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1.
World Neurosurg ; 134: e1015-e1027, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31759150

RESUMO

BACKGROUND: Unfavorable anatomy can preclude traditional anterograde endovascular interventions. Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, can provide alternative pathways for successful treatment of these patients. We aimed to assess the safety, efficacy, and outcomes of endovascular embolization through transcirculation approaches. METHODS: Nine centers provided retrospective data on patients who underwent transcirculation procedures for embolization of intracranial aneurysms (IAs), dural arteriovenous fistulas (dAVFs), and arteriovenous malformations (AVMs). Raymond-Roy Occlusion Classification (RROC) grades and degree of obliteration were used to evaluate treatment success. Minor/major complications and clinical/angiographic outcomes were also assessed. A review of the literature reporting patients who underwent transcirculation embolizations was also performed. RESULTS: Forty patients were included in the study (34 IAs, 3 AVMs, and 3 dAVFs). Most IAs (22/34, 64.7%) were treated electively. Three AVMs and 2 dAVFs presented ruptured. RROC grade I-II was achieved in 97% of IAs. All AVMs and dAVFs were completely obliterated. One patient developed a transient arterial thrombus that was successfully treated with intravenous tirofiban. The most common indications for a transcirculation approach were difficult access angle of the target lesion (42.5%) and occlusion of the parent artery (27.5%). The review of the literature pooled 152 IAs treated via transcirculation approaches. Most common locations were the basilar tip (27%), posterior inferior cerebellar artery (25%), and internal carotid artery (15.1%). The posterior communicating artery was crossed in 60 (39.5%), anterior communicating artery in 48 (31.6%), and vertebral artery in 37 (24.3%) patients. Primary coiling alone was performed in 22 (14.5%), stent-assisted coiling in 67 (44.1%), balloon-assisted coiling in 36 (23.7%), stent-assisted coiling + balloon-assisted coiling in 20 (13.2%) and flow diversion in 7 (4.6%) patients. After intervention, 142 (93.4%) IAs achieved successful RROC grades I-II. Two major complications (1.3%) leading to death were reported, both of which were intraprocedural aneurysmal ruptures with massive subarachnoid hemorrhage and herniation. After a mean angiographic follow-up of 11.3 months, only 6/108 (5.6%) IAs showed intrasaccular filling/recurrence. CONCLUSIONS: Transcirculation approaches seem to be safe and effective in the treatment of IAs, dAVFs, and AVMs. The most common indication for a transcirculation approach is the presence of a difficult angle to access the target lesion and occlusion of the parent artery.

2.
Stroke ; 51(2): 533-541, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31884908

RESUMO

Background and Purpose- There are scarce data regarding the safety of intravenous thrombolysis (IVT) in acute ischemic stroke among patients on direct oral anticoagulants (DOACs). Methods- We performed a systematic review and meta-analysis of the current literature. Data regarding all adult patients pretreated with DOAC who received IVT for acute ischemic stroke were recorded. Meta-analysis was performed by comparing the rate of symptomatic intracerebral hemorrhage in these patients with (1) stroke patients without prior anticoagulation therapy and (2) patients on warfarin with international normalized ratio <1.7. Meta-analyses were further conducted in subgroups as follows: (1) administration of DOAC within 48 hours versus an unknown interval before IVT, (2) consideration of symptomatic intracerebral hemorrhage outcome according to the National Institute of Neurological Disorders (NINDS) versus the European Cooperative Acute Stroke Study II (ECASS-II) criteria. Results- After reviewing 13 392 reports and communicating with certain authors of 12 published studies, a total of 52 823 acute ischemic stroke patients from 6 studies were enrolled in the present meta-analysis: DOACs: 366, warfarin: 2133, and 503 241 patients without prior anticoagulation. We detected no additional risk of symptomatic intracerebral hemorrhage following IVT among patients taking DOACs within 48 hours-DOACs-warfarin: NINDS (odds ratio [OR], 0.55 [95% CI, 0.19-1.59]), ECASS-II (OR, 0.77 [95% CI, 0.28-2.16]); DOACs-no-anticoagulation: NINDS (OR, 1.23 [95% CI, 0.46-3.31]), ECASS-II (OR, 0.87 [95% CI, 0.32-2.41]). Similarly, no additional risk was detected with no time limit between last DOAC intake-DOACs warfarin: NINDS (OR, 0.85 [95% CI, 0.49-1.45]), ECASS-II (OR, 1.11 [95% CI, 0.67-1.85]); DOACs-no-anticoagulation: NINDS (OR, 1.17 [95% CI, 0.43-3.15]), ECASS-II (OR, 0.87 [95% CI, 0.33-2.41]). There was no evidence of heterogeneity across included studies (I2=0%). We also provided the details of 123 individual cases with or without reversal agents before IVT. There was no significant increase in the risk of hemorrhagic transformation (OR, 1.48 [95% CI, 0.50-4.38]), symptomatic hemorrhagic transformation (OR, 0.47 [95% CI, 0.09-2.55]), or early mortality (OR, 0.60 [95% CI, 0.11-3.43]) between cohorts who did or did not receive prethrombolysis idarucizumab. Conclusions- The results of our study indicated that prior intake of DOAC appears not to increase the risk of symptomatic intracerebral hemorrhage in selected AIS patients treated with IVT.

