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1.
Ann Intern Med ; 174(4): JC42, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33819060

RESUMO

SOURCE CITATION: Thomalla G, Boutitie F, Ma H, et al. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. Lancet. 2020;396:1574-84. 33176180.


Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Humanos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
2.
J Stroke Cerebrovasc Dis ; 30(5): 105710, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33690029

RESUMO

BACKGROUND: Faster treatment times are associated with improved outcomes in patients with acute ischemic stroke. In this prospective pilot study, we assess the feasibility of initiating telestroke consultation in emergency medical services unit (TEMS). METHODS: Patients with stroke symptoms were evaluated via TEMS using a video-call with a stroke provider. After TEMS evaluation, patients were transferred to the nearest stroke center (NSC) or thrombectomy capable center (TCS) depending on stroke severity and symptom onset time. We compared time metrics between patients evaluated via TEMS to those via standard telestroke (STS) consultation. RESULTS: 49 patients were evaluated via TEMS between May 2017 and March 2020. Median age was 66, 24 (49%) were females, 15 (30.6%) received intravenous alteplase (tPA) after arrival to a local hospital, and 3 (6.1%) underwent mechanical thrombectomy (MT) after bypassing the NSC. Compared to 52 tPA patients treated through STS consultation, TEMS patients had shorter door to needle (DTN) time (21 vs. 38 min, p < 0.001). In addition, patients who received MT after bypassing the NSC had shorter onset to groin time compared to those transferred from NSC (216 vs. 293 min, P = 0.04). CONCLUSION: Prehospital stroke triaging using TEMS is feasible, and could result in shorter DTN and onset to groin times.


Assuntos
Serviços Médicos de Emergência , Procedimentos Endovasculares , Fibrinolíticos/administração & dosagem , Consulta Remota , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/administração & dosagem , Transporte de Pacientes , Triagem , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Procedimentos Endovasculares/efeitos adversos , Estudos de Viabilidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Comunicação por Videoconferência
3.
Medicine (Baltimore) ; 100(9): e24978, 2021 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-33655967

RESUMO

RATIONALE: Severe hypofibrinogenemia after intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) is rare and easily overlooked, but hypofibrinogenemia increases the risk of major bleeding. However, it is unclear when hypofibrinogenemia reaches the peak and when hypofibrinogenemia is resolved. PATIENT CONCERNS: Case 1 was of a 66-year-old man who was hospitalized due to sudden onset of vague speech and right hemiplegia for 4 hours. Case 2 was of an 84-year-old woman who was hospitalized for sudden onset of left hemiplegia and vague speech for 4 hours. In case 1, fibrinogen levels decreased from normal values to <0.25 g/L within 4.5 hours after commencing IVT and returned to normal at 35 hours later. In case 2, fibrinogen levels decreased from 1.1 to <0.25 g/L within 2 hours after commencing IVT and normalized 36.5 hours later. DIAGNOSES: Both patients were diagnosed with rt-PA-related hypofibrinogenemia. INTERVENTIONS: No antiplatelet or symptomatic treatment was administered during the period of hypofibrinogenemia. OUTCOMES: Fibrinogen levels gradually recovered. In case 1, the patient did not experience cerebral hemorrhage during hypofibrinogenemia. His symptoms improved significantly within 1 week. In case 2, repeat computed tomography revealed minor cerebral hemorrhage, but no deterioration in her condition was noted until she was discharged. LESSONS: Rapid, severe, and prolonged hypofibrinogenemia may occur after IVT with rt-PA, which may increase the risk of massive hemorrhage and affect the related therapy. Prompt diagnosis of hypofibrinogenemia is important for preventing complications. We recommend checking the fibrinogen levels routinely after IVT. Fibrinogen replacement therapy and platelet transfusion are the main management routes for rt-PA-related symptomatic intracranial hemorrhage.


