A 65-year-old woman with hypertension, paroxysmal atrial fibrillation, and hyperlipidemia, who is not on anticoagulation, is evaluated in the emergency department of a large tertiary referral center with left-sided weakness that began two hours ago. On examination, she has a right gaze preference, left facial droop, left arm plegia, left leg paresis, dysarthria, dysphagia, and extinction to double simultaneous stimulation on the left. National Institutes of Health Stroke Scale score is 17. Temperature is 37°C (98.6°F), heart rate 110 beats/min, blood pressure 173/90 mm Hg, and respiratory rate 20 breaths/min. Noncontrast head CT is normal. She is given IV recombinant tissue plasminogen activator (rtPA). Head CT angiogram reveals a right M1 middle cerebral artery occlusion.
Which of the following is the best next step?
A. Once IV rtPA infusion is complete, recheck examination; if not improved, perform endovascular therapy with stent retriever.
B. Wait 20 minutes, recheck examination; if not improved, perform endovascular therapy with stent retriever.
C. Wait 30 minutes, recheck examination; if not improved, perform endovascular therapy with stent retriever.
D. Order a CT perfusion to evaluate for salvageable penumbra before deciding on endovascular therapy.
E. Immediately perform endovascular therapy with stent retriever.
答案解析：
根据最近发布的美国心脏协会指南，如果患者符合以下所有标准（I 类，A 级证据），则应使用支架取栓器接受血管内治疗：卒中前改良 Rankin 量表评分为 0 到 1（最小或既往无神经功能缺损），急性缺血性卒中在发病后四个半小时内接受静脉重组组织型纤溶酶原激活剂 (rtPA)，根据专业医学协会的指南，导致颈内动脉或大脑中动脉近端 (MCA) 闭塞) (M1)，年龄≥18 岁，美国国立卫生研究院卒中量表评分≥6，艾伯塔省卒中计划早期 CT 评分 (ASPECTS) ≥6（评估非增强头部 CT 早期缺血性变化的评分，10 为正常，0 为缺血/整个 MCA 区域的低密度变化），并且可以在症状出现后 6 小时内开始治疗（腹股沟穿刺）。
在进行血管内治疗之前观察 IV rtPA 后的患者以评估临床反应并不是获得有益结果的必要条件，也不建议这样做。不需要 CT 灌注来评估缺血性半影，因为患者在 6 小时血管内窗口内且头部 CT 平扫正常（或 ASPECTS 评分为 10）；它还会延迟血管内治疗，应尽早进行。
正确答案：E
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