New Resident Guide to Stroke Alerts - Part 2

我是何塞·梅里诺，《神经病学》系列期刊的主编。

This is Jose Merino, editor in chief of the Neurology family of journals.

《神经病学》播客为神经科医生和其他临床医生提供实用信息，帮助他们更好地照顾患者。

The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients.

感谢收听，祝您本周愉快。

Thanks for listening and have a great week.

大家好。

Hello everyone.

我是弗吉尼亚大学的安迪·索瑟兰，又和大家见面了。

This is Andy Southerland again from the University of Virginia.

本周的《神经病学》播客，我们继续之前和我的朋友兼同事丹·阿克曼的对话，他是圣卢克大学健康系统神经科主任兼卒中中心主任。

And for this week's Neurology Podcast episode, we're carrying forward from a previous conversation I've been having with my friend and colleague, Dan Ackerman, who is the Chief of Neurology and the Director of the Stroke Center at St.

圣卢克大学健康系统。

Luke's University Health System.

上一期节目中，我和丹就2026年美国心脏协会急性缺血性卒中指南的更新展开了一次深入但有些发散的讨论。这份指南去年一月底发布，二月初正式公布，我们接下来会围绕它详细聊聊。

Dan and I, on our previous episode, had a substantive, if not a bit meandering conversation about the increasing complexity to make thrombolysis decision makings based on our 2026 American Heart Association Acute Ischemic Stroke Guidelines that were published at the end of January, came out early February of this year, which of course we would refer back to, to hear all about that.

现在我们可以借助高级影像技术，在更长的时间窗内更准确地决定是否对患者进行溶栓治疗。

And we can now make better decisions based on advanced imaging for treating patients and that extended time window with thrombolysis.

但今天这期节目，我们还是回到那些2026年的指南上。

But for today's episode, we're gonna get back to those guidelines, those 2026 guidelines.

我也想再提一下我们之前对指南主要作者、芝加哥大学的约翰·普拉巴卡兰的采访。

And I should also refer again to a previous interview with the lead author of those guidelines, John Prabhakaran for University of Chicago.

我们是在今年二月对他做的那次访谈。

We interviewed him back in February of this year.

那期内容和我们今天的讨论是很好的补充，不过我打算快速抛几个指南里新出现或有新见解的要点给丹，看看这些最新数据是怎么改变我们治疗患者的思路的。

And so that's a great corollary to our conversation we're having today, but I'm going to hit Dan with a few rapid fire concepts that were touched on the guidelines that I think are new or provide some new insights, new based on the data into how we treat patients.

所以，丹，你准备好了吗？

So Dan, you ready for it?

快速问答模式，急性卒中治疗决策。

Rapid fire, acute stroke treatment decision making.

来吧，尽管问。

Absolutely hit me.

好的，丹。

All right, Dan.

我刚当住院医那会儿，今年七月一号第一次参加中风急救，有个病人进来，症状很严重，其他方面完全符合溶栓条件，但有阵发性房颤病史。

So I'm a resident going to my first stroke alert on July one this year, and I've got a patient coming in, they're having disabling stroke symptoms and they're in every other way eligible to receive thrombolysis, but they have a history of paroxysmal atrial fibrillation.

他正在服用阿哌沙班，而且当天确实服了一剂。

They are on apixaban and they took a dose of that apixaban.

前一天他忘了吃，但再前一天晚上吃过了。

They forgot to take one yesterday, but they took one the day before, the evening before.

所以，他最后一次服药是在大约三十六小时前。

And so sort of thirty six hours, ago, they took a dose of their apixaban.

按以前的老说法，旧指南可能说，如果在四十八小时内用过抗凝药，溶栓就是相对禁忌。

So based on sort of previous dogma, I think prior guidelines might've said if it's within that forty eight hour window, that's a relative contraindication thrombolysis.

根据新指南，你怎么看？这些新建议对我们做决定有什么指导？

What say you based on the new guidelines and how do they inform us about making that decision?

