特集 神経疾患治療の進歩2024
脳血管障害の治療の進歩
キーワード:
acute ischemic stroke,
intravenous thrombolysis,
endovascular therapy,
direct oral anticoagulant,
intracerebral hemorrhage
2025 年 42 巻 5 号 p. 793-798
詳細
2025 年 42 巻 5 号 p. 793-798
Therapies for cerebrovascular disease evolved rapidly in 2024–2025 across intravenous thrombolysis (IVT), endovascular therapy (EVT), adjunctive pharmacology, and minimally invasive surgery for intracerebral hemorrhage (ICH).
Advance in acute reperfusion therapy : Within 4.5 hours of acute ischemic stroke onset, several trials and an updated meta–analysis support tenecteplase 0.25 mg/kg as noninferior to (and in aggregate marginally favorable over) alteplase 0.9 mg/kg for functional outcomes, with comparable symptomatic intracranial hemorrhage and mortality. Beyond 4.5 hours in large–vessel occlusion (LVO), imaging–selected tenecteplase IVT did not improve 90–day disability, and adding IVT to EVT failed to show benefit ; however, in settings without EVT access, IVT improved functional independence, suggesting context–dependent utility. TEMPO–2 showed no benefit for IVT in minor stroke (NIHSS ≤ 5) with proven occlusion, discouraging routine use in this subgroup. EVT indications continued to broaden. Pooled randomized data in large–core infarction and basilar artery occlusion demonstrated better functional outcomes and lower mortality versus medical therapy. Post–reperfusion management is pivotal. Across four RCTs, more intensive blood–pressure targets after successful EVT did not improve outcomes and were associated with lower odds of achieving mRS 0–2, while symptomatic hemorrhage and mortality were similar.
Advance in antithrombotic therapy : Adjunctive argatroban or eptifibatide with IVT (MOST) was neutral for disability and associated with higher mortality ; dual antiplatelet therapy reduced early neurologic deterioration in moderate noncardioembolic stroke (ATAMIS) without 90–day benefit ; conversely, argatroban improved outcomes in patients with early neurologic worsening (EASE). For secondary prevention in non–valvular atrial fibrillation, early direct oral anticoagulant initiation (≤4 days) was noninferior to delayed initiation, and effects were not modified by infarct size, supporting routine early start ; apixaban was not superior to aspirin for cryptogenic stroke with atrial cardiopathy.
Advance in ICH : A contemporary randomized trial (ENRICH) showed that early minimally invasive endoscopic evacuation improved 6–month disability and reduced 30–day mortality in selected cortical hematomas, marking a rare positive advance in hemorrhagic stroke care.
