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1.
Medicine (Baltimore) ; 99(10): e19358, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32150076

RESUMEN

INTRODUCTION: Intravenous thrombolysis is not suitable for patients undergoing oral anticoagulants therapy, with INR > 1.7 or PT > 15 s. We described a case of intravenous thrombolysis in a patient with INR 1.9. PATIENT CONCERNS: A 66-year-old female patient was diagnosed with acute appendicitis complicated with atrial fibrillation. Seven days after admission, the patient suffered mixed aphasia with right limb asthenia. The NIHSS score was 11 points. and early infarction and hemorrhagic manifestations were not found in the emergency head CT. Thirty minutes after the onset of symptoms, NIHSS of patient increased from 11 to 14, but the INR was 1.92. DIAGNOSIS: Acute ischemic stroke. INTERVENTIONS: The IT therapy was recommended and all the therapy related risks were explained to the patient's parents. Briefly, the patient was given rTPA 38.5 mg. In addition to intravenous thrombolysis, VitK1 40 mg was simultaneously administered. OUTCOME: The patient's symptoms of drowsiness were improved. After 24 hours, all symptoms were stabilized with NIHSS of 2 points, there was a slight language obstruction, and no hemorrhagic transformation in head CT. Three months later, the review showed MRS score of 0, and the patient could take care of herself in daily life. CONCLUSION: The clinical guidelines are still the main reference for guiding clinical practice, and the main thrombolytic standards and contraindications for treatment still need to be conformed. On this basis, for individualized patients, clinicians must accurately judge the cause of acute stroke, to make optimal choice, reduce disability and mortality, and improve quality of life of patients.


Asunto(s)
Seguridad del Paciente/normas , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/normas , Warfarina/efectos adversos , Anciano , Apendicitis/complicaciones , Apendicitis/cirugía , Femenino , Fibrinolíticos/normas , Fibrinolíticos/uso terapéutico , Humanos , Relación Normalizada Internacional/métodos , Complicaciones Posoperatorias/tratamiento farmacológico , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/métodos , Resultado del Tratamiento , Warfarina/uso terapéutico
2.
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
3.
Clin Appl Thromb Hemost ; 26: 1076029620912814, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32191493

RESUMEN

Shear stress (SS)-induced platelet activation is suggested as an essential mechanism of the acute coronary syndrome (ACS). We aimed to compare SS-induced thrombotic and thrombolytic activities among 3 treatment regimens in patients with ACS who underwent percutaneous coronary intervention (PCI). Patients were nonrandomly enrolled and treated with one of 3 regimens (TICA: ticagrelor 180 mg/d; RIVA: clopidogrel 75 mg/d and rivaroxaban 5 mg/d; CLP: clopidogrel 75 mg/d), administered in addition to aspirin (100 mg/d) for 30 days. The global thrombosis test was applied to measure SS-induced thrombotic (occlusion time [OT]) and thrombolytic activity (lysis time [LT]) at day 2 and 30. Aspirin reaction unit (ARU) and P2Y12 reaction unit (PRU) were simultaneously measured using VerifyNow. Group differences in the OT, LT, ARU, and PRU were evaluated. Seventy-five patients (25 patients in each group) finished 30 days of follow-up. Clinical and angiographic characteristics did not differ among the 3 groups, except ACS subtype and pre-PCI coronary flow. No major adverse cardiovascular events occurred in any group during follow-up. The OT and LT did not differ among the 3 groups at day 30 (OT: TICA, 447.2 ± 87.1 vs RIVA, 458.5 ± 70.3, vs CLP, 471.9 ± 90.7, LT: 1522.3 ± 426.5 vs 1734.6 ± 454.3 vs 1510.2 ± 593.9) despite significant differences in the PRU among the 3 groups. Shear stress-induced thrombotic and thrombolytic activities did not differ among the 3 investigated antithrombotic treatments.


Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Estrés Fisiológico , Síndrome Coronario Agudo/cirugía , Adulto , Anciano , Combinación de Medicamentos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/uso terapéutico , Estudios Prospectivos
4.
AJR Am J Roentgenol ; 214(4): 930-937, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32023122

RESUMEN

OBJECTIVE. The purpose of this study is to review the various techniques and clinical management paradigms using tissue plasminogen activator (tPA) to treat severe frostbite injuries, which are relevant to the interventional radiologist. MATERIALS AND METHODS. A literature search yielded 157 citations, which were manually screened for inclusion criteria of case reports, case series, cohort studies, and randomized prospective studies that reported the use of tPA to treat severe frostbite injuries, of which 16 qualified for review. Data extracted from the studies included authors, journal, year of publication, initial assessment and management of severe frostbite injuries, inclusion and exclusion criteria for tPA therapy, treatment and control group size, different imaging modalities used in evaluation of severe frostbite injuries, tPA treatment protocols, outcomes, and side effects or complications. RESULTS. The analyzed series included 209 patients with 1109 digits at risk of amputation who were treated with intraarterial (IA) or IV tPA (116 and 77 patients, respectively). A total of 926 digits at risk were treated with IA tPA and resulted in amputation of 222 digits, for a salvage rate of 76%. Twenty-four of 63 patients underwent amputation after IV tPA, resulting in a salvage rate of 62%. Both digital subtraction angiography and triple-phase bone scan were used for initial imaging evaluation. Additional concurrent treatment included therapeutic heparin, warfarin, nonsteroidal antiinflammatory drugs, pain management, and light dressings with topical antimicrobial agents. CONCLUSION. Severe frostbite injuries can lead to devastating outcomes with loss of limbs and digits, yet clinical management continues to consist primarily of tissue rewarming, prolonged watchful waiting, and often delayed amputation. Recent studies have shown promising results using both IA and IV tPA to reduce amputation after severe frostbite injuries. Through a meta-analysis of thrombolytic therapy in the management of severe frostbite, this article provides a useful guideline for interventional radiologists including a suggested protocol, inclusion and exclusion criteria, and potential complications.


Asunto(s)
Fibrinolíticos/uso terapéutico , Congelación de Extremidades/diagnóstico por imagen , Congelación de Extremidades/tratamiento farmacológico , Radiografía Intervencional , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Humanos
5.
Medicine (Baltimore) ; 99(2): e18665, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31914055

RESUMEN

We assessed the value of fluid-attenuated inversion recovery vascular hyperintensity (FVH)-diffusion-weighted imaging (DWI) mismatch in predicting revascularization and functional outcome in stroke patients with large vessel occlusion (LVO) after endovascular thrombectomy (EVT).Seventy-two acute stroke patients within 6 hour of stroke onset who received EVT were enrolled. FVH-DWI mismatch, revascularization (mTICI score), functional outcome (mRS at 3 months) and other clinical data were collected. Statistical analysis was performed to predict revascularization and functional outcome after stroke.Twenty-nine patients (60.42%) had FVH-DWI mismatch in patients with complete revascularization and 8 patients (33.33%) had FVH-DWI mismatch in patients with no/partial revascularization, and there was significant difference in 2 groups (t = 4.698; P = .045). The good functional outcome group (37/72; 51.39%) had higher FVH score (4.38 ±â€Š1.53 vs 3.49 ±â€Š1.52; t = 2.478; P = .016), higher FVH-DWI mismatch ratio (81.25% vs 48.15%; t = 10.862; P = .002), higher complete revascularization ratio (83.78% vs 48.57%; t = 10.036; P = .002) than the poor functional outcome group (35/72; 48.61%). Spearman's rank correlation analysis revealed that FVH-DWI mismatch was positively correlated with complete revascularization (r = 0.255; P = .030) and good functional outcome (r = 0.417; P = .000). Multivariable logistic regression analysis demonstrated that FVH-DWI mismatch was independently associated with complete revascularization (OR, 0.328; 95% CI, 0.117-0.915; P = .033) and good functional outcome (OR, 0.169; 95% CI, 0.061-0.468; P = .001).Assessments of FVH-DWI mismatch before thrombectomy therapy might be useful for predicting revascularization and functional outcome in stroke patients with LVO.


