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1.
Kyobu Geka ; 72(9): 673-676, 2019 Sep.
Artigo em Japonês | MEDLINE | ID: mdl-31506408

RESUMO

An 80-year-old male patient with a history of total arch replacement for thoracic aortic aneurysm 5 years before was introduced to our hospital with a chief complaint of chest pain. Tissue plasminogen activator (t-PA) had been administrated because of acute brain infarction. A contrast-enhanced computed tomography (CT) scan demonstrated a large hematoma in the posterior mediastinum extending from the level of distal aortic arch to the descending aorta together with left pleural effusion. On the next day after admission, CT scan revealed that the hematoma became smaller. This is a rare case of a posterior mediastinal hematoma caused by t-PA with a history of total aortic arch replacement.


Assuntos
Aneurisma da Aorta Torácica , Infarto Cerebral , Hematoma/etiologia , Terapia Trombolítica/efeitos adversos , Idoso de 80 Anos ou mais , Aorta Torácica , Infarto Cerebral/tratamento farmacológico , Humanos , Masculino , Ativador de Plasminogênio Tecidual
2.
Zhejiang Da Xue Xue Bao Yi Xue Ban ; 48(3): 254-259, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31496156

RESUMO

OBJECTIVE: To investigate the association of atrial fibrillation (AF) with hemorrhagic transformation (HT) in patients with ischemic stroke treated by intravenous thrombolysis. METHODS: Clinical data of 3272 patients treated by intravenous thrombolysis from 71 hospitals in Zhejiang Province during June 2017 and December 2018 were retrospectively reviewed. Intracranial HT was defined as intracranial hemorrhage suggested by imaging examination 24 hours after intravenous thrombolysis. Patients were dichotomized into HT group (n=533) and non-HT group (n=2739). The association of AF and HT was analyzed by univariate analysis and binary logistic regression. RESULTS: Compared with the non-HT group, the HT group were older, had longer onset to needle time (ONT), higher baseline National Institute of Health Stroke Scale (NIHSS) score, higher baseline glucose level, and higher AF rate (P<0.05 or P<0.01). Binary logistic regression analysis revealed that AF was independently associated with HT (OR=2.527, 95%CI:2.030-3.146, P<0.01). CONCLUSIONS: AF is independently associated with the occurrence of HT in ischemic stroke patients treated with intravenous thrombolysis.


Assuntos
Fibrilação Atrial , Isquemia Encefálica , Acidente Vascular Cerebral , Antifibrinolíticos/efeitos adversos , Antifibrinolíticos/farmacologia , Fibrilação Atrial/complicações , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento
3.
J Stroke Cerebrovasc Dis ; 28(9): 2488-2495, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277995

RESUMO

BACKGROUND AND OBJECTIVE: Current standard practice guidelines recommend ICU admission for ischemic stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). More recently, the trend in stroke care is to broaden eligibility for IV thrombolysis. Two examples are a more liberal inclusion criteria known as SMART criteria (sIV-tPA), and the transfer of patients to comprehensive stroke centers (CSC). The present study characterizes ICU interventions in these patients. Understanding which stroke patients that require ICU-level care may allow for placement of patients in the appropriate level of care at hospital admission. METHODS: We performed a retrospective review of consecutive transfer and nontransfer sIV-tPA-treated patients admitted to the ICU at a CSC. We evaluated the frequency, timing, and nature of ICU interventions. RESULTS: Three hundred and thirty one patients were treated with sIV-tPA and 42% required ICU interventions during ICU admission. Of patients requiring ICU interventions, 98% had an ICU intervention performed in triage, prior to admission. National Institute of Health Stroke Scale score only had a moderate association to requirement of ICU interventions. Neither transferring patients to a CSC nor the number of standard IV-tPA contraindications increased ICU interventions. CONCLUSIONS: Liberalized IV-tPA administration did not increase ICU interventions. Nearly all patients that required ICU interventions declared this need in triage, prior to ICU admission. This timing of ICU intervention use during triage is highly sensitive for whether a patient will require ongoing ICU-level care during hospital admission. Identifying ICU intervention use in triage may allow for more effective placement of post-IV-tPA patients in the appropriate inpatient care setting, leading to better utilization of scarce ICU resources.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Unidades de Terapia Intensiva , Admissão do Paciente , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Triagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva/normas , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Seleção de Pacientes , Transferência de Pacientes , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/normas , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Triagem/normas
4.
J Stroke Cerebrovasc Dis ; 28(9): 2481-2487, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277996

