medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2022-16-21-175-183medsovet-7220Research ArticleПРАКТИКАPRACTICEВнутривенный тромболизис при ишемическом инсульте: 10 правил для практического неврологаIntravenous thrombolysis in ischemic stroke: 10 rules for the practical neurologisthttps://orcid.org/0000-0001-6061-8118КулешА. А.КuleshА. А.

Кулеш Алексей Александрович, д.м.н., доцент, профессор кафедры неврологии и медицинской генетики

614000, Пермь, ул. Петропавловская, д. 26

Аlexey А. Кulesh, Dr. Sci. (Med.), Associate Professor, Professor of the Department of Neurology and Medical Genetics 

26, Petropavlovskaya St., Perm, 614990

aleksey.kulesh@gmail.comhttps://orcid.org/0000-0003-2670-4172ДеминД. А.DeminD. А.

Демин Дмитрий Алексеевич, врач-невролог

414011, Астрахань, ул. Покровская Роща, д. 4

Dmitry А. Demin, Neurologist 

4, Pokrovskaya Roscha St., Astrakhan, 414011

demin2404@mail.ruПермский государственный медицинский университет имени академика Е.А. ВагнераРоссияVagner Perm State Medical UniversityRussian FederationФедеральный центр сердечно-сосудистой хирургииРоссияFederal Center for Cardiovascular SurgeryRussian Federation202219112022021175183Copyright © Кулеш А.А., Демин Д.А., 20222022Кулеш А.А., Демин Д.А.Кulesh А.А., Demin D.А.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/7220

Внутривенный тромболизис (ВТ) рекомбинантным тканевым активатором плазминогена на протяжении четверти века остается основным методом реперфузионной терапии при ишемическом инсульте. Основные тенденции применения ВТ в последние годы заключаются в расширении терапевтического окна при использовании дополнительных методов нейровизуализации, уменьшении числа противопоказаний и внедрении в клиническую практику болюсных форм препаратов. Проведение ВТ наибольшему числу пациентов должно рассматриваться в качестве одной из основных задач первичного сосудистого отделения. В статье представлены 10 клинических правил, которые позволяют расширить проведение ВТ при инсульте, обеспечив при этом его эффективность и безопасность: 1) проводить ВТ при подозрении на имитатор инсульта; 2) проводить ВТ пациентам старше 80 (и даже 90) лет; 3) проводить ВТ при малом, но инвалидизирующем инсульте; 4) проводить ВТ при малом вертебробазилярном инсульте и центральном остром вестибулярном синдроме; 5) проводить ВТ при окклюзии крупной артерии; 6) проводить ВТ при подозрении на лакунарный инсульт и наличии хронических изменений при нейровизуализации (лакуны, гиперинтенсивность белого вещества, атрофия); 7) сокращать время «от двери до иглы», использовать тромболитические препараты с болюсной формой введения; 8) использовать возможности нейровизуализации (КТ-перфузия, МР-перфузия, МРТ DWI/FLAIR) для расширения терапевтического окна; 9) обеспечить безопасность ВТ; 10) быть готовым к развитию осложнений. Увеличение частоты ВТ не должно рассматриваться как самоцель, однако интенсификация применения данного метода лечения сопряжена с совершенствованием в клинике всех направлений лечебно-диагностического процесса и улучшением исходов инсульта.

Intravenous thrombolysis (IT) with recombinant tissue plasminogen activator has remained the main method of reperfusion therapy in ischaemic stroke for a quarter of a century. The main trends in the use of IT in recent years are the expansion of the therapeutic window using additional methods of neuroimaging, reducing the number of contraindications and introduction into clinical practice of bolus forms of drugs. Providing IT to the largest number of patients should be considered a major challenge for the primary vascular department. This article presents 10 clinical rules for extending IT in stroke while ensuring its efficacy and safety: 1) conduct IT in suspected stroke; 2) conduct IT in patients over 80 (and even 90) years of age; 3) conduct IT in minor but disabling stroke; 4) conduct IT in minor vertebrobasilar stroke and central acute vestibular syndrome; 5) perform IT in cases of large artery occlusion; 6) perform IT in suspected lacunar stroke and chronic neuroimaging changes (lacunas, white matter hyperintensity, atrophy); 7) reduce door-to-needle time, use thrombolytics with bolus administration; 8) use neuroimaging options (CT perfusion, MR perfusion, MR DWI/FLAIR) to expand the therapeutic window; 9) ensure the safety of IT; 10) be prepared for complications. Increasing the frequency of IT should not be seen as a goal, but intensifying the use of this method of treatment is associated with the improvement of all areas of the diagnostic and treatment process in the clinic and the improvement of stroke outcomes.

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The authors declare that there are no conflicts of interest present.