Résumés
Résumé
Le devenir de l’infarctus cérébral s’est transformé avec l’arrivée de la thrombolyse, lorsque le patient peut être traité. Le rt-PA (recombinant tissue plasminogen activator), par son action thrombolytique, apparaît comme l’espoir de dissoudre des caillots et infléchir favorablement la destinée de l’ischémie cérébrale aiguë. Dans les indications et les contre-indications décrites dans l’étude NINDS (National institute of neurological disorders and stroke), et sous la responsabilité de neurologues entraînés, en raison des risques d’infarctus hémorragique associés, il est aujourd’hui recommandé de pratiquer la thrombolyse intraveineuse avec une dose de rt-PA de 0,9 mg/kg dans les trois premières heures. La thrombolyse par voie intra-artérielle, qui peut être pratiquée, sous certaines conditions, jusqu’à 6 heures après le début des symptômes, n’est praticable que dans les centres médicaux disposant d’un neuroradiologue interventionnel. Nous sommes au tout début du traitement de l’infarctus cérébral : la complexité et la diversité de ses mécanismes et de ses causes exigent l’intervention de neurologues entraînés, équipés d’IRM fonctionnant « 24 h sur 24 », de matériel d’examen par ultrasons et d’une table d’angiographie.
Summary
Thrombolytic therapy are the most important advance in the management of acute ischemic stroke and has been evaluated in several randomised trials. Thrombolysis with recombinant tissue plasminogen activator (rt-Pa) is effective within 3 h of onset of ischemic stroke and this efficacy is similar between different stroke subtypes. New trials will determine if extension of this time-window can be substantiated. Therapy beyond the 3-hour window, with intra-arterial thrombolysis, appears to improve outcome but are applicable to selected group of patients. Thrombolytic drugs can also carry an important risk (5 % to 10 %) of brain hemorrhage and edema that can prove fatal. The risk of symptomatic intracranial hemorrhage is directly proportional to stroke severity and inversely proportional to time to treatment. There is a growing interest in the use of MRI in acute ischemic stroke. It helps identify location of early cerebral ischemia and provides valuable information not only of the penumbra but also of vessel occlusion. Its use might help in selecting patients who will benefit most from treatment such as thrombolysis. In spite of these results, community use of thrombolytic therapy remains dismally low. Many physicians and medical centers are not presently equipped or willing to give thrombolytic drugs for stroke treatment. Increasing stroke awareness in the community, creating stroke unit and physicians education are necessary to extend the effective use of acute treatment in cerebral infarct to a larger group of patients.
Parties annexes
Références
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