急性缺血性卒中延迟治疗窗内的溶栓治疗：更新版系统综述与荟萃分析
结果显示静脉溶栓改善90天极佳功能预后和功能独立，增加症状性颅内出血风险，但未显著影响90天死亡率。
要点
- 影像筛选下超4.5小时溶栓可改善90天功能预后（RR 1.22）
- 溶栓增加症状性颅内出血风险（RR 2.58），但90天死亡率无显著差异
- 支持基于组织窗而非严格时间窗的溶栓决策
核心结论
- 在经高级影像筛选的患者中，4.5小时后静脉溶栓改善功能预后且不增加死亡率，支持基于组织而非严格基于时间的急性缺血性卒中治疗策略。
研究设计与样本
- 按照PRISMA指南进行的系统综述与荟萃分析，检索PubMed、Embase和Cochrane Central至2026年2月。
- 比较静脉溶栓（阿替普酶或替奈普酶）与最佳药物治疗。
主要发现
- 静脉溶栓改善90天极佳功能预后（mRS 0-1；RR 1.22 [95% CI, 1.16-1.29]）。
- 静脉溶栓改善功能独立（mRS 0-2；RR 1.12 [95% CI, 1.06-1.18]）。
- 阿替普酶和替奈普酶均有助于这些获益。
- 溶栓增加症状性颅内出血风险（RR 2.58 [95% CI, 1.58-4.22]）。
- 溶栓未显著影响90天死亡率（RR 1.15 [95% CI, 0.97-1.35]）。
临床怎么用
- 对经影像筛选、发病超过4.5小时或醒后/未知发病的急性缺血性卒中患者，可考虑静脉溶栓以改善功能预后。
- 决策时需权衡功能获益与症状性颅内出血风险增加。
- 支持采用基于组织窗的评估策略而非单纯依赖时间窗。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
BACKGROUND: Intravenous thrombolysis is a standard treatment for acute ischemic stroke but has traditionally been limited to 4.5 hours after symptom onset. This time-based restriction may exclude patients with salvageable brain tissue, especially those with wake-up or unknown-onset strokes. Multimodal imaging allows for the identification of viable penumbra beyond traditional treatment windows. This study compiles randomized evidence evaluating intravenous thrombolysis in imaging-selected patients treated after 4.5 hours.
METHODS: We conducted a systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and Cochrane Central were searched through February 2026 for randomized trials comparing intravenous thrombolysis (alteplase or tenecteplase) with best medical therapy in patients presenting beyond 4.5 hours or with wake-up/unknown-onset stroke selected by imaging. The primary outcome was excellent functional outcome at 90 days (modified Rankin Scale score 0-1). Secondary outcomes included functional independence (modified Rankin Scale score 0-2), symptomatic intracranial hemorrhage, and 90-day mortality.
RESULTS: Fourteen trials involving 4192 participants were analyzed. Intravenous thrombolysis improved excellent functional outcomes (modified Rankin Scale score 0-1; risk ratio, 1.22 [95% CI, 1.16-1.29]) and functional independence (modified Rankin Scale score 0-2; risk ratio, 1.12 [95% CI, 1.06-1.18]). Both alteplase and tenecteplase contributed to these benefits. Thrombolysis increased the risk of symptomatic intracranial hemorrhage (risk ratio, 2.58 [95% CI, 1.58-4.22]) but did not significantly affect 90-day mortality (risk ratio, 1.15 [95% CI, 0.97-1.35]).
CONCLUSIONS: In patients selected using advanced imaging, intravenous thrombolysis performed after 4.5 hours improves functional outcomes without increasing mortality, supporting a tissue-based rather than strictly time-based approach to treating acute ischemic stroke.
引用
- Pitchan Velammal, Dhasakeerthi, Manzoori, et al. Thrombolysis in the Delayed Treatment Window for Acute Ischemic Stroke: Updated Systematic Review and Meta-Analysis. Stroke. 2026. PMID: 42866880. doi:10.1161/STROKEAHA.126.058069
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。