Research progress in ultrasound use for the diagnosis and treatment of cerebrovascular diseases.

Cerebrovascular diseases pose a serious threat to human survival and quality of life and represent a major cause of human death and disability. Recently, the incidence of cerebrovascular diseases has increased yearly. Rapid and accurate diagnosis and evaluation of cerebrovascular diseases are of great importance to reduce the incidence, morbidity and mortality of cerebrovascular diseases. With the rapid development of medical ultrasound, the clinical relationship between ultrasound imaging technology and the diagnosis and treatment of cerebrovascular diseases has become increasingly close. Ultrasound techniques such as transcranial acoustic angiography, doppler energy imaging, three-dimensional craniocerebral imaging and ultrasound thrombolysis are novel and valuable techniques in the study of cerebrovascular diseases. In this review, we introduce some of the new ultrasound techniques from both published studies and ongoing trials that have been confirmed to be convenient and effective methods. However, additional evidence from future studies will be required before some of these techniques can be widely applied or recommended as alternatives.

Research progress in ultrasound use for the diagnosis and treatment of cerebrovascular diseases

Cerebrovascular diseases pose a serious threat to human survival and quality of life and represent a major cause of human death and disability. Recently, the incidence of cerebrovascular diseases has increased yearly. Rapid and accurate diagnosis and evaluation of cerebrovascular diseases are of great importance to reduce the incidence, morbidity and mortality of cerebrovascular diseases. With the rapid development of medical ultrasound, the clinical relationship between ultrasound imaging technology and the diagnosis and treatment of cerebrovascular diseases has become increasingly close. Ultrasound techniques such as transcranial acoustic angiography, doppler energy imaging, three-dimensional craniocerebral imaging and ultrasound thrombolysis are novel and valuable techniques in the study of cerebrovascular diseases. In this review, we introduce some of the new ultrasound techniques from both published studies and ongoing trials that have been confirmed to be convenient and effective methods. However, additional evidence from future studies will be required before some of these techniques can be widely applied or recommended as alternatives.

Pharmacoinvasive strategy versus primary angioplasty in patients with acute ST-segment elevation myocardial infarction / Estrategia farmacoinvasiva versus angioplastia primaria en pacientes con infarto agudo al miocardio con elevación del segmento ST

Abstract: Background: Primary percutaneous coronary intervention (PPCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). The delays associated with PPCI reduce the benefits of this therapy. To minimize these delays, the pharmacoinvasive strategy (PS) was developed, consisting of applying thrombolytic therapy followed by coronary angioplasty 2 to 24 hours after. Objective: To compare the safety and efficiency of PPCI vs PS in STEMI. Methods: We included patients with STEMI who had emergency PCI. The primary endpoint was combined major adverse cardiac events (MACE), death, reinfarction, stroke, target vessel revascularization (TVR) during hospitalization. The secondary endpoints were the individual components of MACE, and major bleeding (Bleeding Academic Research Consortium: BARC ≥ 3). Results: A total of 400 patients, 263 (65.8%) for PPCI group, 114 (28.5%) for PS group and 23 (5.75%) for diagnostic group. The PS group, 79 (69.3%) were then categorized as systematic angioplasty having had a successful thrombolysis, and 35 (30.7%) were rescue angioplasty because they had a failed thrombolysis. There were no differences in MACE: 13 (9.5%) patients in PS and 27 (10.3%) patients in the PPCI (p = 0.806), there were no differences in the individual components of MACE. The rate of major bleeding was the same, 5 (3.6%) and 4 (1.5%) respectively (p = 0.173). The multivariate analysis did not show a relationship between MACE and the reperfusion strategy. Conclusions: The pharmacoinvasive strategy when compared to PPCI has a similar rate of primary and secondary endpoints. There is no increase in major bleeding therefore, it is an important strategy that offers a reperfusion therapy for patients with STEMI in a non-PCI capable hospital.(AU)

