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1.
Lancet Neurol ; 20(9): 721-728, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34418399

RESUMO

BACKGROUND: Non-immunogenic staphylokinase is modified recombinant staphylokinase with low immunogenicity, high thrombolytic activity, and selectivity to fibrin. We aimed to assess the safety and efficacy of a single intravenous bolus of non-immunogenic staphylokinase compared with alteplase in patients with acute ischaemic stroke within 4·5 h after symptom onset. METHODS: We did a randomised, open-label, multicentre, parallel-group, non-inferiority trial in 18 clinical sites in Russia. We included patients aged 18 years and older with a diagnosis of acute ischaemic stroke (up to 25 points on the National Institutes of Health Stroke Scale). The study drug had to be administered within 4·5 h after the onset of symptoms. Patients were randomly assigned to receive either non-immunogenic staphylokinase (10 mg) or alteplase (0·9 mg/kg, maximum 90 mg), both administered intravenously. The randomisation sequence was created by an independent biostatistician using computer-generated random numbers. 84 blocks (block size of four) of opaque sealed envelopes were numbered sequentially from 1 to 336 and were opened in numerical order. Patients were unaware of their assigned treatment and were assessed by the study investigators who were also unaware of the treatment assignment on all trial days. Emergency department staff, who administered the assigned drug and opened the envelopes, were not masked to treatment. The primary efficacy endpoint was a favourable outcome, defined as a modified Rankin scale (mRS) score of 0-1 on day 90. The margin of non-inferiority was established as 16% for the difference in mRS score of 0-1 on day 90. Non-inferiority was tested using Welch's t-test for the primary outcome only. Endpoints were analysed in the per-protocol population, which comprised all randomly assigned patients who completed treatment without any protocol violations; this population was identical to the intention-to-treat population. This trial is completed and registered at ClinicalTrials.gov, NCT03151993. FINDINGS: Of 385 patients recruited from March 18, 2017, to March 23, 2019, 336 (87%) were included in the trial. 168 (50%) patients were randomly assigned to receive non-immunogenic staphylokinase and 168 (50%) to receive alteplase. The median duration of follow-up was 89 days (IQR 89-89). 84 (50%) of 168 patients in the non-immunogenic staphylokinase group had a favourable outcome at day 90 compared with 68 (40%) of 168 patients in the alteplase group (odds ratio [OR] 1·47, 95% CI 0·93 to 2·32; p=0·10). The difference in the rate of favourable outcome at day 90 was 9·5% (95% CI -1·7 to 20·7) and the lower limit did not cross the margin of non-inferiority (pnon-inferiority <0·0001). Symptomatic intracranial haemorrhage occurred in five (3%) patients in the non-immunogenic staphylokinase group and in 13 (8%) patients in the alteplase group (p=0·087). On day 90, 17 (10%) patients in the non-immunogenic staphylokinase group and 24 (14%) patients in the alteplase group had died (p=0·32). 22 (13%) patients in the non-immunogenic staphylokinase group had serious adverse events, compared with 37 (22%) patients in the alteplase group (p=0·044). INTERPRETATION: Non-immunogenic staphylokinase was non-inferior to alteplase for patients with acute ischaemic stroke. Mortality, symptomatic intracranial haemorrhage, and serious adverse events did not differ significantly between groups. Future studies are needed to continue to assess the safety and efficacy of non-immunogenic staphylokinase in patients with acute ischaemic stroke within the 4·5 h time window, and to assess the drug in patients with acute ischaemic stroke outside this time window with reperfusion CT or magnetic resonance angiography followed by thrombectomy if necessary. FUNDING: The Russian Academy of Sciences.


Assuntos
Fibrinolíticos/farmacologia , AVC Isquêmico/tratamento farmacológico , Metaloendopeptidases/farmacologia , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/farmacologia , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Metaloendopeptidases/administração & dosagem , Metaloendopeptidases/efeitos adversos , Metaloendopeptidases/imunologia , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Proteínas Recombinantes , Federação Russa , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos
2.
Int J Mol Sci ; 22(14)2021 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-34299322

RESUMO

Clinical treatments for ischemic stroke are limited. Neural stem cell (NSC) transplantation can be a promising therapy. Clinically, ischemia and subsequent reperfusion lead to extensive neurovascular injury that involves inflammation, disruption of the blood-brain barrier, and brain cell death. NSCs exhibit multiple potentially therapeutic actions against neurovascular injury. Currently, tissue plasminogen activator (tPA) is the only FDA-approved clot-dissolving agent. While tPA's thrombolytic role within the vasculature is beneficial, tPA's non-thrombolytic deleterious effects aggravates neurovascular injury, restricting the treatment time window (time-sensitive) and tPA eligibility. Thus, new strategies are needed to mitigate tPA's detrimental effects and quickly mediate vascular repair after stroke. Up to date, clinical trials focus on the impact of stem cell therapy on neuro-restoration by delivering cells during the chronic stroke stage. Also, NSCs secrete factors that stimulate endogenous repair mechanisms for early-stage ischemic stroke. This review will present an integrated view of the preclinical perspectives of NSC transplantation as a promising treatment for neurovascular injury, with an emphasis on early-stage ischemic stroke. Further, this will highlight the impact of early sub-acute NSC delivery on improving short-term and long-term stroke outcomes.


Assuntos
AVC Isquêmico/terapia , Células-Tronco Neurais/transplante , Transplante de Células-Tronco/métodos , Animais , Barreira Hematoencefálica/metabolismo , Encéfalo/metabolismo , Isquemia Encefálica/metabolismo , Isquemia Encefálica/terapia , Fibrinolíticos/administração & dosagem , Humanos , AVC Isquêmico/metabolismo , Metaloendopeptidases/metabolismo , Traumatismo por Reperfusão/prevenção & controle , Traumatismo por Reperfusão/terapia , Transplante de Células-Tronco/tendências , Acidente Vascular Cerebral/metabolismo , Acidente Vascular Cerebral/terapia , Ativador de Plasminogênio Tecidual/uso terapêutico
3.
J Stroke Cerebrovasc Dis ; 30(9): 105988, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34271275

RESUMO

OBJECTIVE: Acute central retinal artery occlusion (CRAO) is an emergency with poor visual outcome. Intravenous thrombolysis within 4.5 h of vision loss is safe and may improve vision, but is rarely administered because of frequent delays in presentation. We describe a subgroup of CRAO patients presenting within 24 h of vision loss to a tertiary care center affiliated with a comprehensive stroke center. MATERIALS AND METHODS: Retrospective review of 181 consecutive CRAO patients seen at our institution from 2010 to 2020. RESULTS: Out of 181 CRAO patients, 62 (34%) presented within 24 h of vision loss and tended to live closer to the hospital. These patients were more likely to be admitted to the hospital and receive comprehensive stroke work-up compared to patients who presented after 24 h of vision loss. Patients presenting after 24 h did not necessarily receive prior appropriate work-up at outside institutions. Conservative treatments for CRAO were administered to 20/181 patients, and only 3 patients received intravenous thrombolysis. CONCLUSIONS: Patients with CRAO do not present to the emergency department fast enough and diagnosis of CRAO is often delayed. Despite having a protocol in place, only 3/181 patients received IV thrombolysis, emphasizing the difficulty in administering very acute treatments for CRAO. Public education regarding CRAO is necessary to improve presentation times, management, and visual outcomes. Hospitals need to develop accelerated diagnostic pathway protocols for patients with acute vision loss so that CRAO patients may be diagnosed and be considered for potential acute treatments as quickly as possible.


Assuntos
Fibrinolíticos/administração & dosagem , Oclusão da Artéria Retiniana/tratamento farmacológico , Centros de Atenção Terciária , Terapia Trombolítica , Tempo para o Tratamento , Visão Ocular/efeitos dos fármacos , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Programática de Saúde , Serviço Hospitalar de Emergência , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Artéria Retiniana/fisiopatologia , Estudos Retrospectivos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
4.
Int Heart J ; 62(4): 742-751, 2021 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-34234075

RESUMO

Previous studies have indicated that low-dose new generation of P2Y12 receptor antagonists may be more suitable compared with clopidogrel at a standard dose for the dual antiplatelet therapy (DAPT) for East Asian patients receiving percutaneous coronary intervention (PCI). However, there remains no consensus in clinical practice. Thus, in this study, we aimed to determine the efficacy and safety of low-dose P2Y12 receptor antagonists, compared to clopidogrel at a standard dose, in DAPT in East Asian patients after PCI. We systematically searched literatures for randomized controlled trials (RCT) comparing low-dose P2Y12 receptor antagonists with standard-dose clopidogrel for the treatment of East Asian patients undergoing PCI. The endpoints of efficacy include major adverse cardiac events (MACEs), all-cause mortality, and the number of target vessel revascularization. The indicators of safety include major and minor bleeding events. Heterogeneity was evaluated by I2 statistic test. Begg's and Egger's tests were used to evaluate publication bias. In total, 2,747 subjects from 8 RCT studies were included. Low-dose new P2Y12 receptor antagonists, that is, ticagrelor or prasugrel, showed significantly lower incidence of MACEs, as compared with standard-dose clopidogrel, in the East Asian patients who are in DAPT after undergoing PCI. Further, no difference was noted for the risk of major and minor bleeding events. In East Asian patients undergoing PCI and receiving DAPT, the use of low-dose P2Y12 receptor antagonists, ticagrelor or prasugrel, has been determined to be superior than clopidogrel at standard dose; this has been evidenced by a lower incidence of MACEs without increasing the risk of bleeding.


Assuntos
Aspirina/administração & dosagem , Fibrinolíticos/administração & dosagem , Intervenção Coronária Percutânea/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Trombose/prevenção & controle , Aspirina/efeitos adversos , Extremo Oriente , Fibrinolíticos/efeitos adversos , Humanos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Trombose/etiologia
5.
J Clin Neurosci ; 89: 389-396, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34088580

RESUMO

BACKGROUND: The decision to resume antithrombotic therapy after surgical evacuation of chronic subdural hematoma (CSDH) requires judicious weighing of the risk of bleeding against that of thromboembolism. This study aimed to investigate the impact of time to resumption of antithrombotic therapy on outcomes of patients after CSDH drainage. METHODS: Data were obtained retrospectively from three tertiary hospitals in Singapore from 2010 to 2017. Outcome measures analyzed were CSDH recurrence and any thromboembolic events. Logistic and Cox regression tests were used to identify associations between time to resumption and outcomes. RESULTS: A total of 621 patients underwent 761 CSDH surgeries. Preoperative antithrombotic therapy was used in 139 patients. 110 (79.1%) were on antiplatelets and 35 (25.2%) were on anticoagulants, with six patients (4.3%) being on both antiplatelet and anticoagulant therapy. Antithrombotic therapy was resumed in 84 patients (60.4%) after the surgery. Median time to resumption was 71 days (IQR 29 - 201). Recurrence requiring reoperation occurred in 15 patients (10.8%), of which 12 had recurrence before and three after resumption. Median time to recurrence was 35 days (IQR 27 - 47, range 4 - 82 days). Recurrence rates were similar between patients that were restarted on antithrombotic therapy before and after 14, 21, 28, 42, 56, 70 and 84 days, respectively. Thromboembolic events occurred in 12 patients (8.6%), of which five had the event prior to restarting antithrombosis. CONCLUSIONS: Time to antithrombotic resumption did not significantly affect CSDH recurrence. Early resumption of antithrombotic therapy can be safe for patients with a high thromboembolic risk.