其实新指南跟你说的差不多。

I would actually say the new guidelines are a little bit more in line with what you just said.

你刚才说这是溶栓治疗的相对禁忌症。

You mentioned it as a relative contraindication to thrombolysis.

在新指南出台之前，很多人会直接说，这绝对是溶栓的禁忌。

I think before these guidelines came out, a lot of people would have said, no, that is a strict contraindication to thrombolysis.

很多医生一知道患者在服用阿哌沙班、利伐沙班、艾多沙班、达比加群这些口服抗凝药，就会放缓卒中急救流程，心想：不行，不能溶栓。

And a lot of folks would run a stroke code or a stroke a little slower knowing that, hey, this person is on, whether it's apixaban, rivaroxaban, edoxaban, dabigatran, etcetera, any of these direct oral anticoagulants and say, well, no.

他们觉得这类患者根本不适合溶栓治疗。

We know that person's not a candidate for thrombolytics.

其实不然。

Well, no.

新指南认为，这属于相对禁忌，而不是绝对禁忌。

The newer guidelines would suggest that that is a relative contraindication, not a strict contraindication.

回顾相关研究发现，最后一剂药是什么时候吃的，其实影响并不大。

And when we look back at studies on this, it has not been suggested that there is a big contribution in terms of exactly how long ago that last dose was.

是两小时前、十二小时前，还是二十小时前？

Was it two hours ago, twelve hours ago, twenty hours ago?

目前并没有证据显示检测凝血因子Xa活性、出血时间等指标能带来明确益处。

And there has not been shown to be a clear benefit of testing for factor ten a activity levels, bleeding time, and the like.

所以指南建议，嗯，

So the guidelines do suggest that, hey.

这方面还需要更多数据。

We need more data on this.

这并不意味着完全没问题。

It's not to say that this is 100% perfectly fine.

记住，这属于相对禁忌，仍然需要权衡风险与收益。

Remember, that's a relative contraindication, so it's still a risk benefit discussion.

但研究显示，符合指南标准的患者，即使近期使用过DOAC，接受静脉溶栓后出血并发症的风险并未增加。

But studies have not shown an increased risk for hemorrhagic complications in patients who have had recent DOAC exposure who receive IV thrombolysis otherwise according to the guidelines.

因此，我会在这种情况下去考虑给予溶栓治疗，同时确保记录下患者服用的药物种类、最后一次服药时间等所有相关信息，就像我们平时做的那样。

So I would tend to offer it in that situation and make sure that we document what drugs someone's on, how long ago was their last dose, all of this kind of information in addition to what we might normally otherwise get down.

如果患者是在过去24小时，甚至12小时内服用了DOAC，这种情况会改变吗，丹？

Does that change, Dan, if they took the DOAC in the last twenty four hours or even twelve hours?

他们昨晚才服药，今天早上就出现中风症状，这种情况下我们还是按表面情况来判断吗？

You know, they took it last night and they're presenting in the morning with their stroke like symptoms, or is it still looking at it, you know, at face value?

指南只建议以48小时为界，据我所知，目前还没有明确的数据能指出某个具体时间点就绝对不能做。

The guideline just suggests less than forty eight hours, and the data to my knowledge doesn't really delineate, at this point any particular time frame where we would say, no.

有人提出两小时、八小时或十二小时作为分界线。

There's a there's a cutoff there at two hours or eight hours or twelve hours.

所以目前我不会单凭这个时间点来决定是否不给溶栓治疗。

So at this point, I would not use that as a way to decide not to offer lytics based on that time frame.

说得有道理。

Fair enough.

我觉得这个做法很合理。

I think that's very reasonable.

而且我觉得，无论你是刚上岗的住院医，还是在和患者及家属沟通时，都值得好好讨论一下风险和获益，毕竟我们是根据现有数据来做判断的。

And I think, again, it's always a good conversation to have either with your attending if you're that resident on July 1, but particularly with the patient, their family on the risk benefit of what we know based on the data.

