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2.
Lancet Haematol ; 7(1): e40-e49, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31786086

RESUMO

BACKGROUND: Early thrombus removal might prevent post-thrombotic syndrome by preserving venous function and restoring flow. Previous trials comparing additional catheter-directed thrombolysis to standard treatment showed conflicting outcomes. We aimed to assess the benefit of additional ultrasound-accelerated catheter-directed thrombolysis for the prevention of post-thrombotic syndrome compared with standard therapy in patients with iliofemoral deep-vein thrombosis. METHODS: We did a multicentre, randomised, single-blind, allocation-concealed, parallel group, superiority trial in 15 hospitals in the Netherlands. Patients aged 18-85 years with a first-time acute iliofemoral deep-vein thrombosis and symptoms for no more than 14 days were randomly assigned (1:1) to either standard treatment with additional ultrasound-accelerated catheter-directed thrombolysis or standard treatment alone. Randomisation was done with a web-based automatic programme and a random varying block size (2-12), stratified by age and centre. Standard treatment included anticoagulant therapy, compression therapy (knee-high elastic compression stockings; 30-40 mmHg), and early ambulation. Additional ultrasound-accelerated catheter-directed thrombolysis was done with urokinase with a starting bolus of 250 000 international units (IU) in 10 mL NaCl followed by a continuous dose of 100 000 IU/h for a maximum of 96 h through the Ekos Endowave-system. Adjunctive percutaneous transluminal angioplasty, thrombosuction, or stenting was performed at the discretion of the physician who performed the intervention. The primary outcome was the proportion of patients with post-thrombotic syndrome at 12 months diagnosed according to the original Villalta criteria-a Villalta-score of at least 5 on two consecutive occasions at least 3 months apart or the occurrence of venous ulceration-and was assessed in a modified intention-to-treat population of all randomly assigned patients who passed screening and started treatment. The safety analysis was assessed in the same modified intention-to-treat population. This study is complete and is registered at ClinicalTrials.gov, NCT00970619. FINDINGS: Between May 28, 2010, and Sept 18, 2017, 184 patients were randomly assigned to either additional ultrasound-accelerated catheter-directed thrombolysis (n=91) or standard treatment alone (n=93). Exclusion because of screening failure or early withdrawal of informed consent resulted in 77 patients in the intervention group and 75 in the standard treatment group starting allocated treatment. Median follow-up was 12·0 months (IQR 6·0-12·0). 12-month post-thrombotic syndrome occurred in 22 (29%) patients allocated to additional treatment versus 26 (35%) patients receiving standard treatment alone (odds ratio 0·75 [95% CI 0·38 to 1·50]; p=0·42). Major bleeding occurred in four (5%) patients in the intervention group, with associated neuropraxia or the peroneal nerve in one patient, and no events in the standard treatment group. No serious adverse events occurred. None of the four deaths (one [1%] in the intervention group vs three [4%] in the standard treatment group) were treatment related. INTERPRETATION: This study showed that additional ultrasound-accelerated catheter-directed thrombolysis does not change the risk of post-thrombotic syndrome 1 year after acute iliofemoral deep-vein thrombosis compared with standard therapy alone. Although this trial is inconclusive, the outcome suggests the possibility of a moderate beneficial effect with additional ultrasound-accelerated catheter-directed thrombolysis. Further research is therefore warranted to better understand this outcome in the context of previous trials, preferably by combining the available evidence in an individual patient data meta-analysis. FUNDING: The Netherlands Organisation for Health Research and Development (ZonMw), Maastricht University Medical Centre, BTG-Interventional Medicine.