Assuntos
Anticoagulantes/administração & dosagem , Drenagem/métodos , Fibrinolíticos/administração & dosagem , Hematoma Subdural Crônico/cirurgia , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/etiologia , Tromboembolia/epidemiologia , Adulto , Idoso , Anticoagulantes/uso terapêutico , Estudos de Coortes , Drenagem/efeitos adversos , Fibrinolíticos/uso terapêutico , Hematoma Subdural Crônico/tratamento farmacológico , Humanos , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Tromboembolia/tratamento farmacológico
6.
Medicine (Baltimore) ; 100(25): e26453, 2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-34160442

RESUMO

BACKGROUND: Recent observations raised concern that the intravenous recombinant tissue plasminogen activator (rt-PA) may result in damage to stroke patients caused by small artery occlusion (SAO). Thus, we perform a protocol for meta-analysis to investigate the efficacy and safety of intravenous thrombolysis with rt-PA in SAO-patients. METHODS: The search-style electronic libraries, including Pubmed, Embase, the Cochrane Library, Web of Science, Wanfang Data, VIP Chinese Journals, and China Biomedical Literature Service System are used for document retrieval in June 2021 with no restrictions on language. The risk of bias in include articles will be assessed using the Cochrane Risk of Bias Tool. We perform the meta-analysis by Stata version 10.0 software and calculated the statistics using the inverse variance statistical method. Binary outcomes are presented as Mantel-Haenszel-style risk ratios with 95% confidence interval. Continuous outcomes are reported as mean differences. RESULTS: The results of the article will be shown in a peer-reviewed journal. CONCLUSION: Intravenous rt-PA may be effective and safe in SAO-patients.


Assuntos
Arteriopatias Oclusivas/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Hemorragias Intracranianas/epidemiologia , Terapia Trombolítica/métodos , AVC Trombótico/tratamento farmacológico , Ativador de Plasminogênio Tecidual/administração & dosagem , Arteriopatias Oclusivas/complicações , Fibrinolíticos/efeitos adversos , Humanos , Injeções Intravenosas , Hemorragias Intracranianas/induzido quimicamente , Metanálise como Assunto , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Revisões Sistemáticas como Assunto , AVC Trombótico/etiologia , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
7.
Cochrane Database Syst Rev ; 6: CD007574, 2021 06 14.
Artigo em Inglês | MEDLINE | ID: mdl-34125952

RESUMO

BACKGROUND: Most disabling strokes are due to a blockage of a large artery in the brain by a blood clot. Prompt removal of the clot with intra-arterial thrombolytic drugs or mechanical devices, or both, can restore blood flow before major brain damage has occurred, leading to improved recovery. However, these so-called endovascular interventions can cause bleeding in the brain. This is a review of randomised controlled trials of endovascular thrombectomy or intra-arterial thrombolysis, or both, for acute ischaemic stroke. OBJECTIVES: To assess whether endovascular thrombectomy or intra-arterial interventions, or both, plus medical treatment are superior to medical treatment alone in people with acute ischaemic stroke. SEARCH METHODS: We searched the Trials Registers of the Cochrane Stroke Group and Cochrane Vascular Group (last searched 1 September 2020), CENTRAL (the Cochrane Library, 1 September 2020), MEDLINE (May 2010 to 1 September 2020), and Embase (May 2010 to 1 September 2020). We also searched trials registers, screened reference lists, and contacted researchers. SELECTION CRITERIA: Randomised controlled trials (RCTs) of any endovascular intervention plus medical treatment compared with medical treatment alone in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors (MBR and MJ) applied the inclusion criteria, extracted data, and assessed trial quality. Two review authors (MBR and HL) assessed risk of bias, and the certainty of the evidence using GRADE. We obtained both published and unpublished data if available. Our primary outcome was favourable functional outcome at the end of the scheduled follow-up period, defined as a modified Rankin Scale score of 0 to 2. Eighteen trials (i.e. all but one included trial) reported their outcome at 90 days. Secondary outcomes were death from all causes at in the acute phase and by the end of follow-up, symptomatic intracranial haemorrhage in the acute phase and by the end of follow-up, neurological status at the end of follow-up, and degree of recanalisation. MAIN RESULTS: We included 19 studies with a total of 3793 participants. The majority of participants had large artery occlusion in the anterior circulation, and were treated within six hours of symptom onset with endovascular thrombectomy. Treatment increased the chance of achieving a good functional outcome, defined as a modified Rankin Scale score of 0 to 2: risk ratio (RR) 1.50 (95% confidence interval (CI) 1.37 to 1.63; 3715 participants, 18 RCTs; high-certainty evidence). Treatment also reduced the risk of death at end of follow-up: RR 0.85 (95% CI 0.75 to 0.97; 3793 participants, 19 RCTs; high-certainty evidence) without increasing the risk of symptomatic intracranial haemorrhage in the acute phase: RR 1.46 (95% CI 0.91 to 2.36; 1559 participants, 6 RCTs; high-certainty evidence) or by end of follow-up: RR 1.05 (95% CI 0.72 to 1.52; 1752 participants, 10 RCTs; high-certainty evidence); however, the wide confidence intervals preclude any firm conclusion. Neurological recovery to National Institutes of Health Stroke Scale (NIHSS) score 0 to 1 and degree of recanalisation rates were better in the treatment group: RR 2.03 (95% CI 1.21 to 3.40; 334 participants, 3 RCTs; high-certainty evidence) and RR 3.11 (95% CI 2.18 to 4.42; 268 participants, 3 RCTs; high-certainty evidence), respectively. AUTHORS' CONCLUSIONS: In individuals with acute ischaemic stroke due to large artery occlusion in the anterior circulation, endovascular thrombectomy can increase the chance of survival with a good functional outcome without increasing the risk of intracerebral haemorrhage or death.


