目的 探索缺血性脑卒中患者溶栓前血压管理和预后的相关性，并分析溶栓前血压管理考虑颅内外血管状态的必要性。 方法 计算机检索PUBMED数据库，并辅以其他检索，对所有涉及溶栓前血压的文献进行整理，并根据“溶栓类型、是否进行溶栓前血压管理、是否进行溶栓前血管评估”对文献进行分类，对其溶栓后的症状性颅内出血率进行分析对比。 结果 大多数静脉溶栓文献无血管评估的数据，其出血率波动于较高水平；进行了血管评估，而未提及血压管理或虽未进行血压管理，但所有患者的血压符合指南中对于血压的要求的文献也呈现了较高的出血率；有1篇进行了血管评估的动脉溶栓文献没有症状性颅内出血事件发生。 结论 当前证据表明现有的溶栓前血压管理模式还不够完善，这也在一定程度上可以解释目前较高的溶栓后症状性出血率。合理的溶栓前血压管理模式有待进一步探索。溶栓前血压管理考虑颅内外血管状态，根据血管病变程度对溶栓前血压进行分级管理可能会成为一个较佳的血压管理模式。
Citation： ZHAO Jingjing,CHEN Ning,HE Li.. Management of Blood Pressure before Thrombolysis for Ischemic Stroke. West China Medical Journal, 2013, 28(5): 647-650. doi: 10.7507/1002-0179.20130206 Copy
| 1. | Walt G. Who’s world health report 2003[J]. BMJ, 2004, 328(7430): 6. |
| 2. | Diez-Tejedor E, Fuentes B. Acute care in stroke: The importance of early intervention to achieve better brain protection[J]. Cerebrovasc Dis, 2004, 17 (Suppl 1): 130-137. |
| 3. | Baird AE, Austin MC, McKay WJ, et al. Changes in cerebral tissue perfusion during the first 48 hours of ischaemic stroke: Relation to clinical outcome[J]. J Neurol Neurosurg Psychiatry, 1996, 61(1): 26-29. |
| 4. | Albright KC, Schott TC, Jafari N, et al. Tissue plasminogen activator use: Evaluation and initial management of ischemic stroke from an iowa hospital perspective[J]. J Stroke Cerebrovasc Dis, 2005, 14(3): 127-135. |
| 5. | Adams HP Jr, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the stroke council, american heart association[J]. Circulation, 1996, 94(5): 1167-1174. |
| 6. | Lansberg MG, Albers GW, Wijman CA. Symptomatic intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke: A review of the risk factors[J]. Cerebrovasc Dis, 2007, 24(1): 1-10. |
| 7. | Perini F, De Boni A, Marcon M, et al. Systolic blood pressure contributes to intracerebral haemorrhage after thrombolysis for ischemic stroke[J]. J Neurol Sci, 2010, 297(1-2): 52-54. |
| 8. | Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the american heart association/american stroke association stroke council, clinical cardiology council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: The american academy of neurology affirms the value of this guideline as an educational tool for neurologists[J]. Circulation, 2007, 115(20): 478-534. |
| 9. | Tsivgoulis G, Frey JL, Flaster M, et al. Pre-tissue plasminogen activator blood pressure levels and risk of symptomatic intracerebral hemorrhage[J]. Stroke, 2009, 40(11): 3631-3634. |
| 10. | Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: Pooled analysis of atlantis, ecass, and ninds rt-pa stroke trials[J]. Lancet, 2004, 363(9411): 768-774. |
| 11. | Derex L, Hermier M, Adeleine P, et al. Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator[J]. J Neurol Neurosurg Psychiatry, 2005, 76(1): 70-75. |
| 12. | Gilligan AK, Markus R, Read S, et al. Baseline blood pressure but not early computed tomography changes predicts major hemorrhage after streptokinase in acute ischemic stroke[J]. Stroke, 2002, 33(9): 2236-2242. |
| 13. | Harrington C. Managing hypertension in patients with stroke. Are you prepared for labetalol infusion?[J]. Crit Care Nurse, 2003, 23(3): 30-38. |
| 14. | Strandgaard S, Paulson OB. Cerebral autoregulation[J]. Stroke, 1984, 15(3): 413-416. |
| 15. | Brott T, Lu M, Kothari R, et al. Hypertension and its treatment in the ninds rt-pa stroke trial[J]. Stroke, 1998, 29(8): 1504-1509. |
| 16. | Martin-Schild S, Hallevi H, Albright KC, et al. Aggressive blood pressure-lowering treatment before intravenous tissue plasminogen activator therapy in acute ischemic stroke[J]. Arch Neurol, 2008, 65(9): 1174-1178. |
| 17. | Ahmed N, Wahlgren N, Brainin M, et al. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from safe implementation of thrombolysis in stroke-international stroke thrombolysis register (sits-istr) [J]. Stroke, 2009, 40(7): 2442-2449. |
| 18. | Dharmasaroja PA, Dharmasaroja P, Muengtaweepongsa S. Outcomes of thai patients with acute ischemic stroke after intravenous thrombolysis[J]. J Neurol Sci, 2011, 300(1-2): 74-77. |
| 19. | Lindsberg PJ, Soinne L, Roine RO, et al. Community-based thrombolytic therapy of acute ischemic stroke in helsinki[J]. Stroke, 2003, 34(6): 1443-1449. |
| 20. | Alexandrov AV, Demchuk AM, Felberg RA, et al. High rate of complete recanalization and dramatic clinical recovery during tpa infusion when continuously monitored with 2-mhz transcranial doppler monitoring[J]. Stroke, 2000, 31(3): 610-614. |
| 21. | Linfante I, Llinas RH, Selim M, et al. Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator[J]. Stroke, 2002, 33(8):2066-2071. |
| 22. | Molina CA, Alexandrov AV, Demchuk AM, et al. Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator[J]. Stroke, 2004, 35(1): 151-156. |
| 23. | Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial doppler predicts the response to intravenous thrombolysis for stroke[J]. Stroke, 2007, 38(3): 948-954. |
| 24. | Delgado-Mederos R, Ribo M, Rovira A, et al. Prognostic significance of blood pressure variability after thrombolysis in acute stroke[J]. Neurology, 2008, 71(8): 552-558. |
| 25. | Molina CA, Barreto AD, Tsivgoulis G, et al. Transcranial ultrasound in clinical sonothrombolysis (tucson) trial[J]. Ann Neurol, 2009, 66(1): 28-38. |
| 26. | Ibrahim MM, Sebastian J, Hussain M, et al. Does current oral antiplatelet agent or subtherapeutic anticoagulation use have an effect on tissue-plasminogen-activator-mediated recanalization rate in patients with acute ischemic stroke?[J]. Cerebrovasc Dis, 2010, 30(5): 508-513. |
| 27. | Delgado MG, Michel P, Naves M, et al. Early profiles of clinical evolution after intravenous thrombolysis in an unselected stroke population[J]. J Neurol Neurosurg Psychiatry, 2010, 81(3): 282-285. |
| 28. | Saqqur M, Tsivgoulis G, Molina CA, et al. Symptomatic intracerebral hemorrhage and recanalization after iv rt-pa: A multicenter study[J]. Neurology, 2008, 71(17): 1304-1312. |
| 29. | Selim M, Fink JN, Kumar S, et al. Predictors of hemorrhagic transformation after intravenous recombinant tissue plasminogen activator: Prognostic value of the initial apparent diffusion coefficient and diffusion-weighted lesion volume[J]. Stroke, 2002, 33(8): 2047-2052. |
| 30. | Christou I, Alexandrov AV, Burgin WS, et al. Timing of recanalization after tissue plasminogen activator therapy determined by transcranial doppler correlates with clinical recovery from ischemic stroke[J]. Stroke, 2000, 31(8): 1812-1816. |
| 31. | Tsivgoulis G, Saqqur M, Sharma VK, et al. Association of pretreatment blood pressure with tissue plasminogen activator-induced arterial recanalization in acute ischemic stroke[J]. Stroke, 2007, 38(3): 961-966. |
| 32. | Takada T, Yasaka M, Minematsu K, et al. Predictors of clinical outcome in patients receiving local intra-arterial thrombolysis without subsequent symptomatic intracranial hemorrhage against acute middle cerebral artery occlusion[J]. AJNR Am J Neuroradiol, 2004, 25(10): 1796-1801. |
| 33. | Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke[J]. N Engl J Med, 2004, 351(21): 2170-2178. |
| 34. | Latchaw RE, Alberts MJ, Lev MH, et al. Recommendations for imaging of acute ischemic stroke: A scientific statement from the american heart association[J]. Stroke, 2009, 40(11): 3646-3678. |
| 35. | Alexandrov AV, Demchuk AM, Wein TH, et al. Yield of transcranial doppler in acute cerebral ischemia[J]. Stroke, 1999, 30(8): 1604-1609. |
| 36. | Chernyshev OY, Garami Z, Calleja S, et al. Yield and accuracy of urgent combined carotid/transcranial ultrasound testing in acute cerebral ischemia[J]. Stroke, 2005, 36(1): 32-37. |
- 1. Walt G. Who’s world health report 2003[J]. BMJ, 2004, 328(7430): 6.