RESUMO

The Goal: The aim of the study was to investigate whether stroke volume or the presence of ischemic stroke lesion on follow-up computed tomography 1 day after admission had association with sleep apnea among ischemic stroke patients undergoing thrombolysis. MATERIALS AND METHODS: We prospectively recruited 110 consecutive ischemic stroke patients and performed computed tomography on admission and after 24 hours after intravenous thrombolysis. Stroke volume was measured from post-thrombolysis computed tomography scans. Unattended cardiorespiratory polygraphy with a 3-channel device was performed during 48 hours after admission. FINDINGS: Of 110 ischemic stroke patients treated with thrombolysis 65.5% were men. Mean age was 65.8 years and body mass index 27.5 kg/m2. The mean Epworth sleepiness scale score was 4.7. Eight patients (12.7%) with visible acute stroke after thrombolysis and none in the other group had hemorrhage as complication (P ˂ .001). Sleep apnea, determined as a respiratory event index greater than or equal to 5/hour, was diagnosed in 96.4% patients. Respiratory event index greater than 15/h was found in 72.8% of patients. Both mean baseline oxygen desaturation index (23.9 versus 16.5, P = .028) and obstructive apneas/hour (6.2 versus 2.7, P = .007) were higher in visible stroke group. Stroke volume (mean 15.9 mL) correlated with proportion of time spent below saturation less than 90%, P = .025. CONCLUSIONS: Acute ischemic stroke patients treated with thrombolysis with visible stroke were more likely to have nocturnal hypoxemia than patients with not visible strokes. Stroke volume correlated with time spent below saturation of 90%.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Hipóxia/etiologia , Síndromes da Apneia do Sono/etiologia , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Hipóxia/diagnóstico , Hipóxia/fisiopatologia , Infusões Intravenosas , Pulmão/fisiopatologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração , Fatores de Risco , Sono , Síndromes da Apneia do Sono/diagnóstico , Síndromes da Apneia do Sono/fisiopatologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
5.
Vasc Endovascular Surg ; 53(7): 558-562, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31327305

RESUMO

OBJECTIVE: Thrombolytic therapy is widely used in the treatment of arterial occlusions causing acute limb ischemia (ALI); however, knowledge regarding the efficacy of the different catheter systems available is scarce. The objective of this study was to compare the safety and efficacy of 2 catheter-directed infusion systems for intra-arterial thrombolysis in the setting of ALI. METHODS: A retrospective analysis was conducted to study all catheter-directed thrombolysis procedures performed over 32 months in patients diagnosed with ALI. Patients with thrombosis in both native arteries and bypass grafts were included. Patients with contraindications to thrombolysis, or those receiving thrombolysis for deep venous thrombosis, were excluded. The duration of thrombolysis, amount of thrombolytic agent, and technical success rate were recorded. Technical success was defined as complete or near-complete resolution of thrombus burden, allowing for further intervention. Data were stratified to include location of thrombus, procedural complications, mortality, and rates of limb loss. RESULTS: Ninety-one patients met inclusion criteria. Among them, Uni-Fuse and EKOS catheters were used in 69 and 22 patients, respectively. The mean age of the population was 71 (standard deviation [SD]: ±1.5) for patients treated with the EKOS catheter and 70 years (SD: ±2.6) for patients receiving thrombolysis with Uni-Fuse. There was no significant difference in the mean infusion duration (1.65 vs 1.9 days), volume of tissue plasminogen activator (44.6 vs 48.2 mg), or technical success rate (72% vs 86%) between the Uni-Fuse and EKOS cohorts (P > .3). Furthermore, there was no difference in major limb loss or compartment syndrome between each group (P > .4). The overall complication rate was 14% in both groups, with a 30-day mortality rate of 4% when treated with either catheter system. CONCLUSION: This study suggests that a standard multi-hole infusion catheter demonstrates similar clinical safety and efficacy as the ultrasound-accelerated EKOS system in the treatment of ALI.


Assuntos
Cateterismo Periférico , Fibrinolíticos/administração & dosagem , Isquemia/terapia , Doença Arterial Periférica/terapia , Terapia Trombolítica , Trombose/terapia , Terapia por Ultrassom , Doença Aguda , Idoso , Amputação , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Registros Eletrônicos de Saúde , Desenho de Equipamento , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Parenterais , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/instrumentação , Trombose/diagnóstico por imagem , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Terapia por Ultrassom/efeitos adversos , Terapia por Ultrassom/instrumentação , Dispositivos de Acesso Vascular
6.
J Stroke Cerebrovasc Dis ; 28(8): 2255-2261, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31153762

RESUMO

OBJECTIVE: We sought to characterize the US nationwide temporal trends in recanalization therapy utilization for ischemic stroke among patients with and without cancer. METHODS: We identified all acute ischemic stroke (AIS) hospitalizations in the National Inpatient Sample from January 1, 1998 to September 30, 2015. The primary exposure was solid or hematologic cancer. The primary outcome was use of intravenous thrombolysis. The secondary outcome was use of endovascular therapy (EVT). RESULTS: Among 9,508,804 AIS hospitalizations, 503,510 (5.3%) involved cancer patients. Intravenous thrombolysis use among ischemic stroke patients with cancer increased from .01% (95% confidence interval [CI], .00%-.02%) in 1998 to 4.91% (95% CI, 4.33%-5.48%) in 2015, whereas intravenous thrombolysis use among ischemic stroke patients without cancer increased from .02% (95% CI, .01%-.02%) in 1998 to 7.22% (95% CI, 6.98%-7.45%) in 2015. The demographic- and comorbidity-adjusted odds ratio/year of receiving intravenous thrombolysis was similar in patients with cancer (1.21; 95% CI, 1.20-1.23) versus those without (1.20; 95% CI, 1.19-1.21). EVT use among ischemic stroke patients with cancer increased from .05% (95% CI, .02%-.07%) in 2006 to 1.90% (95% CI, 1.49%-2.31%) in 2015, whereas EVT use among ischemic stroke patients without cancer increased from .09% (95% CI, .00%-.18%) in 2006 to 1.88% (95% CI, 1.68%-2.09%) in 2015. CONCLUSIONS: Among 9.5 million AIS hospitalizations, patients with cancer received intravenous thrombolysis about two thirds as often as patients without cancer. This difference persisted over time despite increased utilization in both groups. EVT utilization was similar between cancer and non-cancer AIS patients.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/tendências , Fibrinolíticos/administração & dosagem , Disparidades em Assistência à Saúde/tendências , Neoplasias/epidemiologia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/tendências , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Comorbidade , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , Hospitalização/tendências , Humanos , Masculino , Neoplasias/diagnóstico , Neoplasias/terapia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
7.
BMC Neurol ; 19(1): 127, 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31195995

RESUMO

BACKGROUND: Immune cells are involved in all stages of acute ischaemic stroke (AIS) and possess both neuroprotective and neurodamaging properties. It has been suggested that immune system activation after stroke may be associated with the development of haemorrhagic transformation (HT), which is the main complication limiting the clinical use of intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) for AIS. The purpose of our study was to analyse the association between absolute eosinophil count (AEC) at admission and the occurrence of HT after intravenous rtPA therapy for AIS. METHODS: In this retrospective study we enrolled AIS patients who were treated with rtPA within 4.5 h of symptom onset. Baseline stroke severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS). Patients underwent head computed tomography scans at admission which were repeated 24 h after treatment with rtPA or promptly in case of clinical deterioration. HT was defined as blood at any site in the brain on follow-up head computed tomography scans. Spearman's rank correlation test was used to analyse the correlation between AEC and NIHSS scores. The optimal AEC cut-off value for predicting HT was calculated using the area under the receiver operating characteristic curve. Multiple logistic regression was used to determine the association between AEC included as a binary variable and the incidence of HT. RESULTS: The data of 201 patients was analysed (59.7% females; median age 77 years); 23 (11.4%) of them developed HT. The median of AEC was 62.5% greater in the non-HT group compared to the HT group (0.13 ×  109/l and 0.08 × 109/l, respectively, p = 0.026). No correlation was found between AEC and baseline NIHSS scores (r = 0.061, p = 0.393). AEC ≥ 0.11 × 109/l predicted the occurrence of HT with 69.6% sensitivity and 60.7% specificity. AEC ≥ 0.11 × 109/l was independently associated with a 78% reduction in the odds of developing HT (adjusted odds ratio = 0.223, 95% confidence interval = 0.069-0.723, p = 0.012). CONCLUSION: Higher values of AEC were associated with lower odds of developing HT, thus, AEC at admission could be considered an independent predictive marker of HT after treatment with rtPA for AIS.