Assuntos
Fibrinolíticos/administração & dosagem , AVC Isquêmico/terapia , Trombólise Mecânica/métodos , Terapia Trombolítica/métodos , Idoso , Viés , Causas de Morte , Feminino , Humanos , Infarto da Artéria Cerebral Média/terapia , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/etiologia , AVC Isquêmico/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem
8.
Neurology ; 97(8): e777-e784, 2021 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-34144996

RESUMO

OBJECTIVE: To provide a critical appraisal on the evidence from randomized controlled clinical trials (RCTs) on the utility of direct endovascular treatment (dEVT) compared to the combination of endovascular treatment preceded by IV thrombolysis (bridging therapy [BT]) for patients with acute large vessel occlusion (LVO). METHODS: Eligible RCTs were identified by searching Medline and Scopus. We calculated the corresponding odds ratios (ORs) and 95% confidence intervals (CIs) and pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0 to 2 at 3 months. RESULTS: We included 3 studies comprising 1,092 patients. No difference between the dEVT and BT groups was detected for the outcomes of mRS score of 0 to 2 (OR 1.08, 95% CI 0.85-1.38; adjusted OR 1.11, 95% CI 0.76-1.63), mRS score of 0 to 1 (OR 1.10, 95% CI 0.84-1.43; adjusted OR 1.16, 95% CI 0.84-1.61), and functional improvement at 3 months (common OR 1.08, 95% CI 0.88-1.34; adjusted common OR 1.09, 95% CI 0.86-1.37). Patients receiving dEVT had significantly lower likelihood of successful recanalization before the endovascular procedure compared to those receiving BT (OR 0.37, 95% CI 0.18-0.77). Patients receiving dEVT had lower intracranial bleeding rates compared to those receiving BT (OR 0.67, 95% CI 0.49-0.92) but without a significant difference in the probability of symptomatic intracranial hemorrhage. No differences in all-cause mortality, serious adverse events, or procedural complications between the 2 groups were uncovered. CONCLUSIONS: We detected no differences in functional outcomes of IV thrombolysis-eligible patients with an acute LVO receiving dEVT compared to BT. Because uncertainty for most endpoints remains large and the available data are not able to exclude the possibility of overall benefit or harm, further RCTs are needed.


Assuntos
Procedimentos Endovasculares , Fibrinolíticos/farmacologia , AVC Isquêmico/terapia , Avaliação de Resultados em Cuidados de Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto , Ativador de Plasminogênio Tecidual/farmacologia , Terapia Combinada/estatística & dados numéricos , Procedimentos Endovasculares/estatística & dados numéricos , Fibrinolíticos/administração & dosagem , Humanos , AVC Isquêmico/tratamento farmacológico , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/administração & dosagem
9.
J Stroke Cerebrovasc Dis ; 30(8): 105912, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34130105

RESUMO

BACKGROUND/OBJECTIVE: While postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI. METHODS: A cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure. RESULTS: Incidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3-7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06-6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95-27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5-6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45-144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99-21.29]; p = .002) were at significantly higher risk of death within the 30-day period. CONCLUSION: In this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.


Assuntos
Estenose da Valva Aórtica/cirurgia , Fibrinolíticos/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Bases de Dados Factuais , Quimioterapia Combinada , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/mortalidade
10.
J Stroke Cerebrovasc Dis ; 30(8): 105916, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34144336

RESUMO

OBJECTIVES: There is a paucity of data on the risk of nursing home admission or domiciliary care initiation according to time to intravenous thrombolysis for ischemic stroke. We investigated the association between time to intravenous thrombolysis and the composite of nursing home admission or domiciliary care initiation in patients with acute ischemic stroke. MATERIALS AND METHODS: In this nationwide cohort study, all stroke patients treated with intravenous thrombolysis (2011-2015) and alive at discharge were identified from the Danish Stroke Registry and other nationwide registries. The composite of nursing home admission or domiciliary care initiation one year post-discharge according to time to thrombolysis was examined with multivariable Cox regression. RESULTS: The study population comprised 4,349 patients (median age 67 years [25th-75th percentile 57-75], 65.2% men). The median National Institutes of Health Stroke Scale score at presentation was 5, and the median time from symptom-onset to initiation of thrombolysis was 143 min. The absolute 1-year risk of the composite endpoint was 14.0% (95%CI, 11.5-16.8%) in the ≤90 min group, 16.6% (15.1-18.1%) in the 91-180min group, and 16.0% (14.0-18.2%) in the 181-270 min group. Compared with thrombolysis ≤90 min, time to thrombolysis between 91-180 min and 181-270 min was associated with a significantly higher risk of the composite endpoint (hazard ratio 1.31 [1.04-1.65] and 1.47 [1.14-1.91], respectively). CONCLUSIONS: In patients admitted with ischemic stroke, increasing time to thrombolysis was associated with a greater risk of the composite of nursing home admission or domiciliary care initiation. Continued efforts to shorten the time delay from symptom-onset to initiation of thrombolysis are warranted.


