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2.
Eur J Vasc Endovasc Surg ; 60(4): 578-585, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32665201

RESUMO

OBJECTIVE: Percutaneous thrombus removal is used for the treatment of iliofemoral deep vein thrombosis (DVT), but the efficacy of different treatment modalities has not yet been determined. The aim of this study was to compare the outcomes of patients treated with additional AngioJet pharmacomechanical thrombectomy (PCDT) vs. catheter directed lysis (CDT) alone. METHODS: A retrospective review of all patients who received thrombolysis for the treatment of symptomatic acute iliofemoral DVT between 2011 and 2017 was carried out. Outcome measures included the incidence of post-thrombotic syndrome (PTS), procedural outcomes (lytic exposure), the incidence of complications, and vessel patency. All patients were followed up for a minimum of one year. RESULTS: A total of 151 limbs were treated, 70 limbs with PCDT and 81 limbs with CDT alone. Demographic data and prevalence of risk factors were comparable. Incidence of PTS (Villalta score at one year) showed no significant difference (22.2% PCDT vs. 24.7% CDT alone, p = .74). Use of PCDT resulted in a non-statistically significant trend for fewer bleeds (n = 4/63 [6.3%] vs. 13/76 [17.1%]; relative risk 0.37, 95% confidence interval [CI] 0.13-1.08; p = .07), a statistically significant reduction in lysis duration (40 h [95% CI 34-46] vs. 53 h [95% CI 49-58]; p < .001) and a reduction in lytic dose (49 mg [95% CI 42-55] vs. 57 mg [95% CI 52-61]; p = .011) compared with CDT. This reduction was accentuated in 24 cases primarily treated with AngioJet PowerPulse mode (27 h, 95% CI 20-34 [p < .001] and 42 mg, 95% CI 34-50 [p = .009]). Incidences of complications were comparable between groups, with one death due to an intracranial haemorrhage following CDT. Although the incidence of haemoglobinuria was increased following PCDT (12/63 [19.0%] vs. 3/76 [3.9%]; p = .006), no significant difference in acute kidney injury was observed (3/63 [4.8%] vs. 1/76 [1.3%]; p = .33). No significant difference in vessel patency over two years was observed (p = .73). CONCLUSION: The use of PCDT for the treatment of iliofemoral DVT was observed to provide comparable patient outcomes, comparable vessel patency, an acceptable safety profile, and reduced overall lytic dose.


Assuntos
Veia Femoral , Fibrinolíticos/administração & dosagem , Veia Ilíaca , Trombectomia , Terapia Trombolítica , Trombose Venosa/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Bases de Dados Factuais , Feminino , Veia Femoral/diagnóstico por imagem , Veia Femoral/fisiopatologia , Fibrinolíticos/efeitos adversos , Humanos , Veia Ilíaca/diagnóstico por imagem , Veia Ilíaca/fisiopatologia , Londres , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/etiologia , Estudos Retrospectivos , Fatores de Risco , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/fisiopatologia , Adulto Jovem
3.
J Stroke Cerebrovasc Dis ; 29(8): 105004, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689579

