- 學位論文
急性缺血性腦中風溶栓手術之療效評估
Evaluation of the Outcome of Intra-arterial Thrombolysis Therapy in Acute Ischemia Stroke
摘要
中風長年高居國人死亡原因之第二位。中風可概分為出血性及缺血性兩大類。其中，缺血性中風高達七成。隨著診斷及醫療技術的進步，醫界一直致力提高中風療效，並減少併發症。 依急性缺血性腦中風最新的標準治療，如果患者符合所有治療條件，可於中風後三小時內，進行靜脈rTPA溶栓治療。但臨床上，符合三小時黃金時間可治療的病例並不多。因此，另一種更積極的治療方式，患者前循環中風超過三小時但在六小時之內，後循環中風超過三小時但在十二小時之內，且符合所有條件，可直接以微導管於血管阻塞部位進行動脈溶栓手術。 一九九五年的大型國際研究（NINDS）證實，以靜脈rTPA溶栓治療急性缺血性腦中風三個月後，有臨床療效。但動脈溶栓手術案例數目少，又缺乏大型國際合作研究，迄今仍非美國食品藥物管理局（FDA）認可的標準治療，僅允許於少數醫學中心針對個案建議施行。因此，各醫學中心提出的療效報告，結論並不一致。因此，本研究針對彰化基督教醫院單一機構的案例進行研究。 本研究收集彰化基督教醫院二○○一至二○○七年間，急性缺血性腦中風接受溶栓手術之病例，共四十七例。取其中治療後有進步的病例（NIHSS進步4分以上），以回溯性分析，取以下七種變數：性別、年齡、血管阻塞部位、術後顱內有無出血、血管溶栓打通程度、施打劑量、溶栓手術治療前之中風程度。發現其中四種變數（血管阻塞部位、術後顱內有無出血、血管溶栓打通程度、溶栓手術治療前之中風程度），與進步相關。而另外三個變數（性別、年齡與施打劑量），則與進步無關。 此外，在這四十七例中，有十例於術後發生顱內出血。為了找出影響術後顱內出血之因素，以助未來治療之判斷，因此，也採回溯性分析，發現唯有血管打通程度此變數，與術後顱內出血相關。而另五種變數（性別、年齡、血管阻塞部位、施打劑量、溶栓手術治療前之中風程度），則與術後顱內出血並無相關。 最後，若以血管打通程度（依TIMI分級法，見表四），回溯性分析此四十七例，發現唯有術後顱內出血此變數與之相關，其他變數（性別、年齡、血管阻塞部位、施打劑量、溶栓手術治療前之中風程度）皆無相關。
並列摘要
The clinical presentations of acute ischemic stroke are heterogeneous and sometimes make the correct diagnosis difficult. In Taiwan, it has been the second leading cause of death since the 1970s and has been causing serious individual, family and social burden. There was no standard treatment for acute ischemic stroke until the first international intra-venous r-TPA thrombolysis treatment study published in 1995. The study demonstrated that study groups which were administered r-TPA within three hours of onset had better clinical outcome after three months. However, the narrow therapeutic golden time window and the risk of post-treatment hemorrhage remain controversial and pose many treatment challenges. The intra-arterial thrombolysis treatment for acute ischemic stroke opens wider therapeutic golden time window and has the opportunity of achieving good clinical result according to many individual studies. However, lack of sufficient international studies has made it difficult to come up with a widely accepted standard for clinical treatment. To foster further understanding of the clinical result of acute intra-arterial thrombolysis (I.A.T.), we reviewed our single center experience of I.A.T for acute ischemic stroke patients who are ineligible for intravenous thrombolysis (I.V.T) treatment. There are total 47 cases ( M/F:29/18 ), the mean age is 58.17±15.15. The occlusive sites include 9 cases in basilar artery (19.1%), 15 cases in internal carotid artery (31.9%) and 23 cases in middle cerebral artery (48.9%). Among these 47 cases, 33 show clinical improvement (NIHSS improves at least 4 points) when they were discharged from the hospital. For these 33 cases, there are no significant correlations between the improvement outcome and the patients’ age, sex, and the dosage of Urokinase administered. Significant correlations (p<0.05) observed between the improvement outcome and the patients’ initial NIHSS score, the occlusive site, the post-treatment hemorrhage and re-canalization status. There are total 10 cases of delayed intracranial hemorrhage after the IAT treatment. Only one variable (re-canalization status) shows significant correlation. Other variables (age, sex, occlusive site, the dosage of Urokinase administered, and the patient’s initial NIHSS score) do not show any significant correlation. We use the TIMI grade system to evaluate the re-canalization status. Among all the 47 cases, 9 cases are in the range of TIMI 0-1. The other 19 cases are in TIMI 2 and 19 cases are in TIMI 3. We evaluate the following variables (age, sex, occlusive site, the dosage of Urokinase administered, and the initial NIHSS score) but there are no significant correlations between the re-canalization status and these variables.