2020 年 37 巻 5 号 p. 712-718
The concept of time window for acute thrombolytic therapy has changed based on the tissue–based selection. Patients of more than 4.5 hours of stroke onset require penumbral mismatch to achieve significant improvement with alteplase therapy. The EXTEND trial showed significant improvement (adjusted Odds ratio 1.44, p＝0.04) over placebo in patients with 4.5–9 hours and wake–up strokes. This finding was further confirmed by combined analysis using EXTEND, ECASS4–EXTEND and EPITHET data. How to utilize perfusion imaging in Japan is our task for future.
Several new data regarding prehospital (RIGHT–2 for NTG patch) and acute in–hospital management (SHINE for glucose management ; ENCHANTED for blood pressure management after thrombolysis) were disclosed in 2019. However, none showed significant effect to alter our current guideline.
Long term dual antiplatelet therapy (DAPT) using cilostazol is effective and safer than aspirin or clopidogrel monotherapy. CSPS.com offers new treatment option for high–risk non–cardioembolic ischemic stroke.
RESPECT–ESUS compared the efficacy and safety of dabigatran and aspirin in patients with embolic stroke of undetermined source (ESUS). The study failed to show the usefulness of DOAC, that is in line with NAVIGATE ESUS. We need to re–consider the ESUS concept, as such to differentiate atrial cardiopathy and arteriogenic embolism, etc.
Regarding hemorrhagic stroke, 2 topics are documented. Antedotes for Xa inhibitors, Andexanet Alfa became available in United States. The drug is now awaited in Japan. MISTIE–III trial showed the evidence of acute hematoma evacuation. Survival outcome significantly improved by MISTIE therapy (stereotactic hematoma aspiration, followed by intra–cavity tPA) compared to medical therapy (Hazard 0.67, p＝0.037).
