4. Hakan AY. Curr Neurol Neurosci Rep. 2010;10:14–20;
Andersen KK, et al. Stroke 2009;40:2068–2072
Lancet Neurol . 2014 Apr;13(4):429-38.
National Institutes of Health. National Heart Lung and Blood Institute. Stroke types. October 2015;
Stroke
Hemorrhagic
(<20% of all strokes)
Intracerebral
Ischemic
(>80% of all strokes)
Subarachnoid
Cardio-
embolic
Small
vessel
Specific
cause
Crypto-
genic
Large
artery
5. Stroke Subtype in Taiwan
Taiwan Stroke Registration
Ischemic stroke (81%)Hemorrhagic stroke
(19%)
Atherothrombotic
disease (28%)
Cardiac Embolism (11%)
Lacunar small vessel
disease (38%)
Cryptogenic (22%)
Intracerebral
hemorrhage (16.2%)
SAH (2.8%)
Specific causes(1.5%)Hsieh, F. I., & Chiou, H. Y. (2014) J Stroke, 16(2),
59-64. doi:10.5853/jos.2014.16.2.59
5
7. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
7
19. Lees et al. Lancet 2010;375:1695-1703.
5
60 120 150 210 240 300 330
0
1
2
3
4
Odds ratio (OR)
Oddsratioand95%CI
OR
2.55
OR
1.64
OR
1.34
270 36018090
NNT, Number needed to treat
OTT, Time from stroke onset to start of treatment
mRS, modified Rankin Scale
OTT (min)
NNT
4-5
NNT
9
NNT
14
23. MRI-Guided Thrombolysis for Stroke with Unknown
Time of Onset (WAKE-UP study):
◦ 時間窗: 睡醒時發現中風、不知道或無法告知中風時間,
從最近仍呈現正常時間點起算到評估時間差 >4.5 小時
◦ Advanced neuroimage:
MRI: diffusion-weighted image(DWI) and FLAIR mismatch
◦ Result:
Good outcome (mRS 0-1, 90 days): 53.3% vs 41.8% (OR 1.61)
Symptomatic ICH: 2% vs 0.4% (p 0.15)
Mortality: 4.1% vs 1.2% (p 0.07)
24
24. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
25
34. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
35
37. 中風後多久可進行EVT ?
MR CLEAN ESCAPE EXTEND-IA
SWIFT
PRIME
REVASCAT
Population AIS with LVO AIS with LVO AIS with LVO AIS with LVO AIS with LVO
Design
Standard vs
S+EV
Standard vs
S+EV
IV tPA vs
IVtPA+Solitare
IV tPA vs
IVtPA+Solitare
Standard vs
S+Solitare
NIHSS >2 ≧6 No limits 8-29 ≧6
ASPECT score No ≧6 No ≧6 ≧6, ≧7, ≧8
Ischemic
core, ml
<70
Penumbra V V
Collateral cir. >50% MCA
Time (hr.) 6
12
(84% <6 h)
6 6
8
(90% <6h) 38
38. 中風臨床嚴重度(NIHSS分數)
MR CLEAN ESCAPE EXTEND-IA
SWIFT
PRIME
REVASCAT
Population AIS with LVO AIS with LVO AIS with LVO AIS with LVO AIS with LVO
Design
Standard vs
S+EV
Standard vs
S+EV
IV tPA vs
IVtPA+Solitare
IV tPA vs
IVtPA+Solitare
Standard vs
S+Solitare
NIHSS >2 ≧6 No limits 8-29 ≧6
ASPECT score No ≧6 No ≧6 ≧6, ≧7, ≧8
Ischemic
core, ml
<70
Penumbra V V
Collateral cir. >50% MCA
Time (hr.) 6
12
(84% <6 h)
6 6
8
(90% <6h) 39
39. 中風後，Infarction core
MR CLEAN ESCAPE EXTEND-IA
SWIFT
PRIME
REVASCAT
Population AIS with LVO AIS with LVO AIS with LVO AIS with LVO AIS with LVO
Design
Standard vs
S+EV
Standard vs
S+EV
IV tPA vs
IVtPA+Solitare
IV tPA vs
IVtPA+Solitare
Standard vs
S+Solitare
NIHSS >2 ≧6 No limits 8-29 ≧6
ASPECT score No ≧6 No ≧6 ≧6, ≧7, ≧8
Ischemic
core, ml
<70
Penumbra V V
Collateral cir. >50% MCA
Time (hr.) 6
12
(84% <6 h)
6 6
8
(90% <6h) 40
42. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
43
43. AHA/ASA 2018 Guideline建議 (Class I, Level A)
◦ (1) Causative occlusion of ICA or MCA segment 1
(M1)
◦ (2) Prestroke mRS score:0-1
◦ (3) Age ≥18 years
◦ (4) Treatment within 6 hours of symptom onset.
