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1.
Medicine (Baltimore) ; 99(9): e19247, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32118730

RESUMEN

RATIONALE: The capsular warning syndrome (CWS) is a rare and special type of transient ischemic attacks (TIAs) syndrome. The pathophysiology of CWS is very complicate, and intracranial atherosclerotic stenosis (ICAS) is rare cause. Moreover, the effective and standard therapy has not yet been established. PATIENT CONCERNS: A 47-year-old man experienced repeated and exacerbated TIAs of right hemiparesis and dysarthria. Fourteen hours after the first episode of TIAs, he developed more severe right hemiparesis and dysarthria, the National Institute of Health Stroke Scale (NIHSS) score was 12 points, and did not recover in a long time. DIAGNOSIS: The computed tomography (CT) angiography displayed high stenosis in the M1 segment of the left middle cerebral artery. The patient was diagnosed as CWS with ICAS. INTERVENTIONS: Loading dose of clopidogrel and aspirin were started but were ineffective, then we used recombinant tissue plasminogen (r-tPA) for thrombolysis therapy after repeat CT scan that showed small acute infarcts in the right putamen and no bleeding. OUTCOMES: The patient was successfully treated by r-tPA intravenous thrombolysis after loading dose of dual-anti-platelet. He recovered rapidly, and the NIHSS score was 0 point, modified Rankin Scale score was 0 point, and Barthel Index score was 100 points at 3-month follow-up. LESSONS: r-tPA combined with loading dose of dual antiplatelet appears safe and effective in carefully selected CWS patients with ICAS. The collection of similar cases and further randomized controlled trial research would be desirable.


Asunto(s)
Fibrinolíticos/uso terapéutico , Arteriosclerosis Intracraneal/tratamiento farmacológico , Ataque Isquémico Transitorio/tratamiento farmacológico , Aspirina/administración & dosificación , Aspirina/uso terapéutico , Clopidogrel/administración & dosificación , Clopidogrel/uso terapéutico , Angiografía por Tomografía Computarizada , Diagnóstico Diferencial , Fibrinolíticos/administración & dosificación , Humanos , Arteriosclerosis Intracraneal/complicaciones , Arteriosclerosis Intracraneal/diagnóstico por imagen , Ataque Isquémico Transitorio/complicaciones , Ataque Isquémico Transitorio/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Arteria Cerebral Media/diagnóstico por imagen , Síndrome , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/uso terapéutico , Tomografía Computarizada por Rayos X
2.
Medicine (Baltimore) ; 99(2): e18680, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31914063

RESUMEN

The prognosis of acute ischemic stroke patients treated with intravenous (IV) recombinant tissue plasminogen activator (rtPA) is poorer in patients with atrial fibrillation (AF) than patients without AF, which might be related to the greater stroke severity in AF patients. Higher pre-stroke CHA2DS2-VASc scores are associated with greater stroke severity and poorer outcomes. AF Patients tend to have higher CHA2DS2-VASc scores than the non-AF patients. We thus hypothesized that pre-stroke CHA2DS2-VASc scores can be used to improve outcome stratification of IV thrombolysis therapy in acute stroke patients with and without AF. We retrospectively enrolled ischemic stroke patients who received IV-rtPA and categorized them into 2 groups: low-risk (CHA2DS2-VASc scores ≤ 2) and high-risk (CHA2DS2-VASc scores ≥ 3) groups. We compared the outcomes between AF and non-AF patients and the interactive effects of the levels of CHA2DS2-VASc scores on this outcome difference. In the low-risk group, there was no difference in outcomes between the AF and non-AF patients. In the high-risk group, the AF patients had worse outcomes at 3 and 6 months. Our results suggest that pre-stroke CHA2DS2-VASc scores are a useful outcome predictor of IV thrombolytic therapy in acute stroke patients with AF.


Asunto(s)
Fibrilación Atrial/complicaciones , Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Activador de Tejido Plasminógeno/administración & dosificación
3.
J Stroke Cerebrovasc Dis ; 29(2): 104537, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31806454

