作者投稿
专家审稿
编辑办公
邮件订阅
RSS
-
摘要: 急性缺血性卒中(acute ischemic stroke, AIS)是最常见的卒中类型, 具有高发病率、高死亡率、高致残率的特点。在时间窗内快速进行血管再通、实现血运重建、挽救缺血半暗带是治疗AIS的关键, 主要包括静脉溶栓治疗和血管内治疗。AIS血管再通治疗从静脉溶栓发展到血管内治疗, 经历了30多年的研究历程, 大致可分为3个阶段:第一阶段, 探索静脉溶栓药物, 开创卒中的静脉溶栓时代; 第二阶段, 探索溶栓药物更安全、有效的剂量和更合理的时间窗; 第三阶段, 取栓治疗兴起并飞速发展, 使AIS患者的治疗方法选择多样化、个体化, 根据患者的发病时间、严重程度及影像学改变等, 选择静脉溶栓治疗、桥接治疗(静脉溶栓联合血管内治疗)或单纯血管内治疗。Abstract: Acute ischemic stroke(AIS), characterized by its high morbidity, high mortality, and high disability, is the most common subtype of stroke. Rapidly recanalizing the occluded arteries to salvage ischemic parenchyma in the early stage is essential to treat AIS, which mainly includes intravenous thrombolysis and endovascular treatment. The reperfusion therapy of AIS has been studied for over thirty years developing from intravenous thrombolysis(IVT) to endovascular treatment. There are three main stages in the evolution of reperfusion therapy:(1)investigating thrombolytic agents, which commenced the era of IVT in treating AIS; (2)investigating the dose and time window of thrombolytic agents to maximize the benefit and minimize the risk of IVT; (3)investigating mechanical thrombectomy for AIS, which contributes to the diversification and individualization of reperfusion therapy. Currently, IVT, bridging therapy, and direct mechanical thrombectomy can be applied to treating AIS according to the duration from the onset, the severity of clinical manifestation, and findings in the imaging examination.
-
临床实践指南(下文简称“指南”)是在此前医学研究成果系统总结的基础上，形成的对当前医疗实践的最佳指导意见[1-2]。指南的临床意义和价值，某种程度上取决于其“保鲜期”——即推荐意见的时效性[3]。被最新研究证明无效甚至有害的措施、或被证明有效及更符合成本效益的方案，如不能及时在指南中体现，将对医疗服务的质量和效果产生重要影响[4-5]。此外，医学知识的半衰期相对于其他学科更短[6]，大量医学研究的激增也促使指南必须与时俱进[7]。
与重新制订指南不同，指南修订一般不更改或很少更改原有的临床问题，仅补充纳入新的研究证据，更新原有的推荐意见[8-9]。指南修订是保证推荐意见可信度的关键，指南研究与评价工具AGREE Ⅱ(Appraisal of Guidelines for Research and Evaluation Ⅱ)将指南是否在全文中阐述其修订的周期和策略作为质量评价的重要内容[10]。需强调的是，指南修订仍应基于系统评价证据，遵循科学、规范的方法。作为本专栏第5篇文章，本文将从指南修订的原因、现状、方法和存在的问题等方面展开论述，并在此基础上就如何有效开展修订工作提出思考与建议。
1. 指南修订的原因与现状
指南修订最常见的原因是新的研究证据改变了此前的常规临床实践，除此之外，还有多种因素可影响到指南的修订，现对其进行总结并给出示例(表 1)[11]。
