International Circulation: What are some of the new ideas and concepts behind the use of pre-hospital neuroprotective agents?
《国际循环》：使用院前神经保护剂的新思路和观念是什么？
Dr. Liebeskind: The concept is that treatment should begin as early as possible， irrespective of the nature of the therapy or treatment. Revascularization， or any other techniques to restore blood flow， is going to be limited by the challenge of understanding who has an ischemic stroke and who has a hemorrhage. From the revascularization standpoint， this prevents a lot being done in the pre-hospital setting. A recent German trial attempted pre-hospital thrombolysis， facilitated by imaging in the field. However， this can be a huge logistical challenge and miraculous if it can occur. It may be difficult to implement on a large scale. An alternative approach would be to use neuroprotective therapies. Most of these therapies are at least not harmful in hemorrhagic stroke， and there may be a benefit. Also， imaging to distinguish hemorrhagic from ischemic stroke may not be required.
Dr. Liebeskind: 这种观念是不论采用何种治疗方法，都应该尽可能早的开始治疗。血管再通或使用任何能恢复缺血区血流的技术的使用都因为需要了解患者是发生了缺血性中风还是出血性中风而受到限制。从血管再通的观点上来看，这会限制院前环境中很多工作的开展。最近的一项德国试验尝试了在影像指导下的院前溶栓。然而，如果成功这将是一个巨大的挑战和不可思议之事。这种治疗方法可能难以大规模应用。另一种替代治疗方法就是使用神经保护治疗。很多这样的治疗方法至少对出血性中风不会有害，甚至会有益处。同时，这种治疗并不需要通过影像区分出血还是缺血性中风。
IC: You mentioned that in Los Angeles， paramedics will immediately dial a physician hotline in cases of suspected stroke， how are they diagnosing these strokes?
《国际循环》：您提到在洛杉矶，一旦发生可疑的中风，护理人员就会立即拨打医生热线，请问这些护理人员是如何诊断中风的呢？
Dr. Liebeskind: There are using the LAM score， Los Angeles Motor score， where they recognize weakness in specific parts of the body， such as the face， arm， and leg. Typically we screen for unilateral weakness and attempt to screen-out posterior circulation disease. Our inclusion-exclusion criteria are limited for the paramedics， but can be more elaborate when they call us and go through more detailed criteria. These criteria can depend on base-line functional status or specific cardiac disease. Also， when we are treating with magnesium， we have to be concerned about cardiac conduction delays and renal failure as well， so that is when an investigator on the line is necessary to screen out through these aspects. I should mention that we are doing this with video phone， allowing us to perform instant visual diagnosis.
Dr. Liebeskind: 他们用的是LAM评分，也就是洛杉矶运动评分，他们能识别身体特别部位的无力，比如脸部，上肢和腿部。通常我们筛选出单侧无力并试图筛选出后循环疾病。护理人员所掌握的纳入-排除标准是有限的，但是当他们给我们打电话并进行更细节的筛选时这些标准就会更详尽。这些标准可能依赖于患者的基础功能状态或特别的心脏疾病。同时，当我们用镁离子给患者治疗时，我们还需要考虑到患者的心脏传导延迟和肾衰竭的情况，因此这是那些接电话的医生必需要排除的方面。我还需要提到的是我们是通过可视电话来完成这一工作的，使我们能做出即时的视觉诊断。
IC: What are some the advantages of mechanical embolus removal and some of the risks? How do you prevent vascular injury?
《国际循环》：机械血栓清除的优点和缺点是什么？在做这项手术的时候如何避免血管损伤？
Dr. Liebeskind: Mechanical approaches have benefit in terms of control from a recanalization standpoint. Drugs are obviously more complex. Drug delivery is not as focal or local and therefore more difficult to control. We do not know anything about intraarterial dosing of thrombolytic agents， in regards to specific amounts in different vessel sizes. Another advantage is that we can control things step-wise. The double edged sword is that we have gotten so good with mechanical approaches that we have become excellent in restoring blood flow， reperfusion. While reperfusion is often the goal of therapy， the ultimate goal， or what I suggest as “definitive reperfusion，” is reperfusion without hemorrhage and with clinical benefit at day 90. Avoiding reperfusion injury， whether it is hemorrhagic or ischemic reperfusion injury， is the real challenge.
Dr. Liebeskind:机械性方法的优点是从再通的角度来讲的。药物的作用明显更复杂。给药并不能精确控制它能到达病灶区，因此效果很难控制。我们并不清楚溶栓药物在动脉内的剂量，也就是在不同直径的血管内药物的特定量有多少。机械性治疗的另一个优点是我们能通过分步法控制治疗。机械性治疗也是一把双刃剑，我们已经通过机械性治疗取得了良好的血流恢复效果，也就是再灌注。再灌注通常是治疗的目的，终极目标，或我认为的“绝对的再灌注”，也就是在90天时出现临床效果的没有出血的再灌注。真正的挑战是避免再灌注损伤，不论是出血性再灌注损伤还是缺血性再灌注损伤。
IC: Where do you imagine the research going to overcome some of these challenges?