3.
Acta Neurol Scand ; 140(6): 435-442, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31505028

RESUMO

OBJECTIVES: One of the most important prognostic factors of cerebral venous sinus thrombosis (CVST) is intracranial hemorrhage (ICH). We studied the risk factors, clinical, and radiologic characteristics of early, delayed, and expanded ICH in Iranian patients with CVST. MATERIALS AND METHODS: In a retrospective study, from August 2012 to September 2016, all adult patients with a confirmed diagnosis of CVST were recruited. Demographic, clinical, and radiologic characteristics of the patients were recorded. The predictors of early, delayed, and expanded ICH were assessed through logistic regression analysis. RESULTS: Among 174 eligible patients, 35.1% of the patients had early ICH. Delayed and expanded hemorrhage occurred in 5% and 7.4% of the patients, respectively. Higher age was a risk factor (odds ratio [OR] = 1.038, 95% confidence interval [CI] = 1.008-1.069), and involvement of multiple sinuses/veins was associated with lower risk of early ICH (OR = 0.432, CI = 0.226-0.827). The risk of delayed ICH was higher in the patients with early hemorrhage (OR = 4.44, CI: 0.990-19.94), men (OR = 4.18, CI: 0.919-19.05), and those with a focal neurologic deficit on admission (OR = 16.05, CI: 1.82-141.39). Acute onset was the predictor of the expansion of early ICH (OR = 8.92, CI: 1.81-43.77), whereas female gender-related conditions were associated with a lower risk of hemorrhage expansion (OR = 0.138, CI: 0.025-0.770). Administration of anticoagulants was associated with neither delayed (P value = .140) nor expanded hemorrhage (P-value = .623). CONCLUSIONS: Male gender, early hemorrhages, acute onset, and presence of focal neurologic deficit are the risk factors for delayed and/or expanded hemorrhages in the patients with CVST.


Assuntos
Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/patologia , Trombose dos Seios Intracranianos/complicações , Adulto , Feminino , Humanos , Irã (Geográfico) , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
4.
World Neurosurg ; 129: e831-e837, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31207378

