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1.
Isr Med Assoc J ; 22(1): 60-63, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31927808

RESUMEN

BACKGROUND: In this review, the authors re-examine the role of aspirin in the primary prevention of cardiovascular disease. They discuss the history of the use of aspirin in primary prevention, the current guidelines, and the recent evidence surrounding aspirin use as primary prevention in special populations such as those with moderate cardiovascular risk, diabetes mellitus, and the elderly.


Asunto(s)
Aspirina/uso terapéutico , Enfermedades Cardiovasculares/prevención & control , Fibrinolíticos/uso terapéutico , Aspirina/efectos adversos , Fibrinolíticos/efectos adversos , Humanos , Guías de Práctica Clínica como Asunto , Prevención Primaria/métodos
2.
Vasc Endovascular Surg ; 54(2): 135-140, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31769352

RESUMEN

PURPOSE: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis (USAT) appears to provide promising results for the management of acute submassive pulmonary embolisms (ASMPEs) at tertiary care centers. This study assessed outcome measures at a community-based hospital systems and compared results to known studies. MATERIALS AND METHODS: This is a single-center, retrospective study assessing clinical outcomes of the EkoSonic Endovascular System intervention for ASMPEs performed by three surgical 3 subspecialties (interventional radiology, interventional cardiology, and vascular surgery) part of a pulmonary embolism response team (PERT). We reviewed 146 PERT activations from June 2013 to December 2017. Eighty-three patients with ASMPEs underwent USAT. RESULTS: Our study showed greater differences (P = .01) between baseline and follow-up pulmonary artery systolic pressures (20.9 ± 9.8 mm Hg [n = 14]) compared to the ULTIMA study (12.3 ± 10 mm Hg [n = 30]). Our length-of-stay measures were shorter (6.1 ± 5.1 [n = 83]; P = .0001) compared to the SEATTLE II study (8.8 ± 5.0 [n = 150]). Preprocedure transthoracic echocardiograms (TTEs) were performed for 54 (65%) of 83 patients. Postprocedure TTEs at 48 hours was performed for 52 (62%) of 83 patients. Use of TTEs before and after intervention did not change outcomes. Intracranial hemorrhage was not observed in our patient population. There was no difference in outcomes between the three subspecialties in our study. CONCLUSIONS: Use of USAT in a community-based hospital PERT has similar outcomes to tertiary care centers. Furthermore, similar outcomes were observed between the three subspecialties suggesting development of a comprehensive care team for management of ASMPEs.


Asunto(s)
Cateterismo Periférico , Fibrinolíticos/administración & dosificación , Hospitales Comunitarios , Embolia Pulmonar/terapia , Terapia Trombolítica/métodos , Terapia por Ultrasonido , Enfermedad Aguda , Adulto , Anciano , Cardiólogos , Cateterismo Periférico/efectos adversos , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intraarteriales , Masculino , Michigan , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/fisiopatología , Radiólogos , Estudios Retrospectivos , Especialización , Cirujanos , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Terapia por Ultrasonido/efectos adversos
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.
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
5.
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
6.
J Stroke Cerebrovasc Dis ; 29(2): 104515, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31786042

