| BACKGROUND Cerebrovascular disease is a common and frequently encountered disease which has threatened human being’s health and life severly. In recent years, as the improvement of living standards and the average age of human being has extended, the incidence of cerebrovascular disease has increased. According to the investigation report of the National Ministry of Health, cerebrovascular disease has been the second leading cause of death for many years, in some areas, even up to the first place. The acute cerebral infarction (ACI) with high mortality and high disability rate accounted for60%～90%of cerebrovascular disease. So, how to prevent and cure this disease is the question which the medical staff concern and want to study. In1981, Astrup proposed a theory of ischemia penumbra (IP), which considered that the ischemia cerebral tissue include central necrosis area and ischemia penumbra around it. In the early course of cerebral infarction, the central necrosis area has subjected to irreversible damage, and the IP also appeared nerve function defect or loss. But the brain cells of the IP have not subjected to ischemic necrosis. If restored blood supply in time, most of the brain cells of the IP can avoid ischemic necrosis. Therefore, vascular recanalization is the most reasonable treatment for ACI.OBJECTIVE Many evidences have confirmed that early thrombolysis was the most effective method for vascular recanalization for ACI, so that managed the damaged area to reperfusion as fast as possible, and the nerve functions can be recovered quickly. Currently, the main clinical methods of thrombolysis include intravenous thrombolysis and selective intra-arterial thrombolysis. But both simple intravenous thrombolysis and simple intra-arterial thrombolysis have their own disadvantages. In order to integrate the advantages of them, combined intra-arterial/intravenous thrombolysis has been put forward. This treatment has achieved good clinical effect which was reported by some randomized, multicenter double-blind placebo-controlled trial in abroad. And there were related reports has been in our country. The purpose of this study is to evaluate the safety and efficacy of combined intra-arterial/intravenous thrombolysis contrast simple intravenous thrombolysis for ACI in early stage.METHOD The research object was68patients with ACI, who were selected from September2010to September2012in our hospital. In this review we will systematically and retrospectively analyze the clinical data of these patients. According to the indications and contraindications of the therapy of intravenous thrombolysis or intra-arterial thrombolysis, different patients have been treated with different therapy.37patients who were treated with combined intra-arterial/intravenous thrombolysis for Combined Group, and31patients who were treated with simple intravenous thrombolysis for Venous Group. The patients of the Combined Group were treated with recombinant tissue plasminogen activator (rt-PA), at the dose of0.6mg/kg (maximal dose,60mg),10%of the thrombolytic agent is injected rapidly in1min, and the rest of the thrombolytic agent is dissolved in100ml normal saline and be injected continuously in30min. At the same time, intra-arterial thrombolysis was carried out. And then, implement conventionally disinfection, draping, local anesthetization with lidocaine. Puncture the right femoral artery in Seldinger technology, and insert6F artery sheath. Take the aortic arch angiography with5F Pigtail catheter, and take the common carotid artery and the vertebral artery (or the subclavian artery) with5F Vertebral catheter. Then assess the imaging results combined with the clinical symptoms in order to confirm the site of vascular occlusion. Use heparin at the dose of70～100IU/kg for heparinization. Use6F guide catheter to replace5F Vertebral catheter, and use SilverSpeed-14micro guide wire to guide the Echelon-10micro catheter. To confirm the distal of the vascular occlusion is unobstructed with local micro angiography. Then inject the rt-PA, at the dose of0.3mg/kg (maximum dose,24mg) what is dissolved in40ml normal saline in2hours by micro catheter. The patients of the Venous Group were treated with rt-PA, at the dose of0.9mg/kg (maximal dose,90mg),10%of the thrombolytic agent is injected rapidly in1min, and the rest of the thrombolytic agent is dissolved in250ml normal saline and be injected continuously in60min. Both of the two groups were treated with the following supporting therapy:(1), Add antithrombotic or antiplatelet agents (aspirin,100mg/d) in order to improve the microcirculation in IP area after24hours.(2), All the patients were treated with neuroprotectant, including ganglioside, edaravone, butylphthalide, etc.(3), Monitoring the blood pressure in order to maintain appropriate cerebral perfusion pressure.(4), Detecting blood clotting level on a regular basis to help adjust the treatment plan. Evaluation standard:(1), Respectively, evaluate and contrast the nerve function defect with the National Institutes of Health Stroke Scale (NIHSS) between the two groups before the operation,24hours and7days after the operation.(2), Compare the rate of recanalization between the two groups.(3), Compare the rate of complications and mortality between the two groups.RESULT All the37patients of Combined Group have been treated with combined intra-arterial/intravenous thrombolysis. In this group, there is significant difference of NIHSS score between postoperative and preoperative, P<0.005. There were38occlusive vessels had been checked out in pre-operation, and25cases is postoperative recanalization. The rate of recanalization is65.79%. The rate of hematencephalon is8.10%, and the mortality is10.81%.All the31patients of Venous Group have been treated with simple intravenous thrombolysis. In this group, there is significant difference of NIHSS score between postoperative and preoperative, P<0.01. There were28occlusive vessels had been checked out in pre-operation, and11cases is postoperative recanalization. The rate of recanalization is39.29%. The rate of hematencephalon is9.68%, and the mortality is12.90%. There is significant difference of postoperative NIHSS score between the two groups, P<0.05. There is significant difference of the rate of recanalization between the two groups, P<0.05. The difference of the rate of complications and mortality between the two groups was not significant.CONCLUSION Combined intra-arterial/intravenous thrombolysis with low-dose rt-PA is a safe and effective treatment for patients with ACI, which is selected carefully within6hours. Compared with the treatment of simple intravenous thrombolysis, combined intra-arterial/intravenous thrombolysis can achieve higher rate of recanalization and better clinical effects, and there was not significant increase with the rate of complications and mortality. |
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