Assuntos
Fibrinolíticos/administração & dosagem , Serviços de Assistência Domiciliar , AVC Isquêmico/tratamento farmacológico , Casas de Saúde , Terapia Trombolítica , Tempo para o Tratamento , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Dinamarca/epidemiologia , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , AVC Isquêmico/diagnóstico , AVC Isquêmico/epidemiologia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Alta do Paciente , Sistema de Registros , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
11.
J Stroke Cerebrovasc Dis ; 30(8): 105890, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34107417

RESUMO

OBJECTIVES: Intravenous (IV) tissue plasminogen activator (tPA) should be given to patients with acute ischemic stroke (AIS) and avoided in stroke mimics (SM). Select use of emergency brain magnetic resonance imaging (eMRI-brain) in stroke-alerts aids diagnosis, but accepted utilization criteria for eMRI-brain do not currently exist. We developed criteria for eMRI-brain and report the yield of eMRI-brain in stroke-alert patients. MATERIALS AND METHODS: We developed three history-based criteria for performing eMRI-brain during stroke-alerts: (1) history of previous similar deficits, (2) change in consciousness at onset of symptoms, (3) symptom presentation consistent with migraine aura. We then performed a retrospective chart review of patients who presented as a stroke-alert over a 5-year period and determined how these criteria affected administration of IV tPA to AIS and SM patients. RESULTS: Among 3,512 stroke-alerts, 230 (8.1%) patients met our criteria for eMRI-brain exams: 217 (92.6%) had SM and 17 (7.4%) had AIS. Our IV tPA decision-making analysis showed that based on eMRI-brain IV tPA was less frequently administered to SM patients (PCC-0.841, p=0.036) with less failures to administer IV tPA to patients with AIS (PCC -0.907, p-value=0.013, Pearson correlation coefficient). No patients became ineligible for IV tPA due to MRI-related time delays. CONCLUSIONS: Our history based criteria for performing eMRI-brain during stroke-alerts show a high yield of stroke mimics. Selective eMRI-brain improves decision-making accuracy regarding IV tPA administration.


Assuntos
Encéfalo/diagnóstico por imagem , Regras de Decisão Clínica , Tomada de Decisão Clínica , Serviço Hospitalar de Emergência , Imageamento por Ressonância Magnética , Acidente Vascular Cerebral/diagnóstico por imagem , Encéfalo/fisiopatologia , Diagnóstico Diferencial , Fibrinolíticos/administração & dosagem , Humanos , Infusões Intravenosas , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento
12.
BMC Neurol ; 21(1): 237, 2021 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-34167477

RESUMO

BACKGROUND: Studies have suggested that glycoprotein IIb/IIIa antagonists such as tirofiban are beneficial for patients with acute coronary syndromes. However, it is still uncertain about the efficacy and safety of tirofiban in patients with acute ischemic stroke (AIS). METHODS: In this prospective non-randomized study, 255 AIS patients were recruited from 4 comprehensive stroke centers in China between January, 2017 and May, 2018. Among them,169 patients were treated with aspirin plus clopidogrel and 86 patients were treated with tirofiban. The primary functional outcome was the distribution of the 90 days' modified Rankin Scale (mRS). The safety outcomes included the incidence of intracranial hemorrhage (ICH) at discharge and mortality at 3 months. RESULTS: In the propensity score matched cohort, tirofiban alone was noninferior to the dual antiplatelet with regard to the primary outcome (adjusted common odds ratio, 0.97; 95% confidence interval, 0.46 to 2.04; P = 0.93). Mortality at 90 days was 10% in the dual antiplatelet group and 8% in the tirofiban group (adjusted odds ratio 0.75; 95% CI 0.08 to 7.40, p = 0.81). There was no difference of the ICH rate between two groups (adjusted odds ratio 0.44; 95% CI 0.13 to 1.48, p = 0.18). In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar differences were found for functional and safety outcomes. CONCLUSIONS: Our study suggested that tirofiban use appears to be safe as monotherapy in AIS treatment compared with common dual antiplatelet therapy, however, no improvement in functional outcomes was found. TRIAL REGISTRATION: Chinese clinical trial registry, ChiCTR2000034443 , 05/07/2020. Retrospectively registered.


Assuntos
Fibrinolíticos , AVC Isquêmico , Tirofibana , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Aspirina/uso terapêutico , China , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Clopidogrel/uso terapêutico , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Fibrinolíticos/uso terapêutico , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/mortalidade , Estudos Prospectivos , Tirofibana/administração & dosagem , Tirofibana/efeitos adversos , Tirofibana/uso terapêutico
13.
J Clin Neurosci ; 89: 106-112, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34119252