RESUMO

BACKGROUND AND AIMS: Various reactive oxygen radicals and inflammatory mediators emerge in ischemic stroke, and changes occur in the number of leukocytes and platelets. Variations in the counts and ratios of these cells may be related to the early and late course and prognosis of stroke. In this study, the relationship between changes in counts or ratios of neutrophil, lymphocyte, platelet, and National Health Institute Stroke Scale (NIHSS) scores was investigated in patients who presented with an ischemic stroke and treated with recombinant tissue plasminogen activator (rtPA) and/or thrombectomy. METHODS: Changes in neutrophil, lymphocyte, platelet counts; neutrophil-to-leukocyte ratio (NLR), neutrophil-to-lymphocyte ratio, platelet-to-leukocyte ratio (PLR), and platelet-to- lymphocyte ratio between day of admission (day 0), and 1st, 3rd, and 7th days after application of treatment modalities in 296 patients presented with acute ischemic stroke who underwent rtPA within the first 4,5 hours and / or thrombectomy within 6 hours after stroke and the relationship between these changes and the NIHSS (National Health Institute Stroke Scale) scores were evaluated retrospectively. RESULTS: In our study, leukocyte and neutrophil counts were higher on the first day after acute ischemic stroke. Platelet counts decreased on the 1st and 3rd days relative to baseline values. Lymphocyte values decreased on day 1, 3 and 7 compared to day 0. There was a significant increase in neutrophil-to-lymphocyte ratios at day 1 and 3 compared to day 0. On the 7th day, neutrophil-to-lymphocyte ratios were significantly lower. There was an increase in platelet-to-lymphocyte ratios at day 1 compared to day 0. The increase in NLR values was more evident on day 1. The increase in PLR on the 7th day was also significant. The patients who underwent rtPA and/or thrombectomy had significantly lower NIHSS scores at the 72th hour of the stroke compared to the NIHSS values at hospital admissions. A positive correlation was found between NIHSS difference values and neutrophil-to-lymphocyte and platelet-to-lymphocyte percent changes. CONCLUSIONS: There are dynamic changes in platelet, neutrophil, lymphocyte counts and ratios in early period after treatment with rtPA and/or thrombectomy in acute ischemic stroke. Variations in the counts and ratios of these cells may be related to NIHSS, which determines the degree of neurological damage of stroke.


Assuntos
Plaquetas , Isquemia Encefálica/terapia , Avaliação da Deficiência , Fibrinolíticos/administração & dosagem , Linfócitos , Neutrófilos , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
4.
J Stroke Cerebrovasc Dis ; 29(8): 104991, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689615

RESUMO

BACKGROUND: Fibrinogen is a central protein of hemostasis and a major determinant of plasma viscosity and key factor for platelet activation. The aim of this study is to investigate the relationship between fibrinogen level and short-term outcome in acute ischemic stroke patients receiving intravenous thrombolysis. METHODS: This retrospective study included 176 acute ischemic stroke patients who received intravenous thrombolysis with recombinant tissue plasminogen activator and provided plasma fibrinogen level within 24 h after stroke onset. Patients were categorized by plasma fibrinogen level: Quartile 1 (≤ 1.74 g/L), Quartile 2 (1.75-2.08 g/L), Quartile 3 (2.09-2.69 g/L), and Quartile 4 (> 2.69 g/L). The medical record of each patient was reviewed, and demographic, clinical and laboratory information was abstracted. Functional outcome at 14 days was assessed with the modified Rankin Scale. RESULTS: Poor outcome was present in 75 (42.6%) of the 176 patients that were included in the study (mean age, 72 years; male, 53.4%). After adjustment for potential confounding variables, higher plasma fibrinogen level on admission was associated with poor outcome (adjusted odds ratio 10.45, 95% confidence interval 1.49-73.15 for Q4:Q1; P = 0.02). According to receiver operating characteristic analysis, the best discriminating factor for poor outcome was a plasma fibrinogen level ≥ 2.585 g/L (area under the curve 0.672; sensitivity 50.7%; specificity 86.1%). CONCLUSION: Elevated plasma fibrinogen levels on admission are significantly associated with poor outcome after admission for acute ischemic stroke, suggesting the potential role of plasma fibrinogen level as a predictive marker for short-term poor outcome in acute ischemic stroke patients receiving thrombolytic therapy.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinogênio/metabolismo , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Regulação para Cima
5.
J Stroke Cerebrovasc Dis ; 29(8): 104997, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689627

