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1.
Medwave ; 20(2): e7831, 2020 Mar 03.
Artigo em Espanhol, Inglês | MEDLINE | ID: mdl-32225130

RESUMO

Introduction: Macular hemorrhages result in a sudden and profound loss of vision. The primary treatment modalities include observation, intravitreal injection of antiangiogenic drugs, neodymium-doped yttrium aluminum garnet hialoidotomy, intravitreal injection of gas with or without tissue plasminogen activator, as monotherapy or combined with surgery. In this paper, we report four cases of macular hemorrhages of different causes treated with different approaches, and we review the literature in this regard. Case presentation: All four patients presented different causes of macular hemorrhage. The first case had a preretinal hemorrhage due to a Valsalva retinopathy and was treated with surgery. Case 2 had a multilevel macular hemorrhage due to a rupture of a retinal arteriolar macroaneurysm and was treated with pneumatic displacement, laser, and intravitreal ranibizumab. Case 3 presented an extensive subretinal hemorrhage due to a choroidal rupture after high-energy ocular trauma that was also successfully treated with surgery. The last case was a preretinal hemorrhage due to diabetic retinopathy managed with neodymium-doped yttrium aluminum garnet laser. Different treatment approaches were successfully performed in all cases with good outcomes. Conclusion: There is an extensive range of options available for the management of macular hemorrhages, and the best option depends on the characteristics of each particular case. Proper and timely management of these diseases can achieve an excellent visual outcome, especially if the location of the hemorrhage is preretinal.


Assuntos
Inibidores da Angiogênese/uso terapêutico , Terapia a Laser , Hemorragia Retiniana/terapia , Corioide/patologia , Retinopatia Diabética/complicações , Humanos , Injeções Intravítreas , Hemorragia Retiniana/etiologia , Ruptura , Ativador de Plasminogênio Tecidual
2.
Medicine (Baltimore) ; 99(9): e19247, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32118730

RESUMO

RATIONALE: The capsular warning syndrome (CWS) is a rare and special type of transient ischemic attacks (TIAs) syndrome. The pathophysiology of CWS is very complicate, and intracranial atherosclerotic stenosis (ICAS) is rare cause. Moreover, the effective and standard therapy has not yet been established. PATIENT CONCERNS: A 47-year-old man experienced repeated and exacerbated TIAs of right hemiparesis and dysarthria. Fourteen hours after the first episode of TIAs, he developed more severe right hemiparesis and dysarthria, the National Institute of Health Stroke Scale (NIHSS) score was 12 points, and did not recover in a long time. DIAGNOSIS: The computed tomography (CT) angiography displayed high stenosis in the M1 segment of the left middle cerebral artery. The patient was diagnosed as CWS with ICAS. INTERVENTIONS: Loading dose of clopidogrel and aspirin were started but were ineffective, then we used recombinant tissue plasminogen (r-tPA) for thrombolysis therapy after repeat CT scan that showed small acute infarcts in the right putamen and no bleeding. OUTCOMES: The patient was successfully treated by r-tPA intravenous thrombolysis after loading dose of dual-anti-platelet. He recovered rapidly, and the NIHSS score was 0 point, modified Rankin Scale score was 0 point, and Barthel Index score was 100 points at 3-month follow-up. LESSONS: r-tPA combined with loading dose of dual antiplatelet appears safe and effective in carefully selected CWS patients with ICAS. The collection of similar cases and further randomized controlled trial research would be desirable.


Assuntos
Fibrinolíticos/uso terapêutico , Arteriosclerose Intracraniana/tratamento farmacológico , Ataque Isquêmico Transitório/tratamento farmacológico , Aspirina/administração & dosagem , Aspirina/uso terapêutico , Clopidogrel/administração & dosagem , Clopidogrel/uso terapêutico , Angiografia por Tomografia Computadorizada , Diagnóstico Diferencial , Fibrinolíticos/administração & dosagem , Humanos , Arteriosclerose Intracraniana/complicações , Arteriosclerose Intracraniana/diagnóstico por imagem , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Síndrome , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X
6.
Medicine (Baltimore) ; 99(2): e18665, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914055

