脳血管障害の治療の進歩

抄録

Recent advances on acute stroke therapy for patients with emergent large vessel occlusion (ELVO) using mechanical thrombectomy (MT) devices are huge. The one–year follow–up result of REVASCAT showed the consistent efficacy, and THRACE and SWIFT–PRIME revealed cost effectiveness. ASTER shoed the identical performance of aspiration device and stent retrieversients, it is now argued whether bridging therapy, i.e. intravenous thrombolysis (IVT) followed by MT, is essential for ELVO patients. One meta–analysis showed negative tendency to skip IVT in ELVO patients. The biggest impact in 2017 was the success of DAWN that employed the concept of Clinical–Imaging Mismatch, i.e. ischemic core size of ＜50cc with substantial neurological deficit. The achievement of DAWN can be translated as a big paradigm shift from “time-based” to “tissue-based” strategy.

In terms of thrmobolytic therapy, NOR–TEST used 0.4mg/kg of tenecteplase in unselected group of 1,100 patients with acute ischemic stroke. This trial showed identical efficacy and safety of tenecteplase compared to 0.9mg/kg of alteplase.

Idarucizumab is a specific agent to reverse the pharmacological activity of dabigatran. RE–VERSE AD trial proved the effect of idarucizmab is very quick, definite and sustains over 24 hours. We have now got a new option to treat ischemic stroke patients under dabigatran therapy with quick reversal using this antidote.

The concept of embolic stroke of undetermined source (ESUS) is now under investigation. For this topic, subanalysis of SOCRATES, a comparative study of ticagrelor and aspirin in non–cardioembolic ischemic stroke, presented an interesting result. Among ESUS subgroup, ticagrelor had a significant better efficacy over aspirin in patients with ＜50% stenosis of carotid artery or aortic atheroma. This fact may reveal the heterogeneity of ESUS population.