RESUMEN

BACKGROUND AND PURPOSE: The safety and efficacy of intravenous thrombolytic therapy (IVT) for posterior circulation stroke (PCS) in the real world are rarely studied. This study was designed to evaluate the prestroke and baseline characteristics, stroke sub-types, complications, and outcomes of PCS patients and compare them with anterior circulation stroke (ACS) after intravenous thrombolysis. METHODS: Data of consecutive patients with PCS and ACS treated with alteplase in a standard dose of 0.9 mg/kg in our stroke center were collected and analyzed retrospectively. Presenting characteristics, hemorrhage transformation, mortality, and favorable outcomes (modified Rankin scale 0 or 1) at 90 days were compared between PCS and ACS patients. RESULTS: A total of 462 patients were included in this study, including 350 (75.8%) in ACS group and 112 (24.2%) in PCS group. A history of coronary artery disease was significantly more common in ACS patients than that in PCS patients (15.1% versus 6.3%, P = .015). There was no significant difference in fast glucose and baseline NIHSS scores between PCS and ACS groups. In PCS group, 7 patients (6.3%) had hemorrhage transformation after IVT and 5 patients (4.5%) were symptomatic versus 32 (9.1%) and 22 (6.3%) in ACS group (P > .05). 75.5% PCS patients versus 72.2% ACS patients had excellent recovery outcomes (mRS 0-1) at 90 days (P = .507). For PCS patients, logistic regression analysis after adjusting the covariates identified age (P = .047, OR .920, 95% CI = .847-.999) and atrial fibrillation (P = .007, OR 12.149, 95% CI = 1.966-75.093) as independent significant predictors of hemorrhage transformation. In addition, atrial fibrillation was also an independent predictor of symptomatic intracranial hemorrhage (P = .008, OR 21.176, 95% CI = 2.228-201.273). Multivariate logistic analysis identified hemorrhage transformation (P = .012; OR .131, 95% CI = .027-.644) and onset to drug time (P = .026, OR 1.006, 95% CI = 1.001-1.011) as independent predictors of functional independence (mRS 0-2). Symptomatic intracranial hemorrhage (P = .007, OR 15.094, 95% CI = 2.097-108.661) and baseline NIHSS score (P = .050; OR 1.070, 95% CI = 1.000-1.145) were independent predictors of mortality. CONCLUSION: Our results suggest that IVT in PCS patients is safe and effective as that in ACS patients. In PCS patients, long onset to needle time and hemorrhage transformation were identified as independent predictors of unfavorable outcomes.


Asunto(s)
Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Factores de Edad , Anciano , Circulación Cerebrovascular , Evaluación de la Discapacidad , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intravenosas , Hemorragias Intracraneales/inducido químicamente , Masculino , Persona de Mediana Edad , Recuperación de la Función , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Factores de Tiempo , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
4.
World Neurosurg ; 133: 266-270, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31605861

RESUMEN

BACKGROUND: Residual hematoma after operative management of acute subdural hematoma contributes to reoperation and is cited as a reason for deferment of less invasive drainage strategies. Although local antithrombolytic therapy has been studied in intracerebral hemorrhage and chronic subdural hematoma, to date there are no reports of recombinant tissue plasminogen activator for residual hematoma post drainage for acute subdural hematoma. CASE DESCRIPTION: Two patients presented with altered mental status secondary to acute-on-chronic subdural hematomas and underwent emergent craniotomies. The first, a 78-year-old man, had poor subdural drain output and deteriorated with seizures and evidence of new acute subdural hematoma formation. Recombinant tissue plasminogen activator was injected through the subdural catheter on postoperative day 3. The second patient, a 64-year-old male, received recombinant tissue plasminogen activator postoperatively. Subsequently, both experienced good subdural drainage, clinical and radiologic improvement, and successful discharge to a skilled nursing facility. CONCLUSIONS: Subdural thrombolytic therapy can improve hematoma evacuation. A potential implication of this is facilitation of minimally invasive options such as twist-drill craniotomy, previously deferred due to inadequate evacuation. However, there is a paucity of evidence and more research is needed to substantiate the safety and efficacy, refine this technique, and guide patient selection.


Asunto(s)
Fibrinolíticos/administración & dosificación , Hematoma Subdural/tratamiento farmacológico , Espacio Subdural/cirugía , Activador de Tejido Plasminógeno/administración & dosificación , Anciano , Progresión de la Enfermedad , Drenaje , Fibrinolíticos/uso terapéutico , Hematoma Subdural/cirugía , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del Tratamiento
5.
J Stroke Cerebrovasc Dis ; 29(2): 104541, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31810719

RESUMEN

BACKGROUND AND AIMS: The characteristics of clot causing acute ischemic stroke, such as size, content, and location, are among the main determinants of response to intravenous tissue plasminogen activator [IV tPA]. Clot heterogeneity and permeability are under-recognized features that might provide additional information in predicting the efficacy of IV tPA. METHODS AND PATIENTS: Patients with proximal middle cerebral artery occlusion treated with "IV tPA alone" were included. The mean Hounsfield's unit (HU) value, as objective measure of clot attenuation, and its standard deviation (SD), as proposed measure of clot heterogeneity, were obtained. The difference in HU values between CT Angiography and CT was defined as "clot permeability", or "perviousness'. The size (length and volume-mm3) of pre-clot pouch and occluding clot along with ASPECT score and Maas' silvian and leptomeningeal collateral score were measured. RESULTS: The study included 84 cases (44 women, age: 68 ± 14 years, pretPA NIHSS: 16 ± 5). Patients with excellent response to tPA (31%) had lower thrombus volume (37.54 ± 32.37 versus 63.49 ± 37.36, P = .009) and heterogeneity (4.05 ± 1.49 versus 5.35 ± 2.34, P = .011), along with higher clot permeability (48 ± 35.48 to 31.32 ± 18.62, P = .006). However, significance of permeability did not survived in the regression analysis with adjustment for NIHSS (ß:-.296, P = .003); clot volume (ß:-.240, P = .014) and collateral status (ß:.346, P < .001). In patients with good prognosis, clot volume was significantly lower (37.76 ± 30.08 versus 67.57 ± 37.83, P < .001), whereas permeability was significantly higher (43.97 ± 32.33 versus 31.13 ± 19.01, P = .026). However, this effect did not persist in the regression analysis after adjustment for NIHSS (ß:-.399, P < .001), collateral status (ß: .343, P < .001) and clot volume (ß:-.297, P = .001). Clot permeability was significantly higher (45.78 ± 36.34 versus 33 ± 20.2, P = .045) and heterogeneity was lower (4.1 ± 1.55 to 5.27 ± 2.32, P = .028) in patients with dramatic response to tPA (27%). In patients responding positively to IV tPA (48%), clot permeability was numerically higher (39.85 ± 31.79 to 33.47 ± 19.28, P = .268), while clot volume (48.15 ± 34.5 to 62.07 ± 39.62, P = .093) was lower. Clot volume, permeability and heterogeneity did not show a significant difference in any (38.1%) or symptomatic (8.3%) bleeders after IV tPA. The chance of IV tPA to be beneficial increased in patients with clot volume lower than 45 mm3, with an increased likelihood of this benefit to be observed within the first day after IV tPA. Our detailed explorative ROC analysis was not able to detect a volume threshold above which the positive effect of IV tPA disappeared. CONCLUSION: Clot volume is critical for the effectiveness of IV tPA in acute ischemic stroke. Clot permeability and heterogeneity may modify its effect. CT technologies, which are readily available when evaluating a stroke patient in an emergency setting, provide us with useful parameters regarding the size, permeability and heterogeneity of the clot.