我还想指出，目前我们缺乏高质量的公开数据来支持用非正式的化验结果做临床决策。

I will point out that we really don't have great published data on accuracy of using informal lab values to make decisions.

但大多数医院现在都通过检测抗Xa因子水平来监测肝素的抗凝效果。

But most places, our hospitals are using factor Xa levels monitoring heparin activity in patients.

这样能快速拿到结果，尤其是针对Xa因子抑制剂，比如阿哌沙班和利伐沙班，至少能更有依据地为这些患者制定治疗方案。

So you can get that pretty quickly and particularly for the factor Xa inhibitors, apixaban, rivaroxaban, can at least be more licensed to treat those patients.

我觉得这确实是咱们俩都经常遇到的典型情况。

I think that's a very common presentation as you and I both, as we both see.

好了，再聊聊其他几个方面，特别是关于血管内治疗的新适应症，这些都基于近几年发表的临床试验结果，被正式写进了指南。

All right, touching on a couple of other areas, particularly as it relates to other indications for endovascular therapy that these guidelines really codify based on clinical trials that have come out in the last couple of years.

一个是大面积梗死的患者。

One is patients with large core infarctions.

这到底是什么意思呢？

And what does that mean?

就是说，有些患者来的时候有大血管闭塞，按位置来看本来适合取栓，但灌注成像，或者像CT核心评分这类非灌注影像显示，他们脑组织已经大面积受损——也就是核心梗死范围很大，不过影像上可能还残留一些可挽救的脑组织。

That means that patients coming in with a large vessel occlusion who might otherwise be eligible for thrombectomy based on the location of the occlusion, but their perfusion based imaging or even their non perfusion based imaging suggest such as a CT aspect score, for instance, suggests that they have a significant amount of brain that's injured, large core, but still potentially have some salvageable tissue left based on that imaging.

那指南对这类患者做取栓决策有什么建议？

What do the guidelines tell us about making thrombectomy decisions in that population?

我觉得，在这种情况下，我们是否真的需要灌注成像，这个问题本身是有争议的。

I would say that, the question of whether we even truly need perfusion imaging in a situation like that is debatable.

如果灌注成像的目的是判断梗死核心的大小，那我们倾向于认为，即使核心面积很大，患者接受取栓治疗后的预后仍然会比不治疗好得多。

If the point of that perfusion imaging is to define the size of the core, you know, we would suggest that even in cases where there is a large core, a patient's outcome after reperfusion by thrombectomy is still going to be better than it otherwise would have been.

核心越大，患者从当前的大核心卒中状态恢复到生活自理的可能性就越低，相比小核心的患者来说是这样。

Now the larger the core, the less likely it may be that a person will go from their current state as they're presenting with this large core stroke to independent compared to a patient with a small core.

但归根结底，他们接受取栓后还是能恢复得更好一些。

But, ultimately, they'll still do better and recover better post thrombectomy.

这些患者都已经做过平扫CT了。

So all of those patients will have already gotten non con CTs.

他们也都已经做过CT灌注检查了。

They will have already gotten CT perfusion.

最近刚发表了一些数据，关于卒中患者使用造影剂后引发肾损伤的风险，自从我们开始广泛使用CT血管成像以来，一直有句话叫‘脑优先于肾’，该做的检查我们还是会做。

There is some recent data that was just published with regard to the risk of contrast induced nephropathy, and contrast induced kidney injury in stroke patients, which, you know, ever since we expanded CT angiography, we've always said, look, neurons over nephrons, and we're gonna we're gonna go ahead and just evaluate what we need to.

但考虑到反复使用造影剂和多次辐射并不理想，如果我们做这些检查对临床决策并没有实质帮助，那就不必了。

But given that ongoing repetitive contrast loads and repetitive radiation doses are not ideal, If we don't need that information for our clinical decision making,

我会跳过这一步，直接把病人送进导管室，尽快让大脑恢复灌注。

I would skip the extra step and get that patient into the cath lab and get that brain reperfused faster.

明白了。

Got it.

