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1.
Medicine (Baltimore) ; 98(44): e17678, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689785

RESUMO

RATIONALE: Emergence is not simply the reverse process of induction. Many dynamic situations could occur in this period by distinct neurobiology as recent studies indicated. Herein we report a rare case of failure of emergence from general anesthesia after cervical spine surgery. PATIENT CONCERNS: Despite the perioperative vital signs and laboratory results were unremarkable, the patient could not recover his mental status and spontaneous breathing during emergence. 20 minutes after cessation of anesthetic drug administration, his blood pressure suddenly began to decrease requiring transfusion and vasopressor. DIAGNOSIS: After thorough inspection of intraoperative alterations of hemodynamic and metabolic values, which showed no significant changes except possible signs of delayed volume loss, cerebrovascular bleeding was most suspected as the cause of the event. Computed tomography was performed and infratentorial hemorrhage after cervical spine surgery was checked. INTERVENTIONS: Decompression operation was required for removing the hemorrhage. However, the patient's family refused further management considering his limited life expectancy. OUTCOMES: The patient expired on postoperative day 5. LESSONS: Failure to awaken is a relatively rare event. It could be confused with simple delayed emergence, which is often caused by residual drug effect. However, when it occurs, the result could be devastating. Therefore, appropriate recognition and prompt response are required to decrease the mortality and morbidity of the patient.


Assuntos
Anestesia Geral/efeitos adversos , Hemorragias Intracranianas/induzido quimicamente , Complicações Pós-Operatórias/induzido quimicamente , Descompressão Cirúrgica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Fusão Vertebral/efeitos adversos
2.
J Stroke Cerebrovasc Dis ; 28(11): 104363, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31501038

RESUMO

BACKGROUND AND AIM: Renal dysfunction (RD) is prevalent in patients with acute ischemic stroke requiring intravenous thrombolysis. The relationship between renal function and thrombolysis related intracranial hemorrhagic (ICH) complications is contradictory according to previous studies. The current study is to clarify whether RD could increase the risk of symptomatic intracranial hemorrhage (SICH) after recombinant tissue plasminogen activator (IV rtPA) in acute ischemic stroke patients. METHODS: In this observational study, acute ischemic stroke patients who received IV rtPA within 4.5 hours of symptom onset were retrospectively analyzed. Creatinine levels on admission served to calculate glomerular filtration rate (GFR) to estimate RD. SICH was defined with National Institute of Neurological Disorder and Stroke (NINDS, SICHNINDS) or European Cooperative Acute Stroke Study II (ECASS II, SICHECASSII) criteria. Association of RD with SICH was assessed using continuous GFR or binary GFR (RD defined as GFR < 90 ml/minute/1.73 m2). RESULTS: Of 312 patients included, the incidence of SICHNINDS was 7.69%, of SICHECASSII was 5.45%. Patients with RD had higher prevalence of SICHNINDS (12.80% versus 2.03%, P < .001) and SICHECASS II (9.15% versus 1.35%, P = .002). GFR as a continuous variable was associated with SICHNINDS (ORadjust = .97, P = .003), but not with SICHECASS II. GFR less than 90 ml/minute/1.73 m2 remained independently associated with SICHNINDS (ORadjust = 4.79, P = .016), and SICHECASS II (ORadjust = 2.99, P = .032) in multiple logistic regression analysis. CONCLUSIONS: Renal function is independently associated with SICH after IV rtPA thrombolysis. RD is an independent predictor for both SICHNINDS and SICHECASS II. RD should be considered when evaluating the risk of intravenous thrombolysis with IV rtPA.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Taxa de Filtração Glomerular , Hemorragias Intracranianas/induzido quimicamente , Nefropatias/fisiopatologia , Rim/fisiopatologia , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/fisiopatologia , China/epidemiologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/epidemiologia , Nefropatias/diagnóstico , Nefropatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento
3.
Cancer Treat Res ; 179: 179-189, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31317488

RESUMO

Venous thromboembolism is commonly diagnosed in patients with primary and secondary brain tumors. Anticoagulation management in the setting of brain tumors is complicated by the high background rate of spontaneous intracranial hemorrhage. Until recently, there was limited evidence to support the decision to administer therapeutic anticoagulation in the setting of brain metastases or primary brain tumors. The current evidence suggests that the safety profile of therapeutic low molecular weight heparin for the treatment of venous thromboembolism is contingent on whether the origin of brain tumor is primary (i.e., glioma) versus secondary. In patients with brain metastases, the rate of intracranial hemorrhage often exceeds 20% but is not influenced by the administration of low molecular weight heparin. In contrast, in primary brain tumors such as glioma, therapeutic anticoagulation is associated with an increased risk of intracranial hemorrhage that can negatively impact survival. This chapter reviews the underlying mechanisms contributing to thrombosis and hemorrhage in brain tumors and summarizes the current evidence and approaches in anticoagulation to treat venous thromboembolism.