- 2. Diez-Tejedor E, Fuentes B. Acute care in stroke: The importance of early intervention to achieve better brain protection[J]. Cerebrovasc Dis, 2004, 17 (Suppl 1): 130-137.
- 3. Baird AE, Austin MC, McKay WJ, et al. Changes in cerebral tissue perfusion during the first 48 hours of ischaemic stroke: Relation to clinical outcome[J]. J Neurol Neurosurg Psychiatry, 1996, 61(1): 26-29.
- 4. Albright KC, Schott TC, Jafari N, et al. Tissue plasminogen activator use: Evaluation and initial management of ischemic stroke from an iowa hospital perspective[J]. J Stroke Cerebrovasc Dis, 2005, 14(3): 127-135.
- 5. Adams HP Jr, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the stroke council, american heart association[J]. Circulation, 1996, 94(5): 1167-1174.
- 6. Lansberg MG, Albers GW, Wijman CA. Symptomatic intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke: A review of the risk factors[J]. Cerebrovasc Dis, 2007, 24(1): 1-10.
- 7. Perini F, De Boni A, Marcon M, et al. Systolic blood pressure contributes to intracerebral haemorrhage after thrombolysis for ischemic stroke[J]. J Neurol Sci, 2010, 297(1-2): 52-54.
- 8. Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the american heart association/american stroke association stroke council, clinical cardiology council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: The american academy of neurology affirms the value of this guideline as an educational tool for neurologists[J]. Circulation, 2007, 115(20): 478-534.
- 9. Tsivgoulis G, Frey JL, Flaster M, et al. Pre-tissue plasminogen activator blood pressure levels and risk of symptomatic intracerebral hemorrhage[J]. Stroke, 2009, 40(11): 3631-3634.
- 10. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: Pooled analysis of atlantis, ecass, and ninds rt-pa stroke trials[J]. Lancet, 2004, 363(9411): 768-774.
- 11. Derex L, Hermier M, Adeleine P, et al. Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator[J]. J Neurol Neurosurg Psychiatry, 2005, 76(1): 70-75.
- 12. Gilligan AK, Markus R, Read S, et al. Baseline blood pressure but not early computed tomography changes predicts major hemorrhage after streptokinase in acute ischemic stroke[J]. Stroke, 2002, 33(9): 2236-2242.
- 13. Harrington C. Managing hypertension in patients with stroke. Are you prepared for labetalol infusion?[J]. Crit Care Nurse, 2003, 23(3): 30-38.
- 14. Strandgaard S, Paulson OB. Cerebral autoregulation[J]. Stroke, 1984, 15(3): 413-416.
- 15. Brott T, Lu M, Kothari R, et al. Hypertension and its treatment in the ninds rt-pa stroke trial[J]. Stroke, 1998, 29(8): 1504-1509.
- 16. Martin-Schild S, Hallevi H, Albright KC, et al. Aggressive blood pressure-lowering treatment before intravenous tissue plasminogen activator therapy in acute ischemic stroke[J]. Arch Neurol, 2008, 65(9): 1174-1178.
- 17. Ahmed N, Wahlgren N, Brainin M, et al. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from safe implementation of thrombolysis in stroke-international stroke thrombolysis register (sits-istr) [J]. Stroke, 2009, 40(7): 2442-2449.
