脑梗死急性期静脉溶栓与抗凝治疗的疗效对比与适应证探讨

摘要/Abstract

摘要： 目的探讨急性缺血性脑卒中（AIS）患者接受静脉溶栓（IVT）与抗凝治疗（AC）的临床结局,并分析影响功能预后和颅内出血的关键因素,以优化AIS的治疗策略。方法本研究为回顾性队列研究,纳入2018年1月至2023年12月在我院接受IVT或AC治疗的560例AIS患者。收集患者的人口学信息、卒中严重程度（NIHSS评分）、溶栓时间窗、90天功能结局（mRS评分）、颅内出血发生率及卒中复发率。采用t检验、卡方检验及Logistic回归分析评估不同治疗策略的有效性及安全性。结果功能预后,NIHSS≥5分患者中,IVT组90天良好预后（mRS 0-2）率显著高于AC组（69.1% vs 52.5%,P=0.004）;NIHSS<5分患者中,两组差异无统计学意义（P=0.541）。溶栓时间窗影响,0-1.5 h溶栓的mRS 0-2率最高（80.6%）,1.5-3 h次之（70.3%）,3-4.5 h显著下降（42.5%,P=0.009）。3-4.5 h溶栓的颅内出血风险增加（10.4%,P=0.043）。颅内出血风险,溶栓后颅内出血发生率7.9%,独立危险因素包括高龄（>75岁）、高NIHSS评分（>10）、高血压病史、既往抗血小板治疗（P<0.05）。抗凝组卒中复发率 6.4%,与房颤（P=0.002）、CHA₂DS₂-VASc评分≥4（P<0.001）、华法林INR未达标（P=0.031）显著相关。结论中重度卒中（NIHSS≥5分）患者静脉溶栓优于抗凝治疗,轻度卒中（NIHSS<5分）患者两者差异不显著,需个体化决策。超早期（0-1.5 h）溶栓获益最大,3-4.5 h溶栓疗效下降且出血风险升高,应严格筛选患者。高龄、高NIHSS评分、高血压病史及抗血小板治疗史增加颅内出血风险,需加强监测。抗凝患者卒中复发与房颤及INR控制相关,建议优化抗凝策略,优先使用新型口服抗凝药（NOACs）。

关键词: 急性缺血性脑卒中, 静脉溶栓, 抗凝治疗, 功能预后, 颅内出血, 卒中复发

石洪梅. 脑梗死急性期静脉溶栓与抗凝治疗的疗效对比与适应证探讨[J]. 心血管病防治知识, 2025, 15(12): 39-42.

参考文献

[1] 党超,卢洁,宋海庆,等. 急性脑梗死缺血半暗带临床评估和治疗中国专家共识[J]. 中国神经精神疾病杂志,2021,47(06):324-335.
[2] 黄保岗,吴昊昊,钱芳,等. 应用移动卒中单元对急性缺血性卒中行院前静脉溶栓的疗效分析[J]. 中国脑血管病杂志,2023,20(10):676-682.
[3] 张萌,马咏馨,贾琼,等. 静脉溶栓治疗急性轻型非致残性缺血性脑卒中有效性和安全性的临床观察:一项单中心回顾性观察研究[J]. 首都医科大学学报,2025,46(01):56-62.
[4] 谷亚伟,楚旭,赵路静,等. 小剂量和标准剂量rt-PA静脉溶栓治疗高龄急性缺血性脑卒中的分层研究[J]. 实用医学杂志,2024,40(11):1568-1573.
[5] 洪波,谷亚伟,王利军,等. 小剂量rt-PA静脉溶栓联合依达拉奉右莰醇治疗高龄中重度急性缺血性脑卒中的时机研究[J]. 中国慢性病预防与控制,2024,32(07):514-517.
[6] 赛俊杰,张环,韩红星,等. 发病4.5至9.0小时前循环大血管闭塞急性缺血性卒中患者行桥接治疗与直接取栓的疗效及安全性对比分析[J]. 中国脑血管病杂志,2023,20(10):649-658.
[7] 张丽燕,刘京珍,薛雯,等. 老年急性缺血性脑卒中患者静脉溶栓后出血预测及临床应用价值[J]. 中国老年学杂志,2023,43(16):3871-3874.
[8] Miyamoto S, Hayakawa M, Tsuruta W, et al.Antiplatelets before or during endovascular therapy after intravenous thrombolysis for atherothrombotic large vessel occlusion[J]. Journal of Clinical Neuroscience,2025,133:111014.
[9] Roberta N, Federico R, Alberto P, et al.Abstract WP75: Sex Differences In The Outcomes Of Intravenous Thrombolysis In Acute Ischemic Stroke Patients With Preadmission Use Of Antiplatelet Agents: A Population-based Study In The Swiss Stroke Registry[J]. Stroke,2022,53(S1):P75.
[10] Wang Y, Wei X, Du W, et al.Relationship between baseline mean platelet volume (MPV) and prognosis of patients with acute mild cerebral infarction undergoing intravenous thrombolysis with Alteplase.[J]. Pakistan journal of medical sciences,2024,40(3Part-II):318-325.
[11] Tianming S, Zheyu Z, Bo J, et al.Choice of intravenous thrombolysis therapy in patients with mild stroke complaining of acute dizziness[J]. American Journal of Emergency Medicine,2022,52:20-24.
[12] Department Of Neurology C N C U, Horten Center For Patient Oriented Research And Knowledge Transfer U O Z Z, Neurocenter S N I C, et al. Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms[J]. International Journal of Stroke,2020,15(4):429-437.
[13] 何肖君,戴雅玲,李钻芳,等. 不同溶栓时间窗rt-PA治疗急性缺血性脑卒中后神经血管功能的变化特征[J]. 中国老年学杂志,2023,43(06):1436-1441.
[14] Işık B, Ersoy A.Time Between Symptom Onset and Emergency Department Arrival and Thrombolytic Treatment Rates in Patients with Acute Ischemic Stroke[J]. Arch Basic Clin Res,2024,6(3):170-176.
[15] Qiwen D, Lei Z, Yukai L, et al.Effect of Time Window on Endovascular Thrombectomy with or without Intravenous Thrombolysis in Acute Ischemic Stroke: Results from DIRECT-MT.[J]. Cerebrovascular diseases (Basel, Switzerland),2023:1-8.
[16] Y G, H Z C, Y W H, et al.[Effect of intravenous thrombolysis with recombinant tissue type plasminogen activator (rt-PA) in different time windows on acute cerebral infarction patients with atrial fibrillation].[J]. Zhonghua yi xue za zhi,2016,96(26):2054-2058.
[17] 张静,焦文文,江文. 新型口服抗凝药预防非瓣膜性房颤发生脑卒中的研究进展[J]. 国际神经病学神经外科学杂志,2015,42(06):538-541.
[18] Mo G L, Wen J, Ye Y Y, et al.Efficacy and Safety of New Oral Anticoagulants versus Warfarin in the Resolution of Atrial Fibrillation with Left Atrial/Left Atrial Appendage Thrombus: A Systematic Review and Meta-Analysis[J]. Reviews in Cardiovascular Medicine,2025,26(1):26055.
[19] Patel P, Patel S H, Siddegowda A, et al.Effectiveness of Novel Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.[J]. Cureus,2024,16(5):e61374.