(groin puncture)
◦ (5) NIHSS score ≥6
◦ (6) (Brain CT) ASPECTS ≥6
44
47. 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke
2015 AHA/ASA Focused Update of the 2013 Guidelines for the
Early Management of Patients With Acute Ischemic Stroke
Regarding Endovascular Treatment
2015 Scientific Rationale for the Inclusion and Exclusion
Criteria for Intravenous Alteplase in Acute Ischemic Stroke
48
59. Airway, Breathing and Oxygenation
Airway support and ventilatory assistance are recommended
for the treatment of patients with acute stroke who have
decreased consciousness or who have bulbar dysfunction
that causes compromise of the airway. (class I, level C-EO)
Supplemental oxygen is not recommended in nonhypoxic
patients with AIS. (class III: no benefit, level B-R)
Supplemental oxygen should be provided to maintain oxygen
saturation >94%. (class I, level C-LD)
60
62. Blood sugar(血糖)
Hypoglycermia:
• Hypoglycemia (blood glucose <60 mg/dL) should be treated in
patients with AIS. (class I, level C-LD)
Hyperglycerima:
• 40-70%急性中風患者會出現血糖上升的情況(>110mg/dl)，此
現象可能是糖尿病(已知或先前未被診斷)或是急性中風之壓
力所引起。
• 不論先前是否有糖尿病，急性期血糖的上升可能導致較差的
預後，增加中風後的死亡率，且 對於日後的功能恢復也較差。
64
63. Blood sugar(血糖)
Hyperglycerima:
• 2014年Cochrane整合分析研究發現無法證明以靜脈注射胰島
素嚴格控制血糖可帶來較好的預後，反而有較高風險出現低
血糖事件。
• It is reasonable to treat hyperglycemia to achieve blood glucose
levels in a range of 140 to 180 mg/dL and to closely monitor to
prevent hypoglycemia. (class IIa, Level C-LD)
Cochrane Database Syst Rev. 2014 Jan 23
• 2019 SHINE study: Intense iv glucose control does
not improve functional stroke outcomes.
• 80-130mg/dl(intensive) vs 80-179mg/dl(standard)
• Good outcome: 20.5% vs 21.6%
• Severe Hypoglycermia: 15 vs 0
65
66. 結論及建議：
◦ Ticagrelor is not recommended (over aspirin) in the
acute ischemic stroke. (Class III, no benefit)
SOCRATES trial(2016):
Ticagrelor vs Aspirin within 24 hr after minor stroke(NIHSS <4) or TIA
Primary endpoint (Recurrent stroke, MI, Death to 90 days):
HR, 0.89; 95% CI, 0.78–1.01; P=0.07
◦ IV IIb/IIIa inhibitor：
Tirofiban and Eptifibatide: not well established (Class IIb,
Level B)
Abciximab: harm (Class III)
68
N Engl J Med. 2016 Oct 6;375(14):1395.
Mono antiplatelet therapy
72. Ticagrelor + Aspirin vs Aspirin (n.11016)
RCT study involving patients with NIHSS
<=5 or TIA (ABCD2=6) who were not
undergoing tPA or EVT
Onset <24 hours recruitment
A composite of stroke or death within 30 d
Ticagrelor+Apirin vs Aspirin (5.5 vs 6.6%)
Severe bleeding (0.5 vs 0.1%)
74
THALES
HR 0.83
HR 3.99
76. Lancet Neurol . 2014 Apr;13(4):429-38.;
- 1/4 patients with ischemic stroke have no probable cause found after
standard workup.
- Most cryptogenic ischemic strokes are embolic in origin, arising from
proximal arterial sources, the heart, or venous sources (with right-to-left
shunts).
N Engl J Med 2016 May 26;374(21):2065-74.Covert Atrial Fibrillation
77. N Engl J Med 2014;370:2467e77.
Detection: 16.1% vs. 3.2% 6 mon. Detection: 8.9% vs. 1.4%
N Engl J Med 2014;370:2478e86.
78. 結論及建議：
◦ Urgent anticoagulation, with the goal of preventing
early recurrent stroke, halting neurological worsening,
or improving outcomes after AIS, is not recommended。
(Class III: no benefit, Level A)
80Stroke. 2013; 44: 870-947
1. No evidence that early anticoagulation
reduced the odds of dead or dependent.
(OR 0.99; 95% CI 0.93 to 1.04)
2. Although early anticoagulant therapy was
associated with fewer recurrent ischaemic
strokes (OR 0.76; 95% CI 0.65 to 0.88),
it was also associated with an increase in
symptomatic intracranial haemorrhages
(OR 2.55; 95% CI 1.95 to 3.33).
2015
79. 結論及建議：
◦ Dabigatran, argatroban or other thrombin inhibitors for the
treatment of patients with AIS is not well established。
(Class IIb, Level B-R)
◦ Factor Xa inhibitors in the treatment of AIS are not well
established. (Class IIb, Level B-R)
81Stroke. 2013; 44: 870-947
80. 結論及建議：
◦ For most patients with AIS and atrial fibrillation, it is
reasonable to initiate oral anticoagulation within 4 to 14
days after the onset of neurological symptoms.
(Class IIb, Level B-R)
82Stroke. 2013; 44: 870-947
81. From: Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K
antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary
Flowchart for the initiation or re-initiation of anticoagulation after transient ischaemic attack (TIA)/stroke or intracerebral
haemorrhage. Europace 2015;17:1467-507.
83