RESUMO

BACKGROUND: Treatment of unruptured intracranial aneurysms (IAs) in elderly patients is associated with a high risk of morbidity and mortality, necessitating a thorough understanding of the potential rupture risk. The aim of this study was to identify morphologic parameters and anatomic locations that could discriminate ruptured IAs in patients ≥70 years old. METHODS: Retrospective analysis was performed of three-dimensional angiograms and medical records of 344 patients with 411 saccular IAs. Patients ≥70 years old were defined as elderly. IAs were subdivided into ruptured and unruptured. Morphologic parameters and anatomic locations were compared in elderly and younger (<70 years old) patients with ruptured and unruptured IAs. RESULTS: The study included 266 patients <70 years old and 78 patients ≥70 years old with 411 aneurysms (102 ruptured and 309 unruptured). In the elderly group, 22 of 95 aneurysms were ruptured (23.15%) compared with 80 of 316 (25.3%) in the younger group. Size ratio and aspect ratio were higher in ruptured IAs, but only in the younger group. Undulation index, indicating IA shape irregularity, was significantly different between ruptured and unruptured IAs in younger and elderly groups. The only variables associated with rupture in the elderly group were undulation index (0.11 ± 0.07 vs. 0.07 ± 0.06, P = 0.02) and location (P = 0.001). CONCLUSIONS: Aneurysm size, size ratio, and aspect ratio may not be reliable discriminants of rupture in elderly patients. Unruptured IAs in elderly patients should be evaluated on the basis of shape irregularity and anatomic location.


Assuntos
Aneurisma Roto/patologia , Aneurisma Intracraniano/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
5.
World Neurosurg ; 128: e918-e922, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31096029

RESUMO

BACKGROUND: Cerebral venous thrombosis (CVT) is a common type of stroke in young adults and associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are the most common causes of death in these patients. In contrast with malignant arterial middle cerebral infarction, there are few studies reporting the efficacy of decompressive craniectomy (DC) for treatment of high ICP in patients with CVT. In this study, we assess the clinical outcome of patients with CVT with impending brain herniation treated with DC versus medical management. METHODS: In this retrospective study, medical records of all patients with CVT admitted to our hospital were reviewed. Patients with the following inclusion criteria were entered into the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive midposition pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups. RESULTS: Of 357 patients with CVT hospitalized in our center, 48 patients entered into the study. Twenty-three patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils' reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P < 0.001). Favorable outcome (modified Rankin scale score 0-2) was achieved in 52% of the DC group and 0% of the MG group (P < 0.001). CONCLUSIONS: The results of our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcome in most patients.


Assuntos
Infarto Cerebral/tratamento farmacológico , Infarto Cerebral/cirurgia , Craniectomia Descompressiva/métodos , Procedimentos Neurocirúrgicos/métodos , Trombose Venosa/tratamento farmacológico , Trombose Venosa/cirurgia , Adolescente , Adulto , Idoso , Infarto Cerebral/complicações , Cuidados Críticos , Encefalocele/etiologia , Encefalocele/prevenção & controle , Feminino , Escala de Coma de Glasgow , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Trombose Venosa/complicações , Adulto Jovem
6.
Surg Neurol Int ; 10: 10, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30783541

RESUMO

Background: Enoxaparin was shown to have a neuroprotective effect in animal models as well as a human study following traumatic brain injury. This study was conducted to assess the effect of enoxaparin on the clinical outcome of severe traumatic brain injury (TBI) and its safety. Methods: This study is a randomized double-blinded placebo-controlled trial. The inclusion criteria were age 16-70, a closed head injury, a postresuscitation Glasgow Coma Scale (GCS) between 5 and 8, and a latency time between the injury and entering the study of less than 5 h. The patients were randomized into enoxaparin and placebo groups. In the enoxaparin group, 0.5 mg/kg enoxaparin was injected subcutaneously every 6 h in six total doses. The two groups were compared for the occurrence of intracranial hematoma (ICH) and for clinical neurological outcome, assessed by the Glasgow Outcome Scale. Results: Twenty-seven patients were assigned to the placebo group and 26 to the enoxaparin group. The two groups were similar regarding baseline characteristics, including age, sex, postresuscitation GCS, and best motor response. The occurrence of new ICH or an ICH size increase was insignificantly more frequent in the enoxaparin group than the placebo group (26.9% vs. 7.4%, P = 0.076). The favorable outcome rate in the enoxaparin group was significantly higher than in the placebo group (57.7% vs. 25.9%, P = 0.019). Conclusions: This study showed that the early administration of enoxaparin could lead to favorable outcomes in severe TBI patients without significantly increasing cerebral hemorrhagic complications.