Assuntos
Afibrinogenemia/induzido quimicamente , Fibrinogênio/metabolismo , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Afibrinogenemia/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Doenças Raras , Índice de Gravidade de Doença
4.
Medicine (Baltimore) ; 100(10): e25004, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725879

RESUMO

BACKGROUND: Acute ischemic stroke (AIS) is an important factor leading to adult death and disability globally. For AIS patients who meet certain conditions, recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis is an important method recommended by national guidelines to achieve vascular recanalization. However, complications such as hemorrhagic transformation and vascular reocclusion after thrombolysis are still unsolved problems in clinical. Several systematic reviews of clinical randomized controlled trials (RCTs) in the past have shown that Chinese herbal injections (CHIs) can improve the neurological function of patients, increase the tolerance of ischemic tissues to hypoxia, and inhibit platelet aggregation. Therefore, this study conducted a meta-analysis of AIS treatment with intravenous thrombolysis alone and compared it with the combined application of CHIs. To evaluate whether CHIs have a synergistic effect on thrombolytic therapy and provide a basis for clinical application. METHODS: The following databases will be searched until September 2020: ①English databases: PubMed, Cochrane Library, Embase; ②Chinese databases: CNKI, Wanfang database, Weipu database, SinoMed. RCTs will be included to compare the efficacy of thrombolysis combined with CHIs and thrombolysis alone in the treatment of AIS. Data extraction and risk of bias assessments will be carried out by 2 verifiers independently. The risk of bias will be evaluated through the Cochrane risk of bias tool. Review Manager software 5.3 will be used for statistical analysis. RESULTS: This study will provide comprehensive evidence for the treatment of AIS by CHIs combined with intravenous thrombolysis from multiple aspects. CONCLUSION: The conclusion of the meta-analysis will provide a basis for judging whether CHIs combined with intravenous thrombolysis is an effective measure for the treatment of AIS. ETHICS AND DISSEMINATION: Ethical approval is not needed because this study will be based on data that already published. We will publish the findings of this study in a peer-reviewed journal and related conferences. PROSPERO REGISTRATION NUMBER: CRD42020215546.


Assuntos
Medicamentos de Ervas Chinesas/administração & dosagem , Fibrinolíticos/administração & dosagem , Hemorragia/epidemiologia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Terapia Combinada/efeitos adversos , Terapia Combinada/métodos , Medicamentos de Ervas Chinesas/efeitos adversos , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Infusões Intravenosas/efeitos adversos , Infusões Intravenosas/métodos , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Revisões Sistemáticas como Assunto , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
5.
J Stroke Cerebrovasc Dis ; 30(4): 105638, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33540336

RESUMO

OBJECTIVES: To compare outcomes between two models of acute ischemic stroke care. Namely 1) "drip-and-stay", i.e. IV tissue plasminogen activator (tPA) administered at a spoke hospital in a telestroke network, with the patient remaining at the spoke, versus 2) "drip-and-ship", i.e. tPA administered at a spoke hospital with subsequent patient transfer to a hub hospital, and 3) "hub", i.e. tPA and subsequent treatment at a hub hospital. MATERIALS AND METHODS: We performed a systematic review and meta-analysis according to PRISMA guidelines. Literature searches of MEDLINE, Embase, and Cochrane from inception-October 2019 included randomized control trials and observational cohort studies comparing the drip-and-stay model to hub and drip-and-ship models. Outcomes of interest were functional independence (modified Rankin Scale ≤ 1), symptomatic intracranial hemorrhage (sICH), mortality, and length of stay. Pooled effect estimates were calculated using a fixed-effects meta-analysis and random-effects Bayesian meta-analysis. Non-inferiority was calculated using a fixed-margin method. RESULTS: Of 2806 unique records identified, 10 studies, totaling 4,164 patients, fulfilled the eligibility criteria. Meta-analysis found no significant difference in functional outcomes (mRS0-1) (6 studies, RR=1.09, 95%CI 0.98-1.22, p=0.123), sICH (8 studies, RR=0.98, 95%CI 0.64-1.51, p=0.942), or 90-day mortality (5 studies, RR=0.98, 95%CI 0.73-1.32, p=0.911, respectively) between patients treated in a drip-and-stay model compared to patients treated in drip-and-ship or hub models. There was no significant heterogeneity in these outcomes. Drip-and-stay outcomes (mRS 0-1, sICH) were non-inferior when compared to the combined group. CONCLUSIONS: Our findings indicate that drip-and-stay is non-inferior to current models of drip-and-ship or hub stroke care, and may be as safe and as effective as either.