表 1 影响指南修订的主要因素及示例主要影响因素 示例 研究证据 疾病定义或诊断标准发生改变 2015年，强化血压控制试验[12]和相关研究结果发表；2017版美国成人高血压指南将高血压定义为血压≥130/80 mm Hg[13] 新的疗法更有效 2013年，中国研究显示氯吡格雷联合阿司匹林较单独使用阿司匹林可显著降低卒中再发风险[14]；2014年美国心脏协会/美国卒中协会发布的新版缺血性卒中及短暂性脑缺血发作患者卒中预防指南将联合疗法作为新的推荐意见[15] 原有疗法无效 2017年，研究证实补充钙和维生素D不能降低社区老年人的骨折风险[16]；2018年，美国预防医学工作组将其不推荐的意见写进指南[17] 新发不良事件 2019年11月，美国疾病预防控制中心发布电子烟相关肺损伤爆发的报告[18]，当月即修订了电子烟指南[19] 卫生政策及其他 国家政策 2016年，中国政府全面实施两孩政策，此前的辅助生殖指南，缺乏对高龄产妇的关注，以及相关证据的纳入；2017年，中华医学会生殖医学分会修订了高龄产妇辅助生殖指南并于2019年发表[20] 药品审批 2019年，贝利尤单克隆抗体被我国国家食品药品监督管理局批准可用于治疗系统性红斑狼疮[21]；2020年，中华医学会修订的系统性红斑狼疮诊疗指南将其纳入推荐意见[22] 医疗保险 2019年，丙酚替诺福韦确定将被纳入国家医保目录；当年更新后的慢性乙型肝炎防治指南将其作为首选抗病毒药物之一[23] 突发公共卫生事件 2019年12月中国发现新型冠状病毒疫情，截至2020年3月3日，2个月内国家卫生健康委员会已将《新型冠状病毒肺炎诊疗方案》更新到第7版[24]。除新出现的研究证据外，全国疫情防控形势的变化、对诊断和治疗措施利弊在不同时间的考量、社会、经济、政治等多种因素都影响到诊疗方案短期内的快速更新。突发公共卫生事件既是指南制订的触发因素，也是全程推动其不断更新的主要因素对于国内指南的修订，中华医学会的指南修订周期为2~5年[25]，我国指南修订的比例仅为10%，其中最长修订周期达10年[30]。 指南修订周期方面，一项针对国际指南制订机构的调查显示，22.9%(8/35)的国际指南制订机构修订周期为4~5年，40%(14/35)修订周期为2~3年，8.6%(3/35)修订周期≤1年，28.6%(10/35)未明确修订周期[9]，其中国际主要指南制订机构修订周期见表 2。另一项针对国际指南制订机构的调查显示，92.3%(36/39)的国际指南制订机构进行过指南修订，79.5%(31/39)拥有正式修订程序[29]。
表 2 国内外主要指南制订机构指南修订周期2. 指南修订的方法和流程
当前已有多个指南制订机构给出了修订指南的方法和流程[8-9]，然而，这些方法和流程标准各异，主要适用于本国或本机构。笔者对其进行系统总结，提出了针对我国指南修订的方案(图 1)。对于修订版指南的报告，RIGHT工作组给出了基本条目[31-32]，CheckUp工作组给出了较为详细的清单(表 3)[33-34]，指南制订者可参考相应条目和清单撰写和发布修订版指南。
条目 内容 1 修订版指南与原版指南能够被区分开 2 报告了修订指南的缘由 3 报告了修订版指南与原版指南间范围和目的的变化，并提供了支撑材料 4 报告了在修订过程中对其更新和审阅过的章节 5 报告了哪些推荐意见被保留、删除、增加或修改 6 报告了被修改的推荐意见并提供了支撑材料 7 报告了修订版指南中的专家组成员 8 报告了负责指南修订的专家的利益冲突情况 9 报告了修订版指南的资助机构及其所发挥的作用 10 报告了在指南修订中检索证据的方法 11 报告了在指南修订过程中遴选证据的方法 12 报告了在指南修订过程中评估证据质量的方法 13 报告了在指南修订过程中证据合成的方法 14 报告了修订版指南的外部评审方法 15 报告了要实施修订版指南中更改推荐意见的方法和计划 16 报告了未来再次修订的计划和方法 另外一个值得关注的方法学问题是修订的最佳时机和周期。由于指南包含的推荐意见会在不同的时间段过时(与支持推荐意见的系统评价的时效性直接相关)，指南修订过早，譬如仅有不到30%的推荐意见过时，这时修订指南则可能会浪费资源，降低修订效率；指南修订过迟，虽然可以覆盖所有推荐意见，但部分提前过时的推荐意见则可能已对临床诊疗产生了负面影响。修订周期方面，在某些研究进展比较快的领域，当指南修订完成后，可能部分推荐意见的证据又会过期；或如前所述的突发公共卫生事件，新的研究和情况可能时时在变化，修订周期可能以月甚至周为单位。因此，高效的组织构架和响应机制在临床实践指南的修订过程中也至关重要。基于此，有研究人员提出了"活指南(living guideline)"的概念，即一旦有高质量、能够改变临床实践的证据出现，就应及时制作推荐意见决策表，组织专家进行共识，以最快速度修订指南相应的推荐意见[35]。
3. 指南修订工作存在的问题和挑战
目前指南修订工作尚存在一定问题，面临较大的挑战，主要表现在以下3个方面：(1)缺乏规划和监管。大部分指南在制订之初，就缺乏修订的计划；即使有修订计划，因为原指南工作组人员的变化，特别是主要负责人的变化，3~5年后也无法落实修订工作。其主要原因是制订机构缺乏对指南长远、可持续的规划，以及缺乏主管部门的监管。与我国不同，英国国家健康与临床优化研究所制订的指南，由于良好的顶层设计，每部指南发布后，都会被标记和追踪，定期评估和督促指南的修订工作[27]。(2)缺乏动机和资源。修订指南相对于制订新指南而言，对制订者的吸引力更小，特别是对于不涉及新的药物或器械的指南而言。同样，这类指南也更难募集到足够的经费，从而导致被长时间搁置；此外，制订的新指南即使在原指南基础上变化不大，但本质上属于指南的制订，制订者往往也会按一部新指南来发表和宣传。(3)缺乏科学规范的方法。尽管目前有多个组织在探索指南修订的方法，但具体采用何种方法更加有效，目前尚无统一的标准；此外，也缺乏对指南修订的质量评价，从而导致指南的修订工作在科学性和严谨性方面有所欠缺。