RESUMO

BACKGROUND: Stroke severity can be mitigated by preceding anticoagulant administration in acute ischemic stroke patients with atrial fibrillation (AF). We investigated if such mitigative effects are different between warfarin and direct oral anticoagulants (DOACs). MATERIAL AND METHODS: We collected data from a regional multicenter stroke registry. Ischemic stroke or transient ischemic attack patients with AF were included. Background characteristics, National Institutes of Health Stroke Scale (NIHSS) score on admission, lesion characteristics, and in-hospital death were analyzed according to preceding antithrombotic agents at onset. RESULTS: A total of 2173 patients had AF; 628 were prescribed warfarin, 272 DOACs, 429 antiplatelets alone, and 844 no antithrombotics. The NIHSS score on admission was lowest in the DOACs group compared to the other groups. In neuroimaging analysis, small ischemic lesions were observed more frequently in the DOACs group, while large ischemic lesions were less frequent in this group. When the no antithrombotics group was used as a reference, the adjusted odds ratio for moderate to severe stroke was 0.56 (95% confidence interval, 0.40-0.78) in the DOACs group, while it was 0.98 (0.77-1.24) in the warfarin group and 0.94 (0.72-1.22) in the antiplatelets group. In-hospital mortality was lowest in the DOACs group compared to the other groups. CONCLUSION: Preceding DOAC administration might mitigate the severity of stroke in AF patients more strongly than other antithrombotics, possibly leading to a better outcome in patients with stroke.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/complicações , Fibrinolíticos/administração & dosagem , AVC Isquêmico/tratamento farmacológico , Varfarina/administração & dosagem , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Humanos , AVC Isquêmico/etiologia , AVC Isquêmico/prevenção & controle , Pessoa de Meia-Idade , Varfarina/uso terapêutico
14.
J Stroke Cerebrovasc Dis ; 30(8): 105862, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34034124

RESUMO

BACKGROUND: Morbidity and mortality among homeless people with cardiovascular diseases and stroke in the United States is high. Adverse outcomes within the homeless population may be the result of seeking care too late to receive time-sensitive interventions. We sought to investigate the impact of homelessness on ischemic stroke patients who received intravenous thrombolysis (IVT). METHODS: We determined rates of post-thrombolytic intracranial hemorrhage (ICH), in-hospital death, and development of moderate to severe disability among homeless ischemic stroke patients treated with IVT. Patients were identified using the Nationwide (National) Inpatient Sample between 2002 and 2017. We compared rates of the various outcomes to non-homeless ischemic stroke patients treated with IVT. RESULTS: There were 514 homeless (mean age 54.7 ± 10.2 years, 20.4% women) and 364,408 non-homeless (mean age 68.6 ± 14.7 years, 49.7% women) ischemic stroke patients who received IVT. There was no difference in post-thrombolytic ICH rates between the two groups (6.6% homeless versus 8.8% non-homeless, p = 0.09). Homeless patients were more frequently discharged to self-care (p = 0.003). Homeless patients were less likely than non-homeless patients to suffer in-hospital death (AOR 0.499 [95% CI 0.30-0.84], p = 0.009) and moderate to severe disability (AOR 0.423 [95% CI 0.29 - 0.62], p < 0.001). CONCLUSION: Homeless ischemic stroke patients who receive IVT are not at an increased risk of developing post-thrombolytic ICH or in-hospital death. Efforts are needed to encourage this unique population to seek medical attention as soon as possible for time-sensitive interventions that may decrease the risk of permanent disability or death associated with ischemic stroke.


Assuntos
Fibrinolíticos/administração & dosagem , Pessoas em Situação de Rua , AVC Isquêmico/tratamento farmacológico , Terapia Trombolítica , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Estado Funcional , Mortalidade Hospitalar , Humanos , Infusões Intravenosas , Pacientes Internados , Hemorragias Intracranianas/etiologia , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
Pan Afr Med J ; 38: 185, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33995791

RESUMO

Since the onset of the COVID-19 pandemic, several small cohorts have reported the recurrent occurrence of venous thromboembolic disease (VTE), particulary pulmonary embolism, in serious patients hospitalized in intensive care units. We report the case of a patient who presented a minor COVID-19 infection treated on an outpatient basis with good clinical resolution. She developed a pulmonary embolism three weeks after the onset of symptoms. When she was admitted to the emergency room, the two real time reverse transcription polymerase chain reactions (RT-PCRs) performed were negative, moreover the anti-SARS-CoV-2 Immunoglobulin Gs (IgGs) serological test was positive and the chest scanner without and with injection of contrast product showed specific images of COVID-19 with intermediate pulmonary embolism according to the classification of the European society of cardiology (ESC). This observation is interesting since there are not many studies which address the question of the occurrence of late pulmonary embolism in patients with non-severe COVID-19 and raises the discussion on the criteria for the initiation of thromboembolic prophylaxis treatment at the first diagnosis of the disease and duration of that treatment.


Assuntos
COVID-19/complicações , Embolia Pulmonar/diagnóstico , Adulto , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Embolia Pulmonar/virologia , Reação em Cadeia da Polimerase em Tempo Real , Testes Sorológicos , Índice de Gravidade de Doença , Fatores de Tempo
16.
Medicine (Baltimore) ; 100(21): e25696, 2021 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-34032693

RESUMO

RATIONALE: Free-floating thrombi in the intracranial artery are rare. We report a case of a free-floating and spinning thrombus caused by turbulent flow distal to the basilar artery stenosis. We compare thrombus changes in a series of images according to time and describe the approach to treatment and thrombosis resolution.. PATIENT CONCERNS: A 55-year-old man presented to the emergency department on March 21, 2020, with left-sided weakness, bilateral limb ataxia, and a one-day history of dysarthria. Brain magnetic resonance imaging showed multifocal infarctions in the pons and cerebellum with severe basilar stenosis. DIAGNOSES: Digital subtraction angiography showed severe focal stenosis. A relatively large oval-shaped mobile thrombus was observed spinning due to turbulent flow at the distal portion of the stenosis. INTERVENTIONS: We administered a combination antithrombotic regimen of warfarin and clopidogrel for 50 days. OUTCOMES: No thrombus was observed on the third follow-up digital subtraction angiography. LESSONS: No previous study has directly observed a mobile thrombus in the intracranial artery using digital subtraction angiography. We used a combination antithrombotic strategy, which was effective after long-term, rather than short-term, use.


