Fibrinolyse dans les AVC
Fibrinolyse dans les AVC
Fibrinolyse dans les AVC
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Romain Barthélémy<br />
DESC de Réanimation médicale<br />
Bordeaux –Juin 2008
Blakeley, et al. Thrombolytic therapy for acute ischemic stroke. J Neurol Sci 2007
• 333 patients<br />
• rt‐PA vs. placebo<br />
• délai < 3 heures<br />
• TDM cérébral<br />
(éliminer une hémorragie)<br />
• Contrôle TA<br />
▪ TAS < 185 mmHg<br />
▪ TAD < 110 mmHg<br />
Tissue plasminogen activator for acute ischemic stroke. The National Institute of<br />
Neurological Disorders and Stroke rt‐PA Stroke Study Group. N Engl J Med 1995
Kwiatkowski, et al. The impact of imbalances in baseline stroke severity on outcome in<br />
the National Institute of Neurological Disorders and Stroke Recombinant Tissue<br />
Plasminogen Activator Stroke Study. Ann Emerg Med 2005
Wahlgren, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe<br />
Implementation of Thrombolysis in Stroke‐Monitoring Study (SITS‐MOST): an<br />
observational study. Lancet 2007
• Comment maîtriser le<br />
risque hémorragique <br />
• Comment augmenter<br />
le nombre de<br />
candidats àla<br />
thrombolyse
Jaillard, et al. Hemorrhagic transformation in acute ischemic stroke. The MAST‐E<br />
study. MAST‐E Group. Stroke 1999
• MAST‐E<br />
• <strong>AVC</strong> de moins de 6h<br />
• Streptokinase<br />
• Incidence de SHI = 21%<br />
Jaillard, et al. Hemorrhagic transformation in acute ischemic stroke. The MAST‐E<br />
study. MAST‐E Group. Stroke 1999
Patel, et al. Lack of clinical significance of early ischemic changes on computed<br />
tomography in acute stroke. JAMA 2001
• Evaluation prospective<br />
• 203 malades<br />
Barber, et al. Validity and reliability of a quantitative computed tomography score in<br />
predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS<br />
Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000
• Comment maîtriser le<br />
risque hémorragique <br />
• Comment augmenter<br />
le nombre de<br />
candidats àla<br />
thrombolyse
• ATLANTIS<br />
• 613 patients<br />
• rt‐PA vs placebo<br />
• entre 3 et 5h<br />
Clark, et al. Recombinant tissue‐type plasminogen activator (Alteplase) for ischemic<br />
stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized<br />
controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in<br />
Ischemic Stroke. JAMA 1999
ECASS‐III<br />
Hacke, et al. Association of outcome with early stroke treatment: pooled analysis of<br />
ATLANTIS, ECASS, and NINDS rt‐PA stroke trials. Lancet 2004
• Comment maîtriser le<br />
risque hémorragique <br />
• Comment augmenter<br />
le nombre de<br />
candidats àla<br />
thrombolyse
PATIENT CONTRÔLE<br />
PATIENT THROMBOLYSÉ<br />
Parsons, et al. Diffusion‐ and perfusion‐weighted MRI response to thrombolysis in<br />
stroke. Ann Neurol 2002
Kohrmann, et al. MRI versus CT‐based thrombolysis treatment within and beyond the<br />
3 h time window after stroke onset: a cohort study. Lancet Neurol 2006
• Prospective<br />
• 74 patients<br />
• <strong>AVC</strong> entre 3 et 6h<br />
• Etude IRM<br />
Albers, et al. Magnetic resonance imaging profi<strong>les</strong> predict clinical response to early<br />
reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke<br />
evolution (DEFUSE) study. Ann Neurol 2006
Davis, et al. Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging<br />
Thrombolytic Evaluation Trial (EPITHET): a placebo‐controlled randomised trial.<br />
Lancet Neurol 2008
• Phase II<br />
• Peu de patients<br />
• Vs. placebo<br />
• Critères IRM<br />
• perfusion/diffusion<br />
mismatch > 20%<br />
• <strong>AVC</strong> entre 3 et 9h<br />
Hacke, et al. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRIbased<br />
9‐hour window acute stroke thrombolysis trial with intravenous desmoteplase.<br />
Stroke 2005
• PROACT II<br />
• MELT<br />
Pas de thrombolyse IV <strong>dans</strong> le groupe contrôle<br />
Furlan, et al. Intra‐arterial prourokinase for acute ischemic stroke. The PROACT II<br />
study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism.<br />
JAMA 1999<br />
Ogawa, et al. Randomized trial of intraarterial infusion of urokinase within 6 hours of<br />
middle cerebral artery stroke: the middle cerebral artery embolism local fibrinolytic<br />
intervention trial (MELT) Japan. Stroke 2007
• Thrombolyse<br />
• <strong>AVC</strong> de moins de 3h<br />
• sans hémorragie àla TDM<br />
• En attente de données<br />
• Au‐delà de 3 heures<br />
• Sélection par l’IRM<br />
• Autres molécu<strong>les</strong><br />
• Thrombolyse intra‐artérielle
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