NIHSS ≤ 3 и Лек Исхемичен Инсулт: Двойна Антиагрегантна Терапия
Пациентите с лек исхемичен инсулт или високорискова транзиторна исхемична атака (ТИА) имат значителен риск от ранен рецидив, най-висок през първите дни. NIHSS е ключовият критерий за дефиниране на „лек инсулт" в рандомизираните проучвания и определя кои пациенти имат полза от краткосрочна двойна антиагрегантна терапия.
NIHSS
National Institute of Health Stroke Scale
No stroke symptoms
0
1. a) Level of Consciousness
Alert; keenly responsive
The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.
1. b) Ask for the current month and his/her age
Both questions correct
The answer must be correct - there is no partial credit for being close. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues.
1. c) Ask to blink eyes and squeeze hands
Performs both tasks correctly
Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (i.e., follow s none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored.
2. Test horizontal extraocular movements
Normal
If a patient has an isolated peripheral nerve paresis(CN III, IV or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.
3. Test visual fields
No visual loss
Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found.
4. Test facial palsy
Normal (symmetrical movements)
Ask – or use pantomime to encourage – the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible.
5. a) Test left arm motor drift
No drift for 10 Seconds
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).
5. b) Test right arm motor drift
No drift for 10 Seconds
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).
6. a) Test left leg motor drift
No drift for 5 seconds
The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice.
6. b) Test right leg motor drift
No drift for 5 seconds
The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice.
7. Test limb ataxia
No ataxia
This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. In case of blindness, test by having the patient touch nose from extended arm position.
8. Test sensation
Normal (no sensory loss)
Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss.
9. Test language
No aphasia; normal
If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The examiner must choose a score for the patient with stupor or limited cooperation, but global aphasia answer should be used only if the patient is mute and follows no one-step commands.
10. Test dysarthria
Normal
If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable. Do not tell the patient why he or she is being tested.
11. Test extinction and inattention
No abnormality
Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable.
Основни Рандомизирани Проучвания
| Проучване | Включени пациенти | Схема | Основен резултат |
|---|---|---|---|
| CHANCE | NIHSS ≤ 3 или ТИА с ABCD² ≥ 4, до 24 ч. | Клопидогрел + аспирин 21 дни, след това клопидогрел до 90 дни | По-малко инсулти за 90 дни без увеличение на умерените/тежките кръвоизливи |
| POINT | NIHSS ≤ 3 или ТИА с ABCD² ≥ 4, до 12 ч. | Клопидогрел (натоварваща доза 600 mg) + аспирин за 90 дни | По-малко големи исхемични събития, но повече големи кръвоизливи |
| THALES | NIHSS ≤ 5 или ТИА с ABCD² ≥ 6 или симптоматична стеноза, до 24 ч. | Тикагрелор + аспирин 30 дни | По-малко инсулт или смърт, с повече тежки кръвоизливи |
Анализите на POINT показват, че ползата е съсредоточена през първите седмици, докато рискът от кървене продължава, което подкрепя кратката продължителност на двойната терапия.
Практически Препоръки
- Започване възможно най-рано — идеално до 24 часа от началото на симптомите
- Клопидогрел + аспирин за 21 дни при NIHSS ≤ 3 или високорискова ТИА, след което монотерапия
- Натоварваща доза клопидогрел (300–600 mg) и аспирин в първия ден
- Изключване на вътречерепен кръвоизлив с образна диагностика преди започване
- Кардиоемболичен източник (напр. предсърдно мъждене) изисква антикоагулация, а не двойна антиагрегантна терапия
Тромболиза при Лек Неинвалидизиращ Дефицит
При лек инсулт решението за венозна тромболиза зависи от това дали дефицитът е инвалидизиращ, а не само от стойността на NIHSS:
- Инвалидизиращ дефицит (напр. афазия, хемианопсия, тежка слабост в ръката), дори при нисък NIHSS — тромболиза в терапевтичния прозорец, при липса на противопоказания
- Неинвалидизиращ дефицит (NIHSS 0–5) — проучването PRISMS не показва полза от алтеплаза спрямо аспирин; препоръчва се антиагрегантна терапия
Кога NIHSS Подценява Тежестта
- Изолирана хемианопсия или атаксия на походката — нисък скор, но значима инвалидизация
- Флуктуиращи симптоми — възможна стенозираща лезия на голям съд
- Инсулт в задната циркулация с вертиго и нестабилност
При тези пациенти е важна съдова образна диагностика за изключване на оклузия на голям съд.
Често Задавани Въпроси
Пациент с NIHSS 4 — може ли да получи двойна антиагрегантна терапия? CHANCE и POINT включват NIHSS ≤ 3, а THALES — NIHSS ≤ 5 с тикагрелор. Решението при NIHSS 4–5 се основава на индивидуалната преценка, типа на инсулта и риска от кървене.
Защо само 21 дни? Рискът от рецидив е най-висок през първите седмици, докато рискът от кървене продължава. Кратката схема оптимизира съотношението полза/риск.
Какво при носителство на CYP2C19 алели със загуба на функция? Ефектът на клопидогрел може да е намален. При китайски пациенти, носители на такива алели, проучването CHANCE-2 показва предимство на тикагрелор + аспирин пред клопидогрел + аспирин; приложимостта в европейски популации е по-малко изследвана.
Източници
- Wang Y, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369(1):11–19.
- Johnston SC, et al. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. N Engl J Med. 2018;379(3):215–225.
- Johnston SC, et al. Ticagrelor and aspirin or aspirin alone in acute ischemic stroke or TIA. N Engl J Med. 2020;383(3):207–217.
- Khatri P, et al. Effect of alteplase vs aspirin on functional outcome for patients with acute ischemic stroke and minor nondisabling neurologic deficits: the PRISMS randomized clinical trial. JAMA. 2018;320(2):156–166.
