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1.
Stroke ; 51(7): 2224-2227, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32516064

RESUMO

BACKGROUND AND PURPOSE: This study aims to assess the number of patients with acute ischemic cerebrovascular events seeking in-patient medical emergency care since the implementation of social distancing measures in the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In this retrospective multicenter study, data on the number of hospital admissions due to acute ischemic stroke or transient ischemic attack and numbers of reperfusion therapies performed in weeks 1 to 15 of 2020 and 2019 were collected in 4 German academic stroke centers. Poisson regression was used to test for a change in admission rates before and after the implementation of extensive social distancing measures in week 12 of 2020. The analysis of anonymized regional mobility data allowed for correlations between changes in public mobility as measured by the number and length of trips taken and hospital admission for stroke/transient ischemic attack. RESULTS: Only little variation of admission rates was observed before and after week 11 in 2019 and between the weeks 1 and 11 of 2019 and 2020. However, reflecting the impact of the COVID-19 pandemic, a significant decrease in the number of admissions for transient ischemic attack was observed (-85%, -46%, -42%) in 3 of 4 centers, while in 2 of 4 centers, stroke admission rates decreased significantly by 40% and 46% after week 12 in 2020. A relevant effect on reperfusion therapies was found for 1 center only (thrombolysis, -60%; thrombectomy, -61%). Positive correlations between number of ischemic events and mobility measures in the corresponding cities were identified for 3 of 4 centers. CONCLUSIONS: These data demonstrate and quantify decreasing hospital admissions due to ischemic cerebrovascular events and suggest that this may be a consequence of social distancing measures, in particular because hospital resources for acute stroke care were not limited during this period. Hence, raising public awareness is necessary to avoid serious healthcare and economic consequences of undiagnosed and untreated strokes and transient ischemic attacks.


Assuntos
Betacoronavirus , Isquemia Encefálica/epidemiologia , Infecções por Coronavirus/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Doença Aguda , Idoso , Isquemia Encefálica/terapia , Área Programática de Saúde , Feminino , Alemanha/epidemiologia , Hospitais Especializados/estatística & dados numéricos , Humanos , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Utilização de Procedimentos e Técnicas , Reperfusão/estatística & dados numéricos , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia
2.
N Engl J Med ; 382(21): 1981-1993, 2020 05 21.
Artigo em Inglês | MEDLINE | ID: mdl-32374959

RESUMO

BACKGROUND: In acute ischemic stroke, there is uncertainty regarding the benefit and risk of administering intravenous alteplase before endovascular thrombectomy. METHODS: We conducted a trial at 41 academic tertiary care centers in China to evaluate endovascular thrombectomy with or without intravenous alteplase in patients with acute ischemic stroke. Patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation were randomly assigned in a 1:1 ratio to undergo endovascular thrombectomy alone (thrombectomy-alone group) or endovascular thrombectomy preceded by intravenous alteplase, at a dose of 0.9 mg per kilogram of body weight, administered within 4.5 hours after symptom onset (combination-therapy group). The primary analysis for noninferiority assessed the between-group difference in the distribution of the modified Rankin scale scores (range, 0 [no symptoms] to 6 [death]) at 90 days on the basis of a lower boundary of the 95% confidence interval of the adjusted common odds ratio equal to or larger than 0.8. We assessed various secondary outcomes, including death and reperfusion of the ischemic area. RESULTS: Of 1586 patients screened, 656 were enrolled, with 327 patients assigned to the thrombectomy-alone group and 329 assigned to the combination-therapy group. Endovascular thrombectomy alone was noninferior to combined intravenous alteplase and endovascular thrombectomy with regard to the primary outcome (adjusted common odds ratio, 1.07; 95% confidence interval, 0.81 to 1.40; P = 0.04 for noninferiority) but was associated with lower percentages of patients with successful reperfusion before thrombectomy (2.4% vs. 7.0%) and overall successful reperfusion (79.4% vs. 84.5%). Mortality at 90 days was 17.7% in the thrombectomy-alone group and 18.8% in the combination-therapy group. CONCLUSIONS: In Chinese patients with acute ischemic stroke from large-vessel occlusion, endovascular thrombectomy alone was noninferior with regard to functional outcome, within a 20% margin of confidence, to endovascular thrombectomy preceded by intravenous alteplase administered within 4.5 hours after symptom onset. (Funded by the Stroke Prevention Project of the National Health Commission of the People's Republic of China and the Wu Jieping Medical Foundation; DIRECT-MT ClinicalTrials.gov number, NCT03469206.).


Assuntos
Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Hemorragia Cerebral/etiologia , China , Terapia Combinada , Intervalos de Confiança , Procedimentos Endovasculares , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Reperfusão/métodos , Trombectomia/efeitos adversos , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
3.
J Neurointerv Surg ; 12(7): 664-668, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32451358

RESUMO

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic is still spreading across the world. Although the pandemic has an all-round impact on medical work, the degree of its impact on endovascular thrombectomy (EVT) for patients with acute ischemic stroke (AIS) is unclear. METHODS: We continuously included AIS patients with large artery occlusion who underwent EVT in a comprehensive stroke center before and during the Wuhan shutdown. The protected code stroke (PCS) for screening and treating AIS patients was established during the pandemic. The efficacy and safety outcomes including the rate of successful reperfusion (defined as modified Thrombolysis In Cerebral Infarction (mTICI) graded 2b or 3) and time intervals for reperfusion were compared between two groups: pre-pandemic and pandemic. RESULTS: A total of 55 AIS patients who received EVT were included. The baseline characteristics were comparable between the two groups. The time from hospital arrival to puncture (174 vs 125.5 min; p=0.002) and time from hospital arrival to reperfusion (213 vs 172 min; p=0.047) were significantly prolonged in the pandemic group compared with the pre-pandemic group. The rate of successful reperfusion was not significantly different between the two groups (85.7% (n=18) vs 88.2% (n=30); OR 0.971, 95% CI 0.785 to 1.203; p=1.000). CONCLUSION: The results of this study suggest a proper PCS algorithm which combines the COVID-19 screening and protection measures could decrease the impact of the disease on the clinical outcomes of EVT for AIS patients to the lowest extent possible during the pandemic.


Assuntos
Betacoronavirus , Isquemia Encefálica/epidemiologia , Infecções por Coronavirus/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Trombectomia/tendências , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/cirurgia , Infecções por Coronavirus/cirurgia , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/cirurgia , Reperfusão , Estudos Retrospectivos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Resultado do Tratamento
5.
Arq Neuropsiquiatr ; 78(1): 39-43, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-32074189

RESUMO

OBJECTIVE: Stroke is an important cause of morbidity and mortality worldwide. Reperfusion therapy with intravenous tissue plasminogen activator (IV-tPA) was first implemented in 1996. More recently, endovascular reperfusion with mechanical thrombectomy (MT) demonstrated a robust beneficial effect, extending the 4.5 h time window. In our country, there are difficulties to achieve the implementation of both procedures. Our purpose is to report the early experience of a Comprehensive Stroke Center in the use of MT for acute stroke. METHODS: Analysis of consecutive patients from January 2015 to September 2018, who received reperfusion treatment with MT. Demographic data, treatment times, previous use of IV-tPA, site of obstruction, recanalization, outcomes and disability after stroke were assessed. RESULTS: We admitted 891 patients with acute ischemic stroke during this period. Ninety-seven received IV-tPA (11%) and 27 were treated with MT (3%). In the MT group, mean age was 66.0±14.5 years. Median NIHSS before MT was 20 (range:14‒24). The most prevalent etiology was cardioembolic stroke (52%). Prior to MT, 16 of 27 patients (59%) received IV-tPA. Previous tPA treatment did not affect onset to recanalization time or door-to-puncture time. For MT, door-to-puncture time was 104±50 minutes and onset to recanalization was 289±153 minutes. Successful recanalization (mTICI grade 2b/3) was achieved in 21 patients (78%). At three-month follow-up, the median NIHSS was 5 (range:4‒15) and mRS was 0‒2 in 37%, and ≥3 in 63%. CONCLUSIONS: With adequate logistics and strict selection criteria, MT can be implemented in our population with results like those reported in large clinical trials.