4. 对我国指南修订的思考和建议
中国临床实践指南的修订比例低，修订周期长，不同机构制订的指南修订情况差异较大[30]。为帮助我国指南制订者更好地开展指南修订工作，现提出以下4个方面的思考和建议。
4.1 指南管理者层面(国家卫生健康委员会或其下属部门)
一方面，建立国家层面指南修订或更新的权威网站或数据库[36]；另一方面，应要求和督促指南制订机构承担指南发布后的证据监测和修订责任，定期审查指南的修订情况，提醒指南制订者审核其指南中推荐意见的时效性，对于长时间未修订且可能或者已经给临床造成明显误导和问题的指南，应及时予以废止；此外，在开展医院等级评审工作时，应将是否基于最新指南进行诊疗纳入考核标准。
4.2 指南制订者层面(各学会、协会或工作组)
中华医学会及下属分会是目前我国最大的指南制订机构，近年来高度重视其指南质量，发布的相关管理办法也对指南制/修订工作给出了指导[25]。可在此基础上，进一步完善其指南修订机制和办法。建议由原指南证据评价组或委托循证医学相关组织/单位定期评估已发布的指南，在此基础上，遵循指南修订步骤，更新推荐意见。对于修订版指南的撰写，可参照RIGHT和CheckUp清单[31-34]。
4.3 指南研究者层面(各高校、医院或科研院所开展指南方法学研究的人员)
应开展如何科学、高效修订指南，以及修订后如何尽快替换原有指南的实施研究。如可探究如何通过引入人工智能实时监测新证据，快速合成研究结果。对于修订版指南的传播和实施，如何通过多种形式将修订版指南快速推送给指南的使用者，及时替换原有指南，从而将原有过期指南对临床的不利影响降至最低。
4.4 指南使用者层面(医务人员、患者、公众、媒体或科普工作者)
医务工作者应学习如何查找和评价指南的最新版本；媒体或科普工作者进行科普创作的时候，不仅要循证，而且要基于最新的指南；患者或公众利用互联网查找疾病相关预防、诊断和治疗信息时，也应注意其发布年份。
5. 小结
为确保指南的质量和时效性，指南制订者应充分意识到未及时更新的推荐意见对临床实践的危害，承担主体责任，按照循证的方法，定期开展指南修订工作。具体可参考相关修订流程和注意事项[33]，并在首次指南制订中即做好修订准备。指南管理者、研究者、修订者和使用者应加强联系与合作，开展指南更新领域的深入研究，及时修订和更新指南，充分发挥其作用和价值。即使无法做到让指南实时“保鲜”，至少也应为其贴上定期审查的日期和标签，从而让医务人员和患者使用时更加放心。
利益冲突 无 -
[1] Wang W, Jiang B, Sun H, et al. Prevalence, Incidence, and Mortality of Stroke in China:Results from a Nationwide Population-Based Survey of 480687 Adults[J]. Circulation, 2017, 135:759-771. http://svn.bmj.com/lookup/ijlink?linkType=ABST&journalCode=circulationaha&resid=135/8/759&atom=%2Fsvnbmj%2F2%2F3%2F132.atom
[2] 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组.中国急性缺血性脑卒中诊治指南2018[J].中华神经科杂志, 2018, 51:666-682. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zhsjk201809005 [3] Sussman BJ, Fitch TS. Thrombolysis with fibrinolysin in cerebral arterial occlusion[J]. J Am Med Assoc, 1958, 167:1705-1709. http://onlinelibrary.wiley.com/resolve/reference/PMED?id=13563167
[4] 张和.卒中治疗——Zivin与阿替普酶[J].中国卒中杂志, 2017, 12:727-728. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zgzzzz201708015 [5] Zivin JA, Fisher M, Degirolami U, et al. Tissue plasm-inogen activator reduces neurological damage after cerebral embolism[J]. Science, 1985, 230:1289-1292. http://www.ncbi.nlm.nih.gov/pubmed/3934754
[6] National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke[J]. N Engl J Med, 1995, 333:1581-1587.