RESUMEN

BACKGROUND: Many acute ischemic stroke (AIS) patients present with unknown time of symptom onset (UTO). In these situations, wake-up MRI protocols can guide treatment decisions: patients with DWI (diffusion-weighted imaging) but no fluid-attenuated inversion recovery lesion were shown to benefit from IVT (intravenous thrombolysis). However, initial MRI of some stroke patients is DWI negative, leaving it unclear whether this subgroup profits from IVT. Therefore, we aimed to compare the safety and efficacy of IVT in wake-up AIS patients with or without a DWI lesion in initial imaging. METHODS: We performed a case-control study. All AIS patients with UTO who underwent wake-up MRI and were treated with IVT at a German University Hospital from 2013 to 2017 were included. Patients without (DWI-) were compared to patients with DWI lesion (DWI+) regarding clinico-radiological characteristics, adverse events, and outcome at discharge. Likely stroke mimics were excluded. RESULTS: Eleven DWI- and 32 DWI+ patients were included. There were no statistically significant differences regarding functional scores, age, sex, door-to-needle time, bleeding complications, and death. DWI+ patients more frequently had anterior circulation stroke (P = .049) and higher modified Rankin Scale (mRS) scores at discharge (P = .048). Solely in the DWI+ group 3 bleeding complications (2 asymptomatic hemorrhagic transformations, 1 muscle hematoma) and 3 deaths occurred (P = .29). A favourable outcome (mRS≤ 2) was achieved in 82% of the DWI- and in 58% of the DWI+ group (p > .05). CONCLUSIONS: Our data suggest that IVT may be used in DWI- patients with UTO with acute neurological symptoms very likely to be related to AIS.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Imagen de Difusión por Resonancia Magnética , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/fisiopatología , Toma de Decisiones Clínicas , Técnicas de Apoyo para la Decisión , Evaluación de la Discapacidad , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Selección de Paciente , Valor Predictivo de las Pruebas , Recuperación de la Función , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Tiempo de Tratamiento , 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.
Vasc Endovascular Surg ; 54(1): 58-64, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31500542

RESUMEN

A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart dysfunction and symptomatic improvement received bedside removal of catheters. The mean patient age was 50.6 years and body mass index was 33.6. Mean RV/LV ratio on admission via CT imaging was 1.56, with a mean troponin of 0.44. Interval mean RV/LV ratio on echocardiography after thrombolysis therapy was 0.91. There was a 0% incidence of periprocedural complications. One (20%) patient out of 5 had an emergency department visit 10 days postdischarge for acute shortness of breath, with workup revealing no evidence of recurrent PE. No patient required hospital readmission within 30 days. At the 6-week follow-up, all patients had continued normal right ventricular function noted on echocardiography. This case series demonstrates that for a select population of patients with severe submassive PE, the use of CDT and echocardiography monitoring can facilitate same-day discharge from the ICU.


Asunto(s)
Fibrinolíticos/administración & dosificación , Unidades de Cuidados Intensivos , Tiempo de Internación , Alta del Paciente , Embolia Pulmonar/tratamiento farmacológico , Terapia Trombolítica/métodos , Adulto , Ecocardiografía , Femenino , Fibrinolíticos/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Sistema de Registros , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/instrumentación , Factores de Tiempo , Resultado del Tratamiento , Dispositivos de Acceso Vascular
10.
Ther Adv Cardiovasc Dis ; 13: 1753944719891688, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31814532

RESUMEN

A sizable proportion of coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) with stent implantation have an indication for treatment with oral anticoagulant therapy (OAC). The coexistence of atrial fibrillation (AF) and the need for PCI expose patients to a higher risk of developing thrombotic complications, and a multitargeted antithrombotic treatment strategy, addressing both platelet- and coagulation-mediated triggering mechanisms of thrombosis, is necessary for ensuring full protection from ischemic hazards. The increased bleeding risk identified with triple antithrombotic therapy has driven the search for alternative treatment modalities and pharmacological combination strategies aimed at achieving an optimal balance between safety and efficacy in this complex clinical scenario. Over a short time period, the paradigms surrounding the management of patients undergoing PCI who require OAC have substantially evolved. In this review, we summarize and critically evaluate the results of recent randomized clinical trials investigating the pharmacological management of patients who, in addition to antiplatelet therapy, have an indication for OAC treatment before or at the time of a PCI procedure.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Enfermedad de la Arteria Coronaria/terapia , Trombosis Coronaria/prevención & control , Fibrinolíticos/uso terapéutico , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/uso terapéutico , Anticoagulantes/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Toma de Decisiones Clínicas , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/epidemiología , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/epidemiología , Fibrinolíticos/efectos adversos , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Humanos , Intervención Coronaria Percutánea/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento
11.
J Interv Cardiol ; 2019: 6704031, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31772541