Asunto(s)
Revascularización Cerebral/métodos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Anciano , Anciano de 80 o más Años , Comorbilidad , Imagen de Difusión por Resonancia Magnética , Procedimientos Endovasculares/métodos , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/tratamiento farmacológico , Factores de Tiempo , Activador de Tejido Plasminógeno/uso terapéutico
6.
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
7.
Lancet Haematol ; 7(3): e226-e237, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31982039

RESUMEN

BACKGROUND: Polycythaemia vera is a myeloproliferative neoplasm characterised by excessive proliferation of erythroid, myeloid, and megakaryocytic components in the bone marrow due to mutations in the Janus kinase 2 (JAK2) gene. Ruxolitinib, a JAK 1 and JAK 2 inhibitor, showed superiority over best available therapy in a phase 2 study in patients with polycythaemia vera who were resistant to or intolerant of hydroxyurea. We aimed to compare the long-term safety and efficacy of ruxolitinib with best available therapy in patients with polycythaemia vera who were resistant to or intolerant of hydroxyurea. METHODS: We report the 5-year results for a randomised, open-label, phase 3 study (RESPONSE) that enrolled patients at 109 sites across North America, South America, Europe, and the Asia-Pacific region. Patients (18 years or older) with polycythaemia vera who were resistant to or intolerant of hydroxyurea were randomly assigned 1:1 to receive either ruxolitinib or best available therapy. Patients randomly assigned to the ruxolitinib group received the drug orally at a starting dose of 10 mg twice a day. Single-agent best available therapy comprised hydroxyurea, interferon or pegylated interferon, pipobroman, anagrelide, approved immunomodulators, or observation without pharmacological treatment. The primary endpoint, composite response (patients who achieved both haematocrit control without phlebotomy and 35% or more reduction from baseline in spleen volume) at 32 weeeks was previously reported. Patients receiving best available therapy could cross over to ruxolitinib after week 32. We assessed the durability of primary composite response, complete haematological remission, overall clinicohaematological response, overall survival, patient-reported outcomes, and safety after 5-years of follow-up. This study is registered with ClinicalTrials.gov, NCT01243944. FINDINGS: We enrolled patients between Oct 27, 2010, and Feb 13, 2013, and the study concluded on Feb 9, 2018. Of 342 individuals screened for eligibility, 222 patients were randomly assigned to receive ruxolitinib (n=110, 50%) or best available therapy (n=112, 50%). The median time since polycythaemia vera diagnosis was 8·2 years (IQR 3·9-12·3) in the ruxolitinib group and 9·3 years (4·9-13·8) in the best available therapy group. 98 (88%) of 112 patients initially randomly assigned to best available therapy crossed over to receive ruxolitinib and no patient remained on best available therapy after 80 weeks of study. Among 25 primary responders in the ruxolitinib group, six had progressed at the time of final analysis. At 5 years, the probability of maintaining primary composite response was 74% (95% CI 51-88). The probability of maintaining complete haematological remission was 55% (95% CI 32-73) and the probability of maintaining overall clinicohaematological responses was 67% (54-77). In the intention-to-treat analysis not accounting for crossover, the probability of survival at 5 years was 91·9% (84·4-95·9) with ruxolitinib therapy and 91·0% (82·8-95·4) with best available therapy. Anaemia was the most common adverse event in patients receiving ruxolitinib (rates per 100 patient-years of exposure were 8·9 for ruxolitinib and 8·8 for the crossover population), though most anaemia events were mild to moderate in severity (grade 1 or 2 anaemia rates per 100 patient-years of exposure were 8·0 for ruxolitinib and 8·2 for the crossover population). Non-haematological adverse events were generally lower with long-term ruxolitinib treatment than with best available therapy. Thromboembolic events were lower in the ruxolitinib group than the best available therapy group. There were two on-treatment deaths in the ruxolitinib group. One of these deaths was due to gastric adenocarcinoma, which was assessed by the investigator as related to ruxolitinib treatment. INTERPRETATION: We showed that ruxolitinib is a safe and effective long-term treatment option for patients with polycythaemia vera who are resistant to or intolerant of hydroxyurea. Taken together, ruxolitinib treatment offers the first widely approved therapeutic alternative for this post-hydroxyurea patient population. FUNDING: Novartis Pharmaceuticals Corporation.


Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Interferón alfa-2/uso terapéutico , Interferón-alfa/uso terapéutico , Policitemia Vera/tratamiento farmacológico , Polietilenglicoles/uso terapéutico , Pirazoles/uso terapéutico , Quinazolinas/uso terapéutico , Antivirales/uso terapéutico , Quimioterapia Combinada , Fibrinolíticos/uso terapéutico , Estudios de Seguimiento , Humanos , Hidroxiurea/administración & dosificación , Pipobromán/administración & dosificación , Pronóstico , Proteínas Recombinantes/uso terapéutico , Tasa de Supervivencia , Factores de Tiempo
8.
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
9.
Nat Rev Cardiol ; 17(4): 242-257, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-31953535

RESUMEN

Advances in antiplatelet therapies for patients with cardiovascular disease have improved patient outcomes over time, but the challenge of balancing the risks of ischaemia and bleeding remains substantial. Moreover, many patients with cardiovascular disease have a residual risk of ischaemic events despite receiving antiplatelet therapy. Therefore, novel strategies are needed to prevent clinical events through mechanisms beyond platelet inhibition and with an acceptable associated risk of bleeding. The advent of non-vitamin K antagonist oral anticoagulants, which attenuate fibrin formation by selective inhibition of factor Xa or thrombin, has renewed the interest in dual-pathway inhibition strategies that combine an antiplatelet agent with an anticoagulant drug. In this Review, we highlight the emerging pharmacological rationale and clinical development of dual-pathway inhibition strategies for the prevention of atherothrombotic events in patients with different manifestations of cardiovascular disease, such as coronary artery disease, cerebrovascular disease and peripheral artery disease.


Asunto(s)
Inhibidores del Factor Xa/uso terapéutico , Fibrinolíticos/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Trombosis/prevención & control , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Enfermedades Cardiovasculares/complicaciones , Quimioterapia Combinada , Inhibidores del Factor Xa/administración & dosificación , Fibrinolíticos/administración & dosificación , Humanos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Trombosis/etiología
10.
PLoS One ; 15(1): e0227571, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31923246

RESUMEN

BACKGROUND: Acute myocardial infarction (AMI) complicates the clinical management of atrial fibrillation (AF) because coronary stenting may influence subsequent antithrombotic therapy. We investigated the use of a bare-metal stent (BMS) or a drug-eluting stent (DES) and associated outcomes in patients with pre-existing AF and first AMI undergoing percutaneous coronary intervention. METHODS AND RESULTS: Patient records in this population-based study were retrospectively collected from the Taiwan National Health Insurance Research Database. Using propensity score matching (PSM), we used 1:2 ratio stratification into a DES group of 436 and a BMS group of 785 patients from 2007 to 2011. The mean follow-up of matched cohorts was 1.7 years. After PSM, DESs were associated with lower rates of cardiovascular death (7.8%, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.86 and 10.1%, HR 0.64, 95% CI 0.45-0.90) and primary composite outcome (35.1%, HR 0.76, 95% CI 0.63-0.92 and 48.2%, HR 0.81, 95% CI 0.69-0.96) than BMSs within the first year and at the end of follow-up. Although the greatest benefit from DESs, irrespective of the first- and second- generation DESs, implantation was observed within the first year only, this benefit was not observed in patients with diabetes, chronic kidney disease, or dialysis. CONCLUSIONS: Use of DESs in AMI patients with pre-existing AF is associated with significantly lower rates of cardiovascular death and primary composite outcome within the first year follow-up. However, the effect is not apparent in patients with diabetes, chronic kidney disease or dialysis.


Asunto(s)
Fibrilación Atrial/complicaciones , Infarto del Miocardio/tratamiento farmacológico , Stents , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Stents Liberadores de Fármacos , Femenino , Fibrinolíticos/química , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Resultado del Tratamiento
11.
BMC Neurol ; 20(1): 22, 2020 Jan 16.
Artículo en Inglés | MEDLINE | ID: mdl-31948412