Assuntos
Anticoagulantes/uso terapêutico , Neoplasias Encefálicas/complicações , Hemorragias Intracranianas/etiologia , Tromboembolia Venosa/tratamento farmacológico , Anticoagulantes/efeitos adversos , Neoplasias Encefálicas/patologia , Neoplasias Encefálicas/secundário , Humanos , Hemorragias Intracranianas/induzido quimicamente , Tromboembolia Venosa/etiologia
4.
J Stroke Cerebrovasc Dis ; 28(9): 2363-2375, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31281110

RESUMO

The prevalence of atrial fibrillation (AF), the most common cardiac arrhythmia, increases with age, predisposing elderly patients to an increased risk of embolic stroke. With an increasingly aged population the number of people who experience a stroke every year, overall global burden of stroke, and numbers of stroke survivors and related deaths continue to increase. Anticoagulation with vitamin K antagonists (VKAs) reduces the risk of ischemic stroke in patients with AF; however, increased bleeding risk is well documented, particularly in the elderly. Consequently, VKAs have been underused in the elderly. Alternative anticoagulants may offer a safer choice, particularly in patients who have experienced previous stroke. The aim of this narrative review is to examine available evidence for the effective treatment of patients with AF and previous cerebral vascular events with non-VKA oral anticoagulants, including the most appropriate time to start or reinitiate treatment after a stroke, systemic embolism, or clinically relevant bleed. For patients with AF treated with oral anticoagulants it is important to balance increased protection against future stroke/systemic embolism and reduced risk of major bleeding events. For patients with AF who have previously experienced a cerebrovascular event, the use of oral anticoagulants alone also appears more effective than low-molecular weight heparin (LMWH) alone or LMWH followed by oral anticoagulants. Available data suggest that significant reduction in stroke, symptomatic cerebral bleeding, and major extracranial bleeding within 90 days from acute stroke can be achieved if oral anticoagulation is initiated at 4-14 days from stroke onset.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Esquema de Medicação , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Recidiva , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento
5.
J Clin Neurosci ; 66: 45-50, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31153752

RESUMO

BACKGROUND: Endovascular treatment (ET) has been proved as safety and effective in acute ischemic stroke. However, early reocclusion is an inevitable complication following ET. There is uncertainty effect of early antiplatelet therapy on outcomes in patients with acute ischemic stroke undergoing endovascular treatment. METHODS: We searched major databases for articles published from 2011 to 2019 in the present study. Safety outcomes were any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH) and mortality. Efficacy outcomes were recanalization rate and follow-up functional outcome. Review Manager 5.3 and Stata Software Package 14.0 were used to perform the meta-analysis. RESULTS: Seven studies with a total of 1251 patients were included. A total of 451 (36.1%) patients were administrated by antiplatelet agent following ET. Meta-analysis suggested that early antiplatelet did not increase the risk for ICH (OR 1.15; 95% CI 0.56-2.37; P = 0.70), sICH (OR 1.29; 95% CI 0.79-2.09; P = 0.31) and mortality (OR 0.71; 95% CI 0.45-1.12; P = 0.14). There was no association between antiplatelet therapy and recanalization rate (OR 1.03; 95% CI 0.73-1.46; P = 0.30) or functional outcome (OR 0.97; 95% CI 0.55-1.69; P = 0.90). Sensitivity analysis indicated tirofiban did not associated with any ICH and mortality, nor improve the recanalization rate and functional outcome in patients receiving ET or mechanical thrombectomy (all p > 0.05). CONCLUSIONS: Early antiplatelet therapy may be safe in acute ischemic stroke patients, further studies are needed to confirm the efficacy.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/tendências , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária/tendências , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/diagnóstico , Procedimentos Endovasculares/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/etiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/tendências , Tirofibana/efeitos adversos , Tirofibana/uso terapêutico , Resultado do Tratamento
6.
Crit Care Nurse ; 39(3): e1-e8, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31154337

RESUMO

Intracerebral hemorrhage is a major source of morbidity and mortality, accounting for 10% of all strokes. Oral anticoagulation therapy, while necessary to prevent thromboembolic complications, increases the risk of intracerebral hemorrhage and can potentially worsen bleeding in cases of acute hemorrhage. Before the introduction of direct oral anticoagulant agents in 2010, warfarin was the only option for oral anticoagulation. These new agents have an improved safety profile compared with warfarin but require different reversal strategies. Anticoagulation reversal in the setting of acute intracerebral hemorrhage is an evolving field. This article covers the most common direct oral anticoagulant medications, various available anticoagulant reversal strategies, and the latest guidelines for anticoagulation reversal in patients with acute intracranial hemorrhage.