RESUMO

OBJECTIVE: To study association between blood pressure (BP) and development of early neurological deterioration (END) in acute ischemic stroke patients with intravenous rt-PA thrombolysis and its possible mechanism. METHODS: We prospectively collected data of acute ischemic stroke patients with intravenous rt-PA thrombolysis from March 2015 to June 2019. The collected data include general, clinical data and laboratory test. Moreover, serum levels or activity of malondialdehyde (MDA), superoxide dismutase (SOD), matrix metalloproteinase-9 (MMP-9), occludin(OCLN), ZO-1 and aquaporin 4(AQP-4) were determined. RESULTS: A total of 357 acute ischemic stroke patients received intravenous rt-PA thrombolysis and 16 cases were eventually excluded. Finally, 341 patients were eligible in this study and 65 patients (19.06%) experienced END. Mean systolic blood pressure (SBP) within 24 h, serum levels or activity of MDA, SOD, MMP-9, ZO-1, OCLN, AQP-4 at 24 h after thrombolysis were the independent predictors for END in the total and hypertension population using multivariate logistic regression analysis, and mean SBP within 24 h was the best predictor for END. Receiver operating characteristic (ROC) analysis found that cutoff mean SBP for END was 148.16 mmHg, and sensitivity was 85.6%. The best target SBP level is 140ཞ149 mmHg. Further, spearman correlation tests indicated that BP levels were directly proportional to serum levels or activity of MDA, MMP-9, ZO-1, OCLN, AQP-4 at 24 h after thrombolysis and neurological deterioration severity. CONCLUSIONS: END frequently occurs after thrombolysis, and the best predictor of END is SBP which may be mediated through oxidative stress induced blood-brain barrier disruption and AQP4 upregulation.


Assuntos
Aquaporina 4/sangue , Pressão Sanguínea , Barreira Hematoencefálica/efeitos dos fármacos , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Estresse Oxidativo/efeitos dos fármacos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Idoso , Biomarcadores/sangue , Barreira Hematoencefálica/metabolismo , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Progressão da Doença , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento , Regulação para Cima
6.
J Stroke Cerebrovasc Dis ; 29(8): 104980, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689645

RESUMO

BACKGROUND: The COVID-19 pandemic has presented unprecedented challenges to healthcare organizations worldwide. A steadily rising number of patients requiring intensive care, a large proportion from racial and ethnic minorities, demands creative solutions to provide high-quality care while ensuring healthcare worker safety in the face of limited resources. Boston Medical Center has been particularly affected due to the underserved patient population we care for and the increased risk of ischemic stroke in patients with COVID-19 infection. METHODS: We present protocol modifications developed to manage patients with acute ischemic stroke in a safe and effective manner while prioritizing judicious use of personal protective equipment and intensive care unit resources. CONCLUSION: We feel this information will benefit other organizations facing similar obstacles in caring for the most vulnerable patient populations during this ongoing public health crisis.


Assuntos
Betacoronavirus/patogenicidade , Isquemia Encefálica/virologia , Infecções por Coronavirus/terapia , Procedimentos Endovasculares , Necessidades e Demandas de Serviços de Saúde/organização & administração , Determinação de Necessidades de Cuidados de Saúde/organização & administração , Pneumonia Viral/terapia , Radiografia Intervencionista , Acidente Vascular Cerebral/terapia , Terapia Trombolítica , Boston , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Tomada de Decisão Clínica , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Procedimentos Clínicos/organização & administração , Procedimentos Endovasculares/efeitos adversos , Interações entre Hospedeiro e Microrganismos , Humanos , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Radiografia Intervencionista/efeitos adversos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento , Triagem/organização & administração
7.
Asian Cardiovasc Thorac Ann ; 28(5): 266-272, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32493040

RESUMO

BACKGROUND: Fibrinolytic therapy is an important reperfusion strategy, especially when primary percutaneous coronary interventions cannot be offered to ST-elevation myocardial infarction patients. Given that failed reperfusion after fibrinolytic therapy is common, it is pragmatic that the predictors, outcomes, and angiographic profiles of patients with failed thrombolysis are carefully scrutinized. METHODS: We prospectively studied clinical variables and outcomes over 30 months in 243 ST-elevation myocardial infarction patients who received fibrinolytics as primary treatment. Logistic regression analysis was used to identify predictors of failed thrombolysis. RESULTS: Failed thrombolysis occurred in 38.68% of patients with a mean window period of 6.58 ± 1.42 h, and 55.32% of patients with failed thrombolysis had Killip class >I on presentation. Risk factors such as diabetes mellitus (55.32%), dyslipidemia (60.64%) and obesity (77.66%) were frequently associated with failed thrombolysis; 73.40% of patients with failed thrombolysis had Thrombolysis in Myocardial Infarction flow grade 0/1 in the infarct-related artery, and 58.51% of such patients needed a rescue percutaneous coronary intervention. The mean Thrombolysis in Myocardial Infarction risk score was 5.46 ± 2.77 in failed thrombolysis patients, with mortality of 4.25% at the 6-month follow-up. CONCLUSION: Non-resolution of presenting symptoms and ST changes on electrocardiography at 90 min served as the earliest indicators of failed thrombolysis, with a significant angiographic correlation. Clinical variables such as delayed presentation (>6 h), dyspnea, Killip class >I, cardiogenic shock, Thrombolysis in Myocardial Infarction score, and conventional risk factors including diabetes mellitus, dyslipidemia, and obesity represented cluster of predictors of failed thrombolysis.


