Use of intracranial stent as rescue therapy after mechanical thrombectomy failure-9-year experience in a comprehensive stroke centre.

PURPOSE: There is no established rescue treatment in patients with mechanical thrombectomy (MT) failure. Our aim is to analyse whether the use of an intracranial stent improves prognosis in these patients. METHODS: Retrospective analysis of a prospective cohort of patients with ischemic stroke due to middle cerebral artery occlusion (MCA) or distal intracranial carotid artery (ICA) occlusion, from September 2009 to April 2019 in our comprehensive stroke care centre. Patients with MT failure were identified and dichotomized into two groups according to whether or not an intracranial stent was implanted. We analysed clinical outcomes in both groups. RESULTS: There was MT failure in 60 patients (14%) of the 433 with large vessel occlusion in distal ICA and proximal MCA. A stent was placed in 20 of them (33.3%). Compared to patients without rescue stenting, they showed better rates of independence at 3 months (mRS ≤ 2) 45% vs 2.5% (p < 0.001) and lower mortality 15% vs 50% (p = 0.009), maintaining statistical significance after multivariate analysis, without a significant increase of the rate of symptomatic intracranial haemorrhage (p = 0.209). CONCLUSION: Placement of an intracranial stent as rescue therapy after MT failure was associated with better clinical outcome without significant increase in haemorrhagic complications. We believe that this procedure should be appraised in these patients.

Guía de actuación clínica en la hemorragia subaracnoidea. Sistemática diagnóstica y tratamiento / Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJETIVO: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. MATERIAL Y MÉTODOS: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. RESULTADOS: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. CONCLUSIONES: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes

Oclusión arterial de gran vaso diagnosticada por angiografía portomografía computarizada en el ictus isquémico agudo: frecuencia, factores predictores y seguridad / Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: frequency, predictive factors, and safety

Introducción: Con la creciente disponibilidad de las terapias endovasculares, la demostración de oclusión arterial en el ictus isquémico agudo ha cobrado mayor relevancia. Este estudio evalúa la frecuencia de oclusión arterial y los factores asociados a la misma, así como las complicaciones derivadas del uso de angio-TC en el ictus agudo. Métodos: Se analizan retrospectivamente a los pacientes con ictus isquémico entre el 1 de julio y el 31 de diciembre del 2011. Resultados: Ciento cincuenta y siete pacientes (edad media de 74±11 años, NIHSS 5 [2-13]). Un 56,7% llegó al hospital con menos de 8 h de evolución. Se realizó angio-TC en 71 casos (45,2%), detectando oclusión de gran vaso en 37 (52,1%). La localización más frecuente fue M1 (40%). En el análisis univariante se halló asociación de la escala NIHSS (17 vs. 7, p < 0,001) y la fibrilación auricular (64% vs. 32%, p = 0,006) con la presencia de oclusión arterial. Posteriormente, se realizó una regresión logística, confirmando dicha asociación. No se observó ningún caso de nefropatía por contraste. El tiempo puerta-aguja para fibrinólisis intravenosa fue de 61,2 ± 24,5 min en los pacientes en que se realizó angio-TC y 53,5 ± 34,3 en los que no se realizó (p = 0,495). Conclusiones: La oclusión de gran vaso se detecta en el 23,6% de la muestra, especialmente en los pacientes traídos en las primeras horas. La escala NIHSS es un buen factor predictor

Introduction: Demonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. Methods: We retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011. Results: We included 157 patients (mean age, 74 ± 11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8 hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P < .001) and atrial fibrillation (64% vs 32%, P = .006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming theseassociations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2 ± 24.5 minutes in patients who underwent CT-angiography, and 53.5±34.3 minutes in those who did not (P = .495). Conclusions: Arterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor

Guía para el tratamiento del infarto cerebral agudo / Guidelines for the treatment of acute ischaemic stroke

