文档介绍：缺血性脑卒中急性期溶栓治进展
脑卒中是急诊！
幕上缺血性卒中急性期估计丧失的神经元
损失神经元
损失突触
加速衰老
每秒
32,000

hours
每分
百万
成梗死核心区。
DW1 异常: 类似于核心区
Perfusion 异常: 低灌注区
Diffusion/Perfusion Mismatch=Penumbra
决定溶栓前，了解了4个问题：
1）确定不可逆损伤的梗死核心区的大小
2）是否存在低灌注的半暗带区域及其大小
3）是否存在血管内血栓
4）是否存在颅内出血
DWI/ PWI
MRA
SWI
理想的条件
Thrombolysis trials with penumbral assessment Alteplase
the Diffusion-weighted imaging Evaluation For Understanding Stroke Evolution (DEFUSE) study
Methods: 74 patients presenting with ischemic stroke and did MRI or MRA within 3–6 h of stroke onset and repeated the imaging protocol within 24 h. Further imaging was done at 3 months when clinical outcomes were recorded.
Hypothesis: prespecified MR profiles could be used to identify patients who have a robust clinical response to reperfusion when treated with alteplase 3–6 h after stroke onset.
The key findings: 存在不匹配区者早期再灌注后功能恢复良好(p<0·05), 而不存在不匹配区者即使再灌注临床功能恢复不好。
the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET)
Methods: 100 patients with acute hemispheric ischemic stroke were assigned to receive alteplase or placebo within 3 to 6 h of onset. MRI was used to determine the effect of intravenous alteplase on lesion growth, reperfusion.
Findings: in patients with mismatch, there was evidence of attenuation of infarct volumes with alteplase (p=0·24–0·054 depending on measurement of infarct growth), and a significant (p=0·01) increase in the secondary outcome measure of reperfusion on PWI.
存在 PWI／DWI不匹配区
患者，男，72岁，，既往高血压、高脂血症；查体：右侧上下肢肌力均0级、完全性失语；NIHSS 15分
发病 4h50’后rtPA溶栓，治疗后1h右下肢肌力3级。
10天后出院时：能理解，但只能发“啊”音，右侧上肢肌力1级、下肢肌力4级，NIHSS 7分
DWI
PWI
MRA
溶栓前
溶栓后4小时
MTT
CBF
CBV
溶栓前
溶栓后4h
CBV
MTT
CBF
溶栓前
溶后4h
无症状性出血
血管内血栓
磁敏感成像技术（S W I）
患者，女，75岁，神志模糊、失语3小时，有房颤病史，当时 NIHSS 9分；发病后 5h 予rtPA溶栓，溶栓后1h，神志转清，能自发言语，NIHSS 1分；溶栓后24h ，NIHSS 0分
临床-DWI不匹配：
临床神经功能评分严重，而DWI病灶范围小，提示溶栓效果好
存在其他的不匹配指标指导溶栓
前
后
溶栓前
溶后4h
存在其他指标指导溶栓
可逆性急性已再灌的弥散病灶（Rev