替罗非班是一种糖蛋白IIb/IIIa抑制剂,半衰期短,因此一些中心采用替罗非班防止局部血小板聚集,预防早期再闭塞。研究发现替罗非班用于急性中等缺血性卒中是安全的,能够降低5个月后的死亡率。对于急性缺血性卒中,采用全量阿替普酶立即桥接静脉内替罗非班也是安全和可行的。然而,一项研究

Stroke:CTA对支架血栓切除术的预测价值!

近期,一项发表在杂志Stroke上的研究评估了使用计算机断层扫描血管造影术(CTA确定的闭塞型)确定的闭塞型是否可以使用支架置入器(SR)血栓切除术预测血管内治疗的成功。此项研究回顾性分析了进行CTA检查的中风患者,然后对颅内大动脉闭塞进行血管内治疗。 CTA确定的闭塞类型分为截尾型闭塞或分支部位闭塞,并与血管内治疗期间的数字减影血管造影确定的闭塞型进行了比较。三项快速且易于评估的术前发现(CTA

​AHA2017:现场证争鸣:大面积肺栓塞治疗策略应何去何从?

大面积肺栓塞(PE)属肺栓塞中极高危。对于这些患者,即刻行血栓切除术还是体外膜肺氧合(ECMO)稳定后再择期手术?