RESUMO
A meta-analysis was performed to assess randomized controlled trials comparing local endovascular therapy (with and without intravenous thrombolysis) versus standard care (intravenous thrombolysis alone when appropriate) for acute ischemic stroke. Local endovascular therapy showed a significant improvement in functional independence versus standard care (odds ratio, 1.779; 95% confidence interval, 1.262-2.507; P < .001). This benefit strengthened further on subgroup analyses of trials in which a majority of cases used stent retrievers, trials with intravenous thrombolysis use in both arms when appropriate, and trials that required preprocedural imaging of all patients. There were no significant differences between arms in terms of mortality, hemicraniectomy, intracranial hemorrhage, and cerebral edema rates (P > .05). In conclusion, in the treatment of acute ischemic stroke, local endovascular therapy leads to improved functional independence compared with standard care.
Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Terapia Trombolítica , Administração Intravenosa , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Circulação Cerebrovascular , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Fibrinolíticos/efeitos adversos , Humanos , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do TratamentoAssuntos
Isquemia Encefálica/terapia , Educação de Pós-Graduação em Medicina , Radiografia Intervencionista/normas , Radiologistas/educação , Radiologistas/normas , Radiologia Intervencionista/educação , Radiologia Intervencionista/normas , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Certificação/normas , Competência Clínica/normas , Consenso , Currículo , Técnica Delphi , Educação de Pós-Graduação em Medicina/normas , Humanos , Sociedades Médicas , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Resultado do TratamentoAssuntos
Derivação Arteriovenosa Cirúrgica/normas , Implante de Prótese Vascular/normas , Diagnóstico por Imagem/normas , Procedimentos Endovasculares/normas , Oclusão de Enxerto Vascular/terapia , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Diálise Renal/normas , Trombose/terapia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Consenso , Técnica Delphi , Procedimentos Endovasculares/efeitos adversos , Medicina Baseada em Evidências/normas , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Valor Preditivo dos Testes , Fluxo Sanguíneo Regional , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/fisiopatologia , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
PURPOSE: To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients. METHODS: Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled. Baseline, 30-day, and follow-up clinical and angiographic information were collected. Rates of clinical and angiographic endpoints were compared between patients >or=80 years old versus those <80 years. RESULTS: Patients >or=80 years (n = 15) were more likely to be hypertensive (87% versus 69%) and have underlying coronary artery disease (73% versus 36%, p<0.05) compared to younger patients (n = 229). The rate of periprocedural stroke and/or death was 3-fold higher among patients aged >or=80 years compared with those <80 years (20% versus 7%, p = 0.11). No recurrent stroke or death (excluding periprocedural events) was observed during follow-up in the octogenarian group. In patients who had follow-up angiography, a similar rate of >or=50% restenosis was observed among patients aged >or=80 years and those aged <80 years (25% versus 29%, p>0.1). CONCLUSION: The 3-fold higher periprocedural death and/or stroke rate suggests cautious use of intracranial angioplasty and/or stent placement in octogenarians.
Assuntos
Angioplastia/efeitos adversos , Angioplastia/instrumentação , Arteriosclerose Intracraniana/terapia , Stents , Acidente Vascular Cerebral/etiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Distribuição de Qui-Quadrado , Constrição Patológica , Feminino , Humanos , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/mortalidade , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Recidiva , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto JovemAssuntos
Angiografia Cerebral/normas , Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/terapia , Neuroimagem/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Radiografia Intervencionista/normas , Adulto , Humanos , Guias de Prática Clínica como Assunto , Estados UnidosRESUMO
Epistaxis is not uncommon, with up to 60% of the population suffering from at least one episode in their lifetime and as many as 6% presenting for medical attention. An analysis of emergency room (ER) visits in the United States between 2009 and 2011 identified 1.2 million encounters for epistaxis, accounting for 0.32% of ER visits. Approximately 6% of patients will require more aggressive, invasive management in the form of transnasal ligation of the sphenopalatine artery or endovascular embolization. This article reviews the epidemiology, rationale for endovascular treatment, strategy for treatment, endovascular technique, postprocedural follow-up, and complications and their management.