Assuntos
Trombose Coronária/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Infarto do Miocárdio/tratamento farmacológico , Terapia Trombolítica , Adulto , Idoso , Angiografia Coronária , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Falha de Tratamento
8.
Neurology ; 95(2): e121-e130, 2020 07 14.
Artigo em Inglês | MEDLINE | ID: mdl-32554767

RESUMO

OBJECTIVE: To determine the association of chronic kidney disease (CKD) with the safety and efficacy of IV thrombolysis (IVT) among patients with acute ischemic stroke (AIS). METHODS: A systematic review and pairwise meta-analysis of studies involving patients with CKD undergoing IVT for AIS were conducted to evaluate the following outcomes: symptomatic intracranial hemorrhage (sICH), asymptomatic and any intracranial hemorrhage (ICH), in-hospital and 3-month mortality, 3-month favorable functional outcome (FFO; modified Rankin Scale [mRS] score 0-1), and 3-month functional independence (FI, mRS score 0-2). CKD was defined with estimated glomerular filtration rate (eGFR) ranging from mild (eGFR 60-89 mL/min) to moderate (eGFR 30-59 mL/min) to severe (eGFR 15-29 mL/min). RESULTS: We identified 20 studies comprising 60,486 patients with AIS treated with IVT. In unadjusted analyses, CKD was associated with sICH according to the National Institute of Neurological Disorders and Stroke (NINDS) (7 studies; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19-1.67) and European Cooperative Acute Stroke Study (ECASS) II (9 studies; OR 1.37, 95% CI 1.01-1.85) definitions, any ICH (8 studies; OR 1.42, 95% CI 1.18-1.70), 3-month mortality (9 studies; OR 2.20, 95% CI 1.72-2.81), 3-month FFO (8 studies; OR 0.58, 95% CI 0.47-0.72), and 3-month FI (8 studies; OR 0.57, 95% CI 0.46-0.71). In adjusted analyses, CKD was associated with sICH according to NINDS (4 studies; ORadj 1.34, 95% CI 1.01-1.79) and ECASS II (3 studies; ORadj 2.08, 95% CI 1.27-3.43) definitions, any ICH (6 studies; ORadj 1.41, 95% CI 1.01-1.97), in-hospital mortality (2 studies; ORadj 1.19, 95% CI 1.09-1.30), and 3-month FFO (6 studies; ORadj 0.80, 95% CI 0.70-0.92). CONCLUSIONS: After adjustment for confounders in this pairwise meta-analysis, moderate to severe CKD is associated with increased risks of ICH and worse functional outcomes among patients with AIS treated with IVT.


Assuntos
Fibrinolíticos/uso terapêutico , Insuficiência Renal Crônica/complicações , Terapia Trombolítica/métodos , Administração Intravenosa , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Terapia Trombolítica/efeitos adversos
9.
Internist (Berl) ; 61(7): 746-753, 2020 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-32533196