7.
World Neurosurg ; 123: e747-e752, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30579014

RESUMO

BACKGROUND: Extensive evidence supports mechanical thrombectomy using stentrievers (SR) for acute large vessel occlusion (aLVO). Aspiration is also used as a first pass or adjunct technique during clot removal. Here we report technical results from mechanical thrombectomy cases using SR alone, aspiration alone (AD), or a combination of SR and aspiration (SA) as a first pass for aLVO. METHODS: An institutional stroke database was reviewed for patients presenting to a single academic institution with anterior circulation aLVO and who were treated with mechanical thrombectomy from 2011 to 2017. Patients managed with SR alone, AD, or a combination of these 2 techniques (SA) were identified. The rate of successful recanalization after the first thrombectomy attempt was compared between the 3 groups. RESULTS: A total of 353 patients were analyzed, including 215 in SR, 32 in AD, and 106 in SA groups. There was no significant difference for age and admission National Institutes of Health Stroke Scale between the groups. Successful recanalization rates after the first pass were 35.8% in the SR group, 34.4% in aspiration as a first pass technique, and 55.7% in SA, with a statistically significant higher rate of first pass success in the SA group (P = 0.002). Using balloon-guide catheter doubled the rate of successful first pass recanalization from 21.3% to 41.6% in the SR group (P = 0.005); however, the SA technique was more effective for first pass recanalization when compared with an SR and balloon-guide catheter combination (55.7% vs. 41.6%, P = 0.025). CONCLUSIONS: The combination of SR and catheter aspiration can increase the rate of single pass successful recanalization compared with these techniques individually.


Assuntos
Revascularização Cerebral/instrumentação , Trombose Intracraniana/terapia , Trombólise Mecânica/instrumentação , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/terapia , Artérias Cerebrais , Revascularização Cerebral/métodos , Feminino , Humanos , Masculino , Trombólise Mecânica/métodos , Estudos Retrospectivos , Instrumentos Cirúrgicos , Resultado do Tratamento
8.
Acta Neurol Belg ; 2018 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-30178180

RESUMO

Cerebral venous sinus thrombosis is an uncommon cause of stroke, which is more prevalent in Iran and the Middle East. We aimed to assess the etiology, radiologic, and clinical manifestations of cerebral venous sinus thrombosis, specifically the predictors of patients' outcome in Namazi hospital, Shiraz, Iran. In this retrospective study, we included all adult patients with the diagnosis of cerebral venous sinus thrombosis, who were admitted in hospital, from 2012 to 2016. Demographic data, radiologic findings, clinical presentation, risk factors, treatment, and outcome according to modified Rankin Scale (mRS) on discharge were assessed and the factors associated with hospital fatality and poor outcome (mRS > 2) were investigated through univariable and multivariable analyses. Adjusted odds ratio (OR), 95% confidence interval (CI), and p values were reported. Among 174 patients, 128 (73.6%) were female. The mean age was 37.8 ± 11.2. Total of 39 patients (22.4%) had poor discharge outcome and nine patients died in hospital. Older age (OR = 1.041, CI = 1.000-1.08), decreased level of consciousness (OR = 5.46, CI = 2.17-13.72), focal neurologic deficit (OR = 5.63, CI = 2.14-14.77), and expansion of intracranial hemorrhage (ICH) (OR = 9.13, CI = 1.96-42.64) were predictors of poor outcome according to the logistic regression model. Older age (p = 0.02), focal neurologic deficit (p = 0.005), deep venous system thrombosis (p = 0.002), early intracranial hemorrhage (p = 0.049), delayed hemorrhage (p = 0.007) and hemorrhage expansion (p = 0.002), infratentorial hemorrhagic lesions (p = 0.005), and higher CRP (p = 0.011) were associated with hospital fatality. The patients with gynecologic risk factors were at lower risk of hospital death (p = 0.005). Age, decreased consciousness and focal neurological deficit on admission, and expanded intracranial hemorrhage are predictors of poor outcome. The patients who are at higher risk of unfavorable outcome should be recognized and closely monitored.