《国际循环》：您认为克服这些挑战的研究有哪些？
Dr. Liebeskind: It will take a little while， but we will be looking from an endovascular stroke trial perspective at step-wise approaches， that is， understanding how far to go and when to call it quits in a case. Oddly enough， this is dependent on us， that we are willing to know when to call it quits. Especially in patients with malignant patterns， we need to be able to say that we are not going to treat these patients. It is a real challenge. We want to do something for these patients.
Dr. Liebeskind: 这需要一定的时间，但是我们将会用分步治疗法从血管内中风试验的方面来研究，也就是，理解一个病例会进展到何种程度并在何时放弃治疗。奇怪的是，这依赖于我们自己，我们正试图了解什么时候应放弃治疗。特别是对于那些病情严重的患者，我们需要对患者家属说出我们将不再治疗这些患者的话。这是一个真正的挑战。我们想为这些患者做些事情。
IC: Does this rely on the imaging?
《国际循环》：这些是否依赖于影像学的结果？
Dr. Liebeskind: If you have an imaging pattern that suggests a malignant course， we may want to do something， but our ultimate outcome may be modest.
Dr. Liebeskind: 如果患者的影像学结果表明情况很严重，我们可能希望做一些事情，但是我们最终的结果可能并不乐观。
IC: Your talk emphasized the importance of collaterals in stroke therapy. What kind of research supports this opinion?
《国际循环》：您的演讲中强调了侧支血管在中风治疗中的重要性，有哪些支持这些观点的研究？
Dr. Liebeskind: Paradoxically， the entire literature on blood flow in the brain started with collateral flow， rather than arterial occlusions. The recognition， especially using angiography， that arterial occlusion was a cause of stroke was only defined decades ago. The understanding of flow is much older than that， centuries old. The recent advances have been in the forms of complimentary imaging， such as CT and MRI. We use multimodal approaches to compliment our angiographic studies to define where these collaterals are and to look at the resultant downstream perfusion. You have to define where this data comes from. When you are speaking about collateral perfusion， if you have an MCA occlusion， the flow in the territory is all via collaterals， so all profusion studies， whether a CT， MRI， PET， or any nuclear study will be of collaterals. That may be different with stenosis or a submaximal occlusion. When we talk about flow， when we talk about salvageable tissue， when we talk about mismatch， these are all new terminology for collateral sustenance of the brain. Only certain groups have been involved in the specific research and evidence in terms of collaterals， though the interest has been mounting very quickly in the last several years. The more people look at collaterals， the more people are appreciating this and starting to take heed and consider them in terms of outcomes.
Dr. Liebeskind: 自相矛盾的是，关于大脑血流的所有文献都开始于侧枝循环，而不是动脉闭塞。动脉闭塞是引起中风的原因只是在十几年前定义的，这种认识尤其是通过血管造影术得到的。而对血流的认识比这一观点要古老很多，有百年的历史。最近的进展是在互补成像方面，比如CT和MRI。我们应用了多模式的方法来完成我们的血管造影研究，来阐明这些侧枝循环在哪里并了解它们下游的灌注情况。你需要明确这些数据的来源。当你谈到侧枝循环灌注的时候，如果你发生了MCA闭塞，病变部位的血流完全通过侧枝循环，因此所有的研究，不论是CT，MRI，PET或任何核素研究都将是关于侧枝循环的。这时研究狭窄或亚极量闭塞将很困难。当我们谈到血流的时候，当我们谈到未梗死组织时，当我们谈到失配，这些都是用于描述维持大脑的侧枝循环的新术语。只有特定的组被纳入了特定的研究并确定为侧枝循环，这一研究领域最近几年里发展非常迅速。人们对侧枝循环的研究越多，对它的了解就越多，就会开始关注侧枝循环并认识到它是一种结果。
IC: You mentioned angiogenesis in your talk. What is the time frame for this?
《国际循环》：您在演讲中谈到了血管生成。请问血管生成大概需要多久？
Dr. Liebeskind: Angiogenesis， more specifically arteriogenesis， takes place immediately after stroke onset or vascular occlusion. Recruitment of collaterals and growth of preexisting collateral arterioles takes place almost immediately. This is not a process we have to wait for. Our imaging is actually showing this， both who does and who does not have collaterals as well as the attempted growth or arteriogenesis and collateralization process itself.
Dr. Liebeskind: 血管生成，更具体的说是动脉生成，在中风发生或血管闭塞后会立即发生。启用侧枝循环和已经存在的侧枝动脉的生长几乎是立即发生的。但这不是一个我们能等待的过程。我们的影像学实际上正显示了这一过程，不论是否有侧枝循环，或者正在长出侧枝循环或动脉生成以及侧枝化都会促进血管自身侧枝化。
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