Resumen: Antecedentes: La intervención coronaria percutánea primaria (ICPP) es el tratamiento de elección en infarto agudo al miocardio con elevación del ST (IAMCEST). El retraso relacionado con ICPP disminuye el beneficio. Buscando una reperfusión oportuna se implementa la estrategia farmacoinvasiva (EFI), que consiste en realizar trombólisis seguido de ICP entre 2 a 24 horas después. Objetivo: Comparar la seguridad y eficacia en pacientes sometidos a ICPP contra EFI en IAMCEST. Métodos: Se incluyeron pacientes con IAMCEST sometidos a ICP emergente. El punto final primario son eventos cardiacos adversos mayores (ECAM), muerte, reinfarto, evento vascular cerebral y revascularización del vaso tratado, durante la hospitalización. Los puntos finales secundarios son la presencia de los componentes individuales del ECAM, y el sangrado mayor (BARC ≥ 3). Resultados: Se estudiaron 400 pacientes, 263 (65.8%) de ICPP, 114 (28.5%) a EFI y 23 (5.75%) angiografía diagnóstica. Del grupo EFI, 79 (69.3%) fueron angioplastia sistemática por trombólisis exitosa y 35 (30.7%) por angioplastia de rescate por trombólisis fallida. No se observó diferencia en la frecuencia de ECAM: EFI 13 (9.5%) contra ICPP 27 (10.3%) respectivamente (p = 0.806), tampoco hubo diferencia en los componentes individuales. No se observó diferencia en sangrado mayor, 5 (3.6%) vs 4 (1.5%), (p = 0.173). El análisis multivariado no relacionó la estrategia de reperfusión con los ECAM. Conclusiones: La EFI comparada con ICPP demuestra una tasa similar de ECAM, así como de sus componentes individuales. No se asocia con aumento de hemorragia mayor, concluyendo que ofrece el beneficio de una reperfusión oportuna sin aumento del riesgo en los hospitales que no tienen la capacidad para realizar ICPP.(AU)

Exclusive bed for thrombolysis. A simple measure that allows 85% of ischemic stroke patients to be treated in the first hour.

The door-to-needle time is an important goal to reduce the time to treatment in intravenous thrombolysis. Objective Analyze if the inclusion of an exclusive thrombolytic bed reduces the door-to-needle time. Method One hundred and fifty patients admitted for neurological evaluation with ischemic stroke were separated in two groups: in the first, patients were admitted in the Emergency Room for intravenous thrombolysis (ER Group); in the second, patients were admitted in an exclusive thrombolytic bed in the general neurology ward (TB Group). Results Sixty-eight (86.0%) patients from TB Group were treated in the first 60 minutes of arrival as compared to 48 (67.6%) in the ER Group (p = 0.011). Conclusion The introduction of a thrombolytic bed in a general hospital setting can markedly reduce the door-to-needle time, allowing more than 85% of patients to be treated within the first hour of admission.

Exclusive bed for thrombolysis. A simple measure that allows 85% of ischemic stroke patients to be treated in the first hour / Leito exclusivo para trombólise. Uma medida simples que permite que 85% dos pacientes com acidente vascular cerebral sejam tratados na primeira hora

ABSTRACT The door-to-needle time is an important goal to reduce the time to treatment in intravenous thrombolysis. Objective Analyze if the inclusion of an exclusive thrombolytic bed reduces the door-to-needle time. Method One hundred and fifty patients admitted for neurological evaluation with ischemic stroke were separated in two groups: in the first, patients were admitted in the Emergency Room for intravenous thrombolysis (ER Group); in the second, patients were admitted in an exclusive thrombolytic bed in the general neurology ward (TB Group). Results Sixty-eight (86.0%) patients from TB Group were treated in the first 60 minutes of arrival as compared to 48 (67.6%) in the ER Group (p = 0.011). Conclusion The introduction of a thrombolytic bed in a general hospital setting can markedly reduce the door-to-needle time, allowing more than 85% of patients to be treated within the first hour of admission.

RESUMO A redução no tempo porta-agulha é um objetivo importante para diminuir o tempo de tratamento na trombólise endovenosa. Objetivo Analisar se a inclusão de um leito exclusivo de trombólise reduz o tempo porta-agulha. Método Cento e cinqüenta pacientes admitidos com acidente vascular cerebral isquêmico foram separados em dois grupos: no primeiro, os pacientes foram admitidos no Pronto-Atendimento para trombólise endovenosa (Grupo PA); no segundo, os pacientes foram admitidos no leito de trombólise na enfermaria de neurologia (Grupo LT). Resultados Sessenta e oito (86,0%) pacientes do Grupo LT foram tratados nos primeiros 60 minutos após a chegada, em comparação com 48 (67,6%) no Grupo PA (p = 0,011). Conclusão A introdução de um leito de trombólise em ambiente hospitalar pode reduzir marcadamente o tempo porta-agulha, permitindo que mais de 85% dos pacientes sejam tratados na primeira hora de admissão.

Catheter-directed interventions for acute pulmonary embolism.

