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1.
J Stroke Cerebrovasc Dis ; 29(3): 104545, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31879134

RESUMO

BACKGROUND AND PURPOSE: Currently, mechanical thrombectomy (MT) for emergent large-vessel occlusion (ELVO) has been widely used in the clinic. However, the question about whether MT provides the same benefits between posterior circulation emergent large vessel occlusion (pc-ELVO) and anterior emergent large vessel occlusion (ac-ELVO) remains unclear. MATERIAL AND METHODS: We conducted a systematic review and meta-analysis of 11 studies published between 2011 and 2019 through searching the PubMed, EMBASE, and Cochrane Library. Major clinical outcomes include: (1) favorable functional outcome at 90 days; (2) symptomatic intracerebral hemorrhage (sICH); (3) mortality and; (4) successful recanalization rate. RESULTS: Eleven of 4637 studies met our pre-established inclusion criterion, comprising 4619 patients. In primary analysis, MT in patients with pc-ELVO in comparison to patients with ac-ELVO had a lower likelihood of sICH (odds ratio [OR] = .48; [95% confidence interval (CI), .26-.88]; P = .02) but a higher likelihood of mortality (OR = 1.98; [95% CI, 1.37-2.87]; P = .0003). The pooled evidence indicated that patients with pc-ELVO had worse functional outcome than patients with ac-ELVO in the large sample size group (OR = .79; [95% CI, .63-.98]; P = .03). In addition, no statistical significance was found in the outcome of successful recanalization rate (OR = 1.12; [95% CI, .88-1.42]; P = .35). CONCLUSIONS: Our results showed that patients with pc-ELVO receiving MT reduced the risk of sICH but seemed to be associated with poor prognosis.


Assuntos
Isquemia Encefálica/terapia , Trombólise Mecânica , Acidente Vascular Cerebral/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Avaliação da Deficiência , Feminino , Humanos , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(14): e14956, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30946319

RESUMO

BACKGROUND: Whether bridging strategies[intravenous thrombolysis (IVT) + mechanical thrombectomy (MT)] are superior to mechanical thrombectomy alone for large vessel occlusion(LVO) is still uncertain. A systematic review and meta-analysis was conducted to investigate and evaluate comparative efficacy and safety of bridging strategies vs direct MT in patients with LVO. METHODS: The PubMed, EMBASE and Cochrane library databases were searched to evaluate the efficacy and safety of bridging strategies with direct MT in LVO. Functional independence, mortality, symptomatic intracranial hemorrhage (sICH) and successful recanalization were assessed. The risk ratio (RR) and its 95% confidence interval (CI) were calculated. RESULTS: The proportion of patients who received MT + IVT was significantly higher in functional independence and successful recanalization rate than MT alone patients. However, pooled results showed that the mortality of patients who received MT + IVT was significantly lower than that of MT alone patients. Moreover, no significant differences were observed in the incidence of sICH between the 2 groups. CONCLUSION: The findings of our meta-analysis confirmed that bridging strategies improved functional outcomes, successful recanalization rate and reduced mortality rates. Moreover, the incidence of sICH showed no differences between the bridging strategies and MT alone treatments. However, the conduct of high-quality randomized clinical trials that directly compare both strategies is warranted.


Assuntos
Isquemia Encefálica/terapia , Trombólise Mecânica/métodos , Trombectomia/métodos , Terapia Trombolítica/métodos , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Procedimentos Endovasculares/métodos , Feminino , Humanos , Incidência , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/mortalidade , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
3.
Radiologia ; 61(2): 143-152, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30616862

