急性缺血性卒中后3个月内重复静脉溶栓的安全性和有效性：一项系统评价和个体患者数据荟萃分析。
完整摘要 · 中文译文
背景：当前卒中指南认为，既往3个月内发生过急性缺血性卒中（AIS）是静脉溶栓（IVT）的相对禁忌证，因为认为存在症状性颅内出血（sICH）的风险。该推荐主要基于专家共识，而越来越多的证据表明，在特定患者中重复静脉溶栓（RIVT）可能是可行的。 目的：系统评价既往接受过IVT治疗的卒中后90天内复发性AIS患者接受RIVT的有效性和安全性。 结果：我们进行了一项系统评价和个体患者数据荟萃分析，纳入28篇报告（63例患者），其中44例有个体患者数据可用。总体而言，66.7%的患者获得了良好结局，两次治疗间隔中位时间为7.5天。荟萃分析显示，RIVT后功能结局有更好的非显著性趋势（合并OR = 1.52, 95% CI 0.97-2.39; I2 = 0%），且卒中发作间功能恶化未见显著增加（合并OR = 1.28, 95% CI 0.75-2.19; I2 = 0%）。结局不受治疗间隔、年龄、性别、卒中病因、血管区域或发病至治疗时间的影响。RIVT后未发生sICH。15.9%的患者报告了无症状性颅内或全身出血，而致死性事件（5%）与神经系统并发症无关。出血和致死性事件主要发生在心源性栓塞和更严重卒中的患者中。 结论：90天内的RIVT是罕见事件，其疗效研究不足。在精心选择的复发性急性缺血性卒中患者中，它可能是一种合理的再灌注策略，提示既往卒中的间隔时间不应被视为IVT的孤立排除标准。
完整摘要 · 英文原文
BACKGROUND: Current stroke guidelines consider a previous acute ischemic stroke (AIS) within 3 months a relative contraindication to intravenous thrombolysis (IVT) because of the perceived risk of symptomatic intracranial haemorrhage (sICH). The recommendation is largely based on expert consensus, while growing evidence suggests repeated IVT (RIVT) may be feasible in selected patients. AIMS: To systematically review the efficacy and safety of RIVT for recurrent AIS within 90 days of a previous IVT-treated stroke. RESULTS: We performed a systematic review and individual-patient data meta-analysis, including 28 reports (63 patients), with individual patient data available for 44 cases. Overall, 66.7% of patients achieved a favorable outcome, with a 7.5 days median interval between treatments. Meta-analysis showed a non-significant trend toward better functional outcomes after RIVT (pooled OR = 1.52, 95% CI 0.97-2.39; I2 = 0%) and no significant increase in functional deterioration between stroke episodes (pooled OR = 1.28, 95% CI 0.75-2.19; I2 = 0%). Outcomes were not influenced by treatment interval, age, sex, stroke etiology, vascular territory, or onset-to-treatment time. No sICH occurred after RIVT. Asymptomatic intracranial or systemic haemorrhages were reported in 15.9% of patients, while fatal events (5%) were unrelated to neurological complications. Haemorrhagic and fatal events occurred predominantly in patients with cardioembolic and more severe strokes. CONCLUSIONS: RIVT within 90 days is a rare event and its efficacy is understudied. It may be a reasonable reperfusion strategy in carefully selected patients with recurrent AIS, suggesting that the interval from the previous stroke should not be considered an isolated exclusion criterion for IVT.