[7] Adams HP Jr, Brott TG, Furlan AJ, et al. Guidelines for Thrombolytic Therapy for Acute Stroke:a Supplement to the Guidelines for the Management of Patients with Acute Ischemic Stroke. A statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association[J]. Circulation, 1996, 94:1167-1174. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=10.1177/0148607102026001011
[8] Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study(ECASS)[J]. JAMA, 1995, 274:1017-1025. http://pmj.bmj.com/external-ref?access_num=10.1001/jama.1995.03530130023023&link_type=DOI
[9] Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke(ECASS Ⅱ). Second European-Australasian Acute Stroke Study Investigators[J]. Lancet, 1998, 352:1245-1251. http://www.europepmc.org/abstract/MED/9788453
[10] Clark WM, Wissman S, Albers GW, et al. Recombinant tissue-type plasminogen activator(Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study:a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke[J]. JAMA, 1999, 282:2019-2026. http://www.tandfonline.com/servlet/linkout?suffix=CIT0028&dbid=16&doi=10.1517%2F14656560802521650&key=10.1001%2Fjama.282.21.2019
[11] Clark WM, Albers GW, Madden KP, Hamilton S. The rtPA(alteplase) 0- to 6-hour acute stroke trial, part A(A0276g):results of a double-blind, placebo-controlled, multicenter study. Thromblytic therapy in acute ischemic stroke study investigators[J]. Stroke, 2000, 31:811-816. http://bja.oxfordjournals.org/cgi/ijlink?linkType=ABST&journalCode=strokeaha&resid=31/4/811
[12] Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment:pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials[J]. Lancet, 2004, 363:768-774. http://www.ncbi.nlm.nih.gov/pubmed/15016487
[13] 卢海涛, 张小年, 周维金.缺血性脑卒中患者的早期处理指南(四)[J].中国康复理论与实践, 2004, 10:121-125. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zgkfllysj200402029 [14] Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke[J]. N Engl J Med, 2008, 359:1317-1329. DOI: 10.1007/s00390-008-0018-8
[15] Davis SM, Donnan GA, Parsons MW, et al. Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial(EPITHET):a placebo-controlled randomised trial[J]. Lancet Neurol, 2008, 7:299-309. http://brain.oxfordjournals.org/lookup/external-ref?access_num=18296121&link_type=MED&atom=%2Fbrain%2Fearly%2F2015%2F03%2F23%2Fbrain.awv071.atom
[16] 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[J]. Lancet, 2010, 375:1695-1703.
