1、急性脑梗死溶栓20年回顾与展望,杜万良北京天坛医院神经内科2015.10.11,20年的试验,Randomized Trials of Alteplase vs Placebo,Effect of alteplase on good stroke outcome (mRS 01), by treatment delay, age, and stroke severity,Effect of timing of alteplase treatment on good stroke outcome (mRS 01),20年的指南,指南中的治疗,1994,AntithromboticHeparinT
2、hrombolyticHemodilutionCytoprotectiveNimodipineBarbituratesNaloxoneglutamate antagonistsamphetaminesSurgical Interventionscarotid endarterectomyembolectomy angioplasty,2013,静脉溶栓rtPA替奈普酶、瑞替普酶、去氨普酶、尿激酶及其他纤溶药物安克洛酶和其他降纤药物血管内介入动脉溶栓机械取栓血管成形术和/或支架植入术抗凝剂普通肝素、低分子肝素及达那肝素阿加曲班或其他凝血酶抑制剂抗血小板药阿司匹林氯吡格雷替罗非班和依替巴肽扩容、舒
3、张血管及诱导高血压血管收缩剂白蛋白扩容剂己酮可可碱机械性血流增强神经保护剂他汀类亚低温经颅近红外激光高压氧其他神经保护剂外科干预颈动脉内膜切除术,指南中的影像,1994,CTDiagnostic studies aimed at establishing a likely etiology of acute ischemic stroke, including ultrasound or other imaging of intracranial or extracranial vessels, can, in some circumstances, be helpful in making
4、decisions about treatment. However, there is general agreement that these tests should not delay treatment, and their use should be tailored to specific clinical situations.,2013,未缓解者CT或MRICT灌注、MRI灌注和弥散成像CTA或MRA（动脉溶栓或机械取栓）已缓解者（TIA）CTA或MRADSAMRI或CT,指南中的临床,1994,2013,NIHSS量表诗杜万良唤醒提问命令迟，（3项，3+2+2=7分）凝望视
5、野面容知；（3项，2+3+3=8分）上下左右协调动，（5项，4+4+4+4+2=18分）感觉语音不忽视。（4项，2+3+2+2=9分）,指南中的临床,1994,The early course can be one of worsening (stepwise or stuttering), gradual deterioration or the immediate appearance of severe deficits, or fluctuations,我的经验,发病后3小时内可以用rtPA治疗的患者,发病后3小时内可以用rtPA治疗的患者,发病后3小时内可以用rtPA治疗的患者,发病后4.5小时内可以用rtPA治疗的患者,禁忌症的发展,动脉瘤,颅内肿瘤,总结,所有危险因素都要分层。越来越多的禁忌证将变为相对禁忌证。,微信公众号：发布神经内科学术会、培训班预告,名称：神内学术会,微信号：snxsh2015,