Asunto(s)
Coagulación Sanguínea , Fibrinolíticos/administración & dosificación , Infarto de la Arteria Cerebral Media/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Anciano , Anciano de 80 o más Años , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infarto de la Arteria Cerebral Media/sangre , Infarto de la Arteria Cerebral Media/diagnóstico , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Permeabilidad , Recuperación de la Función , Sistema de Registros , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
6.
J Stroke Cerebrovasc Dis ; 29(2): 104474, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31784381

RESUMEN

OBJECTIVE: To study the rate of symptomatic intracerebral hemorrhage (SxICH) and major systemic hemorrhage (MSH) after acute stroke treatments among different ethnicities/races. BACKGROUND: Studies have reported ethnic/racial disparities in intravenous tPA treatment (IV tPA). The adverse outcome of tPA and/or intra-arterial intervention (IA) among different ethnicities/races requires investigation. METHODS: We retrospectively reviewed all patients from an IRB-approved registry between June 2004 and June 2018. Patients who received IV tPA, IA, or both for acute stroke were identified and classified into 2 ethnic groups: non-Hispanics or Hispanics (NH/H) and 4 racial groups: Asian, Black, Other (Native Americans and Pacific Islanders), and White (A/B/O/W). RESULTS: We identified 916 patients that received acute therapy (A/B/O/W: n = 50/104/16/746, H/NH: n = 184/730). For those received IV tPA only (n = 759), IA only (n = 85), and IV tPA+IA (n = 72), the SxICH rate was 4.3%, 4.7%, and 6.9%; the MSH rate was 1.3%, 0%, and 0%, respectively. No significant difference in the rate of SxICH or MSH among different racial or ethnic groups was found after either therapy. Asian race (OR 14.17, P = .01), in association with age, international normalized value (INR), and Partial thromboplastin time (PTT) (OR 1.06, 46.52, and 1.18, P = .020, 0.037, and 0.042, respectively), was predictive of SxICH after IV tPA. There was a significant correlation between age and National Institute of Health Stroke Scale with SxICH (P < .01, P = .02, respectively). Age, INR, and PTT were independent predictors of SxICH after IV tPA (OR 1.06, 46.52, and 1.18, P = .02, 0.04, and 0.04, respectively). CONCLUSIONS: There was no significant difference in the rate of SxICH or MSH after IV tPA, IA, or IV tPA+IA among different racial or ethnic groups. Larger studies are needed to elucidate the race specific causes of SxICH and MSH after acute stroke treatment.


Asunto(s)
Grupos de Población Continentales , Procedimientos Endovasculares , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/terapia , Trombectomía , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Afroamericanos , Factores de Edad , Americanos Asiáticos , California/epidemiología , Hemorragia Cerebral/inducido químicamente , Hemorragia Cerebral/etnología , Terapia Combinada , Procedimientos Endovasculares/efectos adversos , Grupo de Ascendencia Continental Europea , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intravenosas , Relación Normalizada Internacional , Tiempo de Tromboplastina Parcial , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/sangre , Accidente Cerebrovascular/diagnóstico , Trombectomía/efectos adversos , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
7.
J Stroke Cerebrovasc Dis ; 29(2): 104525, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31812455