RESUMEN

Objectives: The aim of this study was to investigate the outcomes of left atrial appendage occlusion (LAAO) in high bleeding risk patients suffering atrial fibrillation (AF) and to analyze the different antithrombotic therapies following the intervention. Background Methods: This monocentric study included 68 patients with nonvalvular AF with an absolute contraindication to OAT or at high bleeding risk. Follow-up was done with a clinical visit at 3-6-12 months. Results: Successful LAAO was achieved in 67/68 patients. At discharge, 32/68 patients were on dual antiplatelet therapy (APT), 34/68 were without any antithrombotic therapy or with a single antiplatelet drug, and 2/68 were on anticoagulant therapy. At three-month follow-up visit, 73.6% of the patients did not receive dual APT, of whom 14.7% had no thrombotic therapy and 58.9% were on single antiplatelet therapy. During a follow-up of 1.4 ± 0.9 years, 3/62 patients had late adverse effects (2 device-related thrombus without clinical consequences and 1 extracranial bleeding). The device-related thrombosis was not related to the antithrombotic therapy. Conclusions: LAAO is feasible and safe and prevents stroke in patients with AF with contraindication to oral anticoagulant therapy. After LAAO, single antiplatelet therapy seems to be a safe alternative to dual antiplatelet therapy, especially in patients at high bleeding risk. No benefit has been observed with dual APT.


Asunto(s)
Apéndice Atrial/cirugía , Fibrilación Atrial , Fibrinolíticos/efectos adversos , Hemorragia/prevención & control , Implantación de Prótesis , Dispositivo Oclusor Septal , Accidente Cerebrovascular , Anciano , Fibrilación Atrial/complicaciones , Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Contraindicaciones de los Medicamentos , Femenino , Fibrinolíticos/uso terapéutico , Estudios de Seguimiento , Hemorragia/inducido químicamente , Humanos , Italia/epidemiología , Masculino , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/instrumentación , Implantación de Prótesis/métodos , Ajuste de Riesgo/métodos , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Resultado del Tratamiento
12.
Intern Med ; 58(19): 2759-2766, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31582592

RESUMEN

objective In patients continuing antithrombotics, delayed bleeding after gastric endoscopic submucosal dissection (ESD) is a severe complication. Vonoprazan (VPZ) exerts a rapid, potent, and long-lasting antacid effect compared with traditional proton-pump inhibitors (PPIs). This study aimed to compare the incidence of delayed bleeding after gastric ESD between the use of VPZ and PPIs in patients continuing antithrombotics. Methods In this retrospective analysis, we examined 71 patients with 101 lesions treated with traditional PPIs (PPI group) and 59 patients with 90 lesions treated with VPZ (VPZ group). After 2 days (day 0 and 1) of intravenous PPI administration, either an oral PPI or VPZ was administered from postoperative day 2 to 8 weeks after ESD. We assessed the incidence of overall delayed bleeding as well as bleeding that occurred from day 2 until 8 weeks after ESD. Results There was no significant difference in the use of antithrombotic agents between the groups. Overall delayed bleeding occurred 13 times (18%) in 9 patients in the PPI group and 18 times (31%) in 17 patients in the VPZ group (p=0.10). Bleeding from day 2 until 8 weeks after ESD occurred 12 times (17%) in 9 patients in the PPI group and 8 times (14%) in 8 patients in the VPZ group. Conclusion Even with a potent antacid agent, such as VPZ, the incidence of delayed bleeding was high in patients undergoing ESD with continuous antithrombotic agents.


Asunto(s)
Resección Endoscópica de la Mucosa/efectos adversos , Fibrinolíticos/efectos adversos , Hemorragia Posoperatoria/etiología , Neoplasias Gástricas/cirugía , Anciano , Anciano de 80 o más Años , Antiulcerosos/uso terapéutico , Femenino , Humanos , Masculino , Inhibidores de la Bomba de Protones/uso terapéutico , Pirroles , Estudios Retrospectivos , Úlcera Gástrica/tratamiento farmacológico , Sulfonamidas , Factores de Tiempo
13.
J Stroke Cerebrovasc Dis ; 28(12): 104423, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31606319