非增强头颅CT、严重中风、近端大血管闭塞，直接安排。

So noncon head CT, disabling stroke, proximal large vessel occlusion, boom.

仅凭这些数据，就该直接做取栓手术，这正是临床试验支持的方案。

Based on just those data alone, go to thrombectomy and that's what the trials would suggest.

我同意，目前的数据也确实指向这个方向。

I agree, I think that's what our current data suggests as well.

当然，还得跟家属充分沟通，讲清楚预期的预后情况。

Again, always with the conversation with family based on expected outcomes and so forth.

基底动脉闭塞的情况，我觉得没必要花太多时间讨论。

Basilar artery occlusions, I don't know that we need to spend a lot of time with this.

多年来，常规做法都是这样：只要患者是基底动脉闭塞，不管是近端还是中段，考虑到这类患者症状严重、预后极差，就直接安排取栓手术。

I think common practice, standard practice has been for years, just patients with a basilar artery occlusion, top of the basilar, mid basilar, given just the terrible outcome in most situations of people that are coming in that are symptomatic from a basilar artery occlusion going to thrombectomy.

但根据基底动脉闭塞取栓试验的结果，这一点现在已经明确写进了指南。

But based on basilar artery occlusion thrombectomy trials, this is now cemented in the guidelines.

丹，这么说合适吗？

Is that fair to say, Dan?

我们这些干卒中治疗时间够长的人，都还记得以前遇到基底动脉闭塞的病人，总想赶紧做核磁共振，看看桥脑的情况，试图预测预后。

You know, those of us who've been practicing stroke for long enough will remember patients with a basilar occlusion and maybe trying to take them for a stat MRI to look at the condition of the pons and try and somehow figure out, you know, what the outcome is gonna be.

现在这种做法已经不常见了。

I don't believe that's as common a practice.

对现在这些来就诊的病人，大多数情况下，我们都会直接安排取栓手术。

And at this point, for those patients who come in, I think most of the time we're gonna take them straight for thrombectomy.

你们那边也是这么处理的吗？

Is that how you guys play it through?

没错。

Absolutely.

只要家属没出面叫停，我们就直接开绿灯，马上行动。

You know, it's green light go unless unless we're in a situation where the family's calling us off, for some reason or another.

是的。

Yeah.

不是。

No.

这属于紧急情况。

That's an emergency.

如果患者出现与基底动脉闭塞相符的急性症状，就必须尽快开通血管。

Basilar arteries have to be reopened if assuming it's an acute occlusion of the patients similarly symptomatic correlating to that location.

所以现在临床试验已经证实了这一点，并且写进了指南。

So I think that's now supported with clinical trials and made its way into the guidelines.

好的，最后两个话题。

All right, final two topics.

其中一个话题，我觉得作为成人血管神经科医生，我们虽然不至于说很挣扎，但哪怕是我们这些喜欢刺激的人，也会感到一丝紧张——那就是儿童或18岁以下患者的卒中，无论是幼儿还是青少年。多年来，已经有很多研究和临床试验试图明确溶栓和取栓在这一人群中的安全性和有效性。

One topic, which I think as adult vascular neurologists, we all sort of, I don't want to say struggle with, but maybe breeds a little bit more anxiety, even for us adrenaline junkies, is stroke in a pediatric case or in someone less than the age of 18, whether that's a younger child or an adolescent, there's been lots of research over the years, clinical trials to try to define the safety and the efficacy of thrombolysis and thrombectomy in this population.

这些指南现在正式把相关内容纳入了常规的急性卒中指南中。

These guidelines actually bring it in to the common you know, acute stroke guidelines.

这些指南有没有改变你与儿科神经科同事或儿科医生合作治疗儿童和青少年中风的方式？

So has anything about these guidelines affected the way that you're responding to or working with your pediatric neurology colleagues or pediatric colleagues to treat stroke in children and adolescents?

我觉得你说得特别到位，我们确实一直在和儿科神经科医生以及儿科医生合作处理儿童中风的治疗。

Well, I think really hit the nail on the head is that we are working with our pediatric neurology colleagues and our pediatricians with regard to treatment of pediatric stroke.