RESUMEN

BACKGROUND AND PURPOSE: A subset of ischemic stroke patients present with blood pressures above that considered safe for thrombolytic administration, requiring antihypertensive therapy. Guideline statements are ambivalent regarding which antihypertensive agent should be used to obtain a satisfactory blood pressure < 185/110 mm Hg prior to alteplase. METHODS: We reviewed data from consecutive patients at a single institution treated with alteplase from January 2014 to January 2019, collecting door-to-needle times, antihypertensive agent (if used), and antihypertensive-to-needle times. Patients were grouped by initial agent administered. We assessed for differences in door-to-needle times between those needing antihypertensive(s) and those who did not. Antihypertensive-to-needle times were compared across 3 antihypertensive groups (labetalol, nicardipine, and hydralazine). RESULTS: Analysis included 239 patients: 177 receiving no antihypertensive, 44 labetalol, 13 nicardipine, and 5 hydralazine. Those not administered an antihypertensive prior to alteplase had shorter door-to-needle times (52.6 minutes versus 62.1 minutes, P = .016). We found no statistical differences when comparing door-to-needle times across all groups (no med 52.6 minutes, labetalol 64.3 minutes, nicardipine 53.0 minutes, hydralazine 67.4 minutes, P = .052). No differences were found in antihypertensive-to-needle amongst the 3 antihypertensive groups (labetalol 18.75 minutes, nicardipine 12.15 minutes, hydralazine 25.40 minutes, P = .239). CONCLUSIONS: Patients requiring antihypertensives experienced slower door-to-needle times. No statistically significant changes were observed in door-to-needle times by antihypertensive used, however these results may have clinical importance. This study is limited by relatively small sample size. Pooling data from multiple institutions could provide more robust assessment and inform clinical practice.


Asunto(s)
Antihipertensivos/administración & dosificación , Presión Sanguínea/efectos de los fármacos , Fibrinolíticos/administración & dosificación , Hipertensión/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/administración & dosificación , Anciano , Antihipertensivos/efectos adversos , Esquema de Medicación , Femenino , Fibrinolíticos/efectos adversos , Humanos , Hidralazina/administración & dosificación , Hipertensión/diagnóstico , Hipertensión/fisiopatología , Infusiones Intravenosas , Labetalol/administración & dosificación , Masculino , Nicardipino/administración & dosificación , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
8.
J Stroke Cerebrovasc Dis ; 29(2): 104526, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31836356

RESUMEN

BACKGROUND AND PURPOSE: Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. We hypothesized that ENI defined as a percentage change in the National Institute of Health Stroke Scale (NIHSS) score (percent change NIHSS score) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS score (delta NIHSS score) at 24 hours. METHODS: Retrospective analysis of prospectively collected single-center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. We examined delta NIHSS score and percent change NIHSS score in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1). RESULTS: Among 586 patients who met the inclusion criteria, 194 (33.1%) had a favorable outcome at 3 months. In fully adjusted models, both delta NIHSS score (OR per point decrease 1.27; 95% confidence interval [CI] 1.19-1.36) and percent change NIHSS score (OR per 10 percent decrease 1.17; 95% CI 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS score (.755) was greater than delta NIHSS score (.613) or admission NIHSS (.694). CONCLUSIONS: Percentage change in NIHSS score may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatología , Evaluación de la Discapacidad , Femenino , Fibrinolíticos/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Recuperación de la Función , Reproducibilidad de los Resultados , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
9.
J Clin Ethics ; 30(4): 338-346, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31851625

RESUMEN

Although tissue plasminogen activator (tPA) is the only medication approved by the United States Food and Drug Administration (FDA) for acute ischemic stroke, there is no consensus about the need for informed consent for its use. As a result, hospitals throughout the U.S. have varying requirements regarding obtaining informed consent from patients for the use of tPA, ranging from no requirement for informed consent to a requirement for verbal or written informed consent. We conducted a study to (1) determine current beliefs about obtaining patients' informed consent for tPA among a large group of stroke clinicians and (2) identify the ethical, clinical, and organizational factors that influence tPA consent practices. Semi-structured interviews were conducted by trained and experienced investigators and research staff to identify key barriers to implementing acute stroke services. Part of the interview explored current beliefs and practices around informed consent for tPA. This was a multicenter study that included 38 Veterans Health Administration (VHA) hospital locations. Participants were 68 stroke team clinicians, serving primarily on the neurology (35 percent) or emergency medicine (41 percent) service. We conducted thematic analysis based on principles of grounded theory to identify codes about consent for tPA. We used interpretive convergence to ensure consistency among the individual investigators' codes and to ensure that all of the investigators agreed on coding and themes. We found that 38 percent of the stroke clinicians did not believe any form of consent was necessary for tPA, 47 percent thought that some form of consent was necessary, and 15 percent were unsure. Clinicians who believed tPA required informed consent were divided on whether consent should be written (40 percent) or verbal (60 percent). We identified three factors describing clinicians' attitudes about consent: (1) legal and policy factors, (2) ethical factors, and (3) medical factors. The lack of consensus regarding consent for tPA creates the potential for delays in treatment, uneasiness among clinicians, and legal liability. The identified factors provide a potential framework to guide discussions about developing a standard of care for acquiring the informed consent of patients for the administration of tPA.