RESUMO

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


Assuntos
Revascularização Cerebral/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Imagem de Difusão por Ressonância Magnética , Procedimentos Endovasculares/métodos , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/tratamento farmacológico , Fatores de Tempo , Ativador de Plasminogênio Tecidual/uso terapêutico
7.
Medicine (Baltimore) ; 99(2): e18680, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914063

RESUMO

The prognosis of acute ischemic stroke patients treated with intravenous (IV) recombinant tissue plasminogen activator (rtPA) is poorer in patients with atrial fibrillation (AF) than patients without AF, which might be related to the greater stroke severity in AF patients. Higher pre-stroke CHA2DS2-VASc scores are associated with greater stroke severity and poorer outcomes. AF Patients tend to have higher CHA2DS2-VASc scores than the non-AF patients. We thus hypothesized that pre-stroke CHA2DS2-VASc scores can be used to improve outcome stratification of IV thrombolysis therapy in acute stroke patients with and without AF. We retrospectively enrolled ischemic stroke patients who received IV-rtPA and categorized them into 2 groups: low-risk (CHA2DS2-VASc scores ≤ 2) and high-risk (CHA2DS2-VASc scores ≥ 3) groups. We compared the outcomes between AF and non-AF patients and the interactive effects of the levels of CHA2DS2-VASc scores on this outcome difference. In the low-risk group, there was no difference in outcomes between the AF and non-AF patients. In the high-risk group, the AF patients had worse outcomes at 3 and 6 months. Our results suggest that pre-stroke CHA2DS2-VASc scores are a useful outcome predictor of IV thrombolytic therapy in acute stroke patients with AF.


Assuntos
Fibrilação Atrial/complicações , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Ativador de Plasminogênio Tecidual/administração & dosagem
8.
Plast Reconstr Surg ; 145(2): 392-401, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985629

RESUMO

BACKGROUND: Sequential compression devices are often considered a mainstay of prophylaxis against deep venous thromboses in surgical patients. The devices are believed to produce a milking action on the deep veins to prevent venous stasis. A systemic fibrinolytic effect has also been proposed, adding a second mechanism of action. The plasma levels of tissue plasminogen activator and plasminogen activator inhibitor-1 reflect fibrinolytic activity. METHODS: A randomized trial was conducted among 50 consecutive plastic surgery outpatients undergoing cosmetic surgery performed by the author under total intravenous anesthesia and without paralysis. Patients were randomized to receive calf-length sequential compression devices or no sequential compression devices during surgery. Blood samples were obtained from the upper extremity preoperatively and at hourly intervals until the patient was discharged from the postanesthesia care unit. Tissue plasminogen activator and plasminogen activator inhibitor-1 levels were measured. Ultrasound surveillance was used in all patients. There was no outside funding for the study. RESULTS: All patients agreed to participate (inclusion rate, 100 percent). No patient developed clinical signs or ultrasound evidence of a deep venous thrombosis. There were no significant changes in tissue plasminogen activator levels or plasminogen activator inhibitor-1 levels from the preoperative measurements at any hourly interval and no differences in levels comparing patients treated with or without sequential compression devices. CONCLUSIONS: No significant change in systemic fibrinolytic activity occurs during outpatient plastic surgery under total intravenous anesthesia. Sequential compression devices do not affect tissue plasminogen activator or plasminogen activator inhibitor-1 levels, suggesting no fibrinolytic benefit. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.


Assuntos
Fibrinólise/fisiologia , Dispositivos de Compressão Pneumática Intermitente , Adulto , Idoso , Técnicas Cosméticas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Inativadores de Plasminogênio/metabolismo , Estudos Prospectivos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Ativador de Plasminogênio Tecidual/metabolismo , Trombose Venosa/sangue , Trombose Venosa/prevenção & controle , Adulto Jovem
9.
J Stroke Cerebrovasc Dis ; 29(2): 104537, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31806454

RESUMO

BACKGROUND AND PURPOSE: The safety and efficacy of intravenous thrombolytic therapy (IVT) for posterior circulation stroke (PCS) in the real world are rarely studied. This study was designed to evaluate the prestroke and baseline characteristics, stroke sub-types, complications, and outcomes of PCS patients and compare them with anterior circulation stroke (ACS) after intravenous thrombolysis. METHODS: Data of consecutive patients with PCS and ACS treated with alteplase in a standard dose of 0.9 mg/kg in our stroke center were collected and analyzed retrospectively. Presenting characteristics, hemorrhage transformation, mortality, and favorable outcomes (modified Rankin scale 0 or 1) at 90 days were compared between PCS and ACS patients. RESULTS: A total of 462 patients were included in this study, including 350 (75.8%) in ACS group and 112 (24.2%) in PCS group. A history of coronary artery disease was significantly more common in ACS patients than that in PCS patients (15.1% versus 6.3%, P = .015). There was no significant difference in fast glucose and baseline NIHSS scores between PCS and ACS groups. In PCS group, 7 patients (6.3%) had hemorrhage transformation after IVT and 5 patients (4.5%) were symptomatic versus 32 (9.1%) and 22 (6.3%) in ACS group (P > .05). 75.5% PCS patients versus 72.2% ACS patients had excellent recovery outcomes (mRS 0-1) at 90 days (P = .507). For PCS patients, logistic regression analysis after adjusting the covariates identified age (P = .047, OR .920, 95% CI = .847-.999) and atrial fibrillation (P = .007, OR 12.149, 95% CI = 1.966-75.093) as independent significant predictors of hemorrhage transformation. In addition, atrial fibrillation was also an independent predictor of symptomatic intracranial hemorrhage (P = .008, OR 21.176, 95% CI = 2.228-201.273). Multivariate logistic analysis identified hemorrhage transformation (P = .012; OR .131, 95% CI = .027-.644) and onset to drug time (P = .026, OR 1.006, 95% CI = 1.001-1.011) as independent predictors of functional independence (mRS 0-2). Symptomatic intracranial hemorrhage (P = .007, OR 15.094, 95% CI = 2.097-108.661) and baseline NIHSS score (P = .050; OR 1.070, 95% CI = 1.000-1.145) were independent predictors of mortality. CONCLUSION: Our results suggest that IVT in PCS patients is safe and effective as that in ACS patients. In PCS patients, long onset to needle time and hemorrhage transformation were identified as independent predictors of unfavorable outcomes.


Assuntos
Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Fatores Etários , Idoso , Circulação Cerebrovascular , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
10.
World Neurosurg ; 133: 266-270, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31605861

RESUMO

BACKGROUND: Residual hematoma after operative management of acute subdural hematoma contributes to reoperation and is cited as a reason for deferment of less invasive drainage strategies. Although local antithrombolytic therapy has been studied in intracerebral hemorrhage and chronic subdural hematoma, to date there are no reports of recombinant tissue plasminogen activator for residual hematoma post drainage for acute subdural hematoma. CASE DESCRIPTION: Two patients presented with altered mental status secondary to acute-on-chronic subdural hematomas and underwent emergent craniotomies. The first, a 78-year-old man, had poor subdural drain output and deteriorated with seizures and evidence of new acute subdural hematoma formation. Recombinant tissue plasminogen activator was injected through the subdural catheter on postoperative day 3. The second patient, a 64-year-old male, received recombinant tissue plasminogen activator postoperatively. Subsequently, both experienced good subdural drainage, clinical and radiologic improvement, and successful discharge to a skilled nursing facility. CONCLUSIONS: Subdural thrombolytic therapy can improve hematoma evacuation. A potential implication of this is facilitation of minimally invasive options such as twist-drill craniotomy, previously deferred due to inadequate evacuation. However, there is a paucity of evidence and more research is needed to substantiate the safety and efficacy, refine this technique, and guide patient selection.


Assuntos
Fibrinolíticos/administração & dosagem , Hematoma Subdural/tratamento farmacológico , Espaço Subdural/cirurgia , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Progressão da Doença , Drenagem , Fibrinolíticos/uso terapêutico , Hematoma Subdural/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
11.
World Neurosurg ; 133: e835-e841, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31614218

RESUMO

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


Assuntos
Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
12.
Bioelectromagnetics ; 41(1): 52-62, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31802523

RESUMO

We established three types of thrombosis models to explore the effects of the static magnetic field (SMF) on thrombosis in rats and mice with three different MF intensities. In the carrageenan-induced thrombosis model in rats, the SMF treatments reduced the black tail length of rats, extracorporeal thrombus, and the mass of wet and dry thrombus, and improved the coagulation index value. In FeCl3 -induced arterial thrombosis model in rats, the SMF treatment showed some anti-thrombotic effects. More specifically, the SMF treatment affected rodent blood pressure, plasma plasminogen activator inhibitor, tissue-type plasminogen activator, thrombus mass, and thrombus protein content. In the adrenaline-induced thrombosis model in mice, the SMF treatment had certain effects on the diameter and blood flow velocity of mouse auricle microcirculation in fine veins and arteries. Overall, the highest MF intensities we tested, 20-150 mT, showed a trend of anti-thrombotic effect, indicating that the moderate-intensity SMF might serve as a potential treatment for clot-related diseases in the future. Bioelectromagnetics. 2020;41:52-62 © 2019 Bioelectromagnetics Society.


Assuntos
Campos Magnéticos/efeitos adversos , Trombose/prevenção & controle , Animais , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Carragenina/metabolismo , Epinefrina/metabolismo , Frequência Cardíaca , Compostos de Ferro/metabolismo , Masculino , Camundongos , Microcirculação , Ativadores de Plasminogênio/metabolismo , Ratos , Ratos Sprague-Dawley , Ativador de Plasminogênio Tecidual/metabolismo
13.
J Stroke Cerebrovasc Dis ; 29(2): 104541, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31810719

RESUMO

BACKGROUND AND AIMS: The characteristics of clot causing acute ischemic stroke, such as size, content, and location, are among the main determinants of response to intravenous tissue plasminogen activator [IV tPA]. Clot heterogeneity and permeability are under-recognized features that might provide additional information in predicting the efficacy of IV tPA. METHODS AND PATIENTS: Patients with proximal middle cerebral artery occlusion treated with "IV tPA alone" were included. The mean Hounsfield's unit (HU) value, as objective measure of clot attenuation, and its standard deviation (SD), as proposed measure of clot heterogeneity, were obtained. The difference in HU values between CT Angiography and CT was defined as "clot permeability", or "perviousness'. The size (length and volume-mm3) of pre-clot pouch and occluding clot along with ASPECT score and Maas' silvian and leptomeningeal collateral score were measured. RESULTS: The study included 84 cases (44 women, age: 68 ± 14 years, pretPA NIHSS: 16 ± 5). Patients with excellent response to tPA (31%) had lower thrombus volume (37.54 ± 32.37 versus 63.49 ± 37.36, P = .009) and heterogeneity (4.05 ± 1.49 versus 5.35 ± 2.34, P = .011), along with higher clot permeability (48 ± 35.48 to 31.32 ± 18.62, P = .006). However, significance of permeability did not survived in the regression analysis with adjustment for NIHSS (ß:-.296, P = .003); clot volume (ß:-.240, P = .014) and collateral status (ß:.346, P < .001). In patients with good prognosis, clot volume was significantly lower (37.76 ± 30.08 versus 67.57 ± 37.83, P < .001), whereas permeability was significantly higher (43.97 ± 32.33 versus 31.13 ± 19.01, P = .026). However, this effect did not persist in the regression analysis after adjustment for NIHSS (ß:-.399, P < .001), collateral status (ß: .343, P < .001) and clot volume (ß:-.297, P = .001). Clot permeability was significantly higher (45.78 ± 36.34 versus 33 ± 20.2, P = .045) and heterogeneity was lower (4.1 ± 1.55 to 5.27 ± 2.32, P = .028) in patients with dramatic response to tPA (27%). In patients responding positively to IV tPA (48%), clot permeability was numerically higher (39.85 ± 31.79 to 33.47 ± 19.28, P = .268), while clot volume (48.15 ± 34.5 to 62.07 ± 39.62, P = .093) was lower. Clot volume, permeability and heterogeneity did not show a significant difference in any (38.1%) or symptomatic (8.3%) bleeders after IV tPA. The chance of IV tPA to be beneficial increased in patients with clot volume lower than 45 mm3, with an increased likelihood of this benefit to be observed within the first day after IV tPA. Our detailed explorative ROC analysis was not able to detect a volume threshold above which the positive effect of IV tPA disappeared. CONCLUSION: Clot volume is critical for the effectiveness of IV tPA in acute ischemic stroke. Clot permeability and heterogeneity may modify its effect. CT technologies, which are readily available when evaluating a stroke patient in an emergency setting, provide us with useful parameters regarding the size, permeability and heterogeneity of the clot.


