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Large vessel occlusions (Crtical stroke) are the most likely to benefit from thrombectomy
ICA, MCA, and some ACA occlusions
目前健保給付規定 :
(1) 前循環在發作後 8小時內, 後循環在發作後 24小時內 (時間為 Puncture 時間)
(2) 影像診斷為顱內大動脈阻塞，包括 ICA, MCA (M1, M2), ACA, BA, VA
(3) NIHHS ≧ 8 and ≦ 30
萬芳基本不做 ACA, VA = 難以 Approach + NIHSS 通常 < 8
禁忌症：
(1) 蜘蛛網膜下腔出血
(2) 腦內出血
(3) 硬腦膜下出血/顱內出血
教科書 :
還寫到必須打過 tPA
If a patient is a possible candidate for endovascular therapy, vascular imaging (typically CT angiography of the head and neck)
is recommended concurrently with the initial head CT; however, these additional studies should not delay thrombolytic administration.
其實是建議在不會延遲 TPA 的前提下, 和一開始的 CT 一起直接做完
美國中風學會於 2015年6月更新了急性缺血性腦中風的治療指引, 重點包括 :
(1) 適合 IV rt-PA 個案, 即便符合經動脈血管內治療的治療條件
也應該優先接受 IV rt-PA 治療, 且應該越快越好
(2) 最建議經動脈血管內進行取栓治療的病人
應符合中風前日常生活功能不需倚賴他人照顧
與中風症狀相關的內頸動脈或者近端中大腦動脈阻塞
中度以上的中風嚴重程度 (NIHSS 8-30)
電腦斷層影像 ASPECT 分數 ≥ 6
發病 6 小時內開始經動脈血管內治療等條件
(3) 有 IV rt-PA 禁忌如中風發作症狀 > 4.5 小時
過去有腦出血病史, 正在服用新型抗凝血劑
或者阻塞位置非頸動脈或近端中大腦動脈的其他大血管中風個案如後腦循環個案等
如為發病 6 小時內且符合其他經動脈血管內治療治療條件
仍可考慮進行經動脈血管內治療
- Symptom onset to needle time
- Type of stroke, NIHSS or VAN tool
- CT, CTA and CT perfusion results
- Contraindications to tPA/thrombectomy
NIHSS ≥ 6 or VAN positive to predict cortical stroke
VAN :
Patient must have weakness plus one or all of the V, A, or N to be VAN positive.
Step 1 : Weakness
Weakness – ask the patient to raise both arms up for 10 seconds
and assess for drift, weakness or paralysis;
if any of these are present proceed to step 2
Step 2 : V or A or N
Visual disturbance – Field cut, Diplopia or Blindness
Aphasia – Expressive (repeat and name 2 objects)
or receptive (unable to follow commands – close eyes or make a fist)
Neglect – Inability to track to one side, ignoring one side,
unable to feel both sides at the same time or unable to identify own arm
Large vessel signs :
Frontal :
- Weakness disproportion
- Apathy
- Disinhibition
- Execute dysfunction
- Eye deviation
Temporal :
- Aphasia
- Hemianopia
- Weakness disproportion
Parietal :
- Hemineglect
- Hight cortical function
- Visual spatial
Occipital :
- Hemianopia
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