Introducción: Actualización de la guía para el tratamiento del infarto cerebral agudo de la Sociedad Espa˜nola de Neurología basada en la revisión y análisis de la bibliografía existente sobre el tema. Se establecen recomendaciones en base al nivel de evidencia que ofrecen los estudios revisados. Desarrollo: Los sistemas de asistencia urgente extrahospitalaria se organizarán para asegurar la atención especializada de los pacientes y el ingreso en unidades de ictus (UI). Deben aplicarse cuidados generales para mantener la homeostasis (tratar la tensión arterial sistólica > 185 mmHg o diastólica > 105 mmHg, evitar hiperglucemia > 155 mg/dl y controlar la temperatura, tratando con antitérmicos cifras > 37,5 ◦C), y prevenir y tratar las complicaciones. La craniectomía descompresiva debe ser considerada en casos seleccionados de edema cerebral maligno. La trombólisis intravenosa con rtPA se administrará en las primeras 4,5 horas en pacientes sin contraindicación. La trombólisis intraarterial farmacológica puede indicarse en las primeras 6 horas de evolución y la trombectomía mecánica hasta las 8 horas. En el territorio posterior la ventana puede ampliarse hasta 12-24 horas. No hay evidencias para recomendar el uso rutinario de los fármacos denominados neuroprotectores. Se recomienda la anticoagulación en pacientes con trombosis de senos venosos. Se aconseja el inicio precoz de rehabilitación. Conclusiones: El tratamiento del infarto cerebral se basa en la atención especializada en UI, la aplicación urgente de cuidados generales y el tratamiento trombolítico intravenoso en las primeras 4,5 horas. La recanalización intraarterial farmacológica o mecánica pueden ser útiles en casos seleccionados. Terapias de protección y reparación cerebral están en desarrollo

Introduction: Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies. Development: Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 ◦C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible. Conclusion: Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intraarterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated

Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: frequency, predictive factors, and safety.

INTRODUCTION: Demonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. METHODS: We retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011. RESULTS: We included 157 patients (mean age, 74±11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P<.001) and atrial fibrillation (64% vs 32%, P=.006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming these associations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2±24.5minutes in patients who underwent CT-angiography, and 53.5±34.3minutes in those who did not (P=.495). CONCLUSIONS: Arterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor.

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment.

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Guidelines for the preventive treatment of ischaemic stroke and TIA (II). Recommendations according to aetiological sub-type.

BACKGROUND AND OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA). METHODS: We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective. CONCLUSIONS: We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient.

Guidelines for the treatment of acute ischaemic stroke.

INTRODUCTION: Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies. DEVELOPMENT: Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible. CONCLUSION: Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated.

Estenosis crítica de arteria basilar asociada a inestabilidad clínica: propuesta de una nueva indicación de tratamiento endovascular agudo / Critical stenosis of the basilar artery associated with clinical instability: new proposed indication for acute endovascular treatment

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Clinical practice guidelines in intracerebral haemorrhage.

Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognosis with higher rates of morbidity and mortality. Neurological deterioration is often observed during the first hours after onset and determines poor prognosis. Intracerebral haemorrhage, therefore, is a neurological emergency which must be diagnosed and treated properly as soon as possible. In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy, systematic diagnosis, acute treatment and secondary prevention for this condition.

Efficacy of intravenous thrombolysis according to stroke subtypes: the Madrid Stroke Network data.

OBJECTIVES: To identify possible differences in the early response to intravenous thrombolysis (IVT) or in stroke outcome at 3 months, based on stroke subtype in patients with acute ischaemic stroke (IS). METHODS: Multicentre stroke registry data were used, with prospective inclusion of consecutive patients with acute IVT-treated IS in five acute stroke units. We compared clinical improvement (National Institutes of Health Stroke Scale, NIHSS) at 24 h and at day 7 as well as functional outcome at 3 months (Modified Rankin Scale, mRS) amongst the different stroke subtypes (ICD-10). RESULTS: In total, 1479 patients were included; 178 (12%) had large vessel disease (LVD) with carotid stenosis ≥ 50%, 175 (11.8%) had other LVD, 638 (43%) had cardioembolism, 60 (4.1%) had lacunar infarction, 72 (4.9%) were patients with IS of other/unusual cause and 356 (24.1%) had unknown/multiple causes. Patients with lacunar infarction had lower stroke severity (median NIHSS 6) whilst cardioembolic IS was the most severe (median NIHSS 14) (P < 0.001). No differences in NIHSS improvement were found at 24 h. LVD patients with carotid stenosis (odds ratio 0.544; 95% CI 0.383-0.772; P = 0.001) were less likely to improve at day 7 after adjustment for age, gender, vascular risk factors and stroke severity. However, adjusted multivariate analysis showed no influence of stroke subtype on stroke outcome (mRS) at 3 months. Age, systolic blood pressure on admission and stroke severity were independently associated with mRS > 2 at 3 months. CONCLUSION: Although LVD patients with arterial stenosis ≥ 50% improve less than the other aetiologies at day 7, stroke aetiological subtype does not determine differences in IS outcome at 3 months after IVT.