指南明确指出，我们需要像成人中风一样，建立一套系统化的应对流程，相关算法也必须随时准备好。

The guidelines are clear that we need just as organized an approach just as we need to have those algorithms ready.

指南里提到，儿童中风确实有时更难被及时发现，这确实是真的。

Because the guidelines discuss and it's true that pediatric stroke, it takes longer sometimes to recognize.

因为我们平时根本不会往这个方向想。

We're just not expecting it the same way.

虽然我们都清楚这种情况确实会发生，但关键是要真正重视儿童中风的预警机制，确保一旦怀疑，就立即启动警报。

Although we all know it happens, but really making sure that we drill down on those pediatric stroke alerts, recognize that, yes, they have to be called and activated as alerts.

孩子需要尽快做影像检查，还得由有儿童中风经验的医生进行紧急评估。

They need acute imaging, and they need acute evaluation by people with expertise in pediatric stroke.

虽然溶栓和取栓在儿童中也可能适用，但决策过程和成人相比往往要复杂得多。

And while thrombolytics and thrombectomy may still be appropriate in pediatrics, the decision making process really can be much different.

这事儿得有个专门的体系来支持。

You gotta have a dedicated system for it.

这真不能光指望成人神经科医生来处理。

It's really not something that we should just leave up to the adult neurologists.

这完全是另一回事。

It really is just a different ballgame.

但我同意。

But I agree.

我很高兴这些内容被纳入了，这样我们就能开始弥合成人和儿童卒中治疗之间的差距，搞清楚哪些做法可以通用，哪些不行。

I'm so excited that it's in here and that we can start to bridge the gap between what we're doing in adults and what we're doing in pediatrics and making sure we understand what translates from one to another and what does not.

这真是个不错的基础。

So it's a good foundation.

我完全同意，丹。

I agree totally, Dan.

我会建议大家回去参考指南，里面有个特别清晰的儿童卒中准备流程图和工作流程。

And I will refer people back to the guideline because there's a really nice pediatric stroke readiness infographic and workflow.

它还强调了所有那些必须到位的额外环节，首先是血管神经科医生或卒中专家——如果有的话——与负责卒中治疗的神经科医生、儿科团队以及急诊团队之间的协作。

And it highlights all those additional things that really need to be in place, starting with the collaboration between a vascular neurologist or stroke specialist if available or the neurologist in charge of taking care of stroke and the pediatrics team and the emergency department team, of course.

但我们要考虑，这位患者能不能及时做影像检查？

But thinking about, are we going to be able to get acute imaging in this patient?

他能不能配合做核磁共振？能不能躺进磁共振机器里？

Are they able to sit for an MRI or get into an MRI machine?

我们需要不需要安排麻醉团队？

Do we need anesthesia on board?

儿科重症监护团队也必须随时待命。

We need our pediatric ICU and folks on board.

在大多数情况下，神经外科也要参与进来，因为儿童的大脑肿得更快，诸如此类的问题。

Also in most cases, neurosurgery as well, younger brains swell more quickly, all those things.

这些都是制定一套周全的儿童卒中救治流程时必须注意的要点。

Those are caveats to having a well thought out pediatric stroke pathway.

我认为他们最想传达的核心信息是：是的，儿童和青少年确实也会发生卒中，虽然罕见。

And I think the main message they want to send is yes, children, adolescents do have strokes, rare as it may be.

溶栓治疗是安全的。

Thrombolysis is safe.

虽然一些试验还没能充分证明它的全部疗效，但对于青少年大血管闭塞引起的中风，取栓治疗既安全又有效，只要条件允许，我们就应该把它作为最终目标。

Think trials have come short or not been able to be completed to demonstrate full efficacy, but thrombectomy and particularly in an adolescent with a large vessel occlusion stroke, thrombectomy is safe and effective and should be our end goal if able.

最后一个问题。

So last topic.