Assuntos
Fibrinolíticos/administração & dosagem , Transferência de Pacientes , Telemedicina , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Hemorragias Intracranianas/etiologia , /mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
6.
J Stroke Cerebrovasc Dis ; 30(5): 105678, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33640783

RESUMO

INTRODUCTION: Current guidelines allow the administration of intravenous recombinant tissue plasminogen activator (IV r-tPA) to warfarin-treated patients with acute ischemic stroke (AIS) who have an international normalized ratio (INR) of ≤1.7. However, concerns remain about the safety of using IV r-tPA in this situation due to a conceivable risk of symptomatic intracranial hemorrhage (sICH), lack of dedicated randomized controlled trials and the conflicts in the available data. We aimed to determine the risk of sICH in warfarin-treated patients with subtherapeutic INR who received IV r-tPA for AIS in our large volume comprehensive center. METHODS: Patients who had received IV r-tPA for AIS in a 9.6-year period were retrospectively investigated (n = 834). Patients taking warfarin prior to presentation were identified (n = 55). One patient was excluded due to elevated INR beyond the acceptable range for IV r-tPA treatment. Because of the significant difference in the sample size (54 vs 779), warfarin group was matched with 54 non-warfarin patients adjusted for independent risk factors for sICH (age, admission NIHSS, history of diabetes). Good outcome was defined as mRS of 0-2 on discharge and sICH was defined as an ICH causing increase in NIHSS ≥4 or death. Warfarin-treated group was further dichotomized based on INR (1-1.3 vs 1.3-1.7) and safety and outcome measures were compared between resultant groups. RESULTS: No significant difference was found between warfarin-treated and the non-warfarin groups in terms of chance of good outcome on discharge (27.8% in warfarin group vs 26.4% in non-warfarin group; p-value >0.05), or the rate of occurrence of sICH (3.7% in warfarin group vs 11.1% in non-warfarin group; p-value >0.05). Furthermore, rate of sICH (5.1% in patients with INR <1.3 versus 0.0% in patients with INR 1.3-1.7; p-value >0.05) or chance of good outcome on discharge (28.2% of patients with INR <1.3 versus 26.7% in patients with INR 1.3-1.7; p-value >0.05) were not found to be different after the warfarin-treated group was dichotomized. CONCLUSION: Administration of IV r-tPA for AIS in warfarin-treated patients with subtherapeutic INR <1.7 does not increase the risk of sICH.


Assuntos
Anticoagulantes/uso terapêutico , Monitoramento de Medicamentos , Fibrinolíticos/administração & dosagem , Coeficiente Internacional Normatizado , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Varfarina/uso terapêutico , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Hemorragia Cerebral/induzido quimicamente , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , /diagnóstico , Masculino , New York , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Varfarina/efeitos adversos
9.
JAMA ; 325(3): 234-243, 2021 01 19.
Artigo em Inglês | MEDLINE | ID: mdl-33464335

RESUMO

Importance: For patients with large vessel occlusion strokes, it is unknown whether endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment (standard treatment) can achieve similar functional outcomes. Objective: To investigate whether endovascular thrombectomy alone is noninferior to intravenous alteplase followed by endovascular thrombectomy for achieving functional independence at 90 days among patients with large vessel occlusion stroke. Design, Setting, and Participants: Multicenter, randomized, noninferiority trial conducted at 33 stroke centers in China. Patients (n = 234) were 18 years or older with proximal anterior circulation intracranial occlusion strokes within 4.5 hours from symptoms onset and eligible for intravenous thrombolysis. Enrollment took place from May 20, 2018, to May 2, 2020. Patients were enrolled and followed up for 90 days (final follow-up was July 22, 2020). Interventions: A total of 116 patients were randomized to the endovascular thrombectomy alone group and 118 patients to combined intravenous thrombolysis and endovascular thrombectomy group. Main Outcomes and Measures: The primary end point was the proportion of patients achieving functional independence at 90 days (defined as score 0-2 on the modified Rankin Scale; range, 0 [no symptoms] to 6 [death]). The noninferiority margin was -10%. Safety outcomes included the incidence of symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality. Results: The trial was stopped early because of efficacy when 234 of a planned 970 patients had undergone randomization. All 234 patients who were randomized (mean age, 68 years; 102 women [43.6%]) completed the trial. At the 90-day follow-up, 63 patients (54.3%) in the endovascular thrombectomy alone group vs 55 (46.6%) in the combined treatment group achieved functional independence at the 90-day follow-up (difference, 7.7%, 1-sided 97.5% CI, -5.1% to ∞)P for noninferiority = .003). No significant between-group differences were detected in symptomatic intracerebral hemorrhage (6.1% vs 6.8%; difference, -0.8%; 95% CI, -7.1% to 5.6%) and 90-day mortality (17.2% vs 17.8%; difference, -0.5%; 95% CI, -10.3% to 9.2%). Conclusions and Relevance: Among patients with ischemic stroke due to proximal anterior circulation occlusion within 4.5 hours from onset, endovascular treatment alone, compared with intravenous alteplase plus endovascular treatment, met the prespecified statistical threshold for noninferiority for the outcome of 90-day functional independence. These findings should be interpreted in the context of the clinical acceptability of the selected noninferiority threshold. Trial Registration: Chinese Clinical Trial Registry: ChiCTR-IOR-17013568.