Diabetes and previous stroke: hazards for intravenous thrombolysis?

BACKGROUND AND PURPOSE: Alteplase licensing approval in Europe does not advocate intravenous thrombolysis (IVT) for diabetic ischaemic stroke (IS) patients with previous cerebral infarction (PCI). Our aim was to assess whether concomitant diabetes mellitus (DM) and PCI are associated with symptomatic intracerebral haemorrhage (SICH) and poor outcome after IVT. METHODS: Multicentre prospective registry, which included consecutive IVT-treated, acute IS patients from January 2003 to December 2010. The frequency of SICH (SITS-MOST criteria) and 3-month outcomes (mRS) were compared between the following groups: (i) diabetic patients with PCI (DM+/PCI+); (ii) diabetic patients without PCI (DM+/PCI-); (iii) non-diabetic patients with PCI (DM-/PCI+); and (iv) patients without diabetes or PCI (DM-/PCI-). RESULTS: A total of 1475 patients were included. Thirty-four patients (2.3%) had known DM and PCI, 258 (17.5%) were diabetics without PCI, and 119 (8.1%) had a PCI and no DM. Thirty-six patients (2.6%) developed SICH, with no differences between groups (P = 985). Fifteen (40.9%) DM+/PCI+ patients, 113 (46.5%) DM+/PCI- patients, 47 (42%) DM-/PCI+ patients and 414 (40.9%) DM-/PCI- patients had mRS ≥ 3 at 3 months (P = 427). The presence neither of DM nor of PCI, nor their combination, had any impact on the risk of SICH or on outcome at 3 months after adjusting for age, stroke severity and glucose levels on admission. CONCLUSIONS: Acute IS diabetic patients with PCI who were treated with IVT had similar outcomes to patients without such history, with no increase in the rates of SICH. Thus, they should not be excluded from IVT only on the basis of DM and PCI.

Guidelines for the preventive treatment of ischaemic stroke and TIA (I). Update on risk factors and life style.

OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and transient ischaemic attack (TIA). METHODS: We reviewed available evidence on risk factors and means of modifying them to prevent ischaemic stroke and TIA. Levels of evidence and recommendation grades are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: This first section summarises the recommendations for action on the following factors: blood pressure, diabetes, lipids, tobacco and alcohol consumption, diet and physical activity, cardio-embolic diseases, asymptomatic carotid stenosis, hormone replacement therapy and contraceptives, hyperhomocysteinemia, prothrombotic states and sleep apnea syndrome. CONCLUSIONS: Changes in lifestyle and pharmacological treatment for hypertension, diabetes mellitus and dyslipidemia, according to criteria of primary and secondary prevention, are recommended for preventing ischemic stroke.

In-hospital stroke: a multi-centre prospective registry.

BACKGROUND: in-hospital strokes (IHS) are relatively frequent. Avoidable delays in neurological assessment have been demonstrated. We study the clinical characteristics, neurological care and mortality of IHS. METHODS: multi-centre 1-year prospective study of IHS in 13 hospitals. Demographic and clinical characteristics, admission diagnosis, quality of care, thrombolytic therapy and mortality were recorded. RESULTS: we included 273 IHS patients [156 men; 210 ischaemic strokes (IS), 37 transient ischaemic attacks (TIA) and 26 cerebral haemorrhages]. Mean age was 72 ± 12 years. Cardiac sources of embolism were present in 138 (50.5%), withdrawal of antithrombotic drugs in 77 (28%) and active cancers in 35 (12.8%). Cardioembolic stroke was the most common subtype of IS (50%). Reasons for admission were programmed or urgent surgery in 70 (25%), cardiac diseases in 50 (18%), TIA or stroke in 30 (11%) and other medical illnesses in 71 (26%). Fifty-two per cent of patients were evaluated by a neurologist within 3 h of stroke onset. Thirty-three patients received treatment with tPA (15.7%). Thirty-one patients (14.7%) could not be treated because of a delay in contacting the neurologist. During hospitalization, 50 patients (18.4%) died, 41 of them because of the stroke or its complications. CONCLUSIONS: cardioembolic IS was the most frequent subtype of stroke. Cardiac sources of embolism, active cancers and withdrawal of antithrombotic drugs constituted special risk factors for IHS. A significant proportion of patients were treated with thrombolysis. However, delays in contacting the neurologist excluded a similar proportion of patients from treatment. IHS mortality was high, mostly because of stroke.