RESUMO

A 57-year-old woman underwent esophagogastroduodenoscopy due to a continuous drop in hemoglobin levels reaching 7.4 g/dl after treatment with intravenous thrombolytic therapy 1 week earlier because of an ischemic insult. Numerous erosive lesions were found in the gastric corpus. Histological staining of a specimen from the gastric lesions revealed a poorly differentiated adenocarcinoma. Immunohistochemical examination confirmed the diagnosis of gastric metastasis from lung cancer based on positive staining for thyroid transcriptional factor­1 (TTF-1) and cytokeratin 7 (CK7) as well as via negative staining for caudal-type homeobox­2 (CDX-2). Chest computed tomography demonstrated a mediastinal mass, measuring 3.2 cm and involving the cervical and supraclavicular lymph nodes. A lymph node was subsequently extirpated. Immunohistochemical examination confirmed the diagnosis of lymph node metastasis from lung cancer by positive staining for TTF­1 and CK7. Symptomatic gastric metastasis from lung cancer is an extremely rare clinical entity. Transesophageal echocardiography detected a mass measuring 1.6 cm at the mitral valve with pericardial effusion. On the basis of the echocardiographic findings, a malignant origin was suggested after exclusion of infectious endocarditis. We assumed that the multiple organ infarctions (spleen, kidney, and brain) and gastric hematogenous metastasis must have been caused by disseminated arterial tumor embolism from the intracardiac metastasis. The patient was treated palliatively and died.


Assuntos
Adenocarcinoma/patologia , Gastrite/patologia , Hemoglobinas/efeitos dos fármacos , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/efeitos adversos , Ecocardiografia Transesofagiana , Evolução Fatal , Feminino , Humanos , Pessoa de Meia-Idade
13.
J Stroke Cerebrovasc Dis ; 29(7): 104851, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32402722

RESUMO

BACKGROUND: Intracranial hemorrhages (ICH) are classified as symptomatic or asymptomatic according to the presence of clinical deterioration. Here, we aimed to find predictive factors of symptomatic intracranial bleeding in a registry-based stroke research. METHODS: Data of consecutive patients with acute ischemic stroke (AIS) were extracted from the prospective STAY ALIVE stroke registry. Analysis of the total population and treatment sugroups such as endovascular thrombectomy (EVT), intravenous thrombolysis (IVT), or their combination (IVT+EVT) were also done. Outcome measures were ICH, 30- and 90-day clinical outcome based on the modified Rankin Scale (mRS:0-2 as favorable outcome). The hemorrhage was captured by a non-enhanced CT of the skull within 24 h after procedure. RESULTS: A total of 355 patients (mean age: 68±11; female N=177 (49.9%); EVT n=131 (36.9%); IVT n=157 (44.2%); IVT+EVT n=67 (18.9%) were included in the analysis. The total number of ICH was 47 (13%), symptomatic (sICH) 12 (3.4%) and asymptomatic (aICH) 35 (9.9%) in the whole population. NIHSS ≥15.5 at 24 post stroke hours predicted sICH with a sensitivity of 100% and a specificity of 92% (p<0.001). Furthermore, lower age, good collateral circulation on initial CT angiography and lower NIHSS score measured at 24 h independently associated with a favorable 90-day outcome, whereas baseline NIHSS and ASPECT score were not. CONCLUSION: Although partial recanalization, ASPECT< 6, and poor collaterals were significantly associated with sICH, the only independent predictor was NIHSS ≥15.5 at 24 post stroke hours. This suggests a careful evaluation of patients with worsening NIHSS despite an adequate therapy.


Assuntos
Procedimentos Endovasculares/efeitos adversos , Fibrinolíticos/efeitos adversos , Hemorragias Intracranianas/induzido quimicamente , Acidente Vascular Cerebral/terapia , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Circulação Cerebrovascular , Circulação Colateral , Angiografia por Tomografia Computadorizada , Avaliação da Deficiência , Procedimentos Endovasculares/mortalidade , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Hungria , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Trombectomia/mortalidade , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento
14.
Transl Res ; 225: 82-94, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32434005

RESUMO

The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. Fibrinolysis is generally not recommended for routine use in intermediate-risk PE, although most guidelines advise that it may be considered in patients with signs of acute decompensation and an overall low bleeding risk. The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.


Assuntos
Fibrinolíticos/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Humanos , Terapia Trombolítica/efeitos adversos
15.
J Stroke Cerebrovasc Dis ; 29(7): 104865, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32404288

RESUMO

We present what may be the first case report of acute thrombocytopenia after tissue plasminogen activator (tPA) in the setting of stroke. Early fibrinogen degradation coagulopathy (EFDC) after tPA has been described in the past and acute thrombocytopenia may fall into this spectrum. Further studies are needed to evaluate the bleeding and mortality risk associated with thrombocytopenia after tPA.


Assuntos
Plaquetas , Fibrinolíticos/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Trombocitopenia/etiologia , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Doença Aguda , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Contagem de Plaquetas , Acidente Vascular Cerebral/diagnóstico , Trombocitopenia/sangue , Trombocitopenia/diagnóstico , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento
16.
J Stroke Cerebrovasc Dis ; 29(7): 104868, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32417240

RESUMO

BACKGROUND AND PURPOSE: Safety and efficacy of endovascular thrombectomy (EVT) in patients with mild stroke syndromes is unclear, especially in distal vessel occlusions. METHODS: We analysed in our stroke database (HeiReKa) between 2002 and April 2019 safety and efficacy of EVT compared to intravenous thrombolysis (IVT) in patients with occlusions distal to the M1 segment of the middle cerebral artery and the top of the basilar artery who presented with a National Institute of Health Stroke Scale (NIHSS) below 6. Excellent (good) outcome was defined as modified rankin scale (mRS) 0-1 (0-2) or return to baseline mRS (good) after 3 months. Safety endpoints were mortality after 3 months and intracranial hemorrhage according to the Heidelberg Bleeding Classification (HBC). RESULTS: Of 4167 patients 94 met the inclusion criteria. Sixty-four patients were allocated to the IVT group and 30 to the EVT group of which 15 also received IVT; three patients (4.6%) in the IVT group received rescue EVT. Baseline characteristics did not differ but more M2 occlusions were found in the EVT group (93.3% vs. 64.1%, p = 0.02). Intracranial bleeding occurred more often in EVT patients (HBC class 2: 13.3% vs. 1.6%, p = 0.01). Excellent and good outcome were not significantly different (75% vs. 70%, p = 0.65 and 87.5% vs. 73.3%, p = 0.14). Mortality was significantly lower in IVT patients (1.6% vs. 13.3%, p = 0.04). CONCLUSION: Rates of excellent and good outcome after IVT or EVT were almost similar, but safety parameters were increased after EVT. EVT may be considered in selected patients after careful risk/benefit analysis.


Assuntos
Procedimentos Endovasculares , Fibrinolíticos/administração & dosagem , Infarto da Artéria Cerebral Média/terapia , Terapia Trombolítica , Insuficiência Vertebrobasilar/terapia , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Alemanha , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/fisiopatologia , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/mortalidade , Insuficiência Vertebrobasilar/fisiopatologia
17.
J Stroke Cerebrovasc Dis ; 29(7): 104919, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32417241

RESUMO

INTRODUCTION: Administration of intravenous recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy (MT) have become standard therapeutic approaches for acute internal carotid artery and middle cerebral artery M1 segment occlusion (ICA/M1O). However, clinical deterioration of the condition is still observed in some cases. OBJECTIVE: We aimed to identify patients' factors associated with exacerbation. This was a single-center, retrospective study of 35 consecutive patients with acute ICA/M1O who underwent rt-PA/rt-PA and MT at our hospital between January 2016 and September 2019. We divided patients into two groups based on the total NIHSS score at discharge: the "improvement" and "exacerbation" groups. Clinical characteristics, laboratory data, and imaging findings were compared between the groups. RESULTS: The improvement group (13 patients [37%]) had a lower mean age (70 vs. 81 years, p = 0.02), National Institutes of Health Stroke Scale score (NIHSS, 13 vs. 19, p = 0.02), and C-reactive protein (CRP) levels (0.24 vs. 0.92 mg/dl, p < 0.01) than the exacerbation group (22 patients [63%]). Receiver operating characteristic curve analysis revealed the cut-off age to be 79 (sensitivity 76.9%, specificity 72.7%), NIHSS score to be 20 (sensitivity 92.3%, specificity 63.6%), and CRP to be 0.14 mg/dl (sensitivity 69.2%, specificity 81.8%). Multivariate analysis confirmed a CRP level of >0.14 mg/dl (odds ratio, 10.16; 95% confidence interval 1.38-75.13; p = 0.01) to be independently associated with clinical deterioration at discharge. CONCLUSIONS: A CRP level of >0.14 mg/dl is a strong predictor of clinical deterioration at discharge in patients with acute ICA/M1O undergoing recanalization therapy.