从儿童和青少年转向与年龄相关的淀粉样蛋白疾病，比如脑淀粉样血管病或淀粉样蛋白相关成像异常。

So moving from children and adolescents on that end of the age range to age related amyloid based disease, thinking about patients with cerebral amyloid angiopathy or amyloid related imaging abnormalities.

我们现在是越来越常在中风发生前就发现这些情况，还是在急性中风过程中才意识到的？

This is something we're knowing about, seeing increasingly either before the stroke or realizing the acute stroke process?

丹，最新的溶栓治疗准入标准，对患有ARIA或淀粉样蛋白相关成像异常的患者意味着什么？

Dan, what are the new thrombolysis eligibility criteria telling us about patients with ARIA or amyloid related imaging abnormalities?

先澄清一点，ARIA和脑淀粉样血管病之间有重要区别。

So just to be clear, first of all, there's an important difference between ARIA and cerebral amyloid angiopathy.

我们早就知道脑淀粉样血管病了。

We've known about cerebral amyloid angiopathy for quite some time.

但有一点没变，就是那些已被确诊为脑淀粉样血管病、且存在大量微出血的患者。

And, again, what has not changed, people who have known cerebral amyloid angiopathy who have a significant burden of microhemorrhages.

对吧？

Right?

他们的大脑里积累了大量的淀粉样蛋白。

So they've built up this amyloid protein in the brain.

尤其是血管壁沉积了这种蛋白，大大增加了出血的风险。

In particular, there's been vascular deposition that increases the risk for a bleeding complication.

如果他们的核磁共振显示微出血超过十个，或者有表层含铁血黄素沉积——我记得是这样。

And so if they have greater than 10 microhemorrhages on their MRI or if they have, I believe, if they have superficial siderosis on their MRI.

这种表层的含铁血黄素沉积，通常会让患者不符合系统性溶栓的条件，因为出血风险太高了。

So that superficial deposition of, hemosiderin, then they would typically not be considered candidates for systemic thrombolytics because they're at a higher bleeding risk.

在超急性期，我们并不会专门去查这个。

That's not something we are testing in the hyperacute setting.

如果患者恰好在你们医院接受过治疗，手头有过去的核磁片子，能数清楚微出血的数量，那一定要去查一查。

If the person happens to be, you know, if they've been treated at your health system and you've got an old MRI to look at and you can count up these microhemorrhages, that's real important to go ahead and do.

淀粉样蛋白相关影像异常，可能是由抗淀粉样蛋白治疗引发的炎症、出血，或者两者兼有。

Amyloid related imaging abnormality is a sign of either inflammation or bleeding or both as related to anti amyloid therapy.

抗淀粉样蛋白疗法是静脉输注治疗，所以你平时看的用药清单上可能看不到，但它们确实是针对极早期阿尔茨海默病的疾病修饰疗法。

The anti amyloid therapies are IV infusion therapies, which means they may not show up on a typical medication list that you're glancing at, but they are disease modifying therapies for people with very early Alzheimer's disease.

目前最常用的两种是多奈单抗和莱卡奈单抗，当然还有其他药物正在陆续上市。

The two that are out right now that are most commonly used are donanemab and lecanemab, although there are others that are coming to market.

这些疗法的使用人群正在迅速扩大。

And these are really expanding in their scope in terms of how many people are on them.

但当你在接受抗淀粉样蛋白治疗时，溶解并清除大脑中淀粉样蛋白的过程，可能会引发炎症反应，症状看起来像中风，而且确实存在出血风险。

But when you're on one of these anti amyloid therapies, something about the process of solubilizing this amyloid and drawing it out of the brain can produce an inflammatory state that can mimic stroke, and we know it can be a state where bleeding is a potential issue.

事实上，已经出现过病例，患者原本有淀粉样蛋白相关影像异常，却接受了全身溶栓治疗，结果出现了严重并发症。

In fact, there have been cases where people likely had amyloid related imaging abnormality and ended up getting systemic thrombolytics and had pretty severe complications.