Asunto(s)
Isquemia Encefálica/terapia , Consentimiento Informado , Accidente Cerebrovascular/terapia , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Actitud del Personal de Salud , Isquemia Encefálica/complicaciones , Isquemia Encefálica/diagnóstico , Hospitales de Veteranos , Humanos , Entrevistas como Asunto , Investigación Cualitativa , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/efectos adversos , Estados Unidos
10.
Rinsho Shinkeigaku ; 59(11): 699-706, 2019 Nov 08.
Artículo en Japonés | MEDLINE | ID: mdl-31656268

RESUMEN

Tissue plasminogen activator (t-PA) treatment is beneficial for patients with ischemic stroke within 4.5 h of stroke onset, because the risk of intracerebral hemorrhagic transformation (HT) increases with delayed t-PA treatment. The benefits of t-PA thrombolysis are heavily dependent on time to treatment. Development of vasoprotective drugs that attenuate HT after delayed t-PA treatment might improve the prognosis of stroke patients and extend the therapeutic time window of t-PA and endovascular thrombolysis. An angiogenic factor, vascular endothelial growth factor (VEGF), might be associated with the blood-brain barrier (BBB) disruption after focal cerebral ischemia. By using a rat thromboembolic model, delayed t-PA treatment at 4 h after ischemia promoted expression of VEGF in BBB, matrix metalloproteinase-9 (MMP-9) activation, degradation of BBB components, and HT. We demonstrated that HT was inhibited by intravenous administration of an anti-VEGF neutralizing antibody/VEGF receptor antagonist. In addition, for clinical application, reverse translation studies, a path from bedside to bench, are necessary.


Asunto(s)
Hemorragia Cerebral/inducido químicamente , Hemorragia Cerebral/prevención & control , Infarto Cerebral/tratamiento farmacológico , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/efectos adversos , Factor A de Crecimiento Endotelial Vascular/metabolismo , Animales , Barrera Hematoencefálica/metabolismo , Modelos Animales de Enfermedad , Humanos , Metaloproteinasa 9 de la Matriz/metabolismo , Terapia Molecular Dirigida , Pronóstico , Ratas , Receptores de Factores de Crecimiento Endotelial Vascular/metabolismo , Transducción de Señal/efectos de los fármacos
11.
Medicine (Baltimore) ; 98(38): e17331, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31568020

RESUMEN

RATIONALE: The regimen of the recombinant tissue plasminogen activator (rt-PA) is identical in every case where it is indicated in the treatment of cerebral infarction. We report a case of efficient recanalization of large arterial occlusion after rapid injection of rt-PA. PATIENT CONCERNS: A 78-year-old man was admitted with right-sided hemiplegia and global aphasia that occurred an hour ago. DIAGNOSES: His brain computed tomography (CT) revealed no hemorrhage, suggesting cerebral infarction. INTERVENTIONS: Ten percent of a total rt-PA dose was injected over 1 minute promptly. The remainder of rt-PA was designed to be infused for 60 minutes. Unexpectedly, during the study of CT angiography, administration of rt-PA was completed within 5 minutes. CT angiography showed occlusion from carotid bifurcation to the middle cerebral artery. OUTCOMES: After 2 hours of rt-PA administration, the patient began to regain strength in his right arm and leg. By the next day, he had only mild dysarthria and aphasia. Follow-up CT angiography revealed recanalized internal cervical artery and severe residual stenosis with a plaque. He was discharged without any neurologic symptoms. LESSONS: The infusion protocol of rt-PA administration is established in 1995 and has not changed. Successful recanalization of long segmental large vessel occlusion with only intravenous rt-PA is relatively low. In our case, a high concentration of rt-PA may have influenced the successful dissemination of large thrombus in the whole internal cervical artery. Our case is of significance as it raises the question of unanswered efficacy of diverse injection protocol according to thrombus size and bleeding risk.


Asunto(s)
Infarto Cerebral/tratamiento farmacológico , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Anciano , Infarto Cerebral/diagnóstico por imagen , Humanos , Inyecciones Intravenosas/métodos , Masculino , Neuroimagen , Proteínas Recombinantes , Factores de Tiempo , Activador de Tejido Plasminógeno/administración & dosificación , Tomografía Computarizada por Rayos X , Resultado del Tratamiento
12.
J Stroke Cerebrovasc Dis ; 28(12): 104329, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31607439

RESUMEN

BACKGROUND AND PURPOSE: The timely administration of thrombolytic therapy for acute ischemic stroke has been associated with good functional outcomes. Current guidelines recommend alteplase administration within 60 minutes in 75% of eligible patients and within 45 minutes in 50% of patients. There is limited evidence guiding these measures and their effect on outcomes. We report a single-center, retrospective assessment of the safety and efficacy of alteplase treatment within 45 minutes. METHODS: Five hundred and eighty-six patients were treated with alteplase in our emergency departments (EDs) between January 2014 and October 2016; 368 patients were included for analysis. Multivariate regression analysis was used to assess the association between door-to-alteplase (DTA) times and 90-day modified Rankin scale (mRS) scores. Incidence of intracerebral hemorrhage (ICH) was also documented. RESULTS: The median DTA time was 29 minutes versus 64 minutes in the DTA less than or equal to 45 minutes arm and more than 45 minutes arm, respectively. The primary outcome of 90-day mRS 0-1 was achieved in 56% of patients in the less than or equal to 45 minutes group versus 58% in more than 45 minutes group (P = .67). Odds of achieving mRS 0-1 were not significantly impacted by DTA times. In the multivariate regression analysis, patient characteristics associated with achieving mRS 0-1 were: younger age, male sex, not requiring intubation in the ED, and without prior history of hypertension, atrial fibrillation, or stroke. There was no significant difference in rates of ICH for patients less than or equal to 45 minutes versus more than 45 minutes. CONCLUSIONS: Rapid administration of alteplase was not associated with significantly better outcomes nor increased risk of ICH. Conclusions about efficacy are limited due to the retrospective nature of the study, small sample size, and incomplete data points.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/administración & dosificación , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatología , Hemorragia Cerebral/inducido químicamente , Evaluación de la Discapacidad , Esquema de Medicación , Servicio de Urgencia en Hospital , Femenino , Fibrinolíticos/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
13.
West Afr J Med ; 36(3): 290-293, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31625582