Assuntos
Proteína C-Reativa/metabolismo , Artéria Carótida Interna , Estenose das Carótidas/terapia , Infarto da Artéria Cerebral Média/terapia , Trombectomia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/sangue , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Progressão da Doença , Feminino , Humanos , Infarto da Artéria Cerebral Média/sangue , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/fisiopatologia , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/administração & dosagem , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Regulação para Cima
19.
Semin Thorac Cardiovasc Surg ; 32(3): 396-403, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32353408

RESUMO

Multiple treatment options beyond anticoagulation exist for massive and submassive pulmonary embolism to reduce mortality. For some patients, systemic thrombolytics and catheter-directed thrombolysis are appropriate interventions. For others, surgical pulmonary embolectomy can be life-saving. Extracorporeal life support and right ventricular assist devices can provide hemodynamic support in challenging cases. We propose a management algorithm for the treatment of massive and submassive pulmonary embolism, in conjunction with a multidisciplinary pulmonary embolism response team, to guide clinicians in individualizing treatment for patients in a timely manner.


Assuntos
Anticoagulantes/uso terapêutico , Embolectomia , Oxigenação por Membrana Extracorpórea , Implantação de Prótese , Embolia Pulmonar/terapia , Terapia Trombolítica , Doença Aguda , Algoritmos , Anticoagulantes/efeitos adversos , Tomada de Decisão Clínica , Técnicas de Apoio para a Decisão , Embolectomia/efeitos adversos , Embolectomia/mortalidade , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Coração Auxiliar , Hemodinâmica , Humanos , Seleção de Pacientes , Desenho de Prótese , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/mortalidade , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do Tratamento , Função Ventricular Direita
20.
J Stroke Cerebrovasc Dis ; 29(8): 104897, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32430238

RESUMO

BACKGROUND: Pre-hospital delay was a critical factor affecting stroke patients receiving intravenous thrombolytic therapy. The aim of this study was to explore the factors associated with pre-hospital delay and thrombolysis in China. METHODS: Patient data were obtained from emergency department (ED), and the factors of patient pre-hospital delay were recorded through a well-designed form. RESULTS: A total of 630 patients were eventually included in the study. 317 patients were admitted to the ED during the thrombolysis time window, and only 105 patients received intravenous thrombolytic therapy. In the univariate analysis, transportation (OR: 0.15; 95% CI: 0.44 - 0.518; p = 0.001), atrial fibrillation (OR: 0.555; 95% CI: 0.372-0.828; p = 0.004) and response of symptoms (OR: 0.002; 95% CI: 0.000-0.013; p = 0.000) were associated with early arrival. Speech disturbances (OR: 2.095; 95% CI: 1.294-3.391; p = 0.002), smoking (OR: 2.563; 95% CI: 1.527-4.304; p = 0.000), alcohol consumption (OR: 2.155; 95% CI: 1.159-4.005; p = 0.014) and referral presentation (OR: 2.837; 95% CI: 1.584-5.082; p = 0.000) were associated with thrombolysis. In the logistic regression analysis, direct visiting to the hospital after onset and rushing to emergency after onset were independent predictor of early arrival of AIS and intravenous thrombolytic. CONCLUSIONS: The pre-hospital delay of acute ischemic stroke in China was still serious. Strengthening the ability to identify stroke-related symptoms and establishing a mutual referral medical support service model between lower and upper hospitals may effectively shorten the pre-hospital delay of stroke patients.


Assuntos
Serviço Hospitalar de Emergência , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Tempo para o Tratamento , Transporte de Pacientes , Administração Intravenosa , China , Diagnóstico Precoce , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
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