[Neurovascular intervention in the acute phase of cerebral infarction]. / Intervencionismo neurovascular en la fase aguda del infarto cerebral.

BACKGROUND AND PURPOSE: Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid. METHODS: We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005-2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs). RESULTS: A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2-34]; 7 patients had previously received iv t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs ≤ 2) and overall mortality rate was 19.5%. CONCLUSIONS: Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with iv t-PA exclusion criteria or when this is not effective.

Intervencionismo neurovascular en la fase aguda del infarto cerebral / Endovascular treatment for acute stroke: an open field to begin

Introducción: La evidencia de que la recanalización y la reperfusión del lecho vascular distal de pacientes adecuadamente seleccionados son fundamentales para lograr un buen pronóstico funcional ha disparado el interés y la investigación sobre el tratamiento endovascular del ictus isquémico agudo. Desarrollo: La fibrinólisis intravenosa (i.v.) es el tratamiento de elección en pacientes con ictus isquémico agudo, aunque presenta ciertas limitaciones. El tratamiento endovascular supone una alternativa prometedora con ventajas teóricas sobre el tratamiento i.v., como una mayor frecuencia de recanalización y mayor ventana terapéutica. Las estrategias de reperfusión endovascular incluyen fibrinólisis intraarterial con fármacos o tratamiento mecánico con dispositivos que permiten extracción, aspiración, disrupción o atrapamiento del trombo en la pared. El ideal del tratamiento integral del ictus agudo sería aportar especificidad al paciente individual: tratar una oclusión arterial con unas colaterales y con una fisiología de la isquemia cerebral aguda determinadas. Con todos estos datos, ante cualquier paciente podremos decidir la mejor estrategia terapéutica y pasar de un enfoque del paciente basado únicamente en el tiempo a un enfoque basado también en la fisiopatología; por lo tanto, distintos pacientes tendrían diferentes ventanas terapéuticas. La situación del tratamiento endovascular en España es heterogénea y precisa de recursos materiales y humanos para conseguir su implantación en todo el territorio. Conclusiones: El tratamiento endovascular del ictus supone una nueva herramienta terapéutica para lograr la reperfusión de una forma segura en los pacientes no candidatos a alteplasa o que no han conseguido reperfundir con el fibrinolítico i.v (AU)

Introduction: The evidence that recanalization and reperfusion of the distal vascular bed in appropriately selected patients is crucial to achieve good functional outcome has triggered interest and research into endovascular treatment of acute ischemic stroke.Development: Intravenous (iv) thrombolytic therapy is the treatment of choice in patients with acute ischemic stroke, however, it has certain limitations. Endovascular treatment is a promising alternative with theoretical advantages over iv therapy, such as an increased frequency of recanalization and longer therapeutic windows. Endovascular reperfusion strategies include intra-arterial fibrinolysis with drugs, or endovascular mechanical devices for thrombectomy or thrombus disruption, thromboaspiration, or thrombus entrapment in the vessel wall. The ideal of comprehensive treatment of acute stroke would provide specificity to treat an individual patient: with specific arterial occlusion and collaterals and a determined physiology of acute cerebral ischemia. With all this information, we would decide the best therapeutic strategy for the patient, and move from just a time-based approach to include a pathophysiology approach as well, and thus different patients could have different therapeutic windows. The endovascular treatment situation in Spain is heterogeneous and requires human and material resources to enable it to be implemented throughout the country. Conclusions: Endovascular treatment of stroke is a new therapeutic tool for achieving reperfusion safely in patients ineligible for Alteplase or who have failed reperfusion with an iv fibrinolytic (AU)

Trombólisis en Madrid: ¿cada vez más y mejor? Análisis de series temporales durante 4 años / Thrombolysis in Madrid: is there improvement in the 4 years temporal analysis?