Assuntos
Coagulação Sanguínea , Fibrinolíticos/administração & dosagem , Infarto da Artéria Cerebral Média/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infarto da Artéria Cerebral Média/sangue , Infarto da Artéria Cerebral Média/diagnóstico , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Permeabilidade , Recuperação de Função Fisiológica , Sistema de Registros , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
14.
World Neurosurg ; 133: e267-e274, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31505293

RESUMO

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


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Craniectomia Descompressiva/métodos , Hipertensão Intracraniana/cirurgia , Neuroimagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Edema Encefálico/diagnóstico por imagem , Edema Encefálico/etiologia , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Feminino , Fibrinolíticos/uso terapêutico , Escala de Resultado de Glasgow , Humanos , Hipertensão Intracraniana/etiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
15.
J Stroke Cerebrovasc Dis ; 29(2): 104474, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31784381

RESUMO

OBJECTIVE: To study the rate of symptomatic intracerebral hemorrhage (SxICH) and major systemic hemorrhage (MSH) after acute stroke treatments among different ethnicities/races. BACKGROUND: Studies have reported ethnic/racial disparities in intravenous tPA treatment (IV tPA). The adverse outcome of tPA and/or intra-arterial intervention (IA) among different ethnicities/races requires investigation. METHODS: We retrospectively reviewed all patients from an IRB-approved registry between June 2004 and June 2018. Patients who received IV tPA, IA, or both for acute stroke were identified and classified into 2 ethnic groups: non-Hispanics or Hispanics (NH/H) and 4 racial groups: Asian, Black, Other (Native Americans and Pacific Islanders), and White (A/B/O/W). RESULTS: We identified 916 patients that received acute therapy (A/B/O/W: n = 50/104/16/746, H/NH: n = 184/730). For those received IV tPA only (n = 759), IA only (n = 85), and IV tPA+IA (n = 72), the SxICH rate was 4.3%, 4.7%, and 6.9%; the MSH rate was 1.3%, 0%, and 0%, respectively. No significant difference in the rate of SxICH or MSH among different racial or ethnic groups was found after either therapy. Asian race (OR 14.17, P = .01), in association with age, international normalized value (INR), and Partial thromboplastin time (PTT) (OR 1.06, 46.52, and 1.18, P = .020, 0.037, and 0.042, respectively), was predictive of SxICH after IV tPA. There was a significant correlation between age and National Institute of Health Stroke Scale with SxICH (P < .01, P = .02, respectively). Age, INR, and PTT were independent predictors of SxICH after IV tPA (OR 1.06, 46.52, and 1.18, P = .02, 0.04, and 0.04, respectively). CONCLUSIONS: There was no significant difference in the rate of SxICH or MSH after IV tPA, IA, or IV tPA+IA among different racial or ethnic groups. Larger studies are needed to elucidate the race specific causes of SxICH and MSH after acute stroke treatment.


Assuntos
Grupos de Populações Continentais , Procedimentos Endovasculares , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/etnologia , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Afro-Americanos , Fatores Etários , Americanos Asiáticos , California/epidemiologia , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/etnologia , Terapia Combinada , Procedimentos Endovasculares/efeitos adversos , Grupo com Ancestrais do Continente Europeu , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Coeficiente Internacional Normatizado , Tempo de Tromboplastina Parcial , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
16.
J Stroke Cerebrovasc Dis ; 29(2): 104525, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31812455