Assuntos
Fibrinolíticos/administração & dosagem , /cirurgia , Trombectomia , Ativador de Plasminogênio Tecidual/administração & dosagem , Doença Aguda , Idoso , Hemorragia Cerebral/etiologia , Terapia Combinada , Procedimentos Endovasculares , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Trombectomia/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos
10.
Am J Case Rep ; 22: e927137, 2021 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-33441533

RESUMO

BACKGROUND Angioedema is characterized by localized swelling of subcutaneous or submucosal tissue resulting from fluid extravasation due to the loss of vascular integrity. It most commonly occurs with exposure to allergens and certain medications, namely nonsteroidal anti-inflammatory agents and angiotensin-converting enzyme inhibitors. There have been few incidences of angioedema following the administration of tissue plasminogen activator. CASE REPORT We describe an 84-year-old woman with a history of hypertension managed with lisinopril who presented with an acute onset of right-sided hemiparesis, slurred speech, and right-sided hemianopsia. Urgent computed tomography of the head revealed subacute infarct of the left pons without hemorrhage. Intravenous alteplase was administered and within 30 min our patient developed severe orolingual edema requiring emergent intubation. Subsequent imaging revealed acute to subacute infarct of the left occipital lobe in the posterior cerebral artery region, consistent with her initial presenting symptoms. CONCLUSIONS Angioedema induced by tissue plasminogen activator occurs in approximately 1-5% of patients receiving thrombolysis for ischemic stroke and can be life-threatening. The risk is increased in patients taking angiotensin-converting enzyme inhibitors, in patients with ischemic strokes of the middle cerebral artery, and in the presence of C1 esterase inhibitor deficiency. This phenomenon is usually self-limited and treatment is supportive, although evidence supports the use of antihistamines, steroids, epinephrine, and complement inhibitors. Due to the severity of angioedema and the potential progression to airway compromise, it is crucial to closely monitor patients receiving tissue plasminogen activator.


Assuntos
Angioedema/induzido quimicamente , Infarto Encefálico/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Idoso de 80 Anos ou mais , Angioedema/diagnóstico , Angioedema/terapia , Infarto Encefálico/diagnóstico por imagem , Feminino , Humanos , Artéria Cerebral Posterior
11.
JAMA ; 325(3): 244-253, 2021 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-33464334

RESUMO

Importance: Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear. Objective: To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome. Design, Setting, and Participants: Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019. Interventions: Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103). Main Outcomes and Measures: The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours. Results: Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, -11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞]; P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, -0.8% [95% CI, -9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43]; P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, -16.8% [95% CI, -32.1% to -1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88]; P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, -1.8% [95% CI, -9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24]; P = .78). Conclusions and Relevance: Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority. Trial Registration: umin.ac.jp/ctr Identifier: UMIN000021488.


Assuntos
Fibrinolíticos/administração & dosagem , /cirurgia , Trombectomia , Ativador de Plasminogênio Tecidual/administração & dosagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/etiologia , Terapia Combinada , Intervalos de Confiança , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Trombectomia/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
12.
J Stroke Cerebrovasc Dis ; 30(3): 105551, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33348248

RESUMO

OBJECTIVES: The efficacy of thrombolytic therapy with tissue plasminogen activator (tPA) is highly time dependent. Although clinical guidelines do not recommend written informed consent as it may cause treatment delays, local policy can supersede and require it. From 2014 to 2017, three out of five public hospitals in Singapore changed from written to verbal consent at different time points. We aimed to examine the association of hospital policy changes regarding informed consent on door-to-needle (DTN) times. MATERIALS AND METHODS: Using data from the Singapore Stroke Registry and surveys of local practice, we analyzed data of 915 acute ischemic stroke patients treated with tPA within 3 hours in all public hospitals between July 2014 to Dec 2017. Patient-level DTN times before and after policy changes were examined while adjusting for clinical characteristics, within-hospital clustering, and trends over time. RESULTS: Patient characteristics and stroke severity were similar before and after the policy changes. Overall, the median DTN times decreased from 68 to 53 minutes after the policy changes. After risk adjustment, changing from written to verbal informed consent was associated with a 5.6 minutes reduction (95% CI 1.1-10.0) in DTN times. After the policy changed, the percentage of patients with DTN ≤60 minutes and ≤45 minutes increased from 35.6% to 66.1% (adjusted OR 1.75; 95% CI 1.12-2.74) and 9.3% to 36.0% (adjusted OR 2.42; 95% CI 1.37-4.25), respectively. CONCLUSION: Changing from written to verbal consent is associated with significant improvement in the timeliness of tPA administration in acute ischemic stroke.


Assuntos
Fibrinolíticos/uso terapêutico , Consentimento Livre e Esclarecido , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Feminino , Fibrinolíticos/efeitos adversos , Hospitais Públicos , Humanos , Masculino , Pessoa de Meia-Idade , Formulação de Políticas , Sistema de Registros , Estudos Retrospectivos , Singapura , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Comportamento Verbal
14.
J Stroke Cerebrovasc Dis ; 30(2): 105520, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33310594

RESUMO

BACKGROUND: Ticagrelor is a novel antiplatelet agent that is frequently used for secondary prevention in coronary artery disease and has emerging evidence in stroke after the recent results of SOCRATES and THALES trials. The use of intravenous thrombolysis with alteplase in acute ischemic stroke (AIS) patients on ticagrelor is a topic of debate as the safety profile of ticagrelor in this setting is not well established. METHODS: We identified consecutive AIS patients taking ticagrelor who received intravenous alteplase at a comprehensive stroke center from January 2016 to December 2019. We then performed a literature search to capture all known published cases of intravenous thrombolysis in stroke patients on ticagrelor. RESULTS: Of the 3896 patients who were treated for AIS at our local comprehensive stroke center during this time period, two patients received intravenous alteplase while on ticagrelor. Both patients had posterior circulation acute strokes and were successfully treated with intravenous alteplase without a systemic or intracranial bleeding event. Only five other cases of intravenous thrombolysis in AIS patients on ticagrelor have been reported in the literature. Among these cases, four of the five cases had a hemorrhagic complication. CONCLUSION: Despite prior reports of hemorrhagic complications with use of IV alteplase in setting of pre-treatment with ticagrelor, we report the safe use of intravenous thrombolysis in two cases presenting with acute ischemic stroke. Until safety is established in large studies, decision for thrombolysis should be made on case-by-case basis.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Inibidores da Agregação de Plaquetas/administração & dosagem , Terapia Trombolítica , Ticagrelor/administração & dosagem , Ativador de Plasminogênio Tecidual/administração & dosagem , Síndrome Coronariana Aguda/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Ticagrelor/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
15.
J Stroke Cerebrovasc Dis ; 30(2): 105525, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33338755

