2022 年 39 巻 5 号 p. 749-755
Advance in acute recanalization therapy: The most significant topic in 2021 was the validation of the significance of pre–intravenous administration of alteplase in patients of large vessel occlusion (LVO) planned to mechanical thrombectomy. An integrated analysis of 1,633 patients from DIRECT–MT, DEVT, SKIP, and MR CLEAN–NO IV studies, was performed. The risk difference for functional independence was 1% (95% CI −4–5%) and for symptomatic intracranial bleeding 1% (95% CI −1–3%), suggesting non–inferiority of MT alone to MT plus alteplase in several respects. Another meta–analysis of 433 patients in 4 trials of tenecteplase (TNK) found that effective recanalization with TNK was increased 3.05 (95% CI 1.73–5.40) times compared to those with alteplase. TNK also reduces the time required to recanalize the occluded vessel.
Advance in antithrombotic therapy: Dabigatran did not prove efficacy over aspirin among east Asian patients with ESUS (Embolic Stroke of Undetermined Source). Sub–group analysis of CSPS.com study revealed that add–on effect of cilostazol is greater with patients treated with clopidogrel than those with aspirin. Dual antiplatelet therapy (DAPT) using cilostazol might be a potential solution to the genetic polymorphisms in CYP2C19 poor metabolizer.cover poor metabolizer. Cilostazol based DAPT is effective for non–cardioembolic ischemic stroke patients with intracranial arterial stenosis.
Blood pressure control: Hypertension is the most powerful risk factor of stroke, even for the patients with ischemic stroke. A meta–analysis of Boncorago et al. revealed that anti–hypertensive therapy reduces the risk of ischemic stroke/TIA (HR 0.79, 95%CI 0.66–0.94). A post–hoc analysis of ATACH–2 reaffirmed that the blood pressure drop should not exceed 90mmHg to avoid acute kidney injury.
New desease associated with COVID–19: It is the Thrombosis with Thrombocytopenia Syndrome (TTS). Similar to Heparin–induced Thrombocytopenia, heparin aggravates TTS. Intravenous immunoglobulin and non–heparin anticoagulants should be started as soon as possible.