RESUMO
BACKGROUND AND PURPOSE: We sought to compare the clinical outcomes between primary angioplasty and stent placement for symptomatic intracranial atherosclerosis. METHODS: We retrospectively analyzed the clinical and angiographic data of 190 patients treated with 95 primary angioplasty procedures and 98 intracranial stent placements (total of 193 procedures) in 3 tertiary care centers. Stroke and combined stroke and/or death were identified as primary clinical end points during the periprocedural and follow-up period of 5 years. The rates of significant postoperative residual stenosis (>/=50% of greater stenosis immediately after the procedure) and binary restenosis (>/=50% stenosis at follow-up angiography within 3 years) were also compared. The comparative analysis was performed after adjusting for age, sex, and center. RESULTS: Fourteen procedures in the angioplasty-treated group (15%) and 4 in the stent-treated group (4.1%) had significant postoperative residual stenosis (relative risk [RR]=2.8, 95% CI, 0.85 to 9.5, P=0.09, for the adjusted model). There were 3 periprocedural deaths (1.5%), 1 in the angioplasty group (1.1%) and 2 in the stent-treated group (2.0%) and 14 periprocedural strokes (7.3%), 7 periprocedural strokes in each group (7.4% and 7.1%, respectively; hazard ratio=1.1; 95% CI, 0.57 to 1.9, P=0.85). Angiographic follow-up was available for 134 procedures (66 angioplasty-treated and 68 stent-treated cases). Forty-eight procedures (36.1%) had evidence of binary restenosis (25 of 66 angioplasties, 23 of 68 stents, P=0.85). Binary restenosis-free survival at 12 months was 68% for the angioplasty-treated group and 64% for the stent-treated group. There was no difference in follow-up survival (stroke, or stroke and/or death) between the angioplasty-treated and the stent-treated groups (hazard ratio=0.54; 95% CI, 0.11 to 2.5, P=0.44 and hazard ratio=0.50; 95%, CI 0.17 to 1.5, P=0.22, respectively, after adjusting for age, sex, and center). The stroke- and/or death-free survival at 2 years for the angioplasty-treated group and the stent-treated group was 92+/-4% and 89+/-5%, respectively. CONCLUSIONS: Stent treatment for intracranial atherosclerosis may lower the rate of significant postoperative residual stenosis compared with primary angioplasty alone. No benefit of stent placement over primary angioplasty in reducing stroke or stroke and/or death could be identified in this study.
Assuntos
Angioplastia/efeitos adversos , Angioplastia/instrumentação , Arteriosclerose Intracraniana/terapia , Stents/efeitos adversos , Stents/estatística & dados numéricos , Distribuição por Idade , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Recidiva , Estudos Retrospectivos , Medição de Risco , Distribuição por Sexo , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoAssuntos
Descompressão Cirúrgica/métodos , Descompressão Cirúrgica/normas , Nutrição Enteral/métodos , Nutrição Enteral/normas , Gastroenteropatias/terapia , Intubação Gastrointestinal/normas , Cecostomia/normas , Contraindicações , Descompressão Cirúrgica/efeitos adversos , Nutrição Enteral/efeitos adversos , Nutrição Enteral/economia , Gastrostomia/normas , Humanos , Intubação Gastrointestinal/efeitos adversos , Jejunostomia/normasRESUMO
BACKGROUND AND PURPOSE: Medical treatment of symptomatic intracranial stenosis carries a high risk of stroke. This study was done to evaluate the clinical and angiographic outcomes after intracranial angioplasty for this disease. METHODS: A total of 120 patients with 124 intracranial stenoses were treated by primary angioplasty. All patients had neurologic symptoms (stroke or transient ischemic attack) attributable to intracranial stenoses > or =50%. Angiograms were evaluated before and after angioplasty for the degree of stenosis. RESULTS: Pretreatment stenoses varied from 50% to 95% (mean 82.2+/-10.2). Post-treatment stenoses varied from 0% to 90% (mean 36.0+/-20.1). There were 3 strokes and 4 deaths (all neurological) within 30 days of the procedure, giving a combined periprocedural stroke and death rate of 5.8%. A total of 116 patients (96.7%) were available for a mean follow-up time of 42.3 months. There were 6 patients who had a stroke in the territory of treatment and 5 additional patients with stroke in other territories. Ten deaths occurred during the follow-up period, none of which were neurological. Including the periprocedural stroke and deaths, this yielded an annual stroke rate of 3.2% in the territory of treatment and a 4.4% annual rate for all strokes. CONCLUSIONS: Intracranial angioplasty can be performed with a high degree of technical success and a low risk of complications. Long-term clinical follow-up of intracranial angioplasty patients demonstrates a risk of future strokes that compares favorably to patients receiving medical therapy.