脑卒中识别与二级预防：时间窗与长期防复发

先看懂四件事：怎么识别卒中、为什么时间关键、急性期怎么治、长期怎么防复发Stroke Recognition & Secondary Prevention

卒中救治是一条与时间赛跑的链条：识别（BE-FAST）→ 呼叫急救（直达卒中中心）→ 影像评估（CT／血管／灌注）→ 再灌注治疗（溶栓或取栓）→ 二级预防与康复。任何一环延迟，都会直接转化为更多的残疾。

发病机理：血栓、栓塞与危险因素的共同作用Pathogenesis

卒中不是单一疾病：动脉粥样硬化导致原位血栓、房颤导致心源性栓塞、小血管病变导致腔隙性梗死，机制不同，二级预防策略也不同——这正是「病因分型」重要的原因。

哪些因素增加卒中与复发风险

两个容易被忽略的问题

怎么检查：影像、血管与心脏Assessment

怎么治疗：溶栓、取栓与二级预防Treatment

治疗与预防一览

日常管理：怎么防复发：用药与生活方式Daily Management

十个常见误区Ten Common Misconceptions

参考文献与证据来源References & Evidence

本页共 24 条文献，来自国际共识与指南、随机对照试验、荟萃分析与机制研究，链接指向 PubMed。每条结论后的编号对应下方文献；证据不足或结论不一致之处已在正文标注。