Assuntos
Anticoagulantes/administração & dosagem , Cateterismo Periférico , Síndrome Pós-Trombótica/prevenção & controle , Terapia Trombolítica/métodos , Trombose Venosa/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Método Simples-Cego , Meias de Compressão , Adulto Jovem
3.
Vasc Endovascular Surg ; 54(2): 135-140, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31769352

RESUMO

PURPOSE: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis (USAT) appears to provide promising results for the management of acute submassive pulmonary embolisms (ASMPEs) at tertiary care centers. This study assessed outcome measures at a community-based hospital systems and compared results to known studies. MATERIALS AND METHODS: This is a single-center, retrospective study assessing clinical outcomes of the EkoSonic Endovascular System intervention for ASMPEs performed by three surgical 3 subspecialties (interventional radiology, interventional cardiology, and vascular surgery) part of a pulmonary embolism response team (PERT). We reviewed 146 PERT activations from June 2013 to December 2017. Eighty-three patients with ASMPEs underwent USAT. RESULTS: Our study showed greater differences (P = .01) between baseline and follow-up pulmonary artery systolic pressures (20.9 ± 9.8 mm Hg [n = 14]) compared to the ULTIMA study (12.3 ± 10 mm Hg [n = 30]). Our length-of-stay measures were shorter (6.1 ± 5.1 [n = 83]; P = .0001) compared to the SEATTLE II study (8.8 ± 5.0 [n = 150]). Preprocedure transthoracic echocardiograms (TTEs) were performed for 54 (65%) of 83 patients. Postprocedure TTEs at 48 hours was performed for 52 (62%) of 83 patients. Use of TTEs before and after intervention did not change outcomes. Intracranial hemorrhage was not observed in our patient population. There was no difference in outcomes between the three subspecialties in our study. CONCLUSIONS: Use of USAT in a community-based hospital PERT has similar outcomes to tertiary care centers. Furthermore, similar outcomes were observed between the three subspecialties suggesting development of a comprehensive care team for management of ASMPEs.


Assuntos
Cateterismo Periférico , Fibrinolíticos/administração & dosagem , Hospitais Comunitários , Embolia Pulmonar/terapia , Terapia Trombolítica/métodos , Terapia por Ultrassom , Doença Aguda , Adulto , Idoso , Cardiologistas , Cateterismo Periférico/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intra-Arteriais , Masculino , Michigan , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/fisiopatologia , Radiologistas , Estudos Retrospectivos , Especialização , Cirurgiões , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Terapia por Ultrassom/efeitos adversos
4.
World Neurosurg ; 133: e835-e841, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31614218

RESUMO

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


Assuntos
Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
5.
Vasa ; 49(1): 17-22, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31134852

RESUMO

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


Assuntos
Trombose , Fibrinólise , Fibrinolíticos , Humanos , Terapia Trombolítica , Ativador de Plasminogênio Tecidual
6.
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
7.
Vasc Endovascular Surg ; 54(1): 58-64, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31500542

RESUMO

A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart dysfunction and symptomatic improvement received bedside removal of catheters. The mean patient age was 50.6 years and body mass index was 33.6. Mean RV/LV ratio on admission via CT imaging was 1.56, with a mean troponin of 0.44. Interval mean RV/LV ratio on echocardiography after thrombolysis therapy was 0.91. There was a 0% incidence of periprocedural complications. One (20%) patient out of 5 had an emergency department visit 10 days postdischarge for acute shortness of breath, with workup revealing no evidence of recurrent PE. No patient required hospital readmission within 30 days. At the 6-week follow-up, all patients had continued normal right ventricular function noted on echocardiography. This case series demonstrates that for a select population of patients with severe submassive PE, the use of CDT and echocardiography monitoring can facilitate same-day discharge from the ICU.


Assuntos
Fibrinolíticos/administração & dosagem , Unidades de Terapia Intensiva , Tempo de Internação , Alta do Paciente , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/métodos , Adulto , Ecocardiografia , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Sistema de Registros , Estudos Retrospectivos , Índice de Gravidade de Doença , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/instrumentação , Fatores de Tempo , Resultado do Tratamento , Dispositivos de Acesso Vascular
8.
Zhonghua Yi Xue Za Zhi ; 99(44): 3477-3480, 2019 Nov 26.
Artigo em Chinês | MEDLINE | ID: mdl-31826565