RESUMO

PURPOSE: Endovascular treatment with mechanical thrombectomy devices demonstrated high recanalization rates but functional outcome did not correlate with high rates of recanalization obtained. Patient selection prior to the endovascular treatment is very important in the final outcome of the patient. The primary aim of our study was to evaluate the prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) and Pons-Midbrain Index (PMI) scores in patients with Basilar Artery Occlusion (BAO) treated with successful angiographic recanalization after mechanical thrombectomy. METHODS: Retrospective single-center study including 18 patients between 2008 and 2013 who had acute basilar artery occlusion managed with endovascular treatment within 24hours from symptoms onset and with successful angiographic recanalization. The patients were initially classified into two groups according to clinical outcome and mortality at 90 days. For analysis we also divided patients into groups based on pc-ASPECTS (≥8vs.<8) and PMI (≥3vs.<3) on non-contrast CT (NCCT) and CT Angiography Source Images (CTASI). Imaging data were correlated to clinical outcome and mortality rate. RESULTS: CTASI pc-ASPECTS, dichotomized at <8 versus≥8, was associated with a favorable outcome (RR: 2.6; 95% CI: 1.3-5.2) and a reduced risk of death (RR: 6.5: 95% CI: 7.8-23.3). All patients that survived and were functionally independent had pc-ASPECTS score≥8. None of the 5 patients with CTASI pc-ASPECTS score less than 8 survived. CONCLUSION: PC-ASPECTS on CTASI is helpful for predicting functional outcome after BAO recanalization with endovascular treatment. These results should be validated in a randomized controlled trial in order to decide whether or not to treat a patient with BAO.


Assuntos
Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares , Trombólise Mecânica , Insuficiência Vertebrobasilar/cirurgia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Estudos Retrospectivos , Tempo para o Tratamento , Resultado do Tratamento , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/mortalidade
4.
J Stroke Cerebrovasc Dis ; 28(2): 259-266, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30442556

RESUMO

BACKGROUND: Mechanical thrombectomy (MT) in association with intravenous thrombolysis is recommended for treatment of acute ischemic stroke (AIS), with large vessel occlusion (LVO) in the anterior circulation. Because MT is only available in comprehensive stroke centers (CSC), the challenge of stroke organization is to ensure equitable access to the fastest endovascular suite. Our aim was to evaluate the feasibility, efficacy, and safety of MT in patients initially managed in 1 CSC (mothership), compared with patients first managed in primary stroke center (PSC), and then transferred to the CSC for MT (drip-and-ship). METHODS: We retrospectively analyzed 179 consecutive patients (93 in the mothership group and 86 in the drip-and-ship group), with AIS secondary to LVO in the anterior cerebral circulation and a clinical-radiological mismatch (NIHSS ≥ 8 and DWI-ASPECT score ≥5), up to 6 hours after symptoms onset. We evaluated 3-month functional modified Rankin scale (mRS), periprocedural time management, mortality, and symptomatic intracranial haemorrhage (sICH). RESULTS: Despite significant longer process time in the drip-and-ship group, mRS ≤ 2 at 3 months (39.8% versus 44.1%, P = .562), Thrombolysis in cerebral infarction 2b-3 (85% versus 78%, P = .256), and sICH (7.0% versus 9.7%, P = .515) were similar in both group regardless of baseline clinical or radiological characteristics. After multivariate logistic regression, the predictive factors for favorable outcome were age (odds ratio [OR] -5years= 1.32, P < .001), initial NIHSS (OR -5points = 1.59, P = .010), absence of diabetes (OR = 3.35, P = .075), and the delay magnetic resonance imagining-puncture (OR -30min = 1.16, P = .048). CONCLUSIONS: Our study showed encouraging results from a regional protocol of MT comparing patients transferred from PSC or brought directly in CSC.


Assuntos
Infarto Encefálico/cirurgia , Prestação Integrada de Cuidados de Saúde/organização & administração , Fibrinolíticos/administração & dosagem , Trombólise Mecânica , Transferência de Pacientes/organização & administração , Regionalização/organização & administração , Trombectomia , Tempo para o Tratamento/organização & administração , Idoso , Infarto Encefálico/diagnóstico , Infarto Encefálico/mortalidade , Infarto Encefálico/fisiopatologia , Avaliação da Deficiência , Estudos de Viabilidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
5.
J Cardiovasc Med (Hagerstown) ; