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中华脑血管病杂志(电子版)

中华脑血管病杂志(电子版) ›› 2024, Vol. 18 ›› Issue (01) : 71 -80. doi: 10.11817/j.issn.1673-9248.2024.01.012

综述

急性缺血性卒中再灌注治疗后出血转化的研究进展
梁文雯1, 李征2, 万敏2, 骆佳莹1, 贾伟华1,†()   
  1. 1. 261053　山东潍坊，潍坊医学院临床医学院;100043　北京，首都医科大学石景山教学医院　北京市石景山医院神经内科
    2. 100043　北京，首都医科大学石景山教学医院　北京市石景山医院神经内科
  • 收稿日期:2023-08-16 出版日期:2024-02-01
  • 通信作者: 贾伟华
  • 基金资助:
    北京市石景山医院2019级院级科研项目(sjsky-201901)

Research progress on hemorrhagic transformation after reperfusion therapy for acute ischemic stroke

Wenwen Liang1, Zheng Li2, Min Wan2, Jiaying Luo1, Weihua Jia1,†()   

  1. 1. School of Clinical Medicine, Weifang Medical College, Weifang 261053, China;Department of Neurology, Shijingshan Teaching Hosptial of Capital Medical University, Beijing Shijingshan Hosptial, Beijing 100043, China
    2. Department of Neurology, Shijingshan Teaching Hosptial of Capital Medical University, Beijing Shijingshan Hosptial, Beijing 100043, China
  • Received:2023-08-16 Published:2024-02-01
  • Corresponding author: Weihua Jia
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梁文雯, 李征, 万敏, 骆佳莹, 贾伟华. 急性缺血性卒中再灌注治疗后出血转化的研究进展[J]. 中华脑血管病杂志(电子版), 2024, 18(01): 71-80.

Wenwen Liang, Zheng Li, Min Wan, Jiaying Luo, Weihua Jia. Research progress on hemorrhagic transformation after reperfusion therapy for acute ischemic stroke[J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2024, 18(01): 71-80.

急性缺血性脑卒中（AIS）采取再灌注治疗后，引起出血转化（HT）的情况虽不常见，但严重影响患者预后和神经功能恢复。目前研究较多的HT机制包括缺血损伤、缺血再灌注、阿替普酶带来的凝血功能异常及血-脑屏障破坏。通过认识临床危险因素和应用预测模型及多模态影像学检查等手段可以实现对HT的早期发现和早期预防。未来使用新型溶栓药物及新研发的脑保护剂有望进一步控制HT转化率和改善患者预后。本综述总结HT的分类、病理生理学机制、危险因素、预测因子和预测模型，以及相应治疗，以及时发现，更好预防，同时针对性地给予个体化治疗，尽可能降低严重并发症的危害，提高AIS患者再灌注治疗后血管再通获益率及降低神经功能损害，促进预后。

关键词: 急性缺血性卒中, 再灌注治疗, 出血转化, 机制

After reperfusion therapy for acute ischemic stroke (AIS), the hemorrhagic transformation caused by reperfusion is uncommon, but it seriously affects the prognosis and neurological recovery of the patients. At present, the mechanisms of bleeding transformation that have been extensively studied include ischemia injury, ischemia reperfusion, coagulation dysfunction caused by Alteplase (rt-PA), and destruction of blood-brain barrier. The early detection and prevention of hemorrhagic transformation (HT) can be achieved through recognizing clinical risk factors and applying predictive models and multimodal imaging. Future use of novel thrombolytic drugs and newly developed brain protectants is expected to control HT conversion further and improve patients' outcomes. This review summarizes the classification, pathophysiological mechanisms, risk factors, predictors and predictive models, and corresponding treatment of HT, for timely recognizing and prevention, and at the same time, individualized treatment should be given to reduce the harm of serious complications as far as possible, and improve the benefit rate of vascular recanalization in AIS patients after reperfusion therapy and reduce the neurological function damage to promote the prognosis.

Key words: Acute ischemic stroke, Reperfusion therapy, Hemorrhagic transformation, Mechanism
表1 溶栓后脑HT的常用影像学分类系统
分类系统 内容
NINDS HI：头颅CT见急性梗死灶内的点状或边界模糊的不同的低密度/高密度病灶；
PH：头颅CT见典型的同质的边界清楚的高密度病变，伴/不伴脑水肿或占位效应
ECASS HI-1：沿梗死灶边缘小点状出血；
HI-2：梗死区内片状无占位效应出血或多个融合的点状出血；
PH-1：血肿低于梗死面积的30%并有轻微占位效应的出血；
PH-2：血肿超过梗死面积的30%并有明显占位效应的出血或远离梗死灶的出血
HBC 1a HI-1：沿梗死灶边缘小点状出血，无占位效应；
1b HI-2：梗死区内片状无占位效应出血或多个融合的点状出血，无占位效应；
1c PH-1：血肿低于梗死面积的30%并有轻微占位效应的出血；
2：血肿超过梗死面积的30%，有明显占位效应；
3a：远离脑梗死区域的脑实质出血；
3b：脑室内出血；
3c：蛛网膜下出血；
3d：硬膜下出血
表2 溶栓后HT的临床生物学差异
临床指标 HI PH rICH
基线临床严重程度 是 否 未知
早期CT发现 是 否* 未知
90 d时的转归 否 是 未知
rt-PA 否 是 可能
预先使用阿司匹林 否 是 未知
早期FDP凝血功能异常 否 是 未知
早期血管再通治疗 早期治疗 延迟治疗 未知
潜在主要因素 缺血 溶栓 CAA
临床转归 良好：减少梗死体积 不良：增加梗死范围 不良
预防 否 是：检测凝血、血常规 是
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