RESUMEN

BACKGROUND: The Mission Protocol was implemented in 2017 to expedite stroke evaluation and reduce door-to-needle (DTN) times at Zuckerberg San Francisco General Hospital. The key system changes were team-based evaluation of suspected stroke patients at ambulance entrance by an Emergency Department (ED) physician, ED nurse, and neurologist and immediate emergency medical service (EMS) provider transport of patients to CT. METHODS: Patients were eligible for a Mission Protocol prehospital stroke activation if an EMS provider found a positive Cincinnati Prehospital Stroke Scale and a last known normal time within 6 hours. We retrospectively compared treatment metrics between the first year of Mission Protocol patients and patients from the year prior also brought in via ambulance with suspected stroke and a last known normal time within 6 hours. Median Door to CT and DTN times were compared using 2 sample Wilcoxon rank-sum (Mann-Whitney) tests. RESULTS: There were 236 patients in the Mission Protocol group and 112 in the comparison group. The Mission Protocol was associated with a 10 minutes faster median door to CT time (P < .00001), a 6 minutes faster median DTN time (P = .0046), a 22% increase in the proportion of patients treated within 45 minutes of arrival (84% versus 62%), and a 12% increase in the proportion of patients treated within 60 minutes (92% versus 80%). There were 8 stroke mimics treated in the Mission Protocol cohort compared to 2 in the comparison cohort. Symptomatic intracranial hemorrhage occurred in one Mission Protocol patient with an ischemic stroke. CONCLUSIONS: The EMS direct to CT based Mission Protocol was associated with faster median door to CT and DTN times. There was a 22% increase in the proportion of thrombolysis patients treated within 45 minutes or less. More stroke mimic patients received thrombolysis but symptomatic intracranial hemorrhage only occurred in 1 ischemic stroke patient.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Protocolos Clínicos/normas , Servicios Médicos de Urgencia/normas , Fibrinolíticos/administración & dosificación , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/normas , Tiempo de Tratamiento/normas , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Diagnóstico Diferencial , Servicio de Urgencia en Hospital/normas , Femenino , Fibrinolíticos/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Tomografía Computarizada por Rayos X/normas , Resultado del Tratamiento
14.
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
15.
J Stroke Cerebrovasc Dis ; 28(12): 104422, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31624038

RESUMEN

INTRODUCTION: Identifying predictors of good response in thrombolytic-treated stroke is important to clinical care, resource allocation, and research design. We developed a simple, novel measure of "Good Responders" to assess if 2 short-term variables could predict 90-day outcomes after thrombolysis in stroke. METHODS: Intravenous thrombolysis-treated stroke cases from June 2004 to June 2018 were analyzed from a stroke registry. Intraarterial treatment cases were excluded. Good responders (GR++) were defined as those with length of stay less than or equal to 3 days and discharge to home. Poor responders (GR- -) had length of stay more than 3 days and discharge other than home. Mixed responders (GR+/-) composed the remainder. Baseline characteristics and predictors of 90-day outcome were assessed. RESULTS: Of 261 patients, there were 101(38.7%) GR++, 67(25.7%) GR- -, and 93(35.6%) GR+/-. For GR++ versus GR- - versus GR+/-, there were differences in mean age (62.7, 71.2, 69.2; P = .0016), and baseline modified Rankin score (mRS) 0-2 (%: 94.9, 74.6, 84.8; P = .008). Younger age, male sex, lower values for systolic BP, glucose, and baseline mRS were associated with good responders. Older age, atrial fibrillation, symptomatic intracerebral hemorrhage, and baseline mRS greater than 2 were associated with poor responders. At 90 days, mortality was reduced in GR++ versus GR- - versus GR+/- (%alive: 92.6, 72, 86; P = .04), and mRS(0-2) (%: 36.8, 0, 11.8; P < .001). CONCLUSIONS: Good responders to thrombolysis are younger and have better baseline functional status. Our novel definition of "Good Responders", using 2 early variables of home disposition and short length of stay, may help predict 90-day post-thrombolytic outcome. Future work should focus on validating this definition.


Asunto(s)
Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/tratamiento farmacológico , Terminología como Asunto , Terapia Trombolítica , Factores de Edad , Anciano , Bases de Datos Factuales , Femenino , Fibrinolíticos/efectos adversos , Estado de Salud , Humanos , Infusiones Intravenosas , Tiempo de Internación , Masculino , Persona de Mediana Edad , Alta del Paciente , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Resultado del Tratamiento
16.
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
17.
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
18.
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
19.
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
20.
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
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