[17] 中华医学会神经病学分会脑血管病学组急性缺血性脑卒中诊治指南撰写组.中国急性缺血性脑卒中诊治指南2010[J].中国全科医学, 2011, 14:4013-4017. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zgqkyx201135004 [18] 金征宇, 孙昊.新时代放射影像临床诊疗路径的思考[J].协和医学杂志, 2019, 10:2-5. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=xhyx201901002 [19] Thomalla G, Rossbach P, Rosenkranz M, et al. Negative fluid-attenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less[J]. Ann Neurol, 2009, 65:724-732. DOI: 10.1002/ana.21651/full
[20] Thomalla G, Fiebach JB, Østergaard L, et al. A multi-center, randomized, double-blind, placebo-controlled trial to test efficacy and safety of magnetic resonance imaging-based thrombolysis in wake-up stroke(WAKE-UP)[J]. Int J Stroke, 2014, 9:829-836. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=WK_MED201810241505
[21] Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset[J].N Engl J Med, 2018, 379:611-622. http://www.ncbi.nlm.nih.gov/pubmed/29766770
[22] Amiri H, Bluhmki E, Bendszus M, et al. European Cooperative Acute Stroke Study-4:Extending the time for thrombolysis in emergency neurological deficits ECASS-4:ExTEND[J]. Int J Stroke, 2016, 11:260-267. DOI: 10.1177/1747493015620805
[23] Ma H, Parsons MW, Christensen S, et al. A multicentre, randomized, double-blinded, placebo-controlled Phase Ⅲ study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits(EXTEND)[J]. Int J Stroke, 2012, 7:74-80.
[24] 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[J]. Lancet, 2019, 394:139-147. http://www.sciencedirect.com/science/article/pii/S0140673619310530
[25] 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[J]. Stroke, 2019, 50:e344-e418.
[26] Huang Y, Sharma VK, Robinson T, et al. Rationale, design, and progress of the ENhanced Control of Hyperten-sion ANd Thrombolysis strokE stuDy(ENCHANTED) trial:An international multicenter 2×2 quasi-factorial randomized controlled trial of low- vs. standard-dose rt-PA and early intensive vs. guideline-recommended blood pressure lowering in patients with acute ischaemic stroke eligible for thrombolysis treatment[J]. Int J Stroke, 2015, 10:778-788. DOI: 10.1111/ijs.12486
[27] Coutts SB, Berge E, Campbell BC, et al. Tenecteplase for the treatment of acute ischemic stroke:A review of completed and ongoing randomized controlled trials[J]. Int J Stroke, 2018, 13:885-892. DOI: 10.1177/1747493018790024
[28] Bivard A, Huang X, McElduff P, et al. Impact of Computed Tomography Perfusion Imaging on the Response to Tenecteplase in Ischemic Stroke:Analysis of 2 Randomized Controlled Trials[J]. Circulation, 2017, 135:440-448. DOI: 10.1161/CIRCULATIONAHA.116.022582
[29] Campbell BC, Mitchell PJ, Churilov L, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke[J]. N Engl J Med, 2018, 378:1573-1582. DOI: 10.1056/NEJMoa1716405
[30] Campbell BC, Mitchell PJ, Churilov L, et al. Determining the optimal dose of tenecteplase before endovascular therapy for ischemic stroke(EXTEND-IA TNK Part 2):A multicenter, randomized, controlled study[J]. Int J Stroke, 2019. doi: 10.1177/1747493019879652.[Epub ahead of print].