RESUMO

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


Assuntos
Fibrilação Atrial , Isquemia Encefálica , Acidente Vascular Cerebral , Doença Aguda , Fibrinolíticos , Humanos , Estudos Retrospectivos , Terapia Trombolítica , Ativador de Plasminogênio Tecidual , Resultado do Tratamento
10.
Rozhl Chir ; 98(10): 418-421, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31842573

RESUMO

Hepatic artery thrombosis is the most common vascular complication after liver transplantation. Early thrombosis is treated by surgical revascularization; if not feasible, there is need for urgent retransplantation. Late thrombosis is diagnosed mostly when clinical symptoms or graft dysfunction are present, in which case the only possible therapy is retransplantation. We present a case of a young patient with late thrombosis of an aorto-hepatic bypass, in whom we successfully used thrombolytic therapy with stent-graft placement.


Assuntos
Aorta/cirurgia , Implante de Prótese Vascular/métodos , Artéria Hepática/cirurgia , Hepatopatias/cirurgia , Transplante de Fígado/efeitos adversos , Trombose/cirurgia , Procedimentos Endovasculares , Humanos , Reoperação , Terapia Trombolítica , Trombose/etiologia , Trombose/terapia , Fatores de Tempo , Resultado do Tratamento
11.
J Clin Ethics ; 30(4): 338-346, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31851625

RESUMO

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


Assuntos
Isquemia Encefálica/terapia , Consentimento Livre e Esclarecido , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Atitude do Pessoal de Saúde , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Hospitais de Veteranos , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Estados Unidos
12.
Clin Exp Rheumatol ; 37 Suppl 121(6): 125-131, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31856938

RESUMO

OBJECTIVES: Systemic therapy aimed at suppressing the diffuse inflammation in the vessel wall is the major treatment modality for venous thrombosis in Behçet's syndrome (BS). Endovascular and/or surgical interventions are also used. We here report five patients who were referred to our clinic after having such interventions and also present a literature review to assess the outcome of invasive procedures for venous thrombosis in BS. METHODS: Our patients were presented and a literature search for endovascular and/or surgical interventions in Pub-Med was performed. Recanalisation, reocclusion or other complications were assessed as outcomes. RESULTS: Five BS patients with lower extremity thrombosis were referred to our clinic with post thrombotic syndrome due to incomplete recanalisation or infectious complication after endovascular interventions. Twenty-one articles reporting on 36 patients were found suitable for review. There were totally 21 lower extremity venous intervention cases, 14 of which had failure such as complication, reocclusion or incomplete recanalisation. Reocclusions occurred in 10 patients and reinterventions to 8 of them could restore flow only in 4 cases. Ileal infarct and vena cava wall-duodenal perforation were major complications. Invasive procedures of 8 abdominal thrombosis cases resulted with death due to ileus in one patient, and reocclusion in another. Seven of the 12 upper extremity/superior vena cava thrombosis cases resulted with reocclusions. CONCLUSIONS: Endovascular and surgical interventions seemed to be unsuccessful because of recurrent infectious and vascular complications in 22 (53.6%) of 41 patients with venous thrombosis. The indication of these procedures is controversial. Their economic burden on the healthcare system must be considered.


Assuntos
Síndrome de Behçet , Trombose Venosa , Síndrome de Behçet/complicações , Terapia Combinada , Humanos , Terapia Trombolítica , Trombose , Resultado do Tratamento , Trombose Venosa/tratamento farmacológico , Trombose Venosa/etiologia , Trombose Venosa/cirurgia
13.
Cesk Slov Oftalmol ; 75(3): 152-159, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31779464