Assuntos
Isquemia Encefálica/terapia , Trombólise Mecânica/métodos , Reperfusão/métodos , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Argentina , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do Tratamento
6.
Stroke ; 51(3): 922-930, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32078483

RESUMO

Background and Purpose- Mobile stroke units (MSUs) are increasingly used worldwide to provide prehospital triage and treatment. The benefits of MSUs in giving earlier thrombolysis have been well established, but the impacts of MSUs on endovascular thrombectomy (EVT) and effect on disability avoidance are largely unknown. We aimed to determine the clinical impact and disability reduction for reperfusion therapies in the first operational year of the Melbourne MSU. Methods- Treatment time metrics for MSU patients receiving reperfusion therapy were compared with control patients presenting to metropolitan Melbourne stroke units via standard ambulance within MSU operating hours. The primary outcome was median time difference in first ambulance dispatch to treatment modeled using quantile regression analysis. Time savings were subsequently converted to disability-adjusted life years avoided using published estimates. Results- In the first 365-day operation of the Melbourne MSU, prehospital thrombolysis was administered to 100 patients (mean age, 73.8 years; 62% men). The median time savings per MSU patient, compared with the control cohort, was 26 minutes (P<0.001) for dispatch to hospital arrival and 15 minutes (P<0.001) for hospital arrival to thrombolysis. The calculated overall time saving from dispatch to thrombolysis was 42.5 minutes (95% CI, 36.0-49.0). In the same period, 41 MSU patients received EVT (mean age, 76 years; 61% men) with median dispatch-to-treatment time saving of 51 minutes ([95% CI, 30.1-71.9], P<0.001). This included a median time saving of 17 minutes ([95% CI, 7.6-26.4], P=0.001) for EVT hospital arrival to arterial puncture for MSU patients. Estimated median disability-adjusted life years saved through earlier provision of reperfusion therapies were 20.9 for thrombolysis and 24.6 for EVT. Conclusions- The Melbourne MSU substantially reduced time to reperfusion therapies, with the greatest estimated disability avoidance driven by the more powerful impact of earlier EVT. These findings highlight the benefits of prehospital notification and direct triage to EVT centers with facilitated workflow on arrival by the MSU.


Assuntos
Ambulâncias , Serviços Médicos de Emergência , Unidades Móveis de Saúde , Reperfusão , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Vitória
7.
PLoS One ; 15(1): e0227599, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31923917

RESUMO

Vascularized lymph node transfer (VLNT) is a promising treatment modality for lymphedema; however, how lymphatic tissue responds to ischemia has not been well defined. This study investigates the cellular changes that occur in lymph nodes in response to ischemia and reperfusion. Lymph node containing superficial epigastric artery-based groin flaps were isolated in Prox-1 EGFP rats which permits real time identification of lymphatic tissue by green fluorescence during flap dissection. Flaps were subjected to ischemia for either 1, 2, 4, or 8 hours, by temporarily occluding the vascular pedicle. Flaps were harvested after 0 hours, 24 hours, or 5 days of reperfusion. Using EGFP signal guidance, lymph nodes were isolated from the flaps and tissue morphology, cell apoptosis, and inflammatory cytokines were quantified and analyzed via histology, immunostaining, and rtPCR. There was a significant increase in collagen deposition and tissue fibrosis in lymph nodes after 4 and 8 hours of ischemia compared to 1 and 2 hours, as assessed by picrosirius red staining. Cell apoptosis significantly increased after 4 hours of ischemia in all harvest times. In tissue subject to 4 hours of ischemia, longer reperfusion periods were associated with increased rates of CD3+ and CD45+ cell apoptosis. rtPCR analysis demonstrated significantly increased expression of CXCL1/GRO-α with 2 hours of ischemia and increased PECAM-1 and TNF-α expression with 1 hour of ischemia. Significant cell death and changes in tissue morphology do not occur until after 4 hours of ischemia; however, analysis of inflammatory biomarkers suggests that ischemia reperfusion injury can occur with as little as 2 hours of ischemia.


Assuntos
Linfonodos/irrigação sanguínea , Traumatismo por Reperfusão/fisiopatologia , Retalhos Cirúrgicos/irrigação sanguínea , Animais , Dissecação , Artérias Epigástricas/fisiopatologia , Artérias Epigástricas/cirurgia , Feminino , Artéria Femoral/fisiopatologia , Isquemia/fisiopatologia , Linfonodos/fisiopatologia , Linfedema/cirurgia , Masculino , Ratos , Ratos Sprague-Dawley , Reperfusão
9.
Neurology ; 94(8): e842-e850, 2020 02 25.
Artigo em Inglês | MEDLINE | ID: mdl-31959707

RESUMO

Mechanical thrombectomy (MT) is one of the main treatments for acute ischemic stroke (AIS) in patients on effective anticoagulation. The use of direct oral anticoagulants (DOA) has increased, given their efficacy and safety profile compared to vitamin K antagonists (VKA). We compared procedural and clinical outcomes of MT in patients on DOA and VKA treatment before stroke onset. We analyzed 2 groups from the Endovascular Treatment in Ischemic Stroke prospective registry: patients on DOA and patients on VKA treated by MT without thrombolysis. Generalized linear mixed models including center as random effect were used to compare angiographic (rates of reperfusion at end of procedure, number of passes >2, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to anticoagulation subgroups. Comparisons were adjusted for prespecified confounders (age, admission NIH Stroke Scale score) as well as for meaningful baseline between-group differences. Among 221 patients included, more DOA-treated patients (n = 115, 52%) achieved successful (modified Thrombolysis in Cerebral Infarction score [mTICI] 2b/3) or near complete (mTICI 2c/3) reperfusion at the procedure end than did VKA-treated patients, with an adjusted odds ratio (OR) for DOA vs VKA of 3.27 (95% confidence interval [CI], 1.40-7.65) and 2.00 (95% CI, 1.08-3.73), respectively. DOA-treated patients had a lower 90-day mortality risk with an adjusted OR of 0.47 (95% CI, 0.24-0.89) and a better excellent outcome OR of 2.40 (1.10-5.27). There was no significant between-group difference in hemorrhagic or procedural complications. The study highlights the benefits of DOA compared to VKA. Regarding mortality, excellent outcomes, and recanalization rate, DOA appears to provide a favorable setting for MT treatment in AIS.


Assuntos
Anticoagulantes/uso terapêutico , Hemorragia/epidemiologia , Acidente Vascular Cerebral/tratamento farmacológico , Trombectomia/estatística & dados numéricos , Vitamina K/antagonistas & inibidores , Idoso , Anticoagulantes/efeitos adversos , Dabigatrana/efeitos adversos , Dabigatrana/uso terapêutico , Feminino , Humanos , Masculino , Pirazóis/efeitos adversos , Pirazóis/uso terapêutico , Piridonas/efeitos adversos , Piridonas/uso terapêutico , Sistema de Registros , Reperfusão/estatística & dados numéricos , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/cirurgia , Resultado do Tratamento
11.
Stroke ; 51(3): 899-907, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31964289

RESUMO

Background and Purpose- The benefit that endovascular thrombectomy offers to patients with stroke with large vessel occlusions depends strongly on reperfusion grade as defined by the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Our aim was to determine the lifetime health and cost consequences of the quality of reperfusion for patients, healthcare systems, and society. Methods- A Markov model estimated lifetime quality-adjusted life years (QALY) and lifetime costs of endovascular thrombectomy-treated patients with stroke based on eTICI grades. The analysis was performed over a lifetime horizon in a United States setting, adopting healthcare and societal perspectives. The reference case analysis was conducted for stroke at 65 years of age. National health and cost consequences of improved eTICI 2c/3 reperfusion rates were estimated. Input parameters were based on best available evidence. Results- Lifetime QALYs increased for every grade of improved reperfusion (median QALYs for eTICI 0/1: 2.62; eTICI 2a: 3.46; eTICI 2b: 5.42; eTICI 2c: 5.99; eTICI 3: 6.73). Achieving eTICI 3 over eTICI 2b reperfusion resulted on average in 1.31 incremental QALYs as well as healthcare and societal cost savings of $10 327 and $20 224 per patient. A 10% increase in the eTICI 2c/3 reperfusion rate of all annually endovascular thrombectomy-treated patients with stroke in the United States is estimated to yield additional 3656 QALYs and save $21.0 million and $36.8 million for the healthcare system and society, respectively. Conclusions- Improved reperfusion grants patients with stroke additional QALYs and leads to long-term cost savings. Procedural strategies to achieve complete reperfusion should be assessed for safety and feasibility, even when initial reperfusion seems to be adequate.