RESUMEN

Stroke is a leading cause of disability and mortality globally. In the first few hours after ischaemic stroke, the severity and irreversibility of brain injury increase as time passes. The primary goal of the emergent management of acute ischaemic stroke is stabilization and reperfusion of the ischaemic penumbra if eligibility criteria are met and contraindications are ruled out. The primary reperfusion strategies are administration of intravenous tissue plasminogen activator (IV tPA) and endovascular thrombectomy (EVT). Close monitoring is warranted prior to, during, and after these reperfusion procedures to detect early neurologic deterioration that may signify complications from treatment.


Asunto(s)
Isquemia Encefálica/cirugía , Procedimientos Endovasculares/métodos , Fibrinolíticos/administración & dosificación , Reperfusión/métodos , Accidente Cerebrovascular/cirugía , Activador de Tejido Plasminógeno/administración & dosificación , Enfermedad Aguda , Administración Intravenosa , Isquemia Encefálica/diagnóstico , Humanos , Accidente Cerebrovascular/diagnóstico , Resultado del Tratamiento
14.
West Afr J Med ; 36(3): 286-289, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31622495

RESUMEN

Stroke is a leading cause of disability and mortality globally. In the first few hours after ischaemic stroke, the severity and irreversibility of brain injury increase as time passes. The primary goal of the emergent management of acute ischaemic stroke is stabilization and reperfusion of the ischaemic penumbra if eligibility criteria are met and contraindications are ruled out. The primary reperfusion strategies are administration of intravenous tissue plasminogen activator (IV tPA) and endovascular thrombectomy (EVT). Close monitoring is warranted prior to, during, and after these reperfusion procedures to detect early neurologic deterioration that may signify complications from treatment.


Asunto(s)
Isquemia Encefálica/cirugía , Procedimientos Endovasculares/métodos , Fibrinolíticos/administración & dosificación , Reperfusión/métodos , Accidente Cerebrovascular/cirugía , Activador de Tejido Plasminógeno/administración & dosificación , Enfermedad Aguda , Administración Intravenosa , Isquemia Encefálica/diagnóstico , Humanos , Accidente Cerebrovascular/diagnóstico , Resultado del Tratamiento
15.
J Stroke Cerebrovasc Dis ; 28(11): 104327, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31530479

RESUMEN

BACKGROUND: Acute ischemic stroke patients in Lao People's Democratic Republic (Lao PDR) are unable to access the intravenous thrombolytic therapy using recombinant tissue plasminogen activator (rtPA) due to various reasons. AIMS: This study aimed to evaluate the feasibility and safety of thrombolytic therapy administration at Mittaphab Hospital, Lao PDR under the international telestroke consultation system from King Chulalongkorn Memorial Hospital, Thailand. METHODS: Acute ischemic stroke patients who presented at Mittaphab Hospital within 4.5 hours after the onset and received thrombolytic therapy between December 2016 and June 2017 were studied. An immediate real time teleconsultation with 24 hours availability between neurologists at Mittaphab hospital and the Chulalongkorn stroke team was performed in all cases for patient evaluation and decision for thrombolytic treatment. RESULTS: There were 205 patients with acute stroke, 28 patients (14%) arrived at the hospital within 4.5 hours after the onset. Ten patients (5%) were eligible for intravenous rtPA. The mean duration from onset to hospital arrival was 122.50 minutes and the mean door to needle time was 108 minutes. The mean National Institute of Health stroke scale (NIHSS) before thrombolysis was 10. At 90 days, the mean NIHSS was 3 and the mean mRS was 2. Seventy percent of patients had good outcome (mRS ≤2). Only one patient developed massive cerebral infarction. None of the patient developed symptomatic intracerebral hemorrhage or major bleedings. CONCLUSIONS: Telestroke consultation from Thailand can facilitate the thrombolytic therapy for acute ischemic stroke patients in Lao PDR.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/administración & dosificación , Consulta Remota , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Toma de Decisiones Clínicas , Estudios de Factibilidad , Femenino , Fibrinolíticos/efectos adversos , Accesibilidad a los Servicios de Salud , Humanos , Laos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Selección de Paciente , Proteínas Recombinantes/administración & dosificación , Accidente Cerebrovascular/diagnóstico , Tailandia , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
16.
J Stroke Cerebrovasc Dis ; 28(11): 104365, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31530482

RESUMEN

A 64-year-old woman was admitted to our hospital 48 minutes after sudden onset of dysphasia and right hemiplegia. Head computed tomography revealed small infarcts in the left putamen and 4-dimensional computed tomography angiography depicted high-degree stenosis in the left middle cerebral artery and delayed filling of the contrast media in the left middle cerebral artery territory. The patient underwent intravenous tissue plasminogen activator treatment. On day 5 of hospitalization, the patient underwent conventional cerebral angiography, revealing internal carotid artery to middle cerebral artery dissection. Fortunately, subarachnoid hemorrhage as an adverse effect did not occur, although iv-tPA was administered without detecting middle cerebral artery dissection.


