脳血管障害-研究と診療の進歩(6) : 虚血性脳血管障害急性期の血栓溶解療法と抗血栓療法

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  • ノウ ケッカン ショウガイ ケンキュウ ト シンリョウ ノ シンポ 6 キョケツセイ ノウ ケッカン ショウガイ キュウセイキ ノ ケッセン ヨウカイ リョウホウ ト コウケッセン リョウホウ
  • Cerebrovascular Disease : Recent Progress in Research and Clinical Practice (6) : Thrombolytic and Antiplatelet Therapies in Patients with Acute Ischemic Stroke

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Recent evidence and present consensus as well as the future direction of thrombolytic and antithrombotic therapies for the treatment of acute ischemic stroke were reviewed. Intravenous tissue plasminogen activator (t-PA; alteplase) has recently been approved in Japan to use in patients with ischemic stroke within 3 hours of onset. In order to improve the efficacy and maximize the safety, attempts have recently been made to select patients on the basis of perfusion/diffusion mismatch on magnetic resonance imaging, use of third generation t-PAs, and concomitant use of transcranial Doppler or clot retrieval device. Neither unfractionated heparin, low molecular weight heparin, or heparinoid has been proven to improve long-term outcome, while anticoagulant therapy appears to be indicated for the treatment of patients with atherothrombotic stroke, progressing stroke, basilar artery thrombosis, cardioembolic stroke at high risk of early recurrence, coagulopathy including antiphospholipid antibody and Trousseau's syndrome, and intracranial arterial dissection. The thrombin inhibitor argatroban is recommended for the treatment of atherothrombotic stroke within 48 hours of onset. Among antiplatelet agents, aspirin is recommended in patients with ischemic stroke within 48 hours of onset, although the long-term efficacy is modest. The thromboxane synthetase inhibitor ozagrel is also recommended in the Japanese guideline. A trial of the glycoprotein IIb/IIIa inhibitor abciximab has been discontinued because of safety concerns. Many clinical trials of dual antiplatelet therapy are ongoing in patients with acute ischemic stroke.

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