Assuntos
Modelos Econômicos , Saúde Pública/economia , Qualidade de Vida , Acidente Vascular Cerebral/economia , Trombectomia/economia , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão , Acidente Vascular Cerebral/cirurgia , Estados Unidos
12.
Nat Biotechnol ; 38(2): 189-198, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31932726

RESUMO

The ability to preserve metabolically active livers ex vivo for 1 week or more could allow repair of poor-quality livers that would otherwise be declined for transplantation. Current approaches for normothermic perfusion can preserve human livers for only 24 h. Here we report a liver perfusion machine that integrates multiple core physiological functions, including automated management of glucose levels and oxygenation, waste-product removal and hematocrit control. We developed the machine in a stepwise fashion using pig livers. Study of multiple ex vivo parameters and early phase reperfusion in vivo demonstrated the viability of pig livers perfused for 1 week without the need for additional blood products or perfusate exchange. We tested the approach on ten injured human livers that had been declined for transplantation by all European centers. After a 7-d perfusion, six of the human livers showed preserved function as indicated by bile production, synthesis of coagulation factors, maintained cellular energy (ATP) and intact liver structure.


Assuntos
Fígado/lesões , Perfusão/instrumentação , Preservação Biológica , Trifosfato de Adenosina/metabolismo , Alarminas/metabolismo , Animais , Biomarcadores/metabolismo , Eletrólitos/metabolismo , Glucose/metabolismo , Hemodinâmica , Hemólise , Humanos , Fígado/fisiopatologia , Oxigênio/metabolismo , Consumo de Oxigênio , Veia Porta/metabolismo , Reperfusão , Suínos
13.
J Stroke Cerebrovasc Dis ; 29(2): 104499, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31757598

RESUMO

BACKGROUND: Benefits of reperfusion therapies in acute ischemic stroke are highly time-dependent. It is crucial that people who witness the onset of symptoms call emergency medical services (EMS) immediately. The aim of this study was to examine whether there is a gap between recognition of stroke and responding correctly by calling EMS using a scenario-based measure. METHODS: Population-based survey of 1406 individuals from Newcastle upon Tyne, UK, examining stroke recognition and response knowledge using 12 scenario-based vignettes. The response rate was 32% out of 5000 contacted individuals. In total, 16,574 responses to scenarios were examined to investigate whether respondents would recognise stroke symptoms and indicate to call EMS immediately. RESULTS: In 16% of cases people recognised stroke but did not correctly respond by indicating to call EMS. In 49% of responses people recognised stroke and would respond correctly, while in 31% of cases people both failed to correctly recognise and failed to identify the correct response to the stroke scenario. In 5% of cases stroke was not identified but a correct response was indicated. When stroke was recognised, in 25% of responses people indicated that they would not call EMS. Recognition self-efficacy and response self-efficacy were associated with correct response. CONCLUSIONS: A recognition-response gap was identified among UK adults in hypothetical scenarios concerning stroke. Both recognition and translation to adequate EMS response should be explicitly addressed in interventions aiming to improve witness response to stroke. Self-efficacy may be a promising target to close the recognition-response gap.


Assuntos
Isquemia Encefálica/terapia , Serviços Médicos de Emergência , Conhecimentos, Atitudes e Prática em Saúde , Reconhecimento Psicológico , Reperfusão , Acidente Vascular Cerebral/terapia , Tempo para o Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Inglaterra , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Autoeficácia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Inquéritos e Questionários , Telefone , Fatores de Tempo , Adulto Jovem
14.
J Neurointerv Surg ; 12(1): 13-18, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31239333

RESUMO

BACKGROUND: Endovascular therapy (EVT) is currently the most effective treatment for emergent large vessel occlusion (ELVO) stroke. Earlier treatment is associated with a better clinical outcome. Our aim was to examine the association between onset-to-EVT (OTE) time and clinical outcomes using real-world nationwide data from the National Acute Stroke ISraeli (NASIS)-REVASC registry. METHODS: Stroke patients undergoing EVT within the Endovascular Capable Centres (ECCs) in Israel between January 2014 and March 2016 were prospectively included. Several clinical and radiological outcomes were evaluated. The association between OTE time and outcomes was analyzed with logistic regression models using time as a continuous variable and then by OTE groups of <2, 2-4, 4-6, and >6 hours. RESULTS: 299 patients with acute stroke were included in the analysis. OTE time was significantly associated with favorable outcomes. ORs for each hour of delay in EVT were 0.84 (95% CI 0.71 to 0.99) for significant early recovery, 0.80 (95% CI 0.68 to 0.94) for discharge to home, 0.80 (95% CI 0.66 to 0.95) for freedom from disability at discharge, and 0.78 (95% CI 0.67 to 0.91) for excellent reperfusion (Thrombolysis in Cerebral Ischemia 3). The <2 OTE group was significantly associated with better outcomes than the ≥2 OTE group including significant early recovery (OR 3.3, 95% CI 1.2 to 9.1), discharge to home (OR 3.32, 95% CI 1.3 to 8.5), and excellent reperfusion (OR 4.6, 95% CI 1.3 to 29.5). The same trend was observed for freedom from disability at discharge and 3 months (OR 2.08, 95% CI 0.7 to 5.7 and OR 2.57, 95% CI 0.8 to 8.3, respectively). Only 1% of transferred patients achieved an OTE time of <2 hours. CONCLUSIONS: Nationwide real-life registry data indicate that benefit from EVT is strongly associated with OTE time and is most prominent within the 'two golden hours' from stroke onset. This time goal may not be applicable in inter-hospital transfer patients.