因此，淀粉样蛋白相关影像异常现在已被列为溶栓治疗的绝对禁忌症之一。

So amyloid related imaging abnormality itself as a condition is now listed on their recommended absolute contraindications for thrombolytics.

不过要注意，正在接受这类抗淀粉样蛋白治疗的早期阿尔茨海默病患者，也有可能只是得了普通的中风。

Now importantly, someone who is has real early Alzheimer's and is on one of these anti amyloid therapies, they might still just have a regular run of the mill stroke.

当患者出现中风症状时，我们可能一时无法判断是ARIA——这属于溶栓禁忌——还是真的发生了中风，毕竟中风本来就会发生。

When they present with stroke symptoms, we may not know immediately whether they have ARIA, which would be a contraindication, or whether they're just having a stroke because it turns out that strokes happen.

未来或许有些中心会对这类患者紧急做核磁共振，试图区分是淀粉样蛋白相关影像异常还是缺血性中风，但目前对很多地方来说，这还只是非常初步、甚至近乎想象的做法。

There may come a time, there may be some centers that might have a patient like that and consider doing something like a stat MRI to try and differentiate between amyloid related imaging abnormality and ischemic stroke, but that's still a very early, even remote consideration for a lot of places.

像lecanemab、donanemab这些抗淀粉样蛋白药物，用于临床试验中的患者时，很多机构已经把这些药本身视为溶栓的禁忌了。

The use of one of these medications, lucanumab, donanemab, other anti amyloid therapies for patients that might be in the clinical trials, a lot of places may consider those medicines themselves as contraindications to thrombolytics.

我们平时未必会主动问这个问题，但必须做好准备，因为现在用这些药的人数激增，我估计这个数字还会继续快速上升。

It's a contraindication we're not accustomed necessarily to asking about, but we gotta be ready and able to do that because we have seen a big old spike in the number of people that are on these treatments, and I suspect that number will continue to increase very quickly.

所以我们得留个心眼。

So we gotta be aware of it.

是的。

Yeah.

说得对，丹。

Amen, Dan.

我跟你想法一样。

I'm like you.

我很高兴这一点被写进了指南，尽管随着这类患者群体不断扩大，我们还有很多需要了解的地方，而且人数还会继续上升。

I'm glad it was included in the guidelines, even though there's so much more to learn as this population of folks expands, and it's going to.

好的，丹。

Okay, Dan.

为了把话题拉回到重点上来，还有另一类患者群体。

Really just to kinda bring it into the station here, one other population of patients.

现在，判断患者的中风症状或功能障碍是否严重，已经成了常规操作，因为这直接关系到他们是否适合溶栓治疗。

It's become standard of care to really ask that important question of, are someone's stroke symptoms or deficits disabling in order to inform their eligibility for thrombolysis?

但仍有很多患者来就诊时，症状轻微，没有造成明显功能障碍。

But there are still many patients who come in with minor stroke and non disabling symptoms or deficits.

指南里确实提到了这类情况，以及如何最好地管理他们——通常不建议溶栓，但面对症状轻微的中风患者，我们到底该怎么处理？

And the guidelines do touch on that and how we best manage those folks, typically not with thrombolysis, but how do you manage folks with non disabling minor stroke presentations?

我们知道，许多年轻人也会中风，而每个人的康复情况都完全不同。

We know that so many strokes are happening in young patients and stroke recovery is going to look completely different for each individual.

指南里其实提供了一些很有意思的建议，帮助我们判断哪些中风属于致残性，哪些不属于。

The guideline actually does offer some interesting tidbits on how to decide when strokes might be considered disabling or nondisabling.

他们提到，对于卒中评分在0到5分的患者，如果症状持续存在，他们是否还能完成日常基本活动，或者重返工作岗位？

They talk about how for patients with stroke scale of zero to five, if the observed persist, would the patients still be able to do their basic activities and or return to work?

他们还谈到了一些基本事项，比如洗澡、穿衣、行走。

Now and they talk about basic things like bathing, dressing, ambulating.

