Akut İskemik İnmede Reperfüzyon Tedavilerine Güncel Yaklaşım
Özet
Akut iskemik inmenin hızlı şekilde değerlendirilmesi ve yönetimi, inmeye bağlı ölüm ve morbiditenin azaltılması için kritik öneme sahiptir. Akut iskemik inme için reperfüzyon tedavisinin acil hedefi, beynin iskemik ancak henüz enfarkte olmamış bölgelerine kan akışını eski haline getirmektir ve reperfüzyon tedavilerinin etkinliği semptomların başlangıcından itibaren geçen süreye dayanır. IV tromboliz, akut iskemik inme için reperfüzyon tedavisinin temel dayanağıdır. Mekanik trombektomi, proksimal intrakraniyal büyük arter tıkanıklığının neden olduğu akut iskemik inmeli hastalarda endikedir. Semptom başlangıcından itibaren ilk 4,5 saat içindeki hastalarda öncelikli olarak trombolitik tedavi düşünülmelidir. Trombolitik için uygun olmayan hastalar ise ilk 24 saate kadar mekanik trombektomi adayı olarak değerlendirilmelidir.
Referanslar
Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–e66. doi:10.1161/ CIR.0000000000000659.
Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–1329. doi:10.1056/NEJMoa0804656.
Saver JL. Time is brain—quantified. Stroke J Cereb Circ. 2006;37 (1):263–266. doi: 10.1161/01.STR.0000196957.55928.ab.
Meretoja A, Keshtkaran M, Saver JL, et al. Stroke thrombolysis: save a minute, save a day. Stroke J Cereb Circ. 2014;45(4):1053–1058. doi: 10.1161/STROKEAHA.113.002910.
Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581–1588. doi: 10.1056/NEJM199512143332401.
Albers GW, Clark WM, Madden KP, et al. ATLANTIS trial: results for patients treated within 3 hours of stroke onset. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. Stroke. 2002;33(2):493–495. doi: 10.1161/hs0202.102599.
Rai A, Cline B, Williams E, et al. Intravenous thrombolysis outcomes in patients presenting with large vessel acute ischemic strokes—CT angiography-based prognosis. J Neuroimaging. 2015;25(2):238–242. doi:10.1111/jon.12126.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–e418. doi: 10.1161/STR.0000000000000211.
Alvarez-Sabín J, Molina CA, Montaner J, et al. Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator–treated patients. Stroke. 2003;34(5):1235–1241. doi: 10.1161/01.STR.0000068406.30514.31.
Levine SR, Khatri P, Broderick JP, et al. Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke. 2013;44(9):2500–2505. doi: 10.1161/STROKEAHA.113.000878.
Strbian D, Soinne L, Sairanen T, et al. Ultraearly thrombolysis in acute ischemic stroke is associated with better outcome and lower mortality. Stroke. 2010;41(4):712–726. doi: 10.1161/STROKEAHA.109.571976.
Thomalla G, Cheng B, Ebinger M, et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol. 2011;10(11):978–986. doi: 10.1016/S1474-4422(11)70192-2.
Campbell BCV, Ma H, Ringleb PA, et al. Extending thrombolysis to 4·5-9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. Lancet. 2019;394(10193):139–147. doi: 10.1016/S0140-6736(19)31053-0.
Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010; 375:1695. doi: 10.1016/S0140-6736(10)60491-6.
Ravipati K, Guillen R, Belnap S, et al. Maximum intravenous alteplase dose for obese stroke patients is not associated with greater likelihood of worse outcomes. Thromb Res. 2021;204:76–80. doi: 10.1016/j.thromres.2021.06.002.
Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929–1935. doi: 10.1016/S0140-6736(14)60584-5.
Neumann-Haefelin T, du Mesnil de Rochemont R, Fiebach JB, et al. Effect of incomplete (spontaneous and post thrombolytic) recanalization after middle cerebral artery occlusion: a magnetic resonance imaging study. Stroke. 2004;35(1):109–114. doi: 10.1161/01.STR.0000106482.31425.D1.
Menon BK, Al-Ajlan FS, Najm M, et al. Association of Clinical, Imaging, and Thrombus Characteristics With Recanalization of Visible Intracranial Occlusion in Patients With Acute Ischemic Stroke. JAMA. 2018;320(10):1017–1026. doi: 10.1001/jama.2018.12498.
Overgaard K. Thrombolytic therapy in experimental embolic stroke. Cerebrovasc Brain Metab Rev. 1994;6(3):257–286.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–1587. doi: 10.1056/NEJM199512143332401.
Campbell BCV, Mitchell PJ, Churilov L, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018; 378:1573. doi: 10.1056/NEJMoa1716405.
Logallo N, Novotny V, Assmus J, et al. Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol. 2017;16:781. doi: 10.1016/S1474-4422(17)30253-3.
Kvistad CE, Næss H, Helleberg BH, et al. Tenecteplase versus alteplase for the management of acute ischaemic stroke in Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial. Lancet Neurol. 2022;21:511. doi: 10.1016/S1474-4422(22)00124-7.
Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–1731. doi:10.1016/S0140- 6736(16)00163-X.
Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11–21. doi:10.1056/NEJMoa1706442.
Gonzalez RG. Imaging-guided acute ischemic stroke therapy: from “time is brain” to “physiology is brain.” AJNR Am J Neuroradiol. 2006;27:728–735.