RESUMO

OBJECTIVES: The impact of contracting stroke-associate infection (SAI) that requires antibiotic treatment after an acute ischemic stroke (AIS) treated with alteplase remains unclear. We studied the profiles of SAI in patients with AIS treated with alteplase toward identifying predictive factors and prognostic implications at 90 days post-stroke. METHODS: We analyzed 33 parameters readily available within 24 hours after AIS: demographics, risk factors, and several clinical and biochemical parameters. Outcome measures were mRS ≤ 2 and mortality 90 days post-stroke. RESULTS: 83 (23.6%) of 352 patients developed SAI. Multivariate logistic regression analysis showed that atrial fibrillation, mRS above 0 pre-stroke, lower delta NIHSS (the difference between NIHSS score measured upon admission and 24 hours after later), CRP≥10 mg/L, and elevated WBC count affected SAI risk (model including CRP levels and WBC count) and atrial fibrillation, mRS above 0 pre-stroke, lower delta NIHSS, HT, and elevated fibrinogen levels affected SAI risk (model excluding CRP levels and WBC count). 231 patients (74.1%) had mRS ≤ 2 at day 90. Multivariate logistic regression analysis showed that younger age, no hypertension, mRS=0 pre-stroke, higher delta NIHSS, no HT, no SAI, and CRP<10 mg/L, were associated with mRS≤2 at day 90. 54 (15.3%) patients died within 90 days. Multivariate logistic regression analysis showed that pre-stroke mRS>0, lower delta NIHSS, HT, CRP≥10 mg/L, lower triglyceride levels affected the risk of death within 90 days. CONCLUSIONS: Several markers available within 24 hours post-stroke were predictive of SAI that requires antibiotic treatment. SAI affects long-term outcome but not mortality.


Assuntos
Doenças Transmissíveis/microbiologia , Fibrinolíticos/administração & dosagem , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Doenças Transmissíveis/diagnóstico , Doenças Transmissíveis/tratamento farmacológico , Doenças Transmissíveis/mortalidade , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , /diagnóstico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
16.
J Stroke Cerebrovasc Dis ; 30(3): 105526, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33338704

RESUMO

OBJECTIVES: to investigate the relationship between insulin resistance (IR) and clinical outcomes in non-diabetic ischemic stroke patients treated with intravenous thrombolysis. METHODS: We recruited non-diabetic ischemic stroke patients treated with intravenous thrombolysis prospectively. IR was defined as homeostasis model assessment-estimated insulin resistance index ≥2.80. Initial stroke severity was assessed using the National Institutes of Health Stroke Scale scores, and infarct volume was measured using DWI. Clinical outcomes were evaluated by neurological improvement and hemorrhagic transformation at 24 hours, and favorable functional prognosis at 90 days. RESULTS: 232 patients were enrolled into this study. IR group was 67 patients, non-IR group was 165 patients. Compared with the non-IR group, the probability of neurological improvement at 24 h ours and favorable functional outcome at 90 days in IR group were all significantly lower (41.79% vs 63.03%, p<0.01; 73.13% vs 89.09%, p<0.01 respectively), whereas the ratio of hemorrhagic transformation was much higher (16.42% vs 4.85%, p<0.01). In multivariable logistic regression, IR was negatively associated with neurological improvement and favorable functional prognosis (OR=0.39, 95%CI, 0.20-0.76, p<0.01; OR= 0.26, 95%CI, 0.07-0.91, p=0.04, respectively), but was positively correlated with hemorrhagic transformation (OR=4.07, 95%CI, 1.13-14.59, p=0.03) after adjusting traditional risk factors. We analyzed 108 infarct volume data further, the median of volume in IR group was 2.27 cm3, higher than that in non-IR group (1.96 cm3), but no statistical difference (p=0.65). CONCLUSIONS: In non-diabetic ischemic stroke patients treated with intravenous thrombolysis, IR was related with worse clinical outcomes, but not with infarct volume.


Assuntos
Fibrinolíticos/administração & dosagem , Resistência à Insulina , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Biomarcadores/sangue , Glicemia/metabolismo , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Insulina/sangue , /fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
17.
J Stroke Cerebrovasc Dis ; 30(3): 105502, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33360518

RESUMO

OBJECTIVE: Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke (AIS). However, during the hyperacute stroke evaluation, the exclusion of IE may be difficult. We sought to report the prevalence of undiagnosed IE in AIS patients who received IVtPA. METHODS: We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 who received IVtPA for suspected AIS and identified patients diagnosed with IE. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2. RESULTS: Among 1022 AIS patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed middle cerebral artery (MCA) occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage due to mycotic cerebral aneurysm rupture. Blood culture results included MRSE (1), Streptococcus viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcomes, and the mean 3 month mRS was 4.8 (range, 3 to 6). The 90 day mortality was 60%. CONCLUSION: In a series of AIS patients who received IVtPA by academic vascular neurologists, the risk of undiagnosed IE was low (0.5%). Fever was not commonly present during initial evaluation in IE presenting with AIS. Despite affecting younger patients with initial mild deficits, AIS patients with IE who received IVtPA had poor functional outcomes.


