メディカルスタッフレクチャー
脳梗塞急性期治療 2017 Update
キーワード:
mechanical thrombectomy,
clinical–imaging mismatch,
dual antiplatelet therapy,
anticoagulation,
direct oral anticoagulant
2018 年 35 巻 3 号 p. 226-230
詳細
2018 年 35 巻 3 号 p. 226-230
Management of acute ischemic stroke had dramatically changed since 2015 when HERMES collaboration succeed to establish the evidence of acute mechanical thrombectomy (MT). It is required for comprehensive stroke centers to provide MT to patients with emergent large vessel occlusion (ELVO) in addition to rt–PA thrombolysis ＜4.5 hour. The number needed to treat (NNT) for 1 rank improvement on modified Rankin Scale (mRS) score of MT is 2.6, though that of rt–PA is 6.7. Among the candidate of HERMES collaboration, 48% achieved mRS 0–2 at 3 months. This number is reproducible and also is a target for our daily routine practice. We need to blush up pre–hospital transfer and in–hospital triage systems, and create “drip, ship and retrieve” style inter–hospital collaboration with telestroke support.
Acute anti–platelet therapy is chosen for non–cardioembolic ischemic stroke. As shown by CHANCE trial, dual anti–platelet therapy (DAPT) i.e. combination of clopidogrel plus aspirin, is commonly used. However, clopidogrel loading (300mg) is not certified in Japan. Therefore, argatroban hydrate or ozagrel sodium is used in the acute phase.
For cardioemblic stroke, anti–coagulation (A/C) is necessary. When and how to start A/C remains unsolved clinical question. The A/C activity of direct oral anti–coagulants (DOAC) rises rapidly. Thus, it is ideal to start DOAC in the acute stage. Both Italian RAF study (4–14 days) and Japanese RELAXED study (＜14 days) support the validity of acute DOAC therapy.