Assuntos
Artéria Basilar/patologia , Infarto Cerebral/diagnóstico , Fibrinolíticos/administração & dosagem , Trombose/diagnóstico , Insuficiência Vertebrobasilar/diagnóstico , Angiografia Digital , Artéria Basilar/diagnóstico por imagem , Cerebelo/irrigação sanguínea , Cerebelo/diagnóstico por imagem , Angiografia Cerebral , Infarto Cerebral/tratamento farmacológico , Infarto Cerebral/etiologia , Clopidogrel/administração & dosagem , Quimioterapia Combinada/métodos , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Ponte/irrigação sanguínea , Ponte/diagnóstico por imagem , Trombose/complicações , Trombose/tratamento farmacológico , Resultado do Tratamento , Insuficiência Vertebrobasilar/tratamento farmacológico , Insuficiência Vertebrobasilar/etiologia , Insuficiência Vertebrobasilar/patologia , Varfarina/administração & dosagem
17.
CMAJ Open ; 9(2): E585-E591, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34021017

RESUMO

BACKGROUND: We identified the need to modernize frostbite management in our northern centre and implemented a treatment protocol in 2015. Our aim was to describe the clinical course of patients presenting to the hospital since the implementation of the protocol. METHODS: This was a retrospective case series from Whitehorse General Hospital, Whitehorse, Yukon Territory, Canada. We reviewed the charts of patients who presented to the hospital with grade 2-4 frostbite and were treated as per our protocol between Feb. 9, 2015, and Feb. 8, 2020. Patients with grade 2-4 frostbite received iloprost; in addition, those with grade 4 frostbite received alteplase and heparin. We determined the number of digits affected and salvaged, and the time from presentation to the emergency department to treatment initiation. We also examined patients' demographic characteristics, predisposing events, frostbite severity and adverse drug reactions. RESULTS: In 22 patients treated for grade 2-4 frostbite, 142 digits were affected: 59 with grade 2 frostbite, 25 with grade 3 frostbite and 58 with grade 4 frostbite; of the 142, 113 (79.6%) were salvaged. All 29 digits amputated had grade 4 frostbite. The mean time from presentation to iloprost initiation was reduced from 32.9 hours in 2015 to 3.0 hours in 2020. Sports (10 cases [45%]) and alcohol use (6 [27%]) were the most common precipitating events, with alcohol use tending to result in more severe injury (grade 4 in 5 of 6 cases). Adverse reactions with iloprost (e.g., headache) were common but mild. Adverse reactions with alteplase (e.g., bleeding) were less common but of greater clinical significance. INTERPRETATION: Over the study period, our protocol contributed to improvement in frostbite care at our institution, resulting in a digit salvage rate comparable to other published results. Our 5-year experience shows that advanced medical care of frostbite can be achieved, even at a rural centre.


Assuntos
Amputação , Dedos , Congelamento das Extremidades , Heparina , Iloprosta , Ativador de Plasminogênio Tecidual , Adulto , Consumo de Bebidas Alcoólicas/epidemiologia , Amputação/métodos , Amputação/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Dedos/patologia , Dedos/cirurgia , Congelamento das Extremidades/diagnóstico , Congelamento das Extremidades/epidemiologia , Congelamento das Extremidades/cirurgia , Congelamento das Extremidades/terapia , Heparina/administração & dosagem , Heparina/efeitos adversos , Humanos , Iloprosta/administração & dosagem , Iloprosta/efeitos adversos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Esportes/estatística & dados numéricos , Tempo para o Tratamento/normas , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Vasodilatadores/administração & dosagem , Vasodilatadores/efeitos adversos , Yukon/epidemiologia
18.
Am J Emerg Med ; 47: 90-94, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33794475

RESUMO

BACKGROUND & PURPOSE: Alteplase is the standard of care for early pharmacologic thrombolysis after acute ischemic stroke (AIS). Alteplase is also considered a high-alert medication and is fraught with potential for error. We sought to describe the difference in medication error rates in in patients receiving alteplase for acute ischemic stroke from regional hospitals compared to patients receiving alteplase at the Comprehensive Stroke Center. METHODS: This was a retrospective cohort comparison of patients who were greater than 18 years old that received intravenous alteplase for the treatment of AIS from June 2015 to June 2018. Several institution specific databases were utilized to obtain pertinent data. A standardized taxonomy was utilized to classify medication errors. Patients were excluded if they received any fibrinolytic other than alteplase or if alteplase was used for a non-stroke indication. Two cohorts (from regional hospitals or the Comprehensive Stroke Center (CSC)) were compared. RESULTS: A total of 676 patients received alteplase during the study period (34% from the CSC and 66% from regional hospitals). There were 133 (19.8%) errors identified. Ten errors (1.6%) occurred at the CSC and 123 (18.2%) errors occurred at regional hospitals. More patients who had an error with alteplase administration (12.7%) experienced a hemorrhagic conversion compared to those with no error in administration (7.2%, p= 0.04). CONCLUSION: The error rate of alteplase infusion for ischemic stroke is high, particularly in patients from referring centers. Errors may be associated with adverse events. Further education and administration safeguards should be implemented to decrease the risk of medication errors.