Assuntos
Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/métodos , Sistema de Registros , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Procedimentos Endovasculares/tendências , Feminino , Humanos , Israel/epidemiologia , Pessoa de Meia-Idade , Transferência de Pacientes/métodos , Transferência de Pacientes/tendências , Reperfusão/métodos , Reperfusão/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Tempo para o Tratamento/tendências , Resultado do Tratamento
15.
Ann R Coll Surg Engl ; 102(1): 14-17, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31155915

RESUMO

INTRODUCTION: Infra-inguinal vascular reconstruction with active groin infection is a concerning issue. Using resistant grafts to infection is the most adopted approach. However, in absence of these materials in acute situations, the trans-obturator approach allows for limb revascularisation avoiding the infected site. We evaluated the effectiveness of this approach in patients who needed lower limb revascularisation with an ipsilateral groin infection. MATERIALS AND METHODS: A retrospective study was conducted over a four-year period. RESULTS: Over this period, 13 patients underwent trans-obturator reconstructions (13 external iliac-popliteal above-knee and one aortobipopliteal above-knee bypass). Seven patients had been previously revascularised and were admitted for graft infection (six infra-inguinal bypasses, one axillo-bifemoral bypass). Four presented with acute limb ischaemia, three with groin haematoma and one with a groin abscess. The remaining cases consisted of drug-addicted patients with injury of femoral vessels due to self-injection of drugs. The patients underwent reconstructions with autologous grafts which complicated early with groin haematoma. After transobturator revascularisation, the groin underwent debridement with applying vacuum-assisted wound closure device. CONCLUSION: The transobturator approach could be considered as a chance for lower limb revascularisation in case of ipsilateral groin infection. Moreover, avoiding the infected site allowed us to focus separately and safely on the treatment of the inguinal wound.


Assuntos
Abscesso Abdominal/complicações , Infecções Bacterianas/complicações , Perna (Membro)/irrigação sanguínea , Reperfusão/métodos , Idoso , Amputação/estatística & dados numéricos , Anastomose Cirúrgica/métodos , Prótese Vascular , Feminino , Virilha , Humanos , Isquemia/cirurgia , Masculino , Cuidados Pós-Operatórios , Estudos Retrospectivos , Terapia de Salvação/estatística & dados numéricos
16.
Radiol Med ; 125(1): 57-65, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31473929

RESUMO

INTRODUCTION: A direct aspiration first pass technique (ADAPT) is an alternative technique as first-line thrombectomy for large vessel occlusion in acute ischemic stroke, still debated when compared to first-line stent retriever. To retrospectively evaluate technical and clinical outcomes of the ADAPT as first-line treatment for anterior circulation acute ischemic stroke with large-bore reperfusion catheters. METHODS: A multicentric data collection from 14 medical centers was retrospectively analyzed. Large-bore catheters had a distal diameter between 0.64 and 0.71 in; stent retriever was added when aspiration alone failed. Baseline characteristics, technical and clinical variables were collected, including NIHSS, thrombolysis in cerebral infarction (TICI), peri-procedural complications, 90-day mRS and 90-day mortality. RESULTS: Overall, 501 patients were treated. No statistically significant difference in terms of baseline features or tPA administration was recorded between patients treated with ADAPT and with additional stent retriever. ADAPT alone was successful in achieving TICI ≥ 2b in 71.8% with a median of 1.55 aspiration attempts. In terms of TICI ≥ 2b, ADAPT alone was better than additional stent retriever (p < 0.001), while no statistical difference was achieved from catheter diameter. Embolization to a new territory was less frequent in ADAPT group (5.2 vs 18%; p = 0.0026). Patients treated with ADAPT alone had better clinical outcomes in terms of mRS ≤ 2 (p < 0.001). CONCLUSIONS: ADAPT is a valid technique with respect to the rates of TICI 2b/3 recanalization and 90-day mRS scores. In this series, an attempt at recanalization with ADAPT with larger-bore reperfusion catheter may be warranted prior to stentriever thrombectomy.