1. 回顾性分析（BE-FAST 减少卒中漏诊的比例）Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke. 2017;48(2):479-481. pubmed.ncbi.nlm.nih.gov/28082668
2. 汇总分析（静脉溶栓治疗时间与结局）Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, Albers GW, Kaste M, Marler JR, Hamilton SA, Tilley BC, Davis SM, Donnan GA, Hacke W, ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group, Allen K, Mau J, Meier D, del Zoppo G, De Silva DA, Butcher KS, Parsons MW, Barber PA, Levi C, Bladin C, Byrnes G. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet (London, England). 2010;375(9727):1695-1703. pubmed.ncbi.nlm.nih.gov/20472172
3. 多中心研究（中国急性缺血性卒中院前延误及影响因素）Su Y, Qi W, Yu Y, Zhu J, Shi X, Wu X, Chi F, Xia R, Qin L, Cao L, Yang Y, Liu Q, Peng X, Huang G, Chen J, Xue Y, Guan W, Gao D, Ye B, Ren L. Analysis of prehospital delay in acute ischaemic stroke and its influencing factors: a multicentre prospective case registry study in China. Stroke and vascular neurology. 2025;10(5):637-647. pubmed.ncbi.nlm.nih.gov/40037663
4. 基于全国数据的负担估算（2020 年中国卒中负担）Tu WJ, Zhao Z, Yin P, Cao L, Zeng J, Chen H, Fan D, Fang Q, Gao P, Gu Y, Tan G, Han J, He L, Hu B, Hua Y, Kang D, Li H, Liu J, Liu Y, Lou M, Luo B, Pan S, Peng B, Ren L, Wang L, Wu J, Xu Y, Xu Y, Yang Y, Zhang M, Zhang S, Zhu L, Zhu Y, Li Z, Chu L, An X, Wang L, Yin M, Li M, Yin L, Yan W, Li C, Tang J, Zhou M, Wang L. Estimated Burden of Stroke in China in 2020. JAMA network open. 2023;6(3):e231455. pubmed.ncbi.nlm.nih.gov/36862407
5. 随机对照试验（阿替普酶治疗急性缺血性卒中：NINDS）National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The New England journal of medicine. 1995;333(24):1581-1587. pubmed.ncbi.nlm.nih.gov/7477192
6. 随机对照试验（发病 3–4.5 小时阿替普酶溶栓：ECASS III）Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D, ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England journal of medicine. 2008;359(13):1317-1329. pubmed.ncbi.nlm.nih.gov/18815396
7. 随机对照试验（灌注成像指导、发病 9 小时内溶栓：EXTEND）Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, Kleinig TJ, Wijeratne T, Curtze S, Dewey HM, Miteff F, Tsai CH, Lee JT, Phan TG, Mahant N, Sun MC, Krause M, Sturm J, Grimley R, Chen CH, Hu CJ, Wong AA, Field D, Sun Y, Barber PA, Sabet A, Jannes J, Jeng JS, Clissold B, Markus R, Lin CH, Lien LM, Bladin CF, Christensen S, Yassi N, Sharma G, Bivard A, Desmond PM, Yan B, Mitchell PJ, Thijs V, Carey L, Meretoja A, Davis SM, Donnan GA, EXTEND Investigators. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. The New England journal of medicine. 2019;380(19):1795-1803. pubmed.ncbi.nlm.nih.gov/31067369
8. 随机对照试验（MRI 指导的发病时间不明卒中溶栓：WAKE-UP）Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho TH, Fazekas F, Fiehler J, Ford I, Galinovic I, Gellissen S, Golsari A, Gregori J, Günther M, Guibernau J, Häusler KG, Hennerici M, Kemmling A, Marstrand J, Modrau B, Neeb L, Perez de la Ossa N, Puig J, Ringleb P, Roy P, Scheel E, Schonewille W, Serena J, Sunaert S, Villringer K, Wouters A, Thijs V, Ebinger M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Gerloff C, WAKE-UP Investigators. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. The New England journal of medicine. 2018;379(7):611-622. pubmed.ncbi.nlm.nih.gov/29766770
9. 随机对照试验（替奈普酶与阿替普酶在取栓前桥接治疗的比较）Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, Yan B, Bush SJ, Dewey HM, Thijs V, Scroop R, Simpson M, Brooks M, Asadi H, Wu TY, Shah DG, Wijeratne T, Ang T, Miteff F, Levi CR, Rodrigues E, Zhao H, Salvaris P, Garcia-Esperon C, Bailey P, Rice H, de Villiers L, Brown H, Redmond K, Leggett D, Fink JN, Collecutt W, Wong AA, Muller C, Coulthard A, Mitchell K, Clouston J, Mahady K, Field D, Ma H, Phan TG, Chong W, Chandra RV, Slater LA, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Bladin CF, Sharma G, Desmond PM, Parsons MW, Donnan GA, Davis SM, EXTEND-IA TNK Investigators. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. The New England journal of medicine. 2018;378(17):1573-1582. pubmed.ncbi.nlm.nih.gov/29694815
10. 随机对照试验（动脉内治疗急性缺血性卒中：MR CLEAN）Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW, MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. The New England journal of medicine. 2015;372(1):11-20. pubmed.ncbi.nlm.nih.gov/25517348
11. 随机对照试验（快速血管内治疗缺血性卒中：ESCAPE）Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD, ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. The New England journal of medicine. 2015;372(11):1019-1030. pubmed.ncbi.nlm.nih.gov/25671798
12. 随机对照试验（临床-梗死不匹配者发病 6–24 小时取栓：DAWN）Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, Sila CA, Hassan AE, Millan M, Levy EI, Mitchell P, Chen M, English JD, Shah QA, Silver FL, Pereira VM, Mehta BP, Baxter BW, Abraham MG, Cardona P, Veznedaroglu E, Hellinger FR, Feng L, Kirmani JF, Lopes DK, Jankowitz BT, Frankel MR, Costalat V, Vora NA, Yoo AJ, Malik AM, Furlan AJ, Rubiera M, Aghaebrahim A, Olivot JM, Tekle WG, Shields R, Graves T, Lewis RJ, Smith WS, Liebeskind DS, Saver JL, Jovin TG, DAWN Trial Investigators. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. The New England journal of medicine. 2018;378(1):11-21. pubmed.ncbi.nlm.nih.gov/29129157
13. 随机对照试验（灌注筛选下发病 6–16 小时取栓：DEFUSE 3）Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, Sarraj A, Kasner SE, Ansari SA, Yeatts SD, Hamilton S, Mlynash M, Heit JJ, Zaharchuk G, Kim S, Carrozzella J, Palesch YY, Demchuk AM, Bammer R, Lavori PW, Broderick JP, Lansberg MG, DEFUSE 3 Investigators. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. The New England journal of medicine. 2018;378(8):708-718. pubmed.ncbi.nlm.nih.gov/29364767
14. 随机对照试验（氯吡格雷联合阿司匹林治疗小卒中或 TIA：CHANCE）Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J, Dong Q, Xu A, Zeng J, Li Y, Wang Z, Xia H, Johnston SC, CHANCE Investigators. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. The New England journal of medicine. 2013;369(1):11-19. pubmed.ncbi.nlm.nih.gov/23803136
15. 随机对照试验（氯吡格雷与阿司匹林用于急性缺血性卒中与高危 TIA：POINT）Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY, Clinical Research Collaboration, Neurological Emergencies Treatment Trials Network, and the POINT Investigators. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. The New England journal of medicine. 2018;379(3):215-225. pubmed.ncbi.nlm.nih.gov/29766750
16. 随机对照试验（达比加群与华法林在房颤中的比较：RE-LY）Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L, RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. The New England journal of medicine. 2009;361(12):1139-1151. pubmed.ncbi.nlm.nih.gov/19717844
17. 随机对照试验（阿哌沙班与华法林在房颤中的比较：ARISTOTLE）Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L, ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. The New England journal of medicine. 2011;365(11):981-992. pubmed.ncbi.nlm.nih.gov/21870978
18. 系统评价与荟萃分析（新型口服抗凝药在房颤中的疗效与安全性）Dentali F, Riva N, Crowther M, Turpie AG, Lip GY, Ageno W. Efficacy and safety of the novel oral anticoagulants in atrial fibrillation: a systematic review and meta-analysis of the literature. Circulation. 2012;126(20):2381-2391. pubmed.ncbi.nlm.nih.gov/23071159
19. 荟萃分析（老年房颤患者直接口服抗凝药的疗效与危害）Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M. Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis. Circulation. 2015;132(3):194-204. pubmed.ncbi.nlm.nih.gov/25995317
20. 随机对照试验（培哚普利为基础的降压治疗与卒中复发：PROGRESS）PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet (London, England). 2001;358(9287):1033-1041. pubmed.ncbi.nlm.nih.gov/11589932
21. 系统评价（TIA 后早期卒中风险估计）Valls J, Peiro-Chamarro M, Cambray S, Molina-Seguin J, Benabdelhak I, Purroy F. A Current Estimation of the Early Risk of Stroke after Transient Ischemic Attack: A Systematic Review and Meta-Analysis of Recent Intervention Studies. Cerebrovascular diseases (Basel, Switzerland). 2017;43(1-2):90-98. pubmed.ncbi.nlm.nih.gov/27992865
22. 随机对照试验（急性脑出血快速降压：INTERACT2）Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J, INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. The New England journal of medicine. 2013;368(25):2355-2365. pubmed.ncbi.nlm.nih.gov/23713578
23. 随机对照试验（急性脑出血强化降压：ATACH-2）Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW, ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. The New England journal of medicine. 2016;375(11):1033-1043. pubmed.ncbi.nlm.nih.gov/27276234
24. Cochrane 系统评价（组织化卒中单元住院照护）Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. The Cochrane database of systematic reviews. 2013;(9):CD000197. pubmed.ncbi.nlm.nih.gov/24026639