RESUMO

PURPOSE: Describe the clinical finding and course of treatment in patients with a sudden decrease in visual function due to an acute occlusion of the arteria centralis retinae. Patients were primarily indicated for selective angiography with thrombolysis of the ophthalmic artery. MATERIALS AND METHODS: Medical documentation of two patients with acute central retinal artery occlusion with a time duration of up to 5 hours was evaluated retrospectively. The diagnosis of central retinal artery occlusion was determined on the basis of a detailed ophthalmological examination in arteficial mydriasis. The initial best-corrected visual acuity (BCVA) were hand movement in front of the eye with uncertain light projection in first patient and no light perception in the second patient. In both cases a relative afferent pupillary defect of the 4th degree was present with the onset of the ischemic macular edema and an incipient development of the cherry red spot. After evaluation of the overall condition, laboratory findings, exclusion of cancer and surgery in the last three months, a selective angiography of ophthalmic artery and thrombolysis in collaboration with the intervention radiologist were performed.   Results: First patient with a better initial visual acuity, selective angiography demonstrated a decrease in flow in the central retinal artery with subsequent improvement in haemodynamic ratios after application of 12 ml of recombinant tissue plasminogen activator (Alteplase). The BCVA improved to 1/ 60 after interventional procedure. We did not experience any serious treatment side effects during or after intervention. In the second patient, selective angiography of the intracranial arteries and internal carotids revealed the presence of an aneurysm before the ophthalmic artery. Due to the normal flow of the contralateral carotid and the filling of the intracranial vessels on the affected side via the circle of Willis, the internal carotid ligation was performed under the aneurysm. Three months after the surgery BCVA was no light perception and patient had no neurological symptomatology. CONCLUSION: Selective angiography in combination with thrombolysis appears to be a useful imaging as well as therapeutic method for acute central retinal artery occlusion. This technique allows not only to confirm the diagnosis but it can also solve problem causally and improve the visual acuity of the affected person. Sometimes it also helps to clear the cause of the closure and prevent next potential embolization into the intracranial space and possible fatal consequences of CNS involvement or even death.


Assuntos
Angiografia , Oclusão da Artéria Retiniana , Ativador de Plasminogênio Tecidual , Humanos , Oclusão da Artéria Retiniana/diagnóstico por imagem , Oclusão da Artéria Retiniana/tratamento farmacológico , Estudos Retrospectivos , Terapia Trombolítica
14.
BMC Neurol ; 19(1): 265, 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31684901

RESUMO

BACKGROUND: Intravenous thrombolysis (IVT) plays a prominent role in the treatment of acute ischemic stroke (AIS). The sooner IVT is administered, the higher the odds of a good outcome. Therefore, registering the in-hospital time to treatment with IVT, i.e. the door-to-needle time (DNT), is a powerful way to measure quality improvement. The aim of this study was to identify determinants that are associated with extended DNT. METHODS: Patients receiving IVT in 2015 and 2016 registered in the Dutch Acute Stroke Audit were included. DNT and onset-to-door time (ODT) were dichotomized using the median (i.e. extended DNT) and the 90th percentile (i.e. severely extended DNT). Logistic regression was performed to identify determinants associated with (severely) extended DNT/ODT and its effect on in-hospital mortality. A linear model with natural spline was used to investigate the association between ODT and DNT. RESULTS: Included were 9518 IVT treated patients from 75 hospitals. Median DNT was 26 min (IQR 20-37). Determinants associated with a higher likelihood of extended DNT were female sex (OR 1.17, 95% CI 1.05-1.31) and admission during off-hours (OR 1.12, 95% CI 1.01-1.25). Short ODT correlated with longer DNT, whereas longer ODT correlated with shorter DNT. Young age (OR 1.38, 95% CI 1.07-1.76) and admission to a comprehensive stroke center (OR 1.26, 1.10-1.45) were associated with severely extended DNT, which was associated with in-hospital mortality (OR 1.54, 95%CI 1.19-1.98). CONCLUSIONS: Even though DNT in the Netherlands is short compared to other countries, lowering the DNT may be achievable by focusing on specific subgroups.