重要的是，我们不能只靠NIH卒中量表来评估，还得亲自陪患者走一走，看看他们的行动能力，给他们喝点水，做个简单的吞咽筛查，确认他们能不能正常吞咽，这些都很关键。

Importantly, you know, we're not evaluating these patients in their home in addition to doing things like the NIH stroke scale, making sure that we are walking those patients to see how they're doing with that, making sure that we give them something to drink, little dysphagia screen to see are they able to swallow can be very important.

我觉得整个关于‘致残性缺损’讨论里最重要的一句话就是：临床医生应该在与患者及其家属充分沟通后，共同做出这个判断。

I think the most important line in the whole discussion on disabling deficits is that right here, the clinician should make this determination in consultation with the patient and available family.

对某些患者来说明显不致残的症状，对另一些人来说可能却极其严重。

What is clearly nondisabling to some patients could be considered extremely disabling to another.

要记住，这些患者此刻正高度关注自己的症状，所以哪怕小问题也会被放大。

And remembering that these patients are likely in a moment where they are extremely focused on their symptoms, so the symptoms are gonna seem huge.

他们非常焦虑。

They're very anxious.

他们正处于一个需要紧急做决定的时刻。

They're in a, you know, in an acute decision making kind of moment.

所以我们得跟患者聊聊他们的症状，问问这些症状对他们的日常生活有多大影响。

So we have to take that into consideration by talking to patients about their symptoms and asking how much impact would this have on your life from day to day.

对于那些症状明显不影响生活的患者，多项研究指出，系统性溶栓的获益有限，不足以抵消其潜在风险。

And for patients whose symptoms are clearly nondisabling, several studies have suggested that there is insufficient benefit to systemic thrombolysis to justify the risk that does happen.

即使卒中量表评分较低的患者发生出血并发症的风险较小，但风险也绝不是零。

Even though patients who have lower anti stroke scale may be at lower risk to have a bleeding complication, That risk is certainly not zero.

因此，在这种情况下，我们常常会考虑使用双联抗血小板治疗，甚至单用抗血小板药物，而不是选择系统性溶栓。

And so that's a situation where often we may consider treating patients with dual antiplatelet therapy or even antiplatelet monotherapy in lieu of systemic thrombolytics.

如果能确认，对患者来说，这些症状确实不会影响他们的日常生活方式。

If they can confirm that, yes, these symptoms would be nondisabling for them based on their lifestyle from day to day.

我觉得这是一个重要的提醒。

And I think that's an important caveat.

我们在问病史的时候，正因如此，与患者或家属的初次沟通才格外关键——要记住，这不只关乎溶栓或取栓。

Again, as we're taking our history, that's why that sort of initial interaction with the patient and or the caregiver is so vitally important and one in which, to keep in mind that it's not all about just thrombolysis and thrombectomy.

在急性卒中救治的整个过程中，我们还有很多其他选择和措施可以为患者提供。

There are other decisions and things we can do for all the continuum of patients we see in the acute stroke setting.

所以，Dan，一如既往，非常感谢你参加本周的神经病学播客。

So Dan, as always, thank you so much for joining me for this week's Neurology podcast.

Andy，非常感谢你。

Andy, thanks a lot.

我同意你的看法。

I agree with you.

后面还有更多内容。

A lot more to come.

所以，请做好准备。

So just hold on to your hats.

如果您喜欢本播客，请花点时间在苹果播客、谷歌播客、Spotify 或您收听的其他平台订阅、评分和留言评价。

Podcast, please take a few moments to subscribe, rate and review the Neurology podcast through Apple podcasts, Google podcasts, Spotify, or wherever you listen.

您也可以随时访问 neurology.org/podcast 查看我们过往的所有节目，或者在您的播客应用中通过关键词搜索您感兴趣的神经病学话题。

And remember, you can always head to neurology.org podcast for our full list of past episodes, or you can also search by keyword in your podcast app for any neurology specific topics you want to learn about.