Assuntos
Biomarcadores/sangue , Hemorragia Cerebral/etiologia , Eosinófilos , Acidente Vascular Cerebral/complicações , Ativador de Plasminogênio Tecidual/efeitos adversos , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/complicações , Hemorragia Cerebral/sangue , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Curva ROC , Estudos Retrospectivos , Sensibilidade e Especificidade , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/métodos
8.
J Stroke Cerebrovasc Dis ; 28(8): 2337-2342, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31182266

RESUMO

INTRODUCTION: Monitoring of acute ischaemic stroke patients during thrombolysis or thrombectomy is based mostly on frequent physical examinations, since no objective measurement of cerebrovascular haemodynamics is available in routine clinical practice. Near-infrared spectroscopy (NIRS) is a bed-side, noninvasive assessment tool that could help monitor these patients and potentially guide therapeutic interventions. Our goal in this pilot study was to investigate whether NIRS is a suitable method to monitor leptomeningeal collateral circulation via changes in cortical oxygen saturation in the first 24 hours of acute ischaemic stroke. PATIENTS AND METHODS: Our study included 5 patients with acute anterior circulation infarcts. All patients received thrombolytic therapy and 1 had thrombectomy. 24-hour continuous NIRS monitoring was performed on all participants. RESULTS: We aimed to give a detailed description of each NIRS recording and explain how the observed findings could correlate with changes in anterior watershed territory collateral circulation and clinical outcome. CONCLUSION: Our pilot study supports the use of NIRS monitoring in acute ischaemic stroke. We believe that this technique could provide real-time information on the dynamic changes of leptomeningeal collateral circulation and help monitor the effects of thrombolysis and thrombectomy.


Assuntos
Infarto Encefálico/diagnóstico , Infarto Encefálico/terapia , Fibrinolíticos/administração & dosagem , Monitorização Ambulatorial/métodos , Sistemas Automatizados de Assistência Junto ao Leito , Testes Imediatos , Espectroscopia de Luz Próxima ao Infravermelho , Trombectomia , Terapia Trombolítica/métodos , Idoso , Idoso de 80 Anos ou mais , Infarto Encefálico/sangue , Infarto Encefálico/fisiopatologia , Circulação Cerebrovascular , Circulação Colateral , Imagem de Difusão por Ressonância Magnética , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Valor Preditivo dos Testes , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
9.
J Stroke Cerebrovasc Dis ; 28(8): 2287-2291, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31208820

RESUMO

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


Assuntos
Isquemia Encefálica/terapia , Fibrinolíticos/administração & dosagem , Neoplasias/complicações , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Nível de Saúde , Humanos , Hemorragias Intracranianas/induzido quimicamente , Expectativa de Vida , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias/diagnóstico , Neoplasias/mortalidade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento
10.
J Stroke Cerebrovasc Dis ; 28(8): e123-e125, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31230823

RESUMO

Ischemic stroke is one of the most common complications of infective endocarditis (IE). IE must be considered as one of the causes of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), but early diagnosis of IE is difficult. AIS with ELVO must be treated using endovascular thrombectomy (EVT), with or without intravenous thrombolysis (IVT). IVT for AIS due to IE is not well established and remains controversial because of the risk of intracranial hemorrhage. A 42-year-old man suffered from right hemiparesis and disorientation, and AIS with ELVO was diagnosed. EVT with IVT was successfully performed and recanalization was achieved, but catastrophic multiple cerebral microbleeds appeared after treatment. EVT without IVT could be chosen for AIS caused by IE to avoid hemorrhagic complications. Hypointense signal spots on T2*-weighted magnetic resonance imaging (MRI) and susceptibility-weighted MRI could facilitate early diagnosis of IE.


