tailieunhanh - Neurological Emergencies - part 3

Làm thế nào thực tế sử dụng rộng rãi tan huyết (đặc biệt là đối với một điều kiện mà không có truyền thống được nghĩ là trường hợp khẩn cấp) vẫn còn chưa chắc chắn, mặc dù một số đơn vị đã công bố ấn tượng tái tổ hợp mô plasminogen activator | ACUTE STROKE How practicable the widespread use of thrombolysis will be particularly for a condition which has not traditionally been thought of as an emergency remains uncertain although some units have published impressive Recombinant tissue plasminogen activator r-TPA is now licensed in the United States and a European licence is likely to be granted in the near future therefore it seems reasonable to consider using r-TPA in patients presenting within three hours and who are similar to the patients included in the trials provided one has a stroke service which can ensure its safe administration Box . Our view is that further trials are required to establish the balance of risks and benefits in a broader range of patients presenting at different stages with differing severities and types of ischaemic stroke different risk factors and differing scan appearances. Many of the eligibility criteria currently in place are arbitrary and are not based on any reliable evidence. If a larger proportion of patients were eligible for treatment the potential impact on the burden of stroke would be greater and it may then be easier to justify the major changes in the delivery of acute stroke services which are required. Anticoagulants including standard unfractionated heparin low molecular weight heparins and heparinoids A systematic review comparing immediate anticoagulant therapy with control in acute ischaemic stroke including over 20 000 patients concluded that although anticoagulation started in the first day or two may reduce the risk of DVT and PE see above there were no short or long term benefits in terms of survival free of dependency79 Figure . In addition there was no evidence to support the use of anticoagulants in any specific patient category for example presumed cardioembolic stroke or vertebrobasilar stroke . The only situation in which we consider starting anticoagulation with intravenous standard unfractionated heparin is for patients with