Assuntos
Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Hemorragias Intracranianas/induzido quimicamente , Tromboembolia/prevenção & controle , Administração Oral , Anticoagulantes/farmacocinética , Antitrombinas/administração & dosagem , Antitrombinas/efeitos adversos , Benzamidas/administração & dosagem , Benzamidas/efeitos adversos , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Humanos , Hemorragias Intracranianas/prevenção & controle , Guias de Prática Clínica como Assunto , Pirazóis/administração & dosagem , Pirazóis/efeitos adversos , Piridinas/administração & dosagem , Piridinas/efeitos adversos , Piridonas/administração & dosagem , Piridonas/efeitos adversos , Medição de Risco , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Resultado do Tratamento
7.
No Shinkei Geka ; 47(6): 629-636, 2019 Jun.
Artigo em Japonês | MEDLINE | ID: mdl-31235665

RESUMO

BACKGROUND AND PURPOSE: Warfarin-associated intracranial hemorrhage(w-ICH)usually increases and results in unfavorable outcomes. Administration of prothrombin complex concentrate(PCC)can reverse anticoagulation and correct prothrombin time-international normalized ratio(PT-INR)immediately; it is recommended by some guidelines for cases of w-ICH. We assessed the effect of PCC on blood coagulation. METHODS: We administered PCC and vitamin K to 11 patients with w-ICH who were admitted to our hospital between October 2016 and November 2017. We measured the PT-INR at baseline and immediately, 1 hour, 6 hours, and on the day after PCC administration. RESULTS: Patients' mean(range)PT-INR normalized from 1.92(1.64-3.26)to 1.08(1.03-1.29)immediately after receiving PCC. Patients' PT-INR was 1.17(1.08-1.29)1 hour after receiving PCC, 1.22(1.16-1.52)6 hours after receiving PCC, and 1.17(1.05-1.29)on the day after receiving PCC. In all the cases, no side effects emerged. Five patients had a safe operation. All the patients' modified Rankin Scale scores at discharge were stable or within a permissive limit in comparison with the symptoms on admission. CONCLUSION: In our cases, administration of PCC corrected the PT-INR immediately and contributed to a better outcome of w-ICH.


Assuntos
Anticoagulantes , Hemorragias Intracranianas , Varfarina , Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/uso terapêutico , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/tratamento farmacológico , Estudos Retrospectivos , Varfarina/efeitos adversos
8.
J Stroke Cerebrovasc Dis ; 28(8): 2287-2291, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31208820

RESUMO

BACKGROUND AND PURPOSE: Epidemiological correlations between active malignancy (AM) and acute ischemic stroke (AIS) are well-established. However, the effect of reperfusion strategies, particularly mechanical thrombectomy (MT), has been barely investigated in patients with AIS and AM. We aim to evaluate safety and efficacy of reperfusion strategies in such patients. MATERIALS AND METHODS: We performed a case-control analysis comparing patients with AM and AIS (AM group) to a group of cancer-free patients with AIS (control group). All enrolled patients underwent reperfusion therapies (i.e. intravenous thrombolysis, MT, intravenous thrombolysis plus MT). Main outcomes were 3-month functional independence, successful reperfusion, 3-month mortality, symptomatic intracranial hemorrhage. RESULTS: Total 24 patients with AM and AIS (mean age: 69 ± 10.1) were individually matched to 24 control patients (mean age: 70.7 ± 9.3). In both groups 50% were treated with MT, 46% with intravenous thrombolysis and 4% with intravenous thrombolysis plus MT. No difference were found in successful reperfusion, 3-month functional independence, symptomatic intracranial hemorrhage, and mortality. However an overall mortality of 33% in the AM group was reported. CONCLUSIONS: Reperfusion strategies for AIS patients with AM seem to be safe and effective. However an individualized approach to understand cancer stage and life-expectation is warranted.


Assuntos
Isquemia Encefálica/terapia , Fibrinolíticos/administração & dosagem , Neoplasias/complicações , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Nível de Saúde , Humanos , Hemorragias Intracranianas/induzido quimicamente , Expectativa de Vida , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias/diagnóstico , Neoplasias/mortalidade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento
9.
Neurology ; 92(21): e2421-e2431, 2019 05 21.
Artigo em Inglês | MEDLINE | ID: mdl-31068485