Introducción. El tratamiento trombolítico en pacientes con ictus isquémico está limitado por la estrecha ventana terapéutica, aunque puede incrementarse con una adecuada coordinación de los diferenteseslabones de la cadena asistencial.Pacientes y métodos. Estudio observacional, prospectivo, multicéntricode pacientes con ictus isquémico que recibieron tratamiento con activador del plasminógeno tisular recombinante intravenoso entre enero de 2003 y mayo de 2007. Se realizó un análisis descriptivo de variables clínicas y epidemiológicas. Para valorar la tendencia en el tiempo de las relativas a seguridad, eficacia y calidad del procedimiento se llevó a cabo un análisis de series temporales mediantemodelos autorregresivos integrados con media móvil (ARIMA).Resultados. Se trataron 324 pacientes (56 % varones; edad media:65,6 años). Un 53,6 % de los pacientes era independiente a los 3 meses (puntuación: 0-2 en la escala de Rankin modificada). La mortalidad fue del 15,7% y un 3,7% sufrió una hemorragia intracraneal sintomática. El análisis de series temporales mostró un incrementosignificativo de 2 a 20 procedimientos/mes (p<0,0001) y unaumento del porcentaje de pacientes con independencia funcional alos 3 meses (0,83% ARIMA [1, 0, 1] p<0,0001).Conclusiones. La trombólisis intravenosa es un procedimientoseguro y eficaz en el tratamiento del ictus isquémico en la prácticaclínica habitual. A medida que aumenta la experiencia de los profesionalesse incrementa significativamente el número de pacientestratados, con un mayor porcentaje de pacientes que alcanzan la independenciafuncional. El análisis de series temporales es una herramientaútil en estudios de previsión en la gestión sanitaria (AU)

Introduction. Thrombolysis in acute ischemic stroke (IS) islimited by the short time window. However, this can be improvedwith adequate coordination of all the professionals and proceduresinvolved in acute stroke treatment.Patients and methods. A multicenter, observational, prospectivestudy conducted in IS patients treated with intravenousrecombinant tissue plasminogen activator between January 2003and May 2007 was performed. A descriptive analysis of epidemiologicand clinical variables was conducted. Temporal analysisof safety, efficacy and quality parameters was carried out with theAuto-Regressive Integrated Moving Average (ARIMA) (p, d, q)models.Results. From January 2003 to 2007, 324 patients were included(56% males; median age: 65.6). A total of 53.6 % becameindependent at 3 months (score 0-2 on the Modified Rankin Scale).Mortality rate 3 months after treatment was 15.7% and 3.7%suffered symptomatic intracranial bleeding. The temporal analysisshowed a significant increase of thrombolysis, from a meanof 2 procedures per month to 20 (p<0.0001). There was a significantincrease in the percentage of 3-month independent patients(0.83% [ARIMA] (1, 0, 1) p<0.0001).Conclusions. Intravenous thrombolysis is a safe and effectiveprocedure for the treatment of IS in the clinical practice. Asthe experience of all the professionals involved in IS treatmentincreases, the number of patients who receive iv rtPA increases,with better outcome. Temporal analysis by ARIMA models is usefulin planning health policies

P300 event-related potential in euthymic patients with bipolar disorder.

Auditory P300 event-related potential (ERP) and performance on Sustained Attention were evaluated in 24 euthymic bipolar patients and 38 healthy volunteers. There were no significant differences between groups, and performance in sustained attention had no significant influence in the P300 responses. P300 response might be driven by the presence of mood symptoms.

[Thrombolysis in Madrid: is there improvement in the 4 years temporal analysis?]. / Trombólisis en Madrid: ¿cada vez más y mejor? Análisis de series temporales durante 4 años.

INTRODUCTION: Thrombolysis in acute ischemic stroke (IS) is limited by the short time window. However, this can be improved with adequate coordination of all the professionals and procedures involved in acute stroke treatment. PATIENTS AND METHODS: A multicenter, observational, prospective study conducted in IS patients treated with intravenous recombinant tissue plasminogen activator between January 2003 and May 2007 was performed. A descriptive analysis of epidemiologic and clinical variables was conducted. Temporal analysis of safety, efficacy and quality parameters was carried out with the Auto-Regressive Integrated Moving Average (ARIMA) (p, d, q) models. RESULTS: From January 2003 to 2007, 324 patients were included (56% males; median age: 65.6). A total of 53.6 % became independent at 3 months (score 0-2 on the Modified Rankin Scale). Mortality rate 3 months after treatment was 15.7% and 3.7% suffered symptomatic intracranial bleeding. The temporal analysis showed a significant increase of thrombolysis, from a mean of 2 procedures per month to 20 (p<0.0001). There was a significant increase in the percentage of 3-month independent patients (0.83% [ARIMA] (1, 0, 1) p<0.0001). CONCLUSIONS: Intravenous thrombolysis is a safe and effective procedure for the treatment of IS in the clinical practice. As the experience of all the professionals involved in IS treatment increases, the number of patients who receive iv rtPA increases, with better outcome. Temporal analysis by ARIMA models is useful in planning health policies.