RESUMEN

BACKGROUND: Intravenous thrombolysis therapy (IVT) bridged with intra-arterial thrombectomy (IAT) has recently been recommended as favorable treatment option to ensure that the thrombolytic effect is delivered to the affected region for acute ischemic stroke patients. However, there remains a lack of studies reporting outcome prediction in this group of patients. In this study, we aimed to identify indicators from baseline data that could be used for early prediction of long-term functional outcomes. METHODS: This retrospective single center cohort study included acute ischemic stroke (AIS) patients (n = 92) who received IVT and IAT. Functional outcomes were assessed by the National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index. We investigated the relationship between functional outcomes at one-year post-procedure and potential predictors such as occlusion site, modified thrombolysis in cerebral infarction (mTICI) score following the IVT/IAT procedure, and degree of stenosis measured by carotid duplex. RESULTS: 67.4% of the studied patients had satisfactory outcomes with mTICI grades of 2b or 3. From baseline to one-year post-procedure, the NIHSS score improved in 88.0%, the mRS score improved in 69.6%, and the Barthel index improved with 59.8%. Patients with internal carotid artery (ICA) or vertebral artery (VA) stenosis detected by carotid duplex had significantly poorer functional outcomes, measured by the mRS score and Barthel index. In patients with a satisfactory mTICI grade, improvement in the mRS score was only observed in 60.0% of patients with ICA stenosis, compared to 93.8% without ICA stenosis. The VA stenosis was the most significant factor associated with the improvement of mRS (OR = 0.08; 95% CI: 0.01-0.63; P = 0.017) and Barthel Index (OR = 0.06; 95% CI: 0.01-0.47; P = 0.008) in multiple regression analysis. CONCLUSIONS: ICA or VA stenosis detected by carotid duplex could serve as predictors of significantly poorer functional outcomes in stroke patients treated with bridging therapy; they might be useful clinical markers, particularly as stenosis could be detected by a non-invasive and portable method.


Asunto(s)
Accidente Cerebrovascular/terapia , Trombectomía/métodos , Terapia Trombolítica/métodos , Anciano , Isquemia Encefálica/terapia , Estudios de Cohortes , Terapia Combinada , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento
12.
Curr Cardiol Rep ; 22(3): 13, 2020 Jan 29.
Artículo en Inglés | MEDLINE | ID: mdl-31997026

RESUMEN

The PAD population is at increased risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Risk factor modification, symptom control, antithrombotic, and lipid therapies are the mainstays of PAD medical therapy. Recent data has challenged prior recommendations regarding the optimal secondary prevention strategies in PAD. PURPOSE OF REVIEW: To review clinical evidence from large randomized controlled trials showing the benefit of antithrombotic and lipid therapy in the PAD population. RECENT FINDINGS: The COMPASS trial challenged prior recommendations regarding anticoagulation in PAD. Among the PAD subgroup, rivaroxaban 2.5 mg plus aspirin reduced MACE (HR 0.72, 95% CI 0.57-0.90, p = 0.0047), MALE (HR 0.54, 95% CI 0.35-0.82, p = 0.0037), and major amputation (HR 0.30, 95% CI 0.11-0.80, p = 0.011) compared with aspirin monotherapy. The THEMIS trial showed a 55% risk reduction for MALE with ticagrelor DAPT compared with aspirin monotherapy (HR 0.45, 95% CI 0.23-0.86). The FOURIER trial revealed that lowering LDL cholesterol below current targets with a PCSK9 inhibitor reduced MACE (HR 0.73, 95% CI 0.59-0.91, p = 0.0040) and MALE (HR 0.43, 95% CI 0.19-0.99, p = 0.042) in subjects with symptomatic PAD. Recent high-quality evidence shows the benefit of antiplatelet therapy, anticoagulation therapy, and lipid therapy in reducing MACE and MALE in PAD. Despite these findings, implementation remains a challenge and focus should now shift towards adopting evidence-based recommendations in clinical practice.


Asunto(s)
Fibrinolíticos/uso terapéutico , Enfermedad Arterial Periférica/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Humanos , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Proproteína Convertasa 9 , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Resultado del Tratamiento
13.
World Neurosurg ; 133: e835-e841, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31614218

RESUMEN

BACKGROUND: Several independent randomized controlled trials have shown superior efficacy of mechanical thrombectomy (MT) for management of acute ischemic stroke (AIS). However, elderly patients have been underrepresented or excluded in these trials. The aim of this study was to investigate the feasibility and safety of MT in patients with AIS ≥90 years old. METHODS: A retrospective review was performed of patients ≥90 years old presenting with AIS who underwent MT between 2010 and 2018. RESULTS: Of 453 patients with AIS, 5.74% (n = 26) were ≥90 years old, and 69.32% (n = 314) were 60-89 years old. Of baseline characteristics between both groups, there was a significant difference in age, sex, body mass index, smoking, hyperlipidemia, atrial fibrillation, and diabetes mellitus. Mean National Institutes of Health Stroke Scale score on admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tissue plasminogen activator, 57.69% (n = 15) versus 42.68% (n = 134), P = 0.14). There was no difference in periprocedural and postprocedural complications, good Thrombolysis In Cerebral Infarction scores (88.46% [n = 23] vs. 87.58% [n = 275], P = 1.00), good modified Rankin Scale scores (34.62% [n = 4] vs. 49.36% [n = 155], P = 0.40), or mortality (11.54% [n = 3] vs. 13.06% [n = 41], P = 0.82). CONCLUSIONS: Age is a factor that affects functional outcome following MT. Advancements in catheter techniques, technical experience, and great outcomes with MT allow for pushing the boundaries to consider age as one factor, rather than an exclusion criterion. Our results show that MT is safe and feasible in nonagenarians.


