介绍
如果过去三个月内有过脑卒中病史,一般不建议对急性脑梗死进行溶栓治疗。虽然有报道称在脑梗死后三个月内给予溶栓治疗,质疑当前指南的证据,但据我们所知,这是第一次报道,在三天内给予标准剂量的rtPA。我们还讨论了替罗非班在动脉内膜切除术前停止微栓塞的作用。
病例报告
一位84岁的病人在85分钟内出现左臂紧密无力和中度左腿无力、构音障碍、强迫右眼偏斜和严重的左侧忽视(NIHSS 16)。CT头部扫描显示右侧大脑中动脉M1血栓高密度,无相关急性实质改变(图1)。既往有心肌梗死后冠状动脉搭桥手术史,有稳定的慢性白血病和慢性阻塞性肺疾病(COPD)病史。他正在服用阿司匹林75毫克、比索洛尔、呋罗胺、雷米普利和COPD吸入器。他是妻子的主要照顾者,走路拄拐杖,有吸烟史。患者在症状出现后185分钟进行溶栓,使用标准rtPA剂量(0.9 mg/kg)。当天晚些时候完全康复,NIHSS为0。第二天,溶栓后CT显示血栓溶解,无梗死迹象(图2)。颈动脉多普勒扫描显示右侧颈内动脉(ICA)无血流,左侧颈内动脉完全闭塞,斑块轻微。两天后出院,无局灶性神经损伤。不幸的是,在出院当天,他再次入院,症状与第一次出现NIHSS 15相似。CT扫描显示右大脑中动脉血栓的分支和以前一样没有实质的变化(图3)。这个决定是用病人的同意与rtPA治疗,在标准剂量(0.9毫克/公斤)110分钟后第二集,52小时,15分钟后第一个rtPA治疗。 The patient was made aware of the potential increased risk of haemorrhage with the second rtPA treatment. By the next day he made full neurological recovery. Post thrombolysis CT, again, showed resolution of the MCA thrombus with no signs of infarction (Figure 4). Repeat Carotid Doppler this time showed some flow in the previously occluded right ICA indicating partial re-canalisation. Transcranial Doppler (TCD) of the right MCA was performed and showed two microemboli in 15 minutes. The patient was started on dual antiplatelet therapy (Aspirin 75 mg and Clopidogrel 75 mg) as per our hospital protocol. The patient had repeat TCD the next day which showed two microemboli in 20 minutes. After discussion with the vascular surgeons he was started on Tirofiban infusion at a rate of 40 ml/hr for 30 minutes then 10 ml/hr thereafter. TCD was repeated daily over the next three days and no microemboli were detected over 20 minutes each time. The patient remained on Tirofiban infusion for seven days before having a Carotid Endarterectomy (CEA) under local anaesthesia. After surgery the patient had no focal neurology on examination. He was and remained cognitively intact, and eventually was discharged home six days after the procedure with Modified Rankin Score of zero.
图1所示。术前第一次rtPA显示右侧MCA血栓
图2。首次rtPA后未见血栓形成
图3。第二次rtPA显示右侧MCA血栓
图4。第二次rtPA后未见血栓形成
讨论
目前的指南建议,如果在过去三个月内有脑卒中史,则禁止溶栓。这样做的理由是让脑组织变成胶质细胞以减少出血的风险;因此,对于小脑中风或腔隙性脑卒中,在三个月内重复rtPA治疗可能更安全。对于至少在CT扫描中没有实质损伤证据的患者,如本例患者所见,可以认为rtPA可以安全地使用。许多病例在第一次治疗后3个月内重复溶栓,但在使用标准rtPA全剂量后3天内未重复溶栓。此外,糖蛋白IIb/IIIa拮抗剂替罗非班在接受冠状动脉介入治疗的患者中是公认的治疗方法。这是由于其在减少血小板丰富血栓形成方面的积极作用。严重颈动脉狭窄的患者有产生微栓子的风险,因此进一步发生缺血性卒中的风险更高。在这些患者中,双抗血小板可用于抑制微栓子,但在一些患者中,如本例,尽管双抗血小板治疗(阿司匹林和氯吡格雷),微栓子仍继续形成。在这些患者中,替罗非班可以在接受CEA前用于消除微栓子和稳定斑块。