Assuntos
Acidente Vascular Cerebral , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica
15.
BMC Neurol ; 19(1): 285, 2019 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-31722675

RESUMO

BACKGROUND: Capsular warning syndrome (CWS) is a rare clinical syndrome, which is defined as a recurrent transient lacunar syndrome. The mechanism and clinical management of CWS remain unclear. The aim of the study was to discuss the clinical characteristics of CWS and evaluate the different outcome between rt-PA and no rt-PA therapy. METHODS: The present multicenter retrospective study involved three medical centers, and the clinical data were collected from patients with CWS between January 2013 and December 2018. The clinical characteristics of CWS were analyzed. Patients were divided into two groups: rt-PA and no rt-PA groups. The therapeutic effects and prognosis of these two groups were analyzed. A good prognosis was defined as 3-month modified Rankin Scale (mRS) ≤ 2. RESULTS: Our study included 72 patients, 27 patients were assigned to rt-PA group, 45 in no rt-PA group. Hypertension and dyslipidemia were the most common risk factors. The mean number of episodes before irreversible neurological impairment or the symptoms completely disappeared was five times (range: 3-11 times). A total of 58 (80.55%) patients had acute infarction lesions on the diffusion weighted imaging (DWI). The most common infarct location was the internal capsule (41,70.69%), followed by the thalamus and pons. The difference in therapeutic effects between the rt-PA, single and double antiplatelet groups was not statistically significant (P > 0.05). A good prognosis was observed in 61 (84.72%) patients after 3 months, in which 23 (23/27, 85.19%) patients were from the rt-PA group and 38 (38/45,84.44%) patients were from the no rt-PA group (P > 0.05). After 3 months of follow-up, two patients had recurrent ischemic stroke. CONCLUSION: The most effective treatment of CWS remains unclear. Intravenous thrombolysis is safe for CWS patients. Regardless of the high frequency of infarction in CWS patients, more than 80% patients had a favorable functional prognosis.


Assuntos
Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral Lacunar/tratamento farmacológico , Acidente Vascular Cerebral Lacunar/patologia , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/tratamento farmacológico , Síndrome , Terapia Trombolítica/métodos , Resultado do Tratamento
17.
Tidsskr Nor Laegeforen ; 139(17)2019 Nov 19.
Artigo em Norueguês, Inglês | MEDLINE | ID: mdl-31746171

RESUMO

BACKGROUND: ST-elevation myocardial infarction is treated with reperfusion, either in the form of primary percutaneous coronary intervention (PCI) or thrombolytic therapy. The choice of treatment depends on transport time to the nearest PCI centre. Norway's geography means that thrombolytic therapy will be appropriate for many patients. Irrespective of treatment choice, it is important to avoid delays. We wished to compare the outcomes of primary PCI and thrombolytic therapy in our healthcare region and to examine whether reperfusion therapy was administered within the recommended time window. MATERIAL AND METHOD: Using registry data and patient medical records, we compared the outcomes of primary PCI and thrombolytic therapy in cases of ST-elevation myocardial infarction in the Central Norway Regional Health Authority in the period 2015-16. The outcomes analysed were 30-day mortality, ejection fraction measured by echocardiography during the hospital stay, incidence of bleeding complications, and time from diagnosis to start of treatment. RESULTS: The study population comprised 648 patients with ST-elevation myocardial infarction. Of these, 382 were treated with primary PCI and 266 received thrombolytic therapy. The 30-day mortality was 5.5 % in the primary PCI group and 5.6 % in the thrombolysis group (p = 1.0). There were no significant differences in ejection fraction and no cases of serious bleeding. In 45 % of the total population, reperfusion therapy was started later than recommended in guidelines. INTERPRETATION: There was no statistically significant difference in mortality or ejection fraction when comparing primary PCI and thrombolytic therapy in an unselected population with ST-elevation myocardial infarction. Many patients experienced delayed start of treatment . It is important to take action to reduce delays at all stages of the therapeutic chain. Thrombolytic therapy should be considered when it is unclear whether transport time to a PCI centre will exceed that recommended in guidelines.