[31] Fletcher AP, Alkjaersig N, Lewis M, et al. A pilot study of urokinase therapy in cerebral infarction[J]. Stroke, 1976, 7:135-142. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=WK_LWW2017052520654873
[32] 饶明俐, 张秉枢, 常庆有.尿激酶治疗脑血管关闭30例临床分析[J].白求恩医科大学学报, 1978, (04):48-53. http://search.cnki.net/down/default.aspx?filename=BQEB197804007&dbcode=CJFD&year=1978&dflag=pdfdown [33] 国家"九五"公关课题协作组.急性脑梗死(6 h以内)静脉溶栓治疗[J].中风与神经疾病杂志, 2004, 18:259-261. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zfysjjbzz200105001 [34] 国家"九五"公关课题协作组.急性脑梗死六小时以内的静脉溶栓治疗[J].中华神经科杂志, 2002, 35:210-213. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zhsjk200204007 [35] Wang Y, Liao X, Zhao X, et al. Using recombinant tissue plasminogen activator to treat acute ischemic stroke in China:analysis of the results from the Chinese National Stroke Registry(CNSR)[J]. Stroke, 2011, 42:1658-1664. DOI: 10.1161/STROKEAHA.110.604249
[36] Wahlgren N, Ahmed N, Dávalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study(SITS-MOST):an observational study[J]. Lancet, 2007, 369:275-282. DOI: 10.1016/S0140-6736(07)60149-4
[37] Leys D, Cordonnier C, Debette S, et al. Facilities available in French hospitals treating acute stroke patients:comparison with 24 other European countries[J]. J Neurol, 2009, 256:867-873. DOI: 10.1007/s00415-009-5029-2
[38] Del Zoppo GJ, Higashida RT, Furlan AJ, et al. PROACT:a phase Ⅱ randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism[J]. Stroke, 1998, 29:4-11. DOI: 10.1161/01.STR.29.1.4
[39] Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT Ⅱ study:a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism[J]. JAMA, 1999, 282:2003-2011. DOI: 10.1001/jama.282.21.2003
[40] Lewandowski CA, Frankel M, Tomsick TA, et al. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke:Emergency Management of Stroke(EMS) Bridging Trial[J]. Stroke, 1999, 30:2598-2605. DOI: 10.1161/01.STR.30.12.2598
[41] Gobin YP, Starkman S, Duckwiler GR, et al. MERCI 1:a phase 1 study of Mechanical Embolus Removal in Cerebral Ischemia[J]. Stroke, 2004, 35:2848-2854. DOI: 10.1161/01.STR.0000147718.12954.60
[42] 中华医学会神经病学分会, 中华医学会神经病学分会神经血管介入协作组, 急性缺血性脑卒中介入诊疗指南撰写组.中国急性缺血性脑卒中早期血管内介入诊疗指南[J].中华神经科杂志, 2015, 48:356-361. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zhsjk201505002 [43] IMS Study Investigators. Combined intravenous and intra-arterial recanalization for acute ischemic stroke:the Interventional Management of Stroke Study[J]. Stroke, 2004, 35:904-911. DOI: 10.1161/01.STR.0000121641.77121.98
[44] IMS Ⅱ Trial Investigators. The Interventional Management of Stroke(IMS) Ⅱ Study[J]. Stroke, 2007, 38:2127-2135. DOI: 10.1161/STROKEAHA.107.483131
[45] Smith WS. Safety of mechanical thrombectomy and intraven-ous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia(MERCI) trial, part I[J]. AJNR Am J Neuroradiol, 2006, 27:1177-1182.