Asunto(s)
Angiografía de Substracción Digital , Disección de la Arteria Carótida Interna/diagnóstico por imagen , Angiografía Cerebral/métodos , Angiografía por Tomografía Computarizada , Fibrinolíticos/administración & dosificación , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Administración Intravenosa , Femenino , Fibrinolíticos/efectos adversos , Humanos , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
17.
J Stroke Cerebrovasc Dis ; 28(11): 104360, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31501036

RESUMEN

OBJECTIVE: Thrombolytic therapy with intravenous alteplase (IV-rtPA) has a known risk of symptomatic intracerebral hemorrhage (sICH). We aim to identify factors with a significant association with the development of sICH post-IV-rtPA. We also aim to perform an external validation of sICH predicting scores in our patient population. MATERIAL AND METHODS: We performed a retrospective chart review of patients who received IV-rtPA at our tertiary care hospital. We excluded patients who underwent mechanical thrombectomy. We analyzed various factors recorded at presentation such as presenting mean arterial pressure (MAP), blood glucose, National Institutes of Health Stroke Scale (NIHSS) score, verify Aspirin, verify Plavix, age, sex, platelet count, international normalized ratio, prothrombin time, partial thromboplastin time, hemoglobin A1c, low-density lipoprotein, onset to treatment time, weight, sex, and early infarct signs on computed tomography (CT) head and compared them between sICH and non-sICH groups. For validation of sICH scores, we used documented variables to calculate the following scores for each patient: stroke prognostication using age and NIH stroke scale-100 (SPAN-100), DRAGON, CUCCHIARA, hemorrhage after thrombolysis (HAT), SEDAN, totaled health risks in vascular events, and safe implementation of thrombolysis in stroke-symptomatic intracerebral hemorrhage. RESULTS: sICH rate in our cohort of 89 patients was 5.62% according to the European-Australasian Cooperative Acute Stroke Study-II (ECASS-II) criteria and 7.86% according to the National Institute of Neurological Disorders and Stroke (NINDS) criteria. In the multivariate regression analysis, MAP (95% CI, .001-.01; P .002), blood glucose greater than or equal to 185 mg/dL (95% CI, .12-.45; P .001) and presence of early infarct signs (95% CI, .06-.25; P .002) had a significant association with the development of sICH with the ECASS-II definition of sICH post-IV-rtPA, whereas, only MAP (95% CI, 1.01-1.18; P .025) and verify Aspirin less than 500 (95% CI, .01-.80; P .032) had a significant association with the development of sICH with the NINDS definition of sICH post-IV-rtPA. Our study found that HAT (95% CI, .58-.96; P .044) and DRAGON (95% CI, .61-.96; P .012) scores had the highest area under the curve (AUC) with respect to ECASS-II and NINDS criteria of sICH, respectively. CONCLUSIONS: We found that presenting MAP, presence of early infarct signs on CT Head and blood glucose greater than or equal to 185 mg/dL upon a patient's presentation have a significant association with sICH post-IV-rtPA when the ECASS-II definition was used, while presenting MAP and verify Aspirin less than 500 upon a patient's presentation have a significant association with sICH post-IV-rtPA when the NINDS definition was used. Our study found that HAT and DRAGON scores had the highest AUC, and they were the most valid in predicting the development of sICH in our independent cohort. Patients with these risk factors should receive more intensive neurological monitoring.


Asunto(s)
Hemorragia Cerebral/inducido químicamente , Técnicas de Apoyo para la Decisión , Fibrinolíticos/efectos adversos , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/fisiopatología , Femenino , Fibrinolíticos/administración & dosificación , Estado de Salud , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Activador de Tejido Plasminógeno/administración & dosificación , Resultado del Tratamiento , Adulto Joven
18.
J Stroke Cerebrovasc Dis ; 28(11): 104363, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31501038