Assuntos
Angioplastia Coronária com Balão , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Fibrinolíticos , Humanos , Noruega , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia Trombolítica , Fatores de Tempo , Resultado do Tratamento
19.
Medicine (Baltimore) ; 98(42): e17628, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31626146

RESUMO

BACKGROUND: The role of anticoagulation therapy for stroke prevention in older atrial fibrillation (AF) patients with chronic kidney disease (CKD) remains unclear. Therefore, we conducted a meta-analysis to explore the efficacy and safety of anticoagulation therapy in this population. METHODS: The Cochrane Library, PubMed, and Embase databases were systematically searched for studies reporting the effect of anticoagulation therapy in older patients with AF and CKD. The risk ratios (RRs) and 95% confidence intervals (CIs) were regarded as the risk estimates. A random-effects model selected was to evaluate the treatment outcomes. The presentations were based on the Preferred Reporting Items for reporting systematic reviews and meta-analyses statement. RESULTS: A total of 7 studies with 24,794 older patients with AF and CKD were included. The follow-up of the included studies ranged from 0.9 to 9.0 years. In older patients with no dialysis, compared with nonanticoagulants, anticoagulants reduced the risk of all-cause death (RR 0.66, 95% CI 0.54-0.79), but had comparable risks of ischemic stroke/transient ischemic attack (TIA, RR 0.91, 95% CI 0.46-1.79) and bleeding (RR 1.17, 95% CI 0.86-1.60). In older patients with dialysis, compared with nonanticoagulants, anticoagulants increased the risk of bleeding (RR 1.37, 95% CI 1.09-1.74), but had similar risks of ischemic stroke/TIA (RR 1.18, 95% CI 0.88-1.58) and death (RR 0.87, 95% CI 0.60-1.27). CONCLUSION: Compared with nonanticoagulation, anticoagulation therapy is associated with a reduced risk of death in older AF patients with nondialysis, but an increased risk of bleeding in older patients with dialysis.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/prevenção & controle , Terapia Trombolítica/métodos , Fibrilação Atrial/complicações , Humanos , Diálise Renal , Insuficiência Renal Crônica/terapia , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
20.
Cardiovasc Hematol Agents Med Chem ; 17(2): 115-124, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31622211

RESUMO

AIM: This study aims to find out the components responsible for the antithrombotic activity of Nelumbo nucifera. MATERIAL AND METHODS: Petroleum ether, chloroform and hydroalcoholic extracts of whole plant of Nelumbo nucifera (Lotus) were prepared and assessed for its thrombolytic, anti-platelet aggregation activity and bleeding time. The extracts were further analyzed through HPTLC and GC-MS. Statistical analysis was conducted through ANOVA trailed by Tukey's multiple comparison test test. RESULTS: Hydroalcoholic extract showed the highest activity at the concentration of 400µg/ml in thrombolytic assay (42.03 ± 5.76), anti-platelet aggregation assay (57.93 ± 1.68) and bleeding time (70.17 ± 2.16) in comparison to clopodigrel (33.76 ± 3.43), aspirin (66.55 ± 1.86) and aspirin (93.85 ± 2.75) at the concentration of 100 µg/ml respectively. 25 peaks were identified through GC-MS, out of which, ferulic acid (14.2µ/g) and quercetin (5.4 µ/g) are active chemical compounds. HPTLC showed different chromatograms in hydroalcoholic extracts like (1) chlorogenic, (2) quercetin, (3) benzoic acid, (4) caffeic acid, (5) ferulic acid, (6) kaempferol, and (7) gallic acid. CONCLUSION: Based on these findings, flavonoids present in hydroalcoholic extract may be developed into a drug for clinical application for the treatment of thrombosis in patients.


Assuntos
Fibrinolíticos/uso terapêutico , Flavonoides/uso terapêutico , Nelumbo/química , Extratos Vegetais/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/tratamento farmacológico , Animais , Tempo de Lise do Coágulo de Fibrina , Fibrinolíticos/química , Flavonoides/química , Masculino , Extratos Vegetais/química , Agregação Plaquetária/efeitos dos fármacos , Inibidores da Agregação de Plaquetas/química , Ratos Wistar , Terapia Trombolítica
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