Assuntos
Isquemia Encefálica/terapia , Endocardite Bacteriana/complicações , Procedimentos Endovasculares/efeitos adversos , Hemorragias Intracranianas/etiologia , Acidente Vascular Cerebral/terapia , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Angiografia Cerebral/métodos , Imagem de Difusão por Ressonância Magnética , Endocardite Bacteriana/diagnóstico , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
12.
J Vasc Surg ; 69(6): 1976-1988.e7, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159991

RESUMO

BACKGROUND: The major pitfall of arteriovenous grafts (AVGs) for hemodialysis patients is thrombosis and occlusion. Prompt intervention with either surgical or endovascular therapy to salvage the vascular access is crucial in maintaining effective hemodialysis. The purpose of this systematic review and meta-analysis was to assess and compare the efficacy of open surgical vs wholly endovascular therapy for the treatment of thrombosed AVGs. METHODS: This review was conducted according to the PRISMA guidelines. Relative risks **(RRs) and pooled proportions for both primary and secondary outcomes were calculated. RESULTS: A total of eight randomized, controlled trials and two retrospective cohort studies were included, comprising 806 (63%) and 466 (37%) participants in the surgical and wholly endovascular treatment arms respectively. There were no significant differences between endovascular and surgical therapy in the 30-, 60-, and 90-day primary nonpatency rates. However, endovascular therapy reported a significantly higher 1-year primary nonpatency rate (rate ratio [RR], 1.22; 95% confidence interval [CI], 1.13-1.33; P < .01) and the 2-year primary nonpatency rate (RR, 1.26; 95% CI, 1.10-1.45; P < .01) as compared with surgical therapy. Similarly, the endovascular arm had a higher pooled proportion of primary nonpatency of 87.7% (95% CI, 81.5%-92.9%; P = .297), as compared with the surgical arm (72.1%; 95% CI, 66.4%-77.4%; P = .289). In terms of secondary nonpatency rates, there were no significant differences between endovascular and surgical procedures at 30, 60, and 90 days. Endovascular procedures reported a significantly higher technical failure rate as compared with surgical thrombectomy (RR, 1.58; 95% CI, 1.06-2.37; P = .03). There was no significant difference in terms of minor and major complications. CONCLUSIONS: Our data suggest that, for thrombectomy of AVGs, wholly endovascular therapy seems to be inferior to open surgery plus adjuncts based on the long-term patency and technical failure rates. However, further research in the form of a well-conducted randomized trial is warranted to establish a firmer conclusion.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/métodos , Oclusão de Enxerto Vascular/cirurgia , Diálise Renal , Trombectomia/métodos , Terapia Trombolítica/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/instrumentação , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/efeitos adversos , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Pessoa de Meia-Idade , Fatores de Risco , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento , Grau de Desobstrução Vascular , Adulto Jovem
13.
J Clin Neurosci ; 66: 45-50, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31153752

RESUMO

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


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/tendências , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária/tendências , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/diagnóstico , Procedimentos Endovasculares/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/etiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/tendências , Tirofibana/efeitos adversos , Tirofibana/uso terapêutico , Resultado do Tratamento
14.
BMJ Case Rep ; 12(5)2019 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-31061182

RESUMO

We report the experience of reversing dabigatran prior to administering systemic thrombolysis for acute ischaemic cerebellar stroke, which was well tolerated with no haemorrhagic complications after thrombolysis. Given the increasingly common use of dabigatran for atrial fibrillation, the use of idarucizumab to reverse of dabigatran is a novel treatment that should be considered as an important adjunct to facilitate thrombolysis for ischaemic strokes and minimise haemorrhagic complications.


Assuntos
Anticorpos Monoclonais Humanizados/administração & dosagem , Isquemia Encefálica/tratamento farmacológico , Dabigatrana/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/patologia , Humanos , Masculino , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/patologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
15.
J Stroke Cerebrovasc Dis ; 28(7): 1853-1859, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31072698