RESUMEN

BACKGROUND AND AIM: Renal dysfunction (RD) is prevalent in patients with acute ischemic stroke requiring intravenous thrombolysis. The relationship between renal function and thrombolysis related intracranial hemorrhagic (ICH) complications is contradictory according to previous studies. The current study is to clarify whether RD could increase the risk of symptomatic intracranial hemorrhage (SICH) after recombinant tissue plasminogen activator (IV rtPA) in acute ischemic stroke patients. METHODS: In this observational study, acute ischemic stroke patients who received IV rtPA within 4.5 hours of symptom onset were retrospectively analyzed. Creatinine levels on admission served to calculate glomerular filtration rate (GFR) to estimate RD. SICH was defined with National Institute of Neurological Disorder and Stroke (NINDS, SICHNINDS) or European Cooperative Acute Stroke Study II (ECASS II, SICHECASSII) criteria. Association of RD with SICH was assessed using continuous GFR or binary GFR (RD defined as GFR < 90 ml/minute/1.73 m2). RESULTS: Of 312 patients included, the incidence of SICHNINDS was 7.69%, of SICHECASSII was 5.45%. Patients with RD had higher prevalence of SICHNINDS (12.80% versus 2.03%, P < .001) and SICHECASS II (9.15% versus 1.35%, P = .002). GFR as a continuous variable was associated with SICHNINDS (ORadjust = .97, P = .003), but not with SICHECASS II. GFR less than 90 ml/minute/1.73 m2 remained independently associated with SICHNINDS (ORadjust = 4.79, P = .016), and SICHECASS II (ORadjust = 2.99, P = .032) in multiple logistic regression analysis. CONCLUSIONS: Renal function is independently associated with SICH after IV rtPA thrombolysis. RD is an independent predictor for both SICHNINDS and SICHECASS II. RD should be considered when evaluating the risk of intravenous thrombolysis with IV rtPA.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/efectos adversos , Tasa de Filtración Glomerular , Hemorragias Intracraneales/inducido químicamente , Enfermedades Renales/fisiopatología , Riñón/fisiopatología , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiología , Isquemia Encefálica/fisiopatología , China/epidemiología , Femenino , Fibrinolíticos/administración & dosificación , Humanos , Incidencia , Hemorragias Intracraneales/diagnóstico , Hemorragias Intracraneales/epidemiología , Enfermedades Renales/diagnóstico , Enfermedades Renales/epidemiología , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Activador de Tejido Plasminógeno/administración & dosificación , Resultado del Tratamiento
19.
J Stroke Cerebrovasc Dis ; 28(12): 104362, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31562039

RESUMEN

BACKGROUND: Intravenous recombinant tissue plasminogen activator (IV rt-PA) prior to thrombectomy may reduce the risk of intraprocedural distal embolization in acute ischemic stroke patients. METHODS: We analyzed the diffusion-weighted imaging acquired with 1.5- or 3-T magnetic resonance imaging (MRI) scans obtained within 24 hours of thrombectomy in consecutive acute ischemic stroke patients. An independent physician identified distal embolization, defined as discrete foci of restricted diffusion independent of the primary area of infarction on MRI scan. Patients were stratified based on whether they had or did not receive IV rt-PA prior to thrombectomy. RESULTS: Distal embolization was seen in 59 (ipsilateral in 56) of 63 patients (mean age ± SD; 64.6 ± 15.3 years) who underwent thrombectomy (mean number 8.6; range 0-32). There was no difference in mean number of ipsilateral hemispheric distal embolization between the 2 groups (7.9 ± 6.1 versus 7.5 ± 7.6, P = .82). After adjusting for age, admission National Institutes of Health Stroke Scale score, the time interval between symptom onset and thrombectomy, there was no association between receiving IV rt-PA prior to thrombectomy and number of ipsilateral distal emboli (P = .90). There was no relationship between the number of ipsilateral emboli and rates of favorable outcome after adjusting for other confounders (adjusted odds ratio 1.0; 95% confidence interval .89 - 1.0; P = .40). CONCLUSIONS: Although distal embolization is very common after thrombectomy, IV rt-PA prior to procedure does not reduce the risk of intraprocedural distal embolization.


Asunto(s)
Isquemia Encefálica/terapia , Fibrinolíticos/administración & dosificación , Embolia Intracraneal/etiología , Accidente Cerebrovascular/terapia , Trombectomía/efectos adversos , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Imagen de Difusión por Resonancia Magnética , Femenino , Fibrinolíticos/efectos adversos , Humanos , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/prevención & control , Masculino , Persona de Mediana Edad , Proteínas Recombinantes/administración & dosificación , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico por imagen , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento
20.
Neurologist ; 24(5): 143-145, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31478996

RESUMEN

INTRODUCTION: Intravenous thrombolysis within 4.5 hours from symptom onset improves functional outcome in acute ischemic stroke patients. Repeated intravenous tissue plasminogen activator (IVtPA) is contraindicated in patients presenting with early recurrent stroke (ERS) within 3 months from the initial stroke because of a greater risk of intracranial hemorrhage. CASE PRESENTATION: A 59-year-old man presented with ERS, National Institute of Health Stroke Scale of 16, 10 days after a previous stroke. Brain computed tomography (CT) showed a previous hypodensity with 4 cm volume. Angio-CT highlighted the left middle cerebral artery and left internal carotid occlusion. Perfusion CT showed small deep core and large penumbra. The patient underwent IVtPA. After 24 hours, the National Institute of Health Stroke Scale was 7, and CT scan showed an acute ischemic lesion in the left basal ganglia area and frontal lobe without hemorrhagic transformation. CONCLUSION: This case report suggests that further randomized studies may evaluate whether repeated IVtPA may be safe and effective in ERS occurring shortly after a previous stroke when patients experience a period of complete neurological regression, minor disability, and a small infarct volume. Should the hypothesis be confirmed, small volume core and wide volume penumbra at perfusion CT may support the decision of adopting IVtPA repetition.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Encéfalo/diagnóstico por imagen , Isquemia Encefálica/complicaciones , Isquemia Encefálica/diagnóstico , Humanos , Inyecciones Intravenosas , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/diagnóstico , Activador de Tejido Plasminógeno/administración & dosificación , Resultado del Tratamiento
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