Продолжаю, все не влезло:
11. IA thrombolysis is experimental and has not been approved in any country. Intra-arterial thrombolysis with r-proUK reduced disability in patients with occluded M1 or M2 segments of the middle cerebral artery within 6-hour time window in PROACT I and II (grade B evidence). The drug is not available in Europe. Open series have suggested that urokinase may be equally effective and safe as r-proUK. IA thrombolysis has also been used in basilar artery occlusions although IV thrombolysis may be equally effective due to faster delivery of the drug. Large trials to assess IA treatment beyond 3 h and trials to compare IV and IA thrombolysis and their combination are needed.
12. Various mechanical means of clot removal and angioplasty are under investigation. The safety and efficacy of these endovascular techniques including stent protected angioplasty in acute stroke need further assessment.
13. Thrombolysis for stroke in children, in patients older than 80 years, in carotid dissections, and in those with basilar artery occlusions needs further studies although case series suggest that it may have similar utility in those over 80 years of age as in younger patients, in basilar artery occlusions as in anterior circulation strokes, and in carotid dissections.
14. The present guidelines may need updating in many aspects of acute stroke care during thrombolysis. In the pooled analysis (ATLANTIS, ECASS and NINDS) every 10 mg/dl increase of blood sugar reduced odds ratios of good outcome (modified Rankin scale 0-1) by 0.98 and increased odds ratios for a bad outcome (modified Rankin scale 5-6) by 1.04 (grade B evidence). Open studies have revealed similar relationships between admission hyperglycemia and outcome in patients treated with thrombolytics. Accordingly, more active blood glucose control seems indicated in connection with thrombolysis.
15. Neither the pooled analysis (ATLANTIS, ECASS and NINDS) nor the reanalysis of the NINDS t-PA trial allowed assessment of the effect of blood pressure or its management on outcome but there are several case series which strongly suggest that it may not be desirable to reduce blood pressure without good clinical reason such as heart failure or hypertensive encephalopathy. When the occluded artery reopens the blood pressure declines, but if it does not recanalize, the blood pressure remains elevated to ensure perfusion in ischemic penumbra, and then an aggressive reduction of blood pressure may reduce the chances of good outcome. The SITS-MOST register may give an answer to some of these open questions but ongoing randomized trials may also contribute in this respect.
16. The impact of antiplatelet treatment prior to stroke on the risk of symptomatic haemorrhage following stroke needs to be studied further. Existing data do not indicate an increased risk of symptomatic haemorrhage (grade B evidence). Furthermore, the safety and efficacy of post-thrombolytic antithrombotic treatment and anticoagulation to prevent reocclusion need to be analysed in randomized trials.
17. The public should be educated of the value of early expert assessment and treatment.
18. Thrombolysis in stroke should be widely available. Our task is now to increase rapid response to stroke. It is equally important to develop a well-functioning stroke triage and an in-hospital stroke care pathway.