Acute pulmonary embolism (PE) is a leading cause of cardiovascular mortality. Systemic anticoagulation is the standard of care, and treatment can be escalated in the setting of massive or submassive PE, given the high mortality risk. A secondary consideration for intervention is the prevention of late-onset chronic thromboembolic pulmonary hypertension. Treatment options include systemic thrombolysis, catheter-directed interventions, and surgical thromboembolectomy. Whereas systemic thrombolysis seems to be beneficial in the setting of massive PE, it appears to be associated with a higher rate of major complications compared with catheter-directed thrombolysis as shown in recent randomized trials for submassive PE. The hemodynamic and clinical outcomes continue to be defined to determine the indications for and benefits of intervention. The current review summarizes contemporary evidence on the role and outcomes of catheter-directed therapies in the treatment of acute massive and submassive PE.

Sonotrombolisis en el ataque cerebrovascular isquémico: once años de experiencia en Clínica Alemana de Santiago / Sonothrombolysis for acute ischemic stroke

Background: Sonothrombolysis (ST) is an emerging modality for the treatment of stroke. Aim: To assess the feasibility to perform ST in a Chilean hospital. Material and Methods: Patients attended at a private clinic with an acute ischemic stroke, between September 2002 and May 2013 and eligible for endovenous thrombolysis, were studied with a transcranial Doppler (Spencer PMD 100 or 150®). Those with an adequate sonographic window and a demonstrated arterial occlusion were monitored continuously with transcranial Doppler at the site of worst residual flow following the CLOTBUST study protocol. Results: One thousand twenty six patients were studied, of whom 136 received intravenous thrombolysis (rt-PA) and 61, aged 66 ± 18 years (59% males), were subjected to ST (7% of total). Their median National Institutes of Health Stroke Scale score was 14, the lapse from symptom onset to rt-PA was 127 minutes (43-223). Middle cerebral artery (MCA) occlusion was found in 88.5% of patients. Complete recanalization was achieved in 44.3% of patients. Sixty percent had Modified Rankin Scale of 0 to 2 at 3 months (95% confidence intervals (CI) 48.1 to 72). Case fatality was 9.8% and asymptomatic intracranial hemorrhage occurred in 9.8% (95% CI: 4.3 to 20.2). Conclusions: ST can be carried out in a complex medical center and is safe.

[Sonothrombolysis for acute ischemic stroke]. / Sonotrombolisis en el ataque cerebrovascular isquémico: once años de experiencia en Clínica Alemana de Santiago.

BACKGROUND: Sonothrombolysis (ST) is an emerging modality for the treatment of stroke. AIM: To assess the feasibility to perform ST in a Chilean hospital. MATERIAL AND METHODS: Patients attended at a private clinic with an acute ischemic stroke, between September 2002 and May 2013 and eligible for endovenous thrombolysis, were studied with a transcranial Doppler (Spencer PMD 100 or 150®). Those with an adequate sonographic window and a demonstrated arterial occlusion were monitored continuously with transcranial Doppler at the site of worst residual flow following the CLOTBUST study protocol. RESULTS: One thousand twenty six patients were studied, of whom 136 received intravenous thrombolysis (rt-PA) and 61, aged 66 ± 18 years (59% males), were subjected to ST (7% of total). Their median National Institutes of Health Stroke Scale score was 14, the lapse from symptom onset to rt-PA was 127 minutes (43-223). Middle cerebral artery (MCA) occlusion was found in 88.5% of patients. Complete recanalization was achieved in 44.3% of patients. Sixty percent had Modified Rankin Scale of 0 to 2 at 3 months (95% confidence intervals (CI) 48.1 to 72). Case fatality was 9.8% and asymptomatic intracranial hemorrhage occurred in 9.8% (95% CI: 4.3 to 20.2). CONCLUSIONS: ST can be carried out in a complex medical center and is safe.

Notable aumento de la terapia trombolítica en el ACV isquémico / Significant increase in thrombolytic therapy in stroke management

En los últimos tres años se ha logrado en Andalucía, España, un avance significativo en las medidas de actuación en el ataque cerebral agudo. Este avance está relacionado en primer lugar con una mayor participación y compromiso de los profesionales de la salud en sus diferentes áreas para dar respuesta coordinada al ataque cerebral. El PLACA es un plan autonómico que se viene desarrollando desde hace cinco años en Andalucía, contribuyendo así a esta respuesta unitaria con su planificación. Colabora un grupo central formado por expertos de distintas sociedades científicas, coordinados por el Plan Andaluz de Salud y dependiente de la Dirección General del Servicio Andaluz de Salud. En este artículo se presentan los avances conseguidos en los últimos tres años con este plan, así como los objetivos futuros. Actualmente se ha logrado implementar la terapia trombolítica hasta en 55% de los hospitales de la comunidad, con una previsión del 100% para 2010. El incremento del número de trombólisis en los dos últimos años ha sido de más del doble respecto del período anterior. Se expone el importante esfuerzo económico realizado en la divulgación, información de medidas preventivas, formación de profesionales y desarrollo de telemedicina. No obstante, se considera necesario seguir avanzando. Las importantes medidas previstas para los próximos años ayudarán a continuar esta lucha, tratando de dar una respuesta más operativa y rápida, prevenir, y tratar de detener este incremento esperado de incidencia en la población, al mismo tiempo que se analizan mejor los resultados de la actitud terapeútica realizada.(AU)