Assuntos
Endocardite/epidemiologia , Fibrinolíticos/administração & dosagem , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Contraindicações de Medicamentos , Endocardite/diagnóstico , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , /epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Adulto Jovem
18.
J Clin Neurosci ; 82(Pt A): 13-19, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33317721

RESUMO

The study aimed to investigate the role of serum homocysteine in hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH) within 24 h of intravenous (IV) recombinanttissueplasminogenactivator(rt-PA) in acute ischemic stroke (AIS) patients. 236 consecutive AIS patients (169 men, median 65 years old) who underwent to IV rt-PA within 4.5 h of symptom onset were retrospectively recruited and analyzed. The serum homocysteine levels ranged from 4.45 to 67.71 (median 12.05) µmol/L. HT was observed in 28 (11.9%) patients, including 7 (3.0%) sICH patients within 24 h of IV rt-PA. Multiple parameters were compared between HT and non-HT patients as well as sICH and non-sICH patients. The serum homocysteine levels were higher in patients with HT than in those without HT (13.00 vs. 11.70 µmol/L, P = 0.025) and an independent association between serum homocysteine level and HT within 24 h of IV rt-PA was identified via multivariable logistic regression analysis (odds ratio [OR] = 1.103, 95% confidence interval [CI] = 1.021-1.191, P = 0.013). Moreover, serum homocysteine levels were also significantly higher in patients with sICH than in those without sICH (15.19 vs. 11.73 µmol/L, P = 0.005).Our study suggests that serum homocysteine level is an independent predictor for HT within 24 h of IV rt-PA in AIS patients.


Assuntos
Fibrinolíticos/efeitos adversos , Homocisteína/sangue , Hemorragias Intracranianas/sangue , Ativador de Plasminogênio Tecidual/efeitos adversos , Administração Intravenosa , Idoso , Biomarcadores/sangue , Feminino , Humanos , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/métodos
19.
BMJ Case Rep ; 13(12)2020 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-33370942

RESUMO

A potential complication after intravenous administration of recombinant tissue plasminogen activators (rtPAs) for thrombolysis in acute ischaemic stroke is orolingual angioedema, with an incidence of 0.4%-7.9%. In the herewith reported case, we discuss potential links between a history of sarcoidosis and the occurrence of orolingual angioedema after rtPA administration. Sarcoidosis is often accompanied by an elevated ACE level. In contrast, low ACE levels appear to play a role in the pathomechanism currently assumed to trigger angioedema, that is, the activation of the bradykinin and complement pathways. Medication with ACE inhibitors is considered a risk factor for angioedema. Based on these considerations, the patient was also treated with icatibant, a bradykinin B2-receptor antagonist, which has been found useful in recent publications on treating orolingual angioedema after intravenous lysis in ischaemic stroke.


Assuntos
Angioedema/terapia , Bradicinina/análogos & derivados , Infarto da Artéria Cerebral Média/terapia , Sarcoidose/complicações , Terapia Trombolítica/efeitos adversos , Angioedema/induzido quimicamente , Bradicinina/uso terapêutico , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infusões Intravenosas , Intubação Intratraqueal , Lábio/irrigação sanguínea , Pessoa de Meia-Idade , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Língua/irrigação sanguínea , Falha de Tratamento
20.
Arq Neuropsiquiatr ; 78(11): 681-686, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33331463

RESUMO

BACKGROUND: Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. OBJECTIVE: We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. METHODS: Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. RESULTS: 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient's age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37‒14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98‒32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81‒357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37‒14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10‒0.40) remained independently associated. CONCLUSIONS: Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.


Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
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