Ginsberg MD. Adventures in the pathophysiology of brain ischemia: penumbra, gene expression, neuroprotection: The 2002 Thomas Willis Lecture. Stroke. 2003;34(1):214–223. doi:10.1161/01. STR.0000048846.09677.62
Jahan R, Saver JL, Schwamm LH, et al. Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes in Patients With Acute Ischemic Stroke Treated in Clinical Practice. JAMA. 2019;322(3):252-263. doi: 10.1001/jama.2019.8286.
Kunz WG, Hunink MG, Almekhlafi MA, et al. Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke. Neurology. 2020;95(18):e2465–e2475. doi: 10.1212/WNL.0000000000010867.
Referanslar
Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–e66. doi:10.1161/ CIR.0000000000000659.
Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–1329. doi:10.1056/NEJMoa0804656.
Saver JL. Time is brain—quantified. Stroke J Cereb Circ. 2006;37 (1):263–266. doi: 10.1161/01.STR.0000196957.55928.ab.
Meretoja A, Keshtkaran M, Saver JL, et al. Stroke thrombolysis: save a minute, save a day. Stroke J Cereb Circ. 2014;45(4):1053–1058. doi: 10.1161/STROKEAHA.113.002910.
Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581–1588. doi: 10.1056/NEJM199512143332401.
Albers GW, Clark WM, Madden KP, et al. ATLANTIS trial: results for patients treated within 3 hours of stroke onset. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. Stroke. 2002;33(2):493–495. doi: 10.1161/hs0202.102599.
Rai A, Cline B, Williams E, et al. Intravenous thrombolysis outcomes in patients presenting with large vessel acute ischemic strokes—CT angiography-based prognosis. J Neuroimaging. 2015;25(2):238–242. doi:10.1111/jon.12126.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–e418. doi: 10.1161/STR.0000000000000211.
Alvarez-Sabín J, Molina CA, Montaner J, et al. Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator–treated patients. Stroke. 2003;34(5):1235–1241. doi: 10.1161/01.STR.0000068406.30514.31.
Levine SR, Khatri P, Broderick JP, et al. Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke. 2013;44(9):2500–2505. doi: 10.1161/STROKEAHA.113.000878.
Strbian D, Soinne L, Sairanen T, et al. Ultraearly thrombolysis in acute ischemic stroke is associated with better outcome and lower mortality. Stroke. 2010;41(4):712–726. doi: 10.1161/STROKEAHA.109.571976.
Thomalla G, Cheng B, Ebinger M, et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol. 2011;10(11):978–986. doi: 10.1016/S1474-4422(11)70192-2.
Campbell BCV, Ma H, Ringleb PA, et al. Extending thrombolysis to 4·5-9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. Lancet. 2019;394(10193):139–147. doi: 10.1016/S0140-6736(19)31053-0.
Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010; 375:1695. doi: 10.1016/S0140-6736(10)60491-6.
Ravipati K, Guillen R, Belnap S, et al. Maximum intravenous alteplase dose for obese stroke patients is not associated with greater likelihood of worse outcomes. Thromb Res. 2021;204:76–80. doi: 10.1016/j.thromres.2021.06.002.
Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929–1935. doi: 10.1016/S0140-6736(14)60584-5.
Neumann-Haefelin T, du Mesnil de Rochemont R, Fiebach JB, et al. Effect of incomplete (spontaneous and post thrombolytic) recanalization after middle cerebral artery occlusion: a magnetic resonance imaging study. Stroke. 2004;35(1):109–114. doi: 10.1161/01.STR.0000106482.31425.D1.
Menon BK, Al-Ajlan FS, Najm M, et al. Association of Clinical, Imaging, and Thrombus Characteristics With Recanalization of Visible Intracranial Occlusion in Patients With Acute Ischemic Stroke. JAMA. 2018;320(10):1017–1026. doi: 10.1001/jama.2018.12498.
Overgaard K. Thrombolytic therapy in experimental embolic stroke. Cerebrovasc Brain Metab Rev. 1994;6(3):257–286.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–1587. doi: 10.1056/NEJM199512143332401.
Campbell BCV, Mitchell PJ, Churilov L, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018; 378:1573. doi: 10.1056/NEJMoa1716405.
Logallo N, Novotny V, Assmus J, et al. Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol. 2017;16:781. doi: 10.1016/S1474-4422(17)30253-3.
Kvistad CE, Næss H, Helleberg BH, et al. Tenecteplase versus alteplase for the management of acute ischaemic stroke in Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial. Lancet Neurol. 2022;21:511. doi: 10.1016/S1474-4422(22)00124-7.
Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–1731. doi:10.1016/S0140- 6736(16)00163-X.
Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11–21. doi:10.1056/NEJMoa1706442.
Gonzalez RG. Imaging-guided acute ischemic stroke therapy: from “time is brain” to “physiology is brain.” AJNR Am J Neuroradiol. 2006;27:728–735.
Ginsberg MD. Adventures in the pathophysiology of brain ischemia: penumbra, gene expression, neuroprotection: The 2002 Thomas Willis Lecture. Stroke. 2003;34(1):214–223. doi:10.1161/01. STR.0000048846.09677.62
Jahan R, Saver JL, Schwamm LH, et al. Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes in Patients With Acute Ischemic Stroke Treated in Clinical Practice. JAMA. 2019;322(3):252-263. doi: 10.1001/jama.2019.8286.
Kunz WG, Hunink MG, Almekhlafi MA, et al. Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke. Neurology. 2020;95(18):e2465–e2475. doi: 10.1212/WNL.0000000000010867.