RESUMO

OBJECTIVE: Data regarding the efficacy and safety of warfarin and non-vitamin K antagonist oral anticoagulant (NOAC) among patients with chronic kidney disease (CKD) remain scarce. METHODS: Systematic review and meta-analysis of studies involving patients with CKD treated with oral anticoagulants were conducted to evaluate the following outcomes: ischemic stroke, intracerebral hemorrhage (ICH), combined ischemic and hemorrhagic stroke (strokecombined), stroke or systemic embolism, mortality, and major bleeding events. CKD was defined based on creatinine clearance (CrCl) ranging from mild (CrCl: 60-89 mL/min), moderate (CrCl: 30-59 mL/min), to severe (CrCl: 15-29 mL/min). RESULTS: Fifteen studies (7 comparing NOAC vs warfarin and 8 comparing warfarin vs no anticoagulant) were identified comprising 78,053 patients. Warfarin (vs no anticoagulant) was associated with reduced risk of ischemic stroke (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.55-0.84]) and mortality (RR = 0.70; 95% CI 0.62-0.78). In comparison to warfarin, NOAC use lowered the risk of ICH (RR = 0.43; 95% CI 0.33-0.56), strokecombined (RR = 0.83; 95% CI 0.72-0.96), stroke or systemic embolism (RR = 0.73; 95% CI 0.62-0.85), and major bleeding (RR = 0.77; 95% CI 0.66-0.90). In adjusted analyses, warfarin use (vs no anticoagulant) was associated with reduced mortality (HRadj = 0.68; 95% CI 0.61-0.76), whereas NOAC (vs warfarin) use reduced the risk of ICH (HRadj = 0.39; 95% CI 0.30-0.50) and stroke or systemic embolism (HRadj = 0.75; 95% CI 0.65-0.88). Our sensitivity analyses comparing different NOACs exhibited that factor Xa inhibitors (compared to warfarin) consistently reduced strokecombined (RR = 0.84; 95% CI 0.73-0.96), mortality (RR = 0.84; 95% CI 0.70-1.00), ICH (RR = 0.45; 95% CI 0.24-0.85), and major bleeding (RR = 0.76; 95% CI 0.64-0.91). CONCLUSIONS: Among patients with CKD treated with oral anticoagulants, NOACs present with a more favorable safety and efficacy profile for various cardiovascular outcomes.


Assuntos
Anticoagulantes/uso terapêutico , Embolia/prevenção & controle , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/prevenção & controle , Antitrombinas/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Hemorragia/induzido quimicamente , Humanos , Hemorragias Intracranianas/induzido quimicamente , Mortalidade , Varfarina/uso terapêutico
10.
Stroke ; 50(6): 1480-1489, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31084339

RESUMO

Background and Purpose- In clinical trials, the reduced efficacy of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention was reported for patients with nonvalvular atrial fibrillation with a creatinine clearance (CrCl) >95 mL/min compared with that of warfarin. We examined the effectiveness, safety, and net clinical benefit of NOACs compared with warfarin in Asian patients with atrial fibrillation and supranormal renal function. Methods- Using data from the Korean National Health Insurance Service database from January 2014 to December 2016, we included patients with nonvalvular atrial fibrillation with CrCl >80 mL/min. Among these incident oral anticoagulant users with rivaroxaban (n=6297), dabigatran (n=4241), apixaban (n=3395), edoxaban (n=1187), and warfarin (n=9884) were analyzed. Propensity score weighting was used to balance covariates across study groups. Hazard ratios for ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, major bleeding, all-cause death, and the composite outcome defined as ischemic stroke+intracranial hemorrhage+gastrointestinal bleeding+all-cause death were analyzed using Cox regression analysis with warfarin as the reference. Results- Baseline characteristics were well balanced among all groups (mean age, 66±11 years; 63% were men; mean CHA2DS2-VASc score, 3.0±1.8). Forty-five percent of the patients had CrCl >95 mL/min. Pooled NOACs yielded lower risks of ischemic stroke (hazard ratio, 0.51; 95% CI, 0.43-0.60) and the composite outcome (hazard ratio, 0.64; 95% CI, 0.58-0.70) than warfarin in patients with CrCl >80 mL/min. These benefits were consistent in those with CrCl >95 mL/min. All 4 NOACs reduced the risks of ischemic stroke and the composite outcome in both patients with CrCl >80 mL/min and >95 mL/min. Conclusions- The NOACs showed better effectiveness and safety than warfarin in the patients with atrial fibrillation and supranormal renal function; this was consistently observed for all 4 NOACs and in patients with CrCl >95 mL/min.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Vitamina K/antagonistas & inibidores , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Grupo com Ancestrais do Continente Asiático , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Isquemia Encefálica/induzido quimicamente , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/mortalidade , Hemorragia Gastrointestinal/fisiopatologia , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/fisiopatologia , Testes de Função Renal , Masculino , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/induzido quimicamente , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia
11.
Scand Cardiovasc J ; 53(4): 169-175, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31112048