Assuntos
Isquemia Encefálica/cirurgia , Cateteres , Reperfusão/instrumentação , Acidente Vascular Cerebral/cirurgia , Trombectomia/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Digital , Isquemia Encefálica/diagnóstico por imagem , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Reperfusão/métodos , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Trombectomia/métodos , Trombectomia/estatística & dados numéricos , Terapia Trombolítica/métodos , Resultado do Tratamento , Adulto Jovem
18.
World Neurosurg ; 135: e650-e656, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31881341

RESUMO

OBJECTIVE: We sought to assess preliminary technical and clinical outcomes of Catalyst 5 (CAT 5) as front-line aspiration treatment for M2-M3 occlusion in acute ischemic stroke. METHODS: Patients with symptomatic stroke and distal M2 or M3 occlusions were enrolled retrospectively. A direct aspiration first-pass technique was used as the first treatment option for absolute contraindication to intravenous fibrinolytic therapy. Time to recanalization, first attempt recanalization, and number of attempts were recorded. Successful recanalization was defined as a modified thrombolysis in cerebral infarction score ≥2b; incidence of procedure-related complications was recorded. National Institutes of Health Stroke Scale at discharge and modified Rankin Scale score at 90 days were evaluated by a dedicated neurologist. RESULTS: A total of 11 acute occlusions of distal M2-M3 segment were treated with a direct aspiration first-pass technique using CAT 5 (mean age 69.3 years). Tandem occlusion was present in 2 cases. Intracranial preocclusive mean vessel diameter was 1.9 mm. Overall modified thrombolysis in cerebral infarction score ≥2b was obtained in 72.7% of patients with mean time to recanalization of 36.4 minutes and a mean of 1.9 attempts. First-attempt recanalization with CAT 5 was obtained in 54% of patients with a mean time to recanalization of 29.2 minutes. A stent retriever with proximal aspiration was incorporated as a rescue device in 2 cases. Embolization of new territories was reported after CAT 5 aspiration in 1 patient. No intracranial hemorrhage was detected on follow-up computed tomography. The median National Institutes of Health Stroke Scale score at discharge was 3. At 90 days, a modified Rankin Scale score of 0-2 was achieved in 90.9% of patients. CONCLUSIONS: Preliminary experience using CAT 5 in distal occlusions demonstrates that it may be safe and effective in acute stroke treatment.


Assuntos
Isquemia Encefálica/cirurgia , Cateterismo/instrumentação , Reperfusão/instrumentação , Acidente Vascular Cerebral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão/métodos , Estudos Retrospectivos , Trombectomia/instrumentação , Trombectomia/métodos , Resultado do Tratamento
19.
Ann Transplant ; 24: 631-638, 2019 Dec 13.
Artigo em Inglês | MEDLINE | ID: mdl-31831725

RESUMO

BACKGROUND Post-reperfusion syndrome (PRS) during liver transplantation can range from a benign event to a profound hemodynamic excursion from baseline with significant morbidity. Multiple variables can be responsible for the diverse presentations. Over time, our group noticed that a blood flush of the liver graft via a caval vent (in addition to a standard chilled flush via the portal vein) appeared to result in a milder reperfusion effect. Attenuation of PRS via caval vent seemed to minimize hemodynamic instability and reduce metabolic derangements associated with reperfusion. MATERIAL AND METHODS This was a prospective observational pilot study of standard practice with the addition of lab values and hemodynamic evaluations. We methodically observed normal clinical flow in 20 adult orthotopic liver transplant recipients. We analyzed blood and fluid samples at set time intervals during the peri-reperfusion phase. RESULTS Sixteen out of 20 patients received a blood flush via caval venting. Mean arterial pressure (MAP) and heart rate were better preserved in the patient population that received a caval blood flush vent. Elevations in central venous pressure (CVP) were similar between the 2 groups. Lab values (blood gas, electrolyte, and hemoglobin) of the patients' blood were similar, with no notable differences. Analysis of the initial blood flushed through the liver graft proved to be hypothermic, acidotic, and hyperkalemic. CONCLUSIONS Pre-reperfusion caval venting in liver transplantation (in addition to a portal vent and a chilled LR/albumin portal flush solution) appears to have favorable hemodynamic effects. The literature on this technique is sparse and larger studies are needed.