Asunto(s)
Isquemia Encefálica/cirugía , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Factores de Edad , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/tratamiento farmacológico , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del Tratamiento
14.
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
15.
World Neurosurg ; 133: e267-e274, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31505293

RESUMEN

OBJECTIVE: Decompressive craniectomy (DC) has been advocated as a lifesaving procedure in management of patients with raised intracranial pressure due to malignant ischemic stroke (MIS). The aim of this study was to identify comparative radiologic parameters after DC to predict functional outcome at 6 months in patients with MIS. METHODS: A retrospective analysis (2015-2018) of patients (median age 54 years; range, 29-80 years) with MIS who underwent postoperative computed tomography within 24 hours of DC was performed. Multivariate regression analysis was computed to predict clinical outcome at 6 months based on the Glasgow Coma Outcome Scale Extended. RESULTS: With median National Institutes of Health Stroke Scale score of 20 (range, 3-33), mean preoperative stroke volume was 250 ± 75 cm3. Median Glasgow Coma Outcome Scale Extended score at 6 months was 4. Multivariate regression analysis showed that the comparative radiographic characteristics of absence of effacement of cortical sulci (odds ratio 2.88; 95% confidence interval, 1.22-20.71; P = 0.02), absence of hemorrhagic transformation (odds ratio 1.09; 95% confidence interval, 1.99-12.89; P = 0.03), and absence of compression of lateral ventricles (odds ratio 3.75; 95% confidence interval, 1.28-22.4; P = 0.05) on postoperative computed tomography scan were significant independent predictors of good functional outcome (Glasgow Coma Outcome Scale Extended score 5-8). CONCLUSIONS: The comparative radiographic characteristics of absence of effacement of cortical sulci, hemorrhagic transformation, and compression of the lateral ventricles after DC in patients with MIS bore a significant relationship to predicting clinical outcome at 6 months.


Asunto(s)
Isquemia Encefálica/diagnóstico por imagen , Craniectomía Descompresiva/métodos , Hipertensión Intracraneal/cirugía , Neuroimagen , Tomografía Computarizada por Rayos X , Adulto , Anciano , Anciano de 80 o más Años , Edema Encefálico/diagnóstico por imagen , Edema Encefálico/etiología , Isquemia Encefálica/complicaciones , Isquemia Encefálica/tratamiento farmacológico , Femenino , Fibrinolíticos/uso terapéutico , Escala de Consecuencias de Glasgow , Humanos , Hipertensión Intracraneal/etiología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del Tratamiento
16.
J Stroke Cerebrovasc Dis ; 29(2): 104512, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31786044

RESUMEN

BACKGROUND: Extracranial carotid artery (ECA) tortuosity may influences successful recanalization rates of mechanical thrombectomy in acute ischemic stroke (AIS), yet the relationship between ECA tortuosity and the prognosis of patients with anterior circulation AIS who cannot undergo endovascular treatment remains uncertain. We hypothesized that increased tortuosity of the ECA leads to unfavorable outcomes in such patients. METHODS: Patients with anterior circulation AIS who underwent computed tomography angiography of the head and neck in our hospital between March 2018 and November 2018 were retrospectively analyzed. The tortuosity of the bilateral ECA was measured, and functional outcomes were evaluated by a modified Rankin Scale (mRS) at 90 days. Multivariate logistic regression models were used to determine the association between ECA tortuosity and outcomes of patients. RESULTS: A total of 203 patients were enrolled in our study, including 140 patients (68.97%) with favorable outcomes (mRS, 0-2) and 63 patients (31.03%) with unfavorable outcomes (mRS, 3-6). After adjusting for age, atrial fibrillation, stroke territory, and posthospital antithrombotics/statins therapy in multivariate logistic regression model I, ECA tortuosity (odds ratio, 1.052; 95% confidence interval, 1.010-1.096; P = .015) was an independent risk of unfavorable outcomes in enrolled patients. In the other 2 models (II and III) which adjusted for age, sex, baseline National Institutes of Health Stroke Scale score, and with or without posthospital medication, ECA tortuosity was also showed independent relationship to unfavorable outcomes. The optimal cutoff was 12.5 to predict the unfavorable outcomes in a receiver operating characteristic curve. CONCLUSIONS: Our study demonstrated that the ECA tortuosity is an independent predictor of unfavorable outcomes for anterior circulation AIS patients who without undergoing endovascular treatment after hospital admission. ECA tortuosity values greater than 12.5 may indicate an unfavorable outcome.