- 18. Dharmasaroja PA, Dharmasaroja P, Muengtaweepongsa S. Outcomes of thai patients with acute ischemic stroke after intravenous thrombolysis[J]. J Neurol Sci, 2011, 300(1-2): 74-77.
- 19. Lindsberg PJ, Soinne L, Roine RO, et al. Community-based thrombolytic therapy of acute ischemic stroke in helsinki[J]. Stroke, 2003, 34(6): 1443-1449.
- 20. Alexandrov AV, Demchuk AM, Felberg RA, et al. High rate of complete recanalization and dramatic clinical recovery during tpa infusion when continuously monitored with 2-mhz transcranial doppler monitoring[J]. Stroke, 2000, 31(3): 610-614.
- 21. Linfante I, Llinas RH, Selim M, et al. Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator[J]. Stroke, 2002, 33(8):2066-2071.
- 22. Molina CA, Alexandrov AV, Demchuk AM, et al. Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator[J]. Stroke, 2004, 35(1): 151-156.
- 23. Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial doppler predicts the response to intravenous thrombolysis for stroke[J]. Stroke, 2007, 38(3): 948-954.
- 24. Delgado-Mederos R, Ribo M, Rovira A, et al. Prognostic significance of blood pressure variability after thrombolysis in acute stroke[J]. Neurology, 2008, 71(8): 552-558.
- 25. Molina CA, Barreto AD, Tsivgoulis G, et al. Transcranial ultrasound in clinical sonothrombolysis (tucson) trial[J]. Ann Neurol, 2009, 66(1): 28-38.
- 26. Ibrahim MM, Sebastian J, Hussain M, et al. Does current oral antiplatelet agent or subtherapeutic anticoagulation use have an effect on tissue-plasminogen-activator-mediated recanalization rate in patients with acute ischemic stroke?[J]. Cerebrovasc Dis, 2010, 30(5): 508-513.
- 27. Delgado MG, Michel P, Naves M, et al. Early profiles of clinical evolution after intravenous thrombolysis in an unselected stroke population[J]. J Neurol Neurosurg Psychiatry, 2010, 81(3): 282-285.
- 28. Saqqur M, Tsivgoulis G, Molina CA, et al. Symptomatic intracerebral hemorrhage and recanalization after iv rt-pa: A multicenter study[J]. Neurology, 2008, 71(17): 1304-1312.
- 29. Selim M, Fink JN, Kumar S, et al. Predictors of hemorrhagic transformation after intravenous recombinant tissue plasminogen activator: Prognostic value of the initial apparent diffusion coefficient and diffusion-weighted lesion volume[J]. Stroke, 2002, 33(8): 2047-2052.
- 30. Christou I, Alexandrov AV, Burgin WS, et al. Timing of recanalization after tissue plasminogen activator therapy determined by transcranial doppler correlates with clinical recovery from ischemic stroke[J]. Stroke, 2000, 31(8): 1812-1816.
- 31. Tsivgoulis G, Saqqur M, Sharma VK, et al. Association of pretreatment blood pressure with tissue plasminogen activator-induced arterial recanalization in acute ischemic stroke[J]. Stroke, 2007, 38(3): 961-966.
- 32. Takada T, Yasaka M, Minematsu K, et al. Predictors of clinical outcome in patients receiving local intra-arterial thrombolysis without subsequent symptomatic intracranial hemorrhage against acute middle cerebral artery occlusion[J]. AJNR Am J Neuroradiol, 2004, 25(10): 1796-1801.
- 33. Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke[J]. N Engl J Med, 2004, 351(21): 2170-2178.
- 34. Latchaw RE, Alberts MJ, Lev MH, et al. Recommendations for imaging of acute ischemic stroke: A scientific statement from the american heart association[J]. Stroke, 2009, 40(11): 3646-3678.
- 35. Alexandrov AV, Demchuk AM, Wein TH, et al. Yield of transcranial doppler in acute cerebral ischemia[J]. Stroke, 1999, 30(8): 1604-1609.
- 36. Chernyshev OY, Garami Z, Calleja S, et al. Yield and accuracy of urgent combined carotid/transcranial ultrasound testing in acute cerebral ischemia[J]. Stroke, 2005, 36(1): 32-37.