9.
World Neurosurg ; 119: e541-e550, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30075262

RESUMO

OBJECTIVE: Precise morphologic evaluation is important for intracranial aneurysm (IA) management. At present, clinicians manually measure the IA size and neck diameter on 2-dimensional (2D) digital subtraction angiographic (DSA) images and categorize the IA shape as regular or irregular on 3-dimensional (3D)-DSA images, which could result in inconsistency and bias. We investigated whether a computer-assisted 3D analytical approach could improve IA morphology assessment. METHODS: Five neurointerventionists evaluated the size, neck diameter, and shape of 39 IAs using current and computer-assisted 3D approaches. In the computer-assisted 3D approach, the size, neck diameter, and undulation index (UI, a shape irregularity metric) were extracted using semiautomated reconstruction of aneurysm geometry using 3D-DSA, followed by IA neck identification and computerized geometry assessment. RESULTS: The size and neck diameter measured using the manual 2D approach were smaller than computer-assisted 3D measurements by 2.01 mm (P < 0.001) and 1.85 mm (P < 0.001), respectively. Applying the definitions of small IAs (<7 mm) and narrow-necked IAs (<4 mm) from the reported data, interrater variation in manual 2D measurements resulted in inconsistent classification of the size of 14 IAs and the necks of 19 IAs. Visual inspection resulted in an inconsistent shape classification for 23 IAs among the raters. Greater consistency was achieved using the computer-assisted 3D approach for size (intraclass correlation coefficient [ICC], 1.00), neck measurements (ICC, 0.96), and shape quantification (UI; ICC, 0.94). CONCLUSIONS: Computer-assisted 3D morphology analysis can improve accuracy and consistency in measurements compared with manual 2D measurements. It can also more reliably quantify shape irregularity using the UI. Future application of computer-assisted analysis tools could help clinicians standardize morphology evaluations, leading to more consistent IA evaluations.


Assuntos
Angiografia Digital/métodos , Angiografia Cerebral/métodos , Imagem Tridimensional/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Humanos , Variações Dependentes do Observador , Reconhecimento Automatizado de Padrão/métodos
10.
Proc SPIE Int Soc Opt Eng ; 101342017 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-28867867

RESUMO

Neurosurgeons currently base most of their treatment decisions for intracranial aneurysms (IAs) on morphological measurements made manually from 2D angiographic images. These measurements tend to be inaccurate because 2D measurements cannot capture the complex geometry of IAs and because manual measurements are variable depending on the clinician's experience and opinion. Incorrect morphological measurements may lead to inappropriate treatment strategies. In order to improve the accuracy and consistency of morphological analysis of IAs, we have developed an image-based computational tool, AView. In this study, we quantified the accuracy of computer-assisted adjuncts of AView for aneurysmal morphologic assessment by performing measurement on spheres of known size and anatomical IA models. AView has an average morphological error of 0.56% in size and 2.1% in volume measurement. We also investigate the clinical utility of this tool on a retrospective clinical dataset and compare size and neck diameter measurement between 2D manual and 3D computer-assisted measurement. The average error was 22% and 30% in the manual measurement of size and aneurysm neck diameter, respectively. Inaccuracies due to manual measurements could therefore lead to wrong treatment decisions in 44% and inappropriate treatment strategies in 33% of the IAs. Furthermore, computer-assisted analysis of IAs improves the consistency in measurement among clinicians by 62% in size and 82% in neck diameter measurement. We conclude that AView dramatically improves accuracy for morphological analysis. These results illustrate the necessity of a computer-assisted approach for the morphological analysis of IAs.

11.
Med Hypotheses ; 104: 4-9, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28673587

RESUMO

Obesity and diabetes are associated with deficits in multiple neurocognitive domains and increased risk for dementia. Over the last two decades, there has been a significant increase in bariatric and metabolic surgery worldwide, driven by rising intertwined pandemics of obesity and diabetes, along with improvement in surgical techniques. Patients undergoing bariatric surgery achieve a significant decrease in their excess weight and a multitude of sequela associated with obesity, diabetes, and metabolic syndrome. Glucagon-like peptide 1 (GLP-1) is an intestinal peptide that has been implicated as one of the weight loss-independent mechanisms in how bariatric surgery affects type 2 diabetes. GLP-1 improves insulin secretion, inhibits apoptosis and induce pancreatic islet neogenesis, promotes satiety, and can regulate heart rate and blood pressure. Moreover, numerous studies have demonstrated potential neuroprotective and neurotrophic effects of GLP-1. Increased GLP-1 activity has been shown to increase cortical activity, promote neuronal growth, and inhibit neuronal degeneration. Specifically, in experimental studies on Alzheimer's disease, GLP-1 decreases amyloid deposition and neurofibrillary tangles. Furthermore, recent studies have also suggested that GLP-1 based therapies, new class of antidiabetic drugs, have favorable effects on neurodegenerative disorders such as Alzheimer's disease. We present a hypothesis that bariatric surgery can help delay or even prevent the onset of Alzheimer's disease in long-term by increasing the levels of GLP-1. This hypothesis has a potential for many studies from basic science projects to large population studies to fully understand the neurological and cognitive consequences of bariatric surgery and associated rise in GLP-1.


Assuntos
Doença de Alzheimer/prevenção & controle , Cirurgia Bariátrica , Peptídeo 1 Semelhante ao Glucagon/metabolismo , Neurônios/efeitos dos fármacos , Idoso , Idoso de 80 Anos ou mais , Apoptose , Diabetes Mellitus Tipo 2/metabolismo , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/metabolismo , Secreção de Insulina , Modelos Teóricos , Fármacos Neuroprotetores/uso terapêutico , Obesidade/complicações , Obesidade/metabolismo , Risco , Perda de Peso
12.
J Neurol Sci ; 376: 102-105, 2017 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-28431590

RESUMO

BACKGROUND: Current American Stroke Association guidelines recommend initiating intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) within 60min of patient arrival, given the benefits of IVT for AIS are time dependent. This study aimed to identify the delaying factors in door-to-needle time (DTN) in the emergency department of one of the largest comprehensive stroke centers in New York State. We also recommended measures to reduce the delays. METHODS: We retrospectively reviewed the medical charts of all AIS patients who received IVT in our emergency department patients between April 1, 2012 and December 31, 2015 to identify those with a DTN time of >60min. We categorized the factors causing the delay into different groups. For each group, we recommended measures to reduce the treatment delays. RESULTS: A total of 487 patients received IVT for AIS during the 3.7-year period. Of these, 96 patients (20.4%) met our DTN time delay criteria. Delays for obtaining stroke imaging and hypertension control were the most common factors. Thirty eight patients (39.5%) had delay in obtaining CT-based stroke imaging. Twenty-two patients (22.9%) required control of elevated blood pressure prior to IVT. Other causes for delay in DTN time included delay in stroke triage and paging (11.4%), fluctuating neurological symptoms (7.2%), uncertainty about diagnosis (12.5%), delays associated with obtaining consent (9.3%), and uncertainty about the time of symptom onset (5.2%). CONCLUSION: Important and common causes of delay in IVT for AIS were identified in a review of charts at our comprehensive stroke center. The authors recommend strategies to achieve faster DTN time for each of the delaying factor categories including faster acquisition and interpretation of stroke imaging, more effective triage protocols and faster blood pressure control for AIS patients who are eligible for IVT.