Asunto(s)
Isquemia Encefálica/terapia , Arterias Carótidas/diagnóstico por imagen , Angiografía Cerebral/métodos , Circulación Cerebrovascular , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/fisiopatología , Arterias Carótidas/fisiopatología , Evaluación de la Discapacidad , Procedimientos Endovasculares/efectos adversos , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Recuperación de la Función , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Resultado del Tratamiento
17.
J Stroke Cerebrovasc Dis ; 29(1): 104492, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31727598

RESUMEN

Complete spontaneous thrombosis of intracranial aneurysms is uncommon. Although this type of thrombosis is largely asymptomatic, in rare cases it can be accompanied by parent artery occlusion and ischemic stroke. There are limited reports of complete thrombosis of an unruptured aneurysm of the internal carotid artery and middle cerebral artery. Furthermore, there are no reports of occlusion of the vertebral artery caused by thrombosis of an aneurysm. The mechanisms of spontaneous thrombosis are not established. However, aneurysm morphology, arteriosclerosis, and stagnation of aneurysm flow have been suggested. Herein, we present a novel case of Wallenberg's syndrome caused by a fusiform aneurysm in which complete thrombosis of the proximal vertebral artery occurred. We discuss the mechanisms of thrombosis caused by an unruptured aneurysm, which may be useful for managing such patients who present with transient ischemic attacks.


Asunto(s)
Aneurisma Intracraneal/complicaciones , Trombosis Intracraneal/etiología , Síndrome Medular Lateral/etiología , Arteria Vertebral , Fibrinolíticos/uso terapéutico , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/tratamiento farmacológico , Trombosis Intracraneal/diagnóstico por imagen , Trombosis Intracraneal/tratamiento farmacológico , Síndrome Medular Lateral/diagnóstico por imagen , Síndrome Medular Lateral/rehabilitación , Masculino , Persona de Mediana Edad , Fármacos Neuroprotectores/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Rehabilitación de Accidente Cerebrovascular , Resultado del Tratamiento , Arteria Vertebral/diagnóstico por imagen
18.
Lancet Haematol ; 7(1): e61-e72, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31818728

RESUMEN

Sinusoidal obstructive syndrome, also known as hepatic veno-occlusive disease, is a potentially life-threatening complication that occurs in children undergoing haemopoietic stem-cell transplantation (HSCT). Differences in the incidence of genetic predisposition and clinical presentation of sinusoidal obstructive syndrome between children and adults have rendered the historical Baltimore and Seattle diagnostic criteria insufficient for children. In 2017, the European Society for Blood and Marrow Transplantation (EBMT) proposed the first paediatric diagnostic and severity grading guidelines for sinusoidal obstructive syndrome, intended for implementation across European centres. However, universally accepted paediatric criteria are needed to ensure prompt diagnosis, definitive treatment, and improved outcomes for children, adolescents, and young adults with sinusoidal obstructive syndrome, and to facilitate international clinical research collaboration. We convened an international panel of multidisciplinary experts including physicians with expertise in HSCT, paediatric intensive care, nephrology, hepatology, radiology, pathology, and transfusion medicine; HSCT advanced-practice providers and medical trainees; pharmacists; and translational and basic science researchers from the Pediatric Acute Lung Injury and Sepsis Investigators Network, the EBMT, the Pediatric Blood and Marrow Transplant Consortia, and several other institutions with extensive experience in sinusoidal obstructive syndrome. Panellists convened at The University of Texas, MD Anderson Cancer Center (Houston, TX, USA) in February, 2019, to evaluate the available evidence. In this expert position statement paper, we provide consensus recommendations for the international implementation of guidelines for the diagnosis, severity grading, and treatment of sinusoidal obstructive syndrome among children, adolescents, and young adults. We endorse universal adoption of paediatric diagnostic guidelines for sinusoidal obstruction syndrome as proposed by the EBMT, and provide implementation guidance for standardisation across centres; we have further proposed adjunctive use of age-appropriate organ-specific toxicity criteria for severity grading and provided prophylaxis and treatment considerations among children and adolescent and young adult patients. Key recommendations include: (1) liver biopsy, portal venous wedge pressure, and reversal of portal venous flow on Doppler ultrasonography should not be used for the routine diagnosis of sinusoidal obstructive syndrome in children, adolescents, and young adults; (2) platelet refractoriness can be defined as a corrected count increment of less than 5000-7500 following at least two sequential ABO-compatible fresh platelet transfusions; (3) hepatomegaly is best defined as an absolute increase of at least 1 cm in liver length at the midclavicular line; and if a baseline measurement is not available, hepatomegaly can be defined as greater than 2 SDs above normal for age; and (4) the presence and volume of ascites can be categorised as mild (minimal fluid by liver, spleen, or pelvis), moderate (<1 cm fluid), or severe (fluid in all three regions with >1 cm fluid in at least two regions).