RESUMO

BACKGROUND AND PURPOSE: A subset of ischemic stroke patients present with blood pressures above that considered safe for thrombolytic administration, requiring antihypertensive therapy. Guideline statements are ambivalent regarding which antihypertensive agent should be used to obtain a satisfactory blood pressure < 185/110 mm Hg prior to alteplase. METHODS: We reviewed data from consecutive patients at a single institution treated with alteplase from January 2014 to January 2019, collecting door-to-needle times, antihypertensive agent (if used), and antihypertensive-to-needle times. Patients were grouped by initial agent administered. We assessed for differences in door-to-needle times between those needing antihypertensive(s) and those who did not. Antihypertensive-to-needle times were compared across 3 antihypertensive groups (labetalol, nicardipine, and hydralazine). RESULTS: Analysis included 239 patients: 177 receiving no antihypertensive, 44 labetalol, 13 nicardipine, and 5 hydralazine. Those not administered an antihypertensive prior to alteplase had shorter door-to-needle times (52.6 minutes versus 62.1 minutes, P = .016). We found no statistical differences when comparing door-to-needle times across all groups (no med 52.6 minutes, labetalol 64.3 minutes, nicardipine 53.0 minutes, hydralazine 67.4 minutes, P = .052). No differences were found in antihypertensive-to-needle amongst the 3 antihypertensive groups (labetalol 18.75 minutes, nicardipine 12.15 minutes, hydralazine 25.40 minutes, P = .239). CONCLUSIONS: Patients requiring antihypertensives experienced slower door-to-needle times. No statistically significant changes were observed in door-to-needle times by antihypertensive used, however these results may have clinical importance. This study is limited by relatively small sample size. Pooling data from multiple institutions could provide more robust assessment and inform clinical practice.


Assuntos
Anti-Hipertensivos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Fibrinolíticos/administração & dosagem , Hipertensão/tratamento farmacológico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Anti-Hipertensivos/efeitos adversos , Esquema de Medicação , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Hidralazina/administração & dosagem , Hipertensão/diagnóstico , Hipertensão/fisiopatologia , Infusões Intravenosas , Labetalol/administração & dosagem , Masculino , Nicardipino/administração & dosagem , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
17.
J Stroke Cerebrovasc Dis ; 29(2): 104526, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31836356

RESUMO

BACKGROUND AND PURPOSE: Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. We hypothesized that ENI defined as a percentage change in the National Institute of Health Stroke Scale (NIHSS) score (percent change NIHSS score) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS score (delta NIHSS score) at 24 hours. METHODS: Retrospective analysis of prospectively collected single-center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. We examined delta NIHSS score and percent change NIHSS score in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1). RESULTS: Among 586 patients who met the inclusion criteria, 194 (33.1%) had a favorable outcome at 3 months. In fully adjusted models, both delta NIHSS score (OR per point decrease 1.27; 95% confidence interval [CI] 1.19-1.36) and percent change NIHSS score (OR per 10 percent decrease 1.17; 95% CI 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS score (.755) was greater than delta NIHSS score (.613) or admission NIHSS (.694). CONCLUSIONS: Percentage change in NIHSS score may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Reprodutibilidade dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
18.
Vasa ; 49(1): 17-22, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31134852

RESUMO

The outcome of a thrombotic vessel occlusion is related to the resolution of thrombus and restitution of blood flow. Thrombus formation simultaneously activates an enzymatic process that mediates endogenous fibrinolysis to maintain vessel patency. The balance between coagulation and fibrinolysis determines the extent of thrombus formation, its resolution, and clinical outcome. Endogenic fibrinolysis is frequently unable to overcome coagulation and to resolve the thrombus. Therefore, for a complete resolution of thrombus in an acute phase, exogenic fibrinolytic agents are needed. Currently, tissue plasminogen activator (tPA) is most frequently used for therapeutic thrombolysis. Also, heparins, particularly low-molecular-weight heparins and direct oral anticoagulants which are known as anticoagulant drugs, have some pro-fibrinolytic properties. Besides the extent and age of a clot, different other factors influence the lysis of thrombus. Thrombus structure is one of the most important determinants of thrombus lysis. The concentration of thrombolytic agent (tPA) around and inside of thrombus importantly determines clot lysis velocity. Further, flow-induced mechanical forces which stimulate the transport of thrombolytic agent into the clot influence thrombolysis. Inflammation most probably represents a basic pathogenetic mechanism of activation of coagulation and influences the activity of the fibrinolytic system. Inflammation increases tissue factor release, platelet activity, fibrinogen concentration and inhibits fibrinolysis by increasing plasminogen activator inhibitor 1. Therefore, recanalization of a thrombotic vessel occlusion is inversely related to levels of some circulating inflammatory agents. Consequently, inhibition of inflammation with anti-inflammatory drugs may improve the efficacy of prevention of thromboembolic events and stimulate recanalization of thrombotic occlusions of veins.