Notable aumento de la terapia trombolítica en el ACV isquémico / Significant increase in thrombolytic therapy in stroke management

En los últimos tres años se ha logrado en Andalucía, España, un avance significativo en las medidas de actuación en el ataque cerebral agudo. Este avance está relacionado en primer lugar con una mayor participación y compromiso de los profesionales de la salud en sus diferentes áreas para dar respuesta coordinada al ataque cerebral. El PLACA es un plan autonómico que se viene desarrollando desde hace cinco años en Andalucía, contribuyendo así a esta respuesta unitaria con su planificación. Colabora un grupo central formado por expertos de distintas sociedades científicas, coordinados por el Plan Andaluz de Salud y dependiente de la Dirección General del Servicio Andaluz de Salud. En este artículo se presentan los avances conseguidos en los últimos tres años con este plan, así como los objetivos futuros. Actualmente se ha logrado implementar la terapia trombolítica hasta en 55% de los hospitales de la comunidad, con una previsión del 100% para 2010. El incremento del número de trombólisis en los dos últimos años ha sido de más del doble respecto del período anterior. Se expone el importante esfuerzo económico realizado en la divulgación, información de medidas preventivas, formación de profesionales y desarrollo de telemedicina. No obstante, se considera necesario seguir avanzando. Las importantes medidas previstas para los próximos años ayudarán a continuar esta lucha, tratando de dar una respuesta más operativa y rápida, prevenir, y tratar de detener este incremento esperado de incidencia en la población, al mismo tiempo que se analizan mejor los resultados de la actitud terapeútica realizada.

Adjunctive transcutaneous ultrasound with thrombolysis: results of the PLUS (Perfusion by ThromboLytic and UltraSound) trial.

OBJECTIVES: We investigated whether transcutaneous ultrasound (TUS) augments coronary thrombolysis and achieves higher rates of Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 and ST-segment resolution in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: In animal coronary and peripheral artery thrombosis models, low-frequency TUS enhances and accelerates thrombolysis. METHODS: In a double-blind, randomized, controlled international clinical trial, 396 patients with STEMI < or =6 h were randomized to thrombolysis alone or thrombolysis plus TUS. The 60 minute TIMI flow grade, ST-segment resolution (primary end points) and other angiographic, electrocardiographic, and clinical outcomes were compared between treatment groups. RESULTS: The trial was halted after Safety and Efficacy Monitoring Committee interim analysis that demonstrated lack of treatment efficacy. In total, 360 patients were evaluable for angiographic, electrocardiographic, or clinical end points. Sixty minutes after thrombolytic administration, the proportion of patients achieving TIMI flow grade 3 did not differ between TUS and control groups (40.7% vs. 48.5%, respectively; p = 0.10). Achievement of >50% ST-segment resolution at 60 min did not differ between TUS and control groups (53.2% vs. 50.0%; p = 0.93). Thirty-day mortality and composite clinical events-death, reinfarction, recurrent ischemia, stroke, major bleed, left ventricular rupture (9.7 % vs. 10.2%; p = 0.88)-did not differ between TUS and control patients. CONCLUSIONS: Thrombolysis plus TUS failed to improve 60-min TIMI flow grade or ST-segment resolution versus thrombolysis alone.

Tratamento trombolítico do infarto na emergência com teleconsultoria(TIET0: resultados de cinco anos / Thrombolytic theraphy of infarction in emergency medical hotline: five year results

Objetivo: descrever a experiência de cino anos de funcionamento de um Programa de Teleconsultoria para suporte da utilização de agente trombolítico em pacientes infartados, atendidos na Rede de Emergência do Rio de Janeiro e o efeito do Programa na utilização de trombolítico no tratamento do infarto agudo do miocárdio com supra de ST (IAMCSST).Métodos:Em uma coorte de 775 casos de infarto agudo do miocárdio (IAM), foram analisados os dados de 664 pacientes que apresentavam, ao primeiro eletrocardiograma (ECG), IAMCSST, no peíodo compreendido entre a implantação do Progrma TIET, em julho de a 1999, até outubro de 2004.A partir de um fluxograma de atendimento e de um canal de consultoria via telefone e fax, estimula-se a realização da trombólise no local do primeiro atendimento.São analisados os dados relativos à utilização de trombólise química nos grupos admitidos via consultoria e compara-se àqueles diretamente vindos ao HSE, sua evolução hospitalar e impacto quanto à mortalidade...