Asunto(s)
Trasplante de Células Madre Hematopoyéticas/efectos adversos , Enfermedad Veno-Oclusiva Hepática , Adolescente , Bilirrubina/análisis , Biomarcadores/análisis , Niño , Colagogos y Coleréticos/uso terapéutico , Femenino , Fibrinolíticos/uso terapéutico , Enfermedad Veno-Oclusiva Hepática/diagnóstico , Enfermedad Veno-Oclusiva Hepática/terapia , Humanos , Masculino , Polidesoxirribonucleótidos/uso terapéutico , Factores de Riesgo , Índice de Severidad de la Enfermedad , Ultrasonografía Doppler , Ácido Ursodesoxicólico , Adulto Joven
19.
Heart Fail Clin ; 16(1): 107-120, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31735308

RESUMEN

Heart failure (HF) and atrial fibrillation (AF), increasingly common in the aging population, are closely related and commonly found together. This article explores the relationship between AF and HF and the thromboembolic effect of these diseases. Morbidity and mortality are increased when the 2 conditions are seen together. Stroke risks are significant with AF and all subtypes of HF. This article suggests that all patients with AF and HF should be considered for anticoagulation. Current evidence suggests that non-vitamin K antagonist oral anticoagulants are effective and safe in AF and HF in comparison with warfarin.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Insuficiencia Cardíaca/complicaciones , Accidente Cerebrovascular/prevención & control , Administración Oral , Fibrilación Atrial/complicaciones , Insuficiencia Cardíaca/tratamiento farmacológico , Humanos , Accidente Cerebrovascular/etiología
20.
Cardiovasc Interv Ther ; 35(1): 19-29, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31845096

RESUMEN

Percutaneous coronary intervention (PCI) has become a standard-of-care procedure in patients with acute and chronic coronary syndrome. Adjunctive antithrombotic therapy following PCI is the cornerstone of pharmacological treatment to prevent ischemic events. Dual antiplatelet therapy, a combination of aspirin and a P2Y12 inhibitor, has been proven as an initial antithrombotic regimen to reduce thrombotic events in patients undergoing PCI. However, the optimal antithrombotic strategy such as appropriate duration of dual antiplatelet therapy and the safe and effective combination of oral anticoagulation with antiplatelet therapy remains under debate. Since Japanese patients have different risk profiles for both thrombotic and bleeding events compared with Western population, optimal antithrombotic regimen may be different. Recently, the evidence in this field has been rapidly evolving and the antithrombotic strategy varies widely in clinical practice. In this clinical expert consensus document, we provide an in-depth review concerning antithrombotic strategies after PCI from Japanese perspective.


Asunto(s)
Síndrome Coronario Agudo/cirugía , Fibrinolíticos/uso terapéutico , Intervención Coronaria Percutánea/métodos , Trombosis/prevención & control , Anticoagulantes/uso terapéutico , Aspirina/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Quimioterapia Combinada , Humanos , Incidencia , Japón/epidemiología , Trombosis/etiología
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