RESUMO

BACKGROUND AND AIMS: The Neutrophil-to-Lymphocyte Ratio (NLR) is suggested as a readily available and inexpensive biomarker to predict prognosis of acute stroke. Experience with intravenous (IV) tissue plasminogen activator (tPA) treatment is limited. METHODS: Total 142 (80 female, age: 69 ± 13 yearr) consecutive acute stroke patients treated with IV tPA were evaluated. Admission and 24th hour lymphocyte, neutrophil, and monocyte counts were measured and the NLR was calculated. RESULTS: Average NLR elevated (by 3.47 ± 6.75) significantly from admission to 24th hour (P< .001). Total 52% of patients exerted good response to IV tPA (NIHSS ≤1 or decrease in NIHSS ≥4 at end of 24 hour), while 27% showed dramatic response (decrease in NIHSS ≥8 at end of 24 hour). The patients with "thrombolysis resistance" had significantly higher 24 hour Neutrophil-to-Lymphocyte Ratio (24h NLR) (P= .001). At the end of 3rd month, 46.5% of patients had favorable (modified Rankin's score, mRS 0-2) and 32.4% had excellent (mRS 0-1) outcome. Patients without favorable/excellent outcome had significantly higher 24h NLRs. Regression analysis indicated that post-tPA, but not admission NLR, was an independent negative predictor of excellent (ß =-.216, P= .006) and favorable (ß = -.179, P= .034) outcome after adjustment for age, hypertension, and admission NIHSS. Nine patients who developed symptomatic intracerebral hemorrhage had elevated pre-tPA (7.6 ± 7.39 versus 3.33 ± 3.07, P< .001) and 24h NLR (26.2 ± 18.6 versus 5.78 ± 4.47, P< .001). Of note, receiver operating characteristics analysis failed to detect any reliable NLR threshold for absence of tPA effectiveness/dramatic response, 3rd month good/excellent outcome or any type tPA-induced hemorrhage. CONCLUSIONS: As a marker of stroke-associated acute stress response, the NLR, which increases during the first 24 hours, is an epiphenomenon of poor prognosis. However, pretreatment NLR values have no importance in predicting IV tPA response.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Linfócitos , Neutrófilos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Hemorragia Cerebral/sangue , Hemorragia Cerebral/induzido quimicamente , Avaliação da Deficiência , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
16.
J Stroke Cerebrovasc Dis ; 28(8): 2207-2212, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31129109

RESUMO

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


Assuntos
Isquemia Encefálica/terapia , Endocardite/complicações , Procedimentos Endovasculares/métodos , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Administração Intravenosa , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Endocardite/diagnóstico , Endocardite/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do Tratamento
18.
Ann Vasc Surg ; 56: 17-23, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30982504

RESUMO

BACKGROUND: Inferior vena cava thrombosis (IVCT), although rare, has a potential for significant morbidity and mortality. IVCT is often a result of IVC filter thrombosis, but it can also occur de novo. Although anticoagulation remains the standard of care, endovascular techniques to restore IVC patency have become key adjunctive therapies in recent years. This study examines a single-center experience with diagnosis and management of IVCT. METHODS: A retrospective Institutional Review Board-approved review of a single-center institutional database was screened to identify IVCT thrombosis using International Classification of Diseases code 453.2 over a 3-year period. Etiology of IVCT was separated into 2 groups: those with IVC thrombosis in the setting of prior IVC filter place and those in whom IVCT occurred de novo. Patient demographics, presenting characteristics, and management of IVCT were examined. Treatment options included expectant management with anticoagulation versus catheter-directed thrombolysis (CDT), mechanical thrombectomy, stenting, or a combination. For those who underwent intervention, technical success, defined as restoration of IVC patency, was assessed. RESULTS: Forty-one unique patients were identified with radiographically confirmed diagnosis of ICVT (mean age 61, range 25-91; 21 female, 51.2%). Eighteen (43.9%) patients presented with thrombosed IVC filter. Risk factors for venous thromboembolism included tobacco usage, current or prior smoking (n = 17, 41.5%), history of prior deep vein thrombosis (n = 25, 61.0%), malignancy (n = 17, 41.5%), use of hormonal supplements (n = 3, 7.3%), known thrombophilia (n = 4, 9.8%), and obesity (body mass index: mean 29, range 18.8-58.53). Eleven patients (26.8%) presented with pulmonary embolism (PE), and of those 63.6% had IVC filter thrombosis (n = 7). Risk of PE was not significantly different between those patients presenting with a thrombosed IVC filter compared to those with de novo IVCT (38.9% vs. 17.4%, P = 0.12) Management of IVCT included anticoagulation alone (n = 27, 65.9%), CDT (n = 5, 12.2%), mechanical thrombolysis (n = 10, 24.4%), and adjunctive IVC stent (n = 3, 7.3%). Among the 14 (34.1%) patients who had intervention for IVCT, patency was restored in 12 patients (85.7%). CONCLUSIONS: IVCT is a rare event and is associated with known risk factors for venous thromboembolism. PE can occur in roughly 25% of patients presenting with IVCT. Presence of a filter does not appear to confer an advantage in preventing PE when IVCT occurs. Although majority of IVCT is managed with anticoagulation alone, endovascular interventions, including lysis and stenting, can safely restore patency in most properly selected patients.


