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急性缺血性脑卒中的影像与介入－05版Acute_Ischemic_Stroke_-_Imaging_and_Intervention.pdf ACUTE ISCHEMIC STROKE Acute Ischemic Stroke Imaging and Intervention 123 With 107 Figures and 59 Tables R.G. Gonzalez, J.A. Hirsch, W.J. Koroshetz,M.H. Lev, P. Schaefer (Eds.) R. Gilberto González Neuroradiology Division Massachusetts General Hospital and Harvard Medical School Boston, Mass., USA Joshua A. Hirsch Interventional Neuroradiology and Endovascular Neurosugery Service Massachusetts General Hospital Harvard Medical School Boston, Mass., USA W.J. Koroshetz Acute Stroke Service Massachusetts General Hospital Fruit Street, Boston, MA 02114, USA Michael H. Lev Neuroradiology Division Massachusetts General Hospital Harvard Medical School Boston, Mass., USA Pamela W. Schaefer Neuroradiology GRB 285, Fruit Street Massachusetts General Hospital Boston, MA 02114-2696 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specif- ically the rights of translation,reprinting,reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this pub- lication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its cur- rent version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springeronline.com © Springer-Verlag Berlin Heidelberg 2006 Printed in Germany The use of general descriptive names, registered names, trade- marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accu- racy of any information about dosage and application con- tained in this book. In every individual case the user must check such information by consulting the relevant literature. Medical Editor: Dr. Ute Heilmann, Heidelberg, Germany Desk Editor: Wilma McHugh, Heidelberg, Germany Cover design: Frido Steinen-Broo, Estudio Calamar, Spain Layout: Bernd Wieland, Heidelberg, Germany Production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Reproduction and typesetting: AM-productions GmbH, Wiesloch, Germany 21/3151 – 5 4 3 2 1 0 Printed on acid-free paper Library of Congress Control Number 2005928382 ISBN-10 3-540-25264-9 Springer Berlin Heidelberg NewYork ISBN-13 978-3-540-25264-9 Springer Berlin Heidelberg NewYork Acute ischemic stroke is treatable. Rapidly evolving imaging technology is revolutionizing the manage- ment of the acute stroke patient, and the field of acute stroke therapy is undergoing positive change. This book is intended as a guide for a wide variety of cli- nicians who are involved in the care of acute stroke patients, and is a compendium on how acute stroke patients are imaged and managed at the Massachu- setts General Hospital (MGH). The approaches delin- eated in this book derive from the published experi- ences of many groups, and the crucible of caring for thousands of acute stroke patients at the MGH. It is the result of the clinical experiences of the emergency department physicians, neurologists, neuroradiolo- gists, and interventional neuroradiologists that com- prise the acute stroke team. This book focuses on hyperacute ischemic stroke, which we define operationally as that early period after stroke onset when a significant portion of threatened brain is potentially salvageable. The time period this encompasses will depend on many factors; it may only be a few minutes in some indi- viduals or greater than 12 hours in others. In most people, this hyperacute period will encompass less than 6 hours when intervention is usually most effective. The authors believe that patients with acute is- chemic stroke can benefit most from the earliest pos- sible definitive diagnosis and rapid, appropriate treatment. In the setting of hyperacute stroke, imag- ing plays a vital role in the assessment of patients. The most recent advances in imaging can identify the precise location of the occluded vessel, estimate the age of the infarcted core, and estimate the area at risk or the ‘ischemic penumbra’. This book will cover these modern imaging modalities; advanced com- puted tomography and magnetic resonance methods are considered in detail. These two modalities are emphasized because of their widespread availability and the rapid development of their capacities in the diagnosis of stroke. Only brief mention is made of other modalities because they are less widely avail- able and less commonly used in the evaluation of hy- peracute stroke patients. Another major aspect of this book is the use of standard and developing interventions that aim to limit the size of a cerebral infarct and prevent its growth. With the approval of intravenous therapy using recombinant tissue plasminogen activator (rt-PA), this treatment is now in use throughout the United States, Canada, and Europe. Although this is a major advance in the treatment of acute stroke, the 3-hour ‘window’ for rt-PA makes this therapy suitable for only a minority of patients. Studies have indicat- ed that intra-arterial thrombolysis is also effective in patients in a wider window up to 6 hour. More recently, phase II clinical studies have shown that intravenous therapy with a new fibrinolytic agent may be effective up to 9 hours after ischemic stroke onset in patients selected using imaging criteria. Thus, this approach is potentially available to many more individuals. Finally, a wide variety of novel and innovative new devices are being developed to me- chanically recanalize the occluded vessel. It is likely that these devices will come into clinical use in the near future. The authors hope that their experiences as summarized in these pages are of value to the reader and, ultimately, the acute stroke patient. R. Gilberto González V Preface ...