Assuntos
Isquemia Encefálica/terapia , Serviços Médicos de Emergência , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Terapia Trombolítica , Tempo para o Tratamento , Administração Intravenosa , Idoso , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico por imagem , Serviço Hospitalar de Emergência , Feminino , Humanos , Hipertensão/complicações , Hipertensão/terapia , Masculino , New York , Melhoria de Qualidade , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Fatores de Tempo , Tomografia Computadorizada por Raios X
13.
J Stroke Cerebrovasc Dis ; 26(7): 1414-1418, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28438515

RESUMO

OBJECTIVE: To determine the safety of intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke (AIS) who had a platelet count <100,000 /mm3. METHODS: We reviewed the charts of all patients who received IV rtPA for AIS during a 9.6-year period at our stroke center. Those with platelets <100,000/mm3 were identified. Head computed tomography scans performed in 24-36 hours postthrombolysis were reviewed to evaluate the rate of symptomatic intracranial hemorrhage (sICH). RESULTS: A total of 835 patients received IV rtPA for AIS during this period. A total of 5 patients were identified to have a platelet count <100,000/mm3. One of them (20%) developed sICH post-IV tPA administration .The mean platelet count of those 5 patients was 63,000 ± 19,000/mm3. To the best of our knowledge, only 21 thrombocytopenic patients have been reported to receive IV rtPA for AIS in the medical literature. Combining our 5 cases with 21 patients previously reported, we have 26 AIS patients who had a platelet count <100,000/mm3 and received IV rtPA, with 2 of them developing sICH (7.7 %). Comparing the rate of sICH among this group with the patients with normal platelet count in our cohort, there was no statistically significant difference (7.7% versus 6.04%, P value = .73). CONCLUSION: IV rtPA for AIS might be safe in patients with platelet count <100,000/mm3 and it is reasonable not to delay IV rtPA administration while waiting for the platelet count result, unless there is strong suspicion for abnormal platelet count.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Trombocitopenia/complicações , Terapia Trombolítica/métodos , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/sangue , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Masculino , Registros Médicos , Pessoa de Meia-Idade , Contagem de Plaquetas , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Trombocitopenia/sangue , Trombocitopenia/diagnóstico , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
15.
J Spinal Cord Med ; 39(2): 146-54, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26833287

RESUMO

BACKGROUND: Most spinal cord infarctions are due to aortic pathologies and aortic surgeries. Fibrocartilaginous Embolism (FCE) has been reported to represent 5.5% of spinal cord infarctions. Some believe that FCE is more common than presumed and is rather under-diagnosed due to vagueness surrounding its clinical presentation. METHOD: A literature search was conducted for case reports of FCE published before August 2014. PubMed, the Cochrane Central Register and Google Scholar were searched for different combinations of the key words "fibrocartilaginous, "nucleus pulposus", "embolism", "spinal cord", "inter-vertebral disc", "infarction", "stroke", "paraplegia", "quadriplegia", "myelopathy". RESULT: Fifty-five case articles were reviewed, ten of which were translated from foreign languages. A total of 67 cases of FCE were found, 41 tissue-confirmed and 26 clinically suspected. A comprehensive summary of the clinical anatomy, patho-physiologic mechanisms, epidemiology, diagnosis and treatment of FCE is described, along with the conflicting opinions on its incidence and relevance after reviewing all of the related literature. The 41 tissue proven cases are summarized and a schematic approach to the clinical diagnosis of FCE, deducted from their clinical findings, is presented. CONCLUSION: FCE of the spinal cord, often mis-diagnosed as transverse myelitis, may be more common than presumed. Future research into FCE, including the development of a chondrolytic therapy that can be given empirically upon its clinical suspicion to acutely reverse its symptoms, may be of value.