[46] Ogawa A, Mori E, Minematsu K, et al. Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke:the middle cerebral artery embolism local fibrinolytic intervention trial(MELT) Japan[J]. Stroke, 2007, 38:2633-2639. DOI: 10.1161/STROKEAHA.107.488551
[47] Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke[J]. N Engl J Med, 2013, 368:893-903. DOI: 10.1056/NEJMoa1214300
[48] Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke[J]. N Engl J Med, 2013, 368:904-913. DOI: 10.1056/NEJMoa1213701
[49] Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke[J]. N Engl J Med, 2013, 368:914-923. DOI: 10.1056/NEJMoa1212793
[50] Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke(SWIFT):a randomised, parallel-group, non-inferiority trial[J]. Lancet, 2012, 380:1241-1249. DOI: 10.1016/S0140-6736(12)61384-1
[51] Nogueira RG, Lutsep HL, Gupta R, et al. TREVO versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke(TREVO 2):a randomised trial[J]. Lancet, 2012, 380:1231-1240. DOI: 10.1016/S0140-6736(12)61299-9
[52] Berkhemer OA, Fransen PS, Beumer D, et al. A rando-mized trial of intraarterial treatment for acute ischemic stroke[J]. N Engl J Med, 2015, 372:11-20. DOI: 10.1056/NEJMoa1411587
[53] Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke[J]. N Engl J Med, 2015, 372:1019-1030. DOI: 10.1056/NEJMoa1414905
[54] Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection[J]. N Engl J Med, 2015, 372:1009-1018. DOI: 10.1056/NEJMoa1414792
[55] Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke[J]. N Engl J Med, 2015, 372:2285-2295. DOI: 10.1056/NEJMoa1415061
[56] Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke[J]. N Engl J Med, 2015, 372:2296-2306. DOI: 10.1056/NEJMoa1503780
[57] Badhiwala JH, Nassiri F, Alhazzani Waleed, et al. Endovascular Thrombectomy for Acute Ischemic Stroke:A Meta-analysis[J]. JAMA, 2015, 314:1832-1843. DOI: 10.1001/jama.2015.13767
[58] Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke(THRACE):a randomised controlled trial[J]. Lancet Neurol, 2016, 15:1138-1147. DOI: 10.1016/S1474-4422(16)30177-6
[59] Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment:A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association[J]. Stroke, 2015, 46:3020-3035. DOI: 10.1161/STR.0000000000000074
[60] Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct[J]. N Engl J Med, 2018, 378:11-21. DOI: 10.1056/NEJMoa1706442
[61] Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging[J]. N Engl J Med, 2018, 378:708-718. DOI: 10.1056/NEJMoa1713973
[62] 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组, 中华医学会神经病学分会神经血管介入协作组.中国急性缺血性脑卒中早期血管内介入诊疗指南2018[J].中华神经科杂志, 2018, 51:683-691. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zhsjk201809006 [63] Liu X, Dai Q, Ye R, et al. Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion(BEST):an open-label, randomised controlled trial[J]. Lancet Neurol, 2020, 19:115-122. DOI: 10.1016/S1474-4422(19)30395-3
