脳血管障害最新の治療2020

抄録

New evidences are being accumulated year by year regarding therapeutic concept and methodology of stroke. Dramatical change had occurred even on grade A–therapies especially for acute reperfusion. Variety of mechanical thrombectomy (MT) devices (5 stents and 4 aspirators) are available nowadays. Treatment indication is determined by advanced brain imaging, i.e. penumbral mismatch or DWI–FLAIR mismatch. So–called “Tissue-based strategy” is the current standard for decision making in patients with late time window (＞6h) or unclear onset time. DIRECT–MT study revealed direct MT without rt–PA pre–infusion showed non–inferiority to those combined with rt–PA.

For non–cardioembolic stroke, dual antiplatelet therapy (DAPT) using aspirin and clopidogrel became current standard therapy during the acute phase. Optimal DAPT duration is suggested as 21 days by pooled analysis of CHANCE and POINT trials. Long–term DAPT for more than 1 year is usually harmful with bleeding risk. However, cilostazol–based DAPT in combination with clopidogrel or aspirin might be a good option as shown in CSPS.com study.

For patients with non–valvular atrial fibrillation, anti–coagulation therapy is highly recommended for secondary prevention of stroke. RELAXED study showed that initiation within 14 days of onset seems effective and safe, should the patient be able to swallow rivaroxaban early after stroke. Another topic of anti–coagulation is the introduction of effective antidotes : 4–factor prothrombin complex concentrate for warfarin and Idarucizumab for dabigatran.