Assuntos
Doenças das Cartilagens/diagnóstico , Embolia/diagnóstico , Infarto/diagnóstico , Mielite/diagnóstico , Medula Espinal/irrigação sanguínea , Doenças das Cartilagens/epidemiologia , Diagnóstico Diferencial , Embolia/epidemiologia , Humanos , Infarto/epidemiologia , Medula Espinal/patologia
16.
Cerebrovasc Dis ; 40(5-6): 201-4, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26402147

RESUMO

BACKGROUND: The NINDS trial demonstrated the efficacy of intravenous (IV) recombinant tissue plasminogen activator (rtPA) in improving the neurologic outcome in patients presenting with acute ischemic strokes. Patients who had a prior history of intracranial hemorrhage (ICH) were excluded from this trial, possibly due to a hypothetical increase in the subsequent bleeding risk. Thus, there is little data available, whether against or in favor of, the use of IV rtPA in patients with prior ICH. We aim to aid in determining the safety of IV rtPA in such patients through a retrospective hospital-based single center study. METHODS: We reviewed the brain imaging of all patients who received IV rtPA at our comprehensive stroke center from January 2006 to April 2014 for evidence of prior ICH at the time of IV rtPA administration. Their outcomes were determined in terms of subsequent development of symptomatic ICH as defined by the NINDS trial. RESULTS: Brain imaging for 640 patients was reviewed. A total of 27 patients showed evidence of prior ICH at the time of IV thrombolysis, all intra-parenchymal. Only 1 patient (3.7%) developed subsequent symptomatic ICH after the administration of IV rtPA. Of the remaining 613 patients who received IV rtPA, 25 patients (4.1%) developed symptomatic ICH. CONCLUSION: This retrospective study provides Level C evidence that patients with imaging evidence of prior asymptomatic intra-parenchymal hemorrhage presenting with an acute ischemic stroke do not show an increased risk of developing symptomatic ICH after IV thrombolysis.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Hemorragias Intracranianas/epidemiologia , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Encefalopatias/diagnóstico , Calcinose/diagnóstico , Diagnóstico Diferencial , Imagem de Difusão por Ressonância Magnética , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/uso terapêutico , Humanos , Malformações Arteriovenosas Intracranianas/diagnóstico , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Risco , Centros de Atenção Terciária/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/uso terapêutico
17.
Int J Stroke ; 10 Suppl A100: 113-8, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26377963

RESUMO

BACKGROUND: Intracranial aneurysms are currently considered as contraindication for intravenous thrombolysis in acute ischemic stroke, very likely due to a possible increase in the risk of bleeding from aneurysm rupture; however, there is limited data available on whether intravenous thrombolysis is safe for acute ischemic stroke patients with pre-existing intracranial aneurysms. AIMS AND/OR HYPOTHESIS: To find out the safety of intravenous thrombolysis in acute ischemic stroke patients who harbor unruptured intracranial aneurysms. METHODS: We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with intravenous thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those with unruptured intracranial aneurysm present on cerebrovascular images prior to acute reperfusion therapy were identified. Post-thrombolysis brain imaging was reviewed to evaluate for any intraparenchymal or subarachnoid hemorrhage related or unrelated to the aneurysm. RESULTS: A total of 637 patients received intravenous thrombolysis for acute ischemic stroke in our center during an 8·3-year period. Thirty-three (5·2%) were found to have at least one intracranial aneurysms. Twenty-three (70%) of those received only intravenous thrombolysis, and 10 patients received combination of intravenous and intra-arterial thrombolysis. The size of the largest aneurysm was 10 mm in maximum diameter (range: 2-10 mm). The mean size of aneurysms was 4·8 mm. No symptomatic intracranial hemorrhage occurred among the 23 patients receiving only intravenous thrombolysis. Out of those who received a combination of intravenous and intra-arterial thrombolysis, one developed symptomatic intracranial hemorrhage in the location of acute infarct, distant to the aneurysm location. CONCLUSION: Our findings suggest that neither intravenous thrombolysis nor combination of intravenous and intra-arterial thrombolysis increases the risk of aneurysmal hemorrhage in acute ischemic stroke patients who harbor unruptured intracranial aneurysms less than 10 mm in diameter. Their listing in exclusion criteria for intravenous thrombolysis should be reconsidered to assure appropriate use of acute reperfusion therapy in this group of patients.


Assuntos
Aneurisma Intracraniano/complicações , Reperfusão/métodos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/complicações , Feminino , Humanos , Estudos Longitudinais , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomógrafos Computadorizados
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