Terapia Fibrinolítica / Evaluation of thrombolytic experience

Propósito: evaluar la experiencia trombolítica de los últimos tres años en el Departamento de Radiología del Hospital Universitario San Vicente de Paúl, como base para el planteamiento de un protocolo de terapia local y su evaluación prospectiva en un futuro trabajo. Conclusiones: basándose en la experiencia recogida en el Departamento de Radiología, se cree que la terapia trombolítica, aplicada mediante catéter intravascular, constituye una alternativa terapéutica útil en pacientes con trombosis arterial, venosa o de injertos periféricos, en quienes la cirugía no es una primera opción viable. Ellos manifiestan mejores tasas de éxito que las reportadas con el manejo anticoagulante tradicional. Esperamos en el futuro contar con protocolos que nos permitan utilizar fármacos que, como la urocinasa o el activador tisular del plasminógeno recombinante, han mostrado mayor porcentaje de éxito, en un tiempo más corto y con un menor número de complicaciones

Tromboelastógrafo / Thromboelastography

El Tromboelastógrafo (TEG) ha demostrado ser una invaluable técnica para monitorizar la coagulación sanguínea, tanto para la terapia farmacológica, como para guía de reemplazo de los componentes sanguíneos de la coagulación durante el trasplante de hígado. El TEG monitoriza la coagulabilidad sanguínea, incluyendo la coagulación y la fibrinólisis, y provee información clínica útil en aproximadamente 30 minutos. El objetivo de este artículo de revisión es mostrar la importancia de este interesante monitor hematológico, en casos donde las pruebas de coagulación convencionales tienen serias limitaciones para uso clínico, asesorando la función hemostática.

Trombectomía percutánea con catéter tipo hydrolyser como una alternativa en el tratamiento de las trombosis en el Hospital Central Militar / Percutaneous thrombectomy by hydrolyser catheter as an alternative treatment for thrombosis in the Military Central Hospital

Es un estudio in vitro, en tubos de cristal de 0.5 cm de diámetro y con coágulos de 5 hasta 60 días de evolución; se realizo succión con catéter hydrolyser. Ensayo clínico controlado. En 27 pacientes clasificados en dos grupos, a uno se realizó terapia anticoagulante y el otro fue sometido a trombectomía percutánea con catéter hydrolyser (TPCH). Se estuvo la resolución satisfactoria del 100 por ciento en coágulos con evolución hasta de 45 días; los coágulos de 50 a 60 días tuvieron de 90 a 0 por ciento de resolución. El grupo de edad más afectado por trombosis fue el de 51 a 75 años existiendo predominio en el sexo femenino con un 55 por ciento. Los pacientes anticoagulados tuvieron un promedio de encame de 7.75 días y los pacientes tratados con TPCH tuvieron 2.33 días de encame en promedio (p< 0.05). En cuanto a la mejoría clínica, no se observó diferencia estadísticamente significativa entre ambos grupos. En conclusión la trombectomía con catéter hydrolyser es un procedimiento seguro y efectivo, con una rápida trombólisis, prometiendo ser una alternativa más en el tratamiento de las trombosis

Trombosis venosa de esfuerzo (Síndrome de Paget-Schroetter): trombólisis y resección de la primera costilla / Effort venous thrombosis (Paget-Schroetter Syndrome): thrombolysis and first rib resection

Se presentan 3 pacientes con trombosis venosa axilo-subclavia o síndrome de Paget Schroetter, manejados exitosamente con infusión sistémica de estreptoquinasa, más la resección transaxilar de la primera costilla. Creemos que éste es el primer reporte en la literatura nacional sobre el empleo de fibrinolíticos en el síndrome de Paget-Schroetter.

Cardiología intervensionista: 1982-1990

The results of several cardiovascular invasive procedures performed at Shaio Foundation of Bogotá (Colombia) between 1982 and 1990 are the subject of this report. Patient's age ranged between 8 months and 76 years. The attempted procedure was succesful in 95 percent of the cases. Among all procedures there were 80 atrioseptostomies for trasposition of great vessels; 400 intravenous streptokinase infusions; 1.100 coronary angioplasties; 169 peripheral angioplasties; 35 pulmonary valvuloplasties; 125 mitral valvuloplasties and 11 aortic valvuloplasties. For each one of the procedures a discussion of its indications, results, morbidity and mortality is done