Assuntos
Transplante de Fígado/efeitos adversos , Transplante de Fígado/métodos , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/prevenção & controle , Idoso , Pressão Sanguínea , Pressão Venosa Central , Feminino , Frequência Cardíaca , Hemodinâmica , Humanos , Fígado/irrigação sanguínea , Circulação Hepática , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Veia Porta , Estudos Prospectivos , Reperfusão/efeitos adversos , Reperfusão/métodos , Traumatismo por Reperfusão/fisiopatologia , Síndrome , Veias Cavas
20.
Rev. Esc. Enferm. USP ; 53: e03487, Jan.-Dez. 2019. tab, graf
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1020392

RESUMO

RESUMO Objetivo Avaliar o efeito da Justicia acuminatissima , Sara Tudo do Amazonas, na função renal, na hemodinâmica renal, no perfil oxidativo e na histologia renal em ratos com injúria renal aguda isquêmica. Método Ensaio pré-clínico com ratos Wistar, adultos, machos (250-350 g), distribuídos nos grupos Sham, Isquemia e Isquemia + Sara Tudo. Foram avaliados os parâmetros hemodinâmicos, a função renal, o estresse oxidativo e a histologia renal. Resultados O pré-tratamento com o Sara Tudo atenuou a lesão funcional, o que foi evidenciado pelo aumento no clearance de creatinina, redução dos marcadores oxidativos e elevação de tióis, pela melhora significativa do fluxo sanguíneo renal, diminuição da resistência vascular renal e redução da lesão tubulointersticial no tecido renal. Conclusão A renoproteção da Justicia acuminatissima , Sara Tudo, na injúria renal aguda isquêmica, caracterizou-se por melhora significativa da função renal, reduzindo a lesão oxidativa, com impacto positivo na histologia renal.


RESUMEN Objetivo Evaluar el efecto de la planta Justicia acuminatissima , "Sana Todo del Amazonas", en la función renal, la hemodinámica renal, el perfil oxidativo y la histología renal en ratones con injuria renal aguda isquémica. Método Ensayo pre clínico con ratones Wistar, adultos, machos (250-350 g), distribuidos en los grupos Sham, Isquemia e Isquemia + Sana Todo. Fueron evaluados los parámetros hemodinámicos, la función renal, el estrés oxidativo y la histología renal. Resultados El pre tratamiento con el Sana Todo atenuó la lesión funcional, lo que fue evidenciado por el aumento en el aclaramiento de creatinina, reducción de los marcadores oxidativos y elevación de tioles, por la mejora significativa del flujo sanguíneo renal, disminución de la resistencia vascular renal y reducción de la lesión tubulointersticial en el tejido renal. Conclusión La renoprotección de la Justicia acuminatissima , "Sana Todo del Amazonas", en la injuria renal aguda isquémica se caracterizó por mejora significativa de la función renal, reduciendo la lesión oxidativa, con impacto positivo en la histología renal.


ABSTRACT Objective To evaluate the effects of Justicia acuminatissima , or Amazonian Sara Tudo , on renal hemodynamics, oxidative profile, and renal histology in rats with ischemic acute kidney injury. Method Preclinical assay with adult male Wistar rats, weighing from 250 g to 350 g, distributed into Sham, ischemia, and ischemia + Sara Tudo groups. Hemodynamic parameters, renal function, oxidative stress, and renal histology were evaluated. Results Pretreatment with Sara Tudo reduced the functional injury, which was shown by the increase in creatinine clearance and thiols; reduction of oxidative markers, renal vascular resistance, and tubulointerstitial injury in the renal tissue; and the significant improvement in renal blood flow. Conclusion The renoprotection provided by Justicia acuminatissima , or Sara Tudo , in cases of ischemic acute kidney injury was characterized by a marked improvement in renal function, reducing the oxidative injury, and impacting on renal histology positively.


Assuntos
Ratos , Reperfusão , Medicamentos Fitoterápicos , Lesão Renal Aguda , Terapias Complementares , Ratos Wistar , Experimentação Animal
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