RESUMO

Objectives. Stroke is a common condition after a transient ischemic attack (TIA) or minor ischemic stroke (IS). Adding clopidogrel to aspirin may yield more beneficial outcomes than aspirin mono-therapy; meanwhile, the risk of bleeding in the acute phase remains poorly understood. Therefore, there is increasing emphasis on the risks and benefits of clopidogrel with aspirin compared with aspirin mono-therapy in an effort to treat TIA/IS. Design. We searched several electronic databases, including PubMed, Cochrane, and Embase, to identify eligible randomized controlled trials (RCTs) based on the index words comparing dual-antiplatelet therapy to aspirin mono-therapy for secondary stroke prevention updated to December, 2018. Results. A total of 11 RCTs met our inclusion criteria. The pooled analysis showed that clopidogrel plus aspirin was associated with a trend toward a reduction in recurrent IS (RR = 0.72, 95%CI = 0.65-0.81, p < .001), but not the recurrent stroke rate (RR = 0.81, 95% CI = 0.63-1.03, p = .09) than aspirin mono-therapy. There were differences in bleeding episodes (RR = 1.81, 95%CI = 1.65-1.99, p < .001), moderate-severe major bleeding (RR = 1.64, 95% CI = 1.24-2.16, p = .0005), or mild bleeding (RR = 2.25, 95%CI = 1.54-3.31, p < .001) between the study groups. Meanwhile, no benefit of reducing the risk of intracranial hemorrhage with dual-antiplatelet therapy was found in TIA/IS patients (RR = 1.44, 95% CI = 0.95-2.19, p = .09). Conclusions. The addition of clopidogrel to aspirin for patients with TIA or IS appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone.


Assuntos
Aspirina/uso terapêutico , Isquemia Encefálica/tratamento farmacológico , Clopidogrel/uso terapêutico , Ataque Isquêmico Transitório/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária , Acidente Vascular Cerebral/tratamento farmacológico , Idoso , Aspirina/efeitos adversos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Clopidogrel/efeitos adversos , Quimioterapia Combinada , Feminino , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Resultado do Tratamento
12.
J Stroke Cerebrovasc Dis ; 28(8): 2207-2212, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31129109

RESUMO

OBJECTIVES: To evaluate the safety of acute ischemic stroke (AIS) therapy in patients with infective endocarditis (IE) with intravenous thrombolysis (IVT) or endovascular therapy (EVT) such as mechanical thrombectomy. METHODS: We conducted a retrospective study of patients who underwent AIS therapy with IVT or EVT at a tertiary referral center from 2013 to 2017, that were later diagnosed with acute IE as the causative mechanism. We then performed a systematic review of reports of acute ischemic reperfusion therapy in IE since 1995 for their success rates in terms of neurological outcome, and mortality, and their risk of hemorrhagic complication. RESULTS: In the retrospective portion, 8 participants met criteria, of whom 4 received IVT and 4 received EVT. Through systematic review, 24 publications of 32 participants met criteria. Combined, a total of 40 participants were analyzed: 18 received IVT alone, 1 received combined IVT plus EVT, and 21 received EVT alone. IVT compared to EVT were similar in rates of good neurologic outcomes (58% versus 76%, P= .22) and mortality (21% versus 19%, P= .87), but had higher post-therapy intracranial hemorrhage (63% versus 18% [P= .006]). CONCLUSION: IV thrombolysis has a higher rate of post-therapy intracranial hemorrhage compared to EVT. EVT should be considered as first-line AIS therapy for patients with known, or suspected, IE who present with a large vessel occlusion.


Assuntos
Isquemia Encefálica/terapia , Endocardite/complicações , Procedimentos Endovasculares/métodos , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Administração Intravenosa , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Endocardite/diagnóstico , Endocardite/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do Tratamento
13.
J Stroke Cerebrovasc Dis ; 28(7): 1979-1986, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30982718

RESUMO

BACKGROUND: Hemorrhagic infarction (HI) is among the most severe complications that can occur following the administration of intravenous recombinant tissue plasminogen activator (rt-PA). In the present study, we aimed to determine the optimal cut-off points of blood pressure (BP) for HI after rt-PA treatment, and to compare our findings with those for other prediction models. METHODS: We analyzed data from 109 consecutive patients with stroke treated at our hospital between 2009 and 2016. HI was confirmed via computed tomography or magnetic resonance imaging. Patients were classified into a symptomatic HI group, an asymptomatic HI group, and a non-HI group. BP was measured on admission and before rt-PA treatment. Glucose Race Age Sex Pressure Stroke Severity (GRASPS) and Totaled Health Risks in Vascular Events (THRIVE) scores were also calculated. Receiver operating characteristic (ROC) analysis was used to determine factors associated with symptomatic and asymptomatic HI. RESULTS: Among the 109 total patients, 25 patients developed symptomatic HI, while 22 patients developed asymptomatic HI. ROC analysis for predicting symptomatic and asymptomatic HI revealed that the area under the curve for pretreatment systolic BP (SBP) was .88 (95% confidence interval[CI]: .83-.94), while those for GRASPS and THRIVE scores were .75 (95% CI: .66-.85) and .69 (95% CI: .59-.79), respectively. We identified an optimal cut-off point of 160 mm Hg (sensitivity: 82.3%; specificity: 76.6%; diagnostic accuracy: 80.0%; positive predictive value: 76.6%; negative predictive value: 82.5%). CONCLUSIONS: Pre-treatment SBP may be a simple predictor of symptomatic and asymptomatic HI in patients with stroke undergoing rt-PA treatment.