[64] Toni D, Mangiafico S, Agostoni E, et al. Intravenous thrombolysis and intra-arterial interventions in acute ischemic stroke:Italian Stroke Organisation(ISO)-SPREAD guidelines[J]. Int J Stroke, 2015, 10:1119-1129. DOI: 10.1111/ijs.12604
[65] Wahlgren N, Moreira T, Michel P, et al. Mechanical thrombectomy in acute ischemic stroke:Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN[J]. Int J Stroke, 2016, 11:134-147. DOI: 10.1177/1747493015609778
[66] Coutinho JM, Liebeskind DS, Slater LA, et al. Combined Intravenous Thrombolysis and Thrombectomy vs Thrombecto-my Alone for Acute Ischemic Stroke:A Pooled Analysis of the SWIFT and STAR Studies[J]. JAMA Neurol, 2017, 74:268-274. DOI: 10.1001/jamaneurol.2016.5374
[67] Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke[J]. Stroke, 2007, 38:948-954. DOI: 10.1161/01.STR.0000257304.21967.ba
[68] Guedin P, Larcher A, Decroix JP, et al. Prior IV Thrombolysis Facilitates Mechanical Thrombectomy in Acute Ischemic Stroke[J]. J Stroke Cerebrovasc Dis, 2015, 24:952-957. DOI: 10.1016/j.jstrokecerebrovasdis.2014.12.015
[69] Behme D, Kabbasch C, Kowoll A, et al. Intravenous Thrombolysis Facilitates Successful Recanalization with Stent-Retriever Mechanical Thrombectomy in Middle Cerebral Artery Occlusions[J]. J Stroke Cerebrovasc Dis, 2016, 25:954-959. DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.007
[70] Kaesmacher J, Kleine JF. Bridging Therapy with i.v. rtPA in MCA Occlusion Prior to Endovascular Thrombectomy:a Double-Edged Sword?[J]. Clin Neuroradiol, 2018, 28:81-89. DOI: 10.1007/s00062-016-0533-0
[71] Almekhlafi MA, Hill MD, Roos YM, et al. Stroke Laterality Did Not Modify Outcomes in the HERMES Meta-Analysis of Individual Patient Data of 7 Trials[J]. Stroke, 2019, 50:2118-2124. DOI: 10.1161/STROKEAHA.118.023102
[72] Saver JL, Goyal M, van der Lugt A, et al. Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke:A Meta-analysis[J]. JAMA, 2016, 316:1279-1288. DOI: 10.1001/jama.2016.13647
[73] Wang H, Zi W, Hao Y, et al. Direct endovascular treatment:an alternative for bridging therapy in anterior circulation large-vessel occlusion stroke[J]. Eur J Neurol, 2017, 24:935-943. DOI: 10.1111/ene.13311
[74] Liu M, Li G. Is Direct Endovascular Treatment as an Alternative of Bridging Therapy in Acute Stroke Patients with Large Vessel Occlusion?[J]. J Stroke Cerebrovasc Dis, 2019, 28:531-541. DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.007
-
期刊类型引用(6)
1. 张毅，罗勤，赵智慧，赵青，柳志红. 超声辅助导管溶栓在肺血栓栓塞症中的应用进展. 协和医学杂志. 2022(01): 104-109 . 
本站查看
2. 杨宏伟. 不同剂量重组组织型纤溶酶原激活剂治疗急性肺栓塞患者的效果. 中国医学创新. 2022(05): 144-148 . 百度学术
3. 唐时林，丘述兴，黄海滨. 脊柱术后急性肺栓塞溶栓治疗1例报道及文献复习. 中华骨与关节外科杂志. 2022(04): 283-288 . 百度学术
4. 陈孟金. 凝血功能和狼疮抗凝物相关指标在急性肺栓塞中的临床诊断价值. 中国卫生检验杂志. 2022(09): 1092-1094 . 百度学术
5. 杨亚坤，韩松，刘宁，张旭妃，张林朋，韩明阳，张云馨，闫长祥. 集束化干预措施下颅脑肿瘤术后肺血栓栓塞症严重程度危险因素分析. 中国医药导报. 2021(14): 76-80 . 百度学术
6. 付文海，黎岳鑫，陈泱晓，陈扬航，任妮，江倩，马冉，王涛，王欣妮，张挪富，刘春丽. 中高危急性肺栓塞初始溶栓与抗凝治疗的疗效与安全性的系统评价与meta分析. 重庆医学. 2021(15): 2653-2660 . 百度学术
其他类型引用(2)
下载:
计量
- 文章访问数: 693
- HTML全文浏览量: 47
- PDF下载量: 172
- 被引次数: 8