Assuntos
Fibrinolíticos/administração & dosagem , AVC Isquêmico/tratamento farmacológico , Erros de Medicação/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Hospitais Especializados/estatística & dados numéricos , Humanos , AVC Isquêmico/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/efeitos adversos
19.
PLoS One ; 16(4): e0249524, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33852611

RESUMO

BACKGROUND: Patients with AF often have multimorbidity (the presence of ≥2 concomitant chronic conditions). OBJECTIVE: To describe baseline characteristics, patterns of antithrombotic therapy, and factors associated with oral anticoagulant (OAC) prescription in patients with AF and ≥2 concomitant, chronic, comorbid conditions. METHODS: Phase III of the GLORIA-AF Registry enrolled consecutive patients from January 2014 through December 2016 with recently diagnosed AF and CHA2DS2-VASc score ≥1 to assess the safety and effectiveness of antithrombotic treatment. RESULTS: Of 21,241 eligible patients, 15,119 (71.2%) had ≥2 concomitant, chronic, comorbid conditions. The proportions of patients with multimorbidity receiving non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKA) were 60.2% and 23.6%, respectively. The proportion with paroxysmal AF was 57.0% in the NOAC group and 45.4% in the VKA group. Multivariable log-binomial regression analysis found the following factors were associated with no OAC prescription: pattern of AF (paroxysmal, persistent, or permanent), coronary artery disease, myocardial infarction, prior bleeding, smoking status, and region (Asia, North America, or Europe). Factors associated with OAC prescriptions were age, body mass index, renal function, hypertension, history of cerebral ischemic symptoms, and AF ablation. CONCLUSION: Multimorbid AF patients prescribed NOACs have fewer comorbidities than those prescribed VKAs. Age, AF pattern, comorbidities, and renal function are associated with OAC prescription.


Assuntos
Fibrilação Atrial/epidemiologia , Fibrinolíticos/administração & dosagem , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Fibrinolíticos/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Fatores de Risco
20.
Neurology ; 96(23): e2839-e2853, 2021 06 08.
Artigo em Inglês | MEDLINE | ID: mdl-33875560

RESUMO

OBJECTIVE: To evaluate the comparative safety and efficacy of direct endovascular thrombectomy (dEVT) compared to bridging therapy (BT; IV tissue plasminogen activator + EVT) and to assess whether BT potential benefit relates to stroke severity, size, and initial presentation to EVT vs non-EVT center. METHODS: In a prospective multicenter cohort study of imaging selection for endovascular thrombectomy (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke [SELECT]), patients with anterior circulation large vessel occlusion (LVO) presenting to EVT-capable centers within 4.5 hours from last known well were stratified into BT vs dEVT. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] score 0-2). Secondary outcomes included a shift across 90-day mRS grades, mortality, and symptomatic intracranial hemorrhage. We also performed subgroup analyses according to initial presentation to EVT-capable center (direct vs transfer), stroke severity, and baseline infarct core volume. RESULTS: We identified 226 LVOs (54% men, mean age 65.6 ± 14.6 years, median NIH Stroke Scale [NIHSS] score 17, 28% received dEVT). Median time from arrival to groin puncture did not differ in patients with BT when presenting directly (dEVT 1.43 [interquartile range (IQR) 1.13-1.90] hours vs BT 1.58 [IQR 1.27-2.02] hours, p = 0.40) or transferred to EVT-capable centers (dEVT 1.17 [IQR 0.90-1.48] hours vs BT 1.27 [IQR 0.97-1.87] hours, p = 0.24). BT was associated with higher odds of 90-day functional independence (57% vs 44%, adjusted odds ratio [aOR] 2.02, 95% confidence interval [CI] 1.01-4.03, p = 0.046) and functional improvement (adjusted common OR 2.06, 95% CI 1.18-3.60, p = 0.011) and lower likelihood of 90-day mortality (11% vs 23%, aOR 0.20, 95% CI 0.07-0.58, p = 0.003). No differences in any other outcomes were detected. In subgroup analyses, patients with BT with baseline NIHSS scores <15 had higher functional independence likelihood compared to those with dEVT (aOR 4.87, 95% CI 1.56-15.18, p = 0.006); this association was not evident for patients with NIHSS scores ≥15 (aOR 1.05, 95% CI 0.40-2.74, p = 0.92). Similarly, functional outcomes improvements with BT were detected in patients with core volume strata (ischemic core <50 cm3: aOR 2.10, 95% CI 1.02-4.33, p = 0.044 vs ischemic core ≥50 cm3: aOR 0.41, 95% CI 0.01-16.02, p = 0.64) and transfer status (transferred: aOR 2.21, 95% CI 0.93-9.65, p = 0.29 vs direct to EVT center: aOR 1.84, 95% CI 0.80-4.23, p = 0.15). CONCLUSIONS: BT appears to be associated with better clinical outcomes, especially with milder NIHSS scores, smaller presentation core volumes, and those who were "dripped and shipped." We did not observe any potential benefit of BT in patients with more severe strokes. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT02446587. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with ischemic stroke from anterior circulation LVO within 4.5 hours from last known well, BT compared to dEVT leads to better 90-day functional outcomes.


Assuntos
Arteriopatias Oclusivas/terapia , Doenças Arteriais Cerebrais/terapia , Fibrinolíticos/administração & dosagem , AVC Isquêmico/terapia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Trombectomia/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/tratamento farmacológico , Doenças Arteriais Cerebrais/tratamento farmacológico , Estudos de Coortes , Feminino , Humanos , AVC Isquêmico/tratamento farmacológico , Masculino , Pessoa de Meia-Idade
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