Stroke subtype STROKE 15 85 Ischemic Stroke 20

Stroke subtype STROKE 15% 85% Ischemic Stroke 20% Large Artery 25% Lacunae 20% Embolism 30% Cryptogenic Hemorrhage 5% Unusual Heterogeneity of Pathogenesis MCA main trunk infarct n n In situ thrombosis Artery to artery embolism Low flow infarct Cardiac emboli MCA penetrating artery infarct (lacunae) n n n Large artery disease Lipohylinosis, microaneurysm Microatheroma In situ thrombosis Artery to artery embolism Low flow infarct Cardiac emboli Lacunae

缺血性腦中風 n n 目前台灣地區最常見的腦中風型態 TOAST criteria Large artery n Small vessel occlusion n Cardiac embolism n Undetermined etiology n Other etiologies n

What’s t. PA?

NINDS rt-PA Study: % patients ≥ 4 pt improvement in NIHSS Part 1 Primary Outcome (24 hrs) NS 47% 39% NEJM 1995; 333: 1581 -1587

NINDS rt-PA Study: % patients with little or no disability Part 2 Primary Outcome (3 mos) 50% 44% 38% 39% 32% 31% 26% 20% Global comparison of all scales combined (Wald test), p<0. 01 NEJM 1995; 333: 1581 -1587

NINDS rt-PA Study: Hemorrhage n n n 22 symptomatic ICHs Only 2 were in the placebo group Mortality around 50%

ECASS-3

ECASS-3 functional outcome

Primary and secondary endpoints

ECASS-3 Safety outcome

CTA

CTP

超過了三小時，怎麼辦？ Intraarterial thrombolysis

Intra-arterial Thrombolysis Occluded artery Flow Restored by IA t. PA Intuitive appeal: 1. Local delivery 2. Fewer bleeding complications 3. Thrombolysis until recanalization

MERCI

Possible indication for IA or mechanical thrombolysis n n n 發病6 小時內 ( basilar artery occlusion可至 24小時內) ICA 或 MCA occlusion NIH stroke scale >10 V/Q [(PWI-DWI) / PWI ] mismatch >25% 相關人員配備齊全 無其它禁忌症

MRI DWI and PWI mismatch