Assuntos
Anticoagulantes/uso terapêutico , Trombectomia , Terapia Trombolítica , Veia Cava Inferior , Trombose Venosa/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Flebografia/métodos , Estudos Retrospectivos , Fatores de Risco , Stents , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento , Grau de Desobstrução Vascular , Filtros de Veia Cava/efeitos adversos , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/fisiopatologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia , Trombose Venosa/fisiopatologia
19.
Vasc Med ; 24(2): 122-131, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30950331

RESUMO

Venous thromboembolism (VTE) is a common vascular condition. New medications are available to prevent hospital-associated VTE. Strategies are being studied to increase appropriate diagnostic testing utilization. Management of deep vein thrombosis (DVT) and pulmonary embolism (PE) has evolved with the advent of new anticoagulant options and catheter-directed intervention. In light of this, providers are commonly challenged with the decision regarding inpatient versus outpatient management. Which patients require long-term (> 3 months) anticoagulation is challenging and multiple clinical prediction models may be used to help determine the risk-benefit ratio in each patient. The management of VTE is an ongoing area of research and is rapidly evolving.


Assuntos
Anticoagulantes/administração & dosagem , Fibrinolíticos/administração & dosagem , Terapia Trombolítica/métodos , Tromboembolia Venosa/tratamento farmacológico , Anticoagulantes/efeitos adversos , Tomada de Decisão Clínica , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Seleção de Pacientes , Recidiva , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologia
20.
J Stroke Cerebrovasc Dis ; 28(6): 1440-1447, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30952531

RESUMO

BACKGROUND AND PURPOSE: 15% of cerebral venous thrombosis (CVT) patients have poor outcomes despite anticoagulation. Uncontrolled studies suggest that endovascular approaches may benefit such patients. In this study, we analyze Nationwide Inpatient Sample (NIS) data to evaluate the safety and efficacy of endovascular therapy (ET) versus medical management in CVT. We also examined the yearly trends of ET utilization in the United States. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes were utilized to identify CVT patients who received ET. To make the data nationally representative, weights were applied per NIS recommendations. Since ET was not randomly assigned to patients and was likely to be influenced by disease severity, propensity score weighting methods were utilized to correct for this treatment selection bias. Outcome variables included in-hospital mortality and discharge disposition. To determine if our primary outcomes were associated with ET, we used weighted multivariable logistic regression analyses. RESULTS: Of the 49,952 estimated CVT cases, 48,704 (97%) received medical management and 1248 (3%) received ET (mechanical thrombectomy [MT] alone, N = 269 [21%], MT ± thrombolysis, N = 297 [24%], and thrombolysis alone, N = 682 [55%]). Patients who received ET were older with more CVT associated complications including venous infarct, intracranial hemorrhage, coma, seizure, and cerebral edema. There was a significant yearly rise in the use of ET, with a trend favoring MT versus thrombolysis alone. ET was independently associated with an increased risk of death (odds ratio 1.96, 95% confidence interval 1.15-3.32). CONCLUSIONS: Patients receiving ET experienced higher mortality after adjusting for age and CVT associated complications. Large, well designed prospective randomized trials are warranted for further evaluation of the safety and efficacy of ETs.


Assuntos
Procedimentos Endovasculares/tendências , Pacientes Internados , Trombose Intracraniana/terapia , Padrões de Prática Médica/tendências , Trombectomia/tendências , Terapia Trombolítica/tendências , Trombose Venosa/terapia , Adulto , Idoso , Fármacos Cardiovasculares/uso terapêutico , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/mortalidade , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/mortalidade
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