Assuntos
Trombose , Fibrinólise , Fibrinolíticos , Humanos , Terapia Trombolítica , Ativador de Plasminogênio Tecidual
19.
Zhonghua Yi Xue Za Zhi ; 99(44): 3477-3480, 2019 Nov 26.
Artigo em Chinês | MEDLINE | ID: mdl-31826565

RESUMO

Objective: To detect the ideal treatment for acute ischemic stroke (AIS) patients with atrial fibrillation (AF) within 4.5 hours from onset. Methods: A total of 95 AIS patients with AF was retrospectively analyzed from April 2014 to January 2019. Thirty patients (group A) were treated with endovascular treatment directly, 35 (group B) patients were treated with intravenous recombinant tissue plasminogen activator (rtPA) followed by endovascular treatment, and 30 (group C) patients were treated with intravenous rtPA only. There were no significant differences among the groups in baseline data as age, gender, underlying diseases, medication, National Institutes of Health Stroke Scale (NIHSS) score, time from onset to treatment. Modified thrombolysis in cerebral infarction (mTICI), Symptomatic hemorrhagic transformation (SICH), 90 d prognosis of modified Rankin Scale (mRS) and death were compared. Results: Recanalization (mTICI≥2b) was similar in group A and B (70.0% vs. 68.6%, P>0.05). SICH of group A (6.7%) was significantly lower than that of group B (31.4%, P<0.05), but similar with that of group C (13.7%, P>0.05). Prognosis (mRS≤2) was significantly better in group A (70.0%) than that in group B (37.1%) and group C (30.0%), both P<0.01. The mortality rate in group A (6.7%) was lower than that in group B (14.3%) and group C (20.0%) without statistically significant, both P>0.05. Conclusion: AIS patients with AF within 4.5 hours from onset should receive endovascular treatment directly.


Assuntos
Fibrilação Atrial , Isquemia Encefálica , Acidente Vascular Cerebral , Doença Aguda , Fibrinolíticos , Humanos , Estudos Retrospectivos , Terapia Trombolítica , Ativador de Plasminogênio Tecidual , Resultado do Tratamento
20.
J Clin Ethics ; 30(4): 338-346, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31851625

RESUMO

Although tissue plasminogen activator (tPA) is the only medication approved by the United States Food and Drug Administration (FDA) for acute ischemic stroke, there is no consensus about the need for informed consent for its use. As a result, hospitals throughout the U.S. have varying requirements regarding obtaining informed consent from patients for the use of tPA, ranging from no requirement for informed consent to a requirement for verbal or written informed consent. We conducted a study to (1) determine current beliefs about obtaining patients' informed consent for tPA among a large group of stroke clinicians and (2) identify the ethical, clinical, and organizational factors that influence tPA consent practices. Semi-structured interviews were conducted by trained and experienced investigators and research staff to identify key barriers to implementing acute stroke services. Part of the interview explored current beliefs and practices around informed consent for tPA. This was a multicenter study that included 38 Veterans Health Administration (VHA) hospital locations. Participants were 68 stroke team clinicians, serving primarily on the neurology (35 percent) or emergency medicine (41 percent) service. We conducted thematic analysis based on principles of grounded theory to identify codes about consent for tPA. We used interpretive convergence to ensure consistency among the individual investigators' codes and to ensure that all of the investigators agreed on coding and themes. We found that 38 percent of the stroke clinicians did not believe any form of consent was necessary for tPA, 47 percent thought that some form of consent was necessary, and 15 percent were unsure. Clinicians who believed tPA required informed consent were divided on whether consent should be written (40 percent) or verbal (60 percent). We identified three factors describing clinicians' attitudes about consent: (1) legal and policy factors, (2) ethical factors, and (3) medical factors. The lack of consensus regarding consent for tPA creates the potential for delays in treatment, uneasiness among clinicians, and legal liability. The identified factors provide a potential framework to guide discussions about developing a standard of care for acquiring the informed consent of patients for the administration of tPA.


Assuntos
Isquemia Encefálica/terapia , Consentimento Livre e Esclarecido , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Atitude do Pessoal de Saúde , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Hospitais de Veteranos , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Estados Unidos
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