Assuntos
Pressão Sanguínea , Fibrinolíticos/efeitos adversos , Hemorragias Intracranianas/induzido quimicamente , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Infusões Intravenosas , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/fisiopatologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/efeitos adversos , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Ativador de Plasminogênio Tecidual/administração & dosagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento
14.
J Clin Neurosci ; 64: 134-140, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30952555

RESUMO

Intravenous tissue-plasminogen activator (IV-TPA) treatment in acute ischemic stroke (AIS) patients due to small vessel occlusion (SVO) has been debated because of its small expected benefit and symptomatic intracranial hemorrhage (SICH) risk. Furthermore, data on subgroups of SVO patients are limited. From a prospective multicenter stroke registry database, AIS patients due to SVO within 24 h from onset were selected. Efficacy outcomes were 3-month modified Rankin Scale (mRS) score 0-1 proportion and mRS score distribution. Additionally, subgroup analyses were conducted by age, sex, initial National Institute Health Stroke Scale (NIHSS) score, and presenting limb paresis. This study included 2482 patients: 193 in the IV-TPA group and 2289 in the control group. After adjusting covariates, IV-TPA treatment was associated with an increased mRS 0-1 outcome (adjusted OR [95% CI], 1.56 [1.06-2.29]; P = 0.0249), but was not significantly associated with a favorable mRS shift (1.33 [0.98-1.81]; P = 0.0709). SICH and 3-month death occurred in three (1.6%) and none in the IV-TPA group versus one (0.04%) and 16 (0.7%) in the control group. In subgroup analyses, the IV-TPA effect appeared significantly greater in patients aged ≥80 versus <80 for mRS score distribution (Pinteraction = 0.012). This study showed that, in SVO patients, IV-TPA within 4.5 h may improve functional outcome with a low SICH risk. The benefit appeared more substantial in patients aged ≥80.


Assuntos
Infarto Cerebral/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
15.
N Engl J Med ; 380(14): 1326-1335, 2019 04 04.
Artigo em Inglês | MEDLINE | ID: mdl-30730782

RESUMO

BACKGROUND: Andexanet alfa is a modified recombinant inactive form of human factor Xa developed for reversal of factor Xa inhibitors. METHODS: We evaluated 352 patients who had acute major bleeding within 18 hours after administration of a factor Xa inhibitor. The patients received a bolus of andexanet, followed by a 2-hour infusion. The coprimary outcomes were the percent change in anti-factor Xa activity after andexanet treatment and the percentage of patients with excellent or good hemostatic efficacy at 12 hours after the end of the infusion, with hemostatic efficacy adjudicated on the basis of prespecified criteria. Efficacy was assessed in the subgroup of patients with confirmed major bleeding and baseline anti-factor Xa activity of at least 75 ng per milliliter (or ≥0.25 IU per milliliter for those receiving enoxaparin). RESULTS: Patients had a mean age of 77 years, and most had substantial cardiovascular disease. Bleeding was predominantly intracranial (in 227 patients [64%]) or gastrointestinal (in 90 patients [26%]). In patients who had received apixaban, the median anti-factor Xa activity decreased from 149.7 ng per milliliter at baseline to 11.1 ng per milliliter after the andexanet bolus (92% reduction; 95% confidence interval [CI], 91 to 93); in patients who had received rivaroxaban, the median value decreased from 211.8 ng per milliliter to 14.2 ng per milliliter (92% reduction; 95% CI, 88 to 94). Excellent or good hemostasis occurred in 204 of 249 patients (82%) who could be evaluated. Within 30 days, death occurred in 49 patients (14%) and a thrombotic event in 34 (10%). Reduction in anti-factor Xa activity was not predictive of hemostatic efficacy overall but was modestly predictive in patients with intracranial hemorrhage. CONCLUSIONS: In patients with acute major bleeding associated with the use of a factor Xa inhibitor, treatment with andexanet markedly reduced anti-factor Xa activity, and 82% of patients had excellent or good hemostatic efficacy at 12 hours, as adjudicated according to prespecified criteria. (Funded by Portola Pharmaceuticals; ANNEXA-4 ClinicalTrials.gov number, NCT02329327.).


Assuntos
Coagulantes/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Fator Xa/uso terapêutico , Hemorragia/tratamento farmacológico , Proteínas Recombinantes/uso terapêutico , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/metabolismo , Inibidores do Fator Xa/uso terapêutico , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia/induzido quimicamente , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/tratamento farmacológico , Masculino , Curva ROC
17.
J Vasc Interv Radiol ; 30(2): 134-140, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30717945

RESUMO

PURPOSE: To determine whether thrombolysis with a lower dose of intravenous recombinant tissue plasminogen activator before mechanical thrombectomy is beneficial for functional outcomes compared with mechanical thrombectomy alone. MATERIALS AND METHODS: Data for 100 Japanese patients who underwent mechanical thrombectomy between July 2014 and November 2017 were retrospectively reviewed. These patients were divided into groups according to whether they received intravenous thrombolysis before mechanical thrombectomy, and outcomes were compared. Favorable outcome was defined as a modified Rankin scale score ≤ 2 at 3 months after treatment. RESULTS: Thirty-four patients for the thrombolysis group and 66 patients for the thrombectomy-only group were identified. The thrombolysis and nonthrombolysis groups did not differ significantly in baseline characteristics (mean age, 74.3 y vs 75.7 y [P = .485]; mean preoperative National Institute Health Stroke Scale score, 19.8 vs 19.6 [P = .825]). There were no significant differences in the times required for, or the rates of, successful recanalization. However, the thrombolysis group had a higher rate of complete recanalization (67.6% vs 43.9%; P = .041). Postoperative symptomatic intracranial hemorrhage was not significantly different between groups. Favorable outcomes were observed in 73.5% of patients in the thrombolysis group and 51.5% in the nonthrombolysis group (P = .028). CONCLUSIONS: This single-center retrospective study shows that lower-dose intravenous thrombolysis improves the outcomes of mechanical thrombectomy for Japanese patients with acute anterior-circulation stroke treated within 4.5 hours of onset.


Assuntos
Procedimentos Endovasculares/instrumentação , Fibrinolíticos/administração & dosagem , Stents , Acidente Vascular Cerebral/terapia , Trombectomia/instrumentação , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Hemorragias Intracranianas/induzido quimicamente , Japão , Masculino , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Sucção , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Dispositivos de Acesso Vascular
18.
J Vasc Interv Radiol ; 30(2): 141-147.e1, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30611627

RESUMO

PURPOSE: To assess the safety of low-dose intra-arterial (IA) tirofiban bolus after unsuccessful mechanical thrombectomy in patients with ischemic stroke due to large artery occlusion in anterior cerebral circulation. MATERIALS AND METHODS: Patients with ischemic stroke who were treated with mechanical thrombectomy were enrolled in a multicenter registry. Low-dose tirofiban was injected into the residual arterial thrombus in patients after unsuccessful mechanical thrombectomy. The major safety measurement was defined as symptomatic intracranial hemorrhage (SICH). The functional outcome at 90 days was assessed with the modified Rankin Scale, and a score of 0-2 was defined as favorable. RESULTS: Of the 632 enrolled patients, 154 (24.4%) received IA tirofiban treatment. The SICH rate was 13.6% (21/154) in patients with tirofiban and 16.7% (80/478) in patients without tirofiban (P = .361). IA tirofiban was not associated with increased risk of SICH (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.36-1.31; P = .26). IA tirofiban treatment did not increase the risk of mortality at 90 days of the index stroke (OR, 0.66; 95% CI, 0.36-1.31; P = .15). Patients with large artery atherosclerosis stroke who were treated with tirofiban were associated with decreased risk of death (OR, 11.3% vs 23.4%; P = .042) compared to patients who were not treated with tirofiban. CONCLUSIONS: Low-dose IA tirofiban administration may be relatively safe in patients with ischemic stroke after unsuccessful recanalization.


Assuntos
Isquemia Encefálica/terapia , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Trombectomia/efeitos adversos , Terapia Trombolítica , Tirofibana/administração & dosagem , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , China , Feminino , Humanos , Injeções Intra-Arteriais , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Tirofibana/efeitos adversos , Resultado do Tratamento
19.
J Stroke Cerebrovasc Dis ; 28(3): 531-541, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30595512

RESUMO

BACKGROUND: Although endovascular treatment (EVT) is very effective for acute ischemia stroke (AIS) patients with proximal large vessels occlusion (LVO), whether bridging rPA before EVT in stroke patients of LVO is of any benefit and is currently one of the most urgent unanswered questions. We aim to comprehensively determine the efficacy and safety of direct EVT (DEVT) in AIS patients with LVO versus bridging therapy (BT). METHODS: Clinical researches published in the Embase, PubMed, and Cochrane Library electronic databases up to May 2017 were identified for analysis. Two reviewers extracted data and conducted quality assessment independently. Statistical tests were performed to check for heterogeneity and publication bias. Subgroup and sensitivity analysis were also conducted to evaluate the robustness of the conclusions. RESULTS: Overall, 13 studies involving 3302 patients met the inclusion criteria. The AIS patients with DEVT had a similar likelihood to achieve good functional outcome at 3 months (risk ratio [RR] = .93, 95% confidence interval [CI] = .85-1.01, P = .094), mortality at 3 months (RR = 1.10, 95% CI = .91-1.33, P = .33), and symptomatic intracranial hemorrhage (RR = 1.06, 95% CI = .74-1.51, P = .75) versus BT; furthermore, the risk of intracranial hemorrhage was lower in DEVT group (RR = .76, 95% CI = .60-.95, P = .02). No significant difference in recanalization rate existed between the 2 groups (RR = .97, 95% CI = .92-1.02, P = .22); however, in the subgroup analysis, it had a rise trend after DEVT than BT in IVT-eligible group (RR = 1.45, 95% CI = .95-2.22, P = .09). CONCLUSIONS: DEVT appears to have equally effectiveness to BT with a low risk of intracranial hemorrhage in AIS patients with LVO, especially for anterior circulation, which offered a practical information to select appropriate therapeutic strategies for patients with LVO, though the level of evidence seems to be quite shaky.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares , Fibrinolíticos/administração & dosagem , Ativadores de Plasminogênio/administração & dosagem , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Tomada de Decisão Clínica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Ativadores de Plasminogênio/efeitos adversos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do Tratamento
20.
Am J Med ; 132(5): 596-604.e11, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30639551

RESUMO

BACKGROUND: Nonvitamin K antagonist oral anticoagulants (NOACs) are alternatives to warfarin in patients with nonvalvular atrial fibrillation. Randomized trials compared NOACs with warfarin, but none have compared individual NOACs against each other for safety and effectiveness. METHODS: We performed a retrospective new-user cohort study of patients with nonvalvular atrial fibrillation enrolled in US Medicare who initiated warfarin (n = 183,318), or a standard dose of dabigatran (150 mg twice daily; n = 86,198), rivaroxaban (20 mg once daily; n = 106,389), or apixaban (5 mg twice daily; n = 73,039) between October 2010 and September 2015. Propensity score-adjusted Cox proportional hazards regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the outcomes of thromboembolic stroke, intracranial hemorrhage, major extracranial bleeding, and all-cause mortality, comparing each NOAC with warfarin, and with each other NOAC. RESULTS: Compared with warfarin, each NOAC was associated with reduced risks of thromboembolic stroke (20%-29% reduction; P = .002 [dabigatran], P < 0.001 [rivaroxaban, apixaban]), intracranial hemorrhage (35%-62% reduction; P < 0.001 [each NOAC]), and mortality (19%-34% reduction; P < .001 [each NOAC]). The NOACs were similar for thromboembolic stroke but rivaroxaban was associated with increased risks of intracranial hemorrhage (vs dabigatran: HR = 1.71; 95% CI, 1.35-2.17), major extracranial bleeding (vs dabigatran: HR = 1.32; 95% CI, 1.21-1.45; vs apixaban: HR = 2.70; 95% CI, 2.38-3.05), and death (vs dabigatran: HR = 1.12; 95% CI, 1.01-1.24; vs apixaban: HR = 1.23; 95% CI, 1.09-1.38). Dabigatran was associated with reduced risk of intracranial hemorrhage (HR = 0.70; 95% CI ,0.53-0.94) and increased risk of major extracranial bleeding (HR = 2.04; 95% CI, 1.78-2.32) compared with apixaban. CONCLUSIONS: Among patients treated with standard-dose NOAC for nonvalvular atrial fibrillation and warfarin users with similar baseline characteristics, dabigatran, rivaroxaban, and apixaban were associated with a more favorable benefit-harm profile than warfarin. Among NOAC users, dabigatran and apixaban were associated with a more favorable benefit-harm profile than rivaroxaban.


Assuntos
Anticoagulantes , Fibrilação Atrial , Embolia Intracraniana , Hemorragias Intracranianas , Acidente Vascular Cerebral , Administração Oral , Idoso , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/classificação , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Feminino , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/epidemiologia , Embolia Intracraniana/etiologia , Embolia Intracraniana/prevenção & controle , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/prevenção & controle , Masculino , Medicare/estatística & dados numéricos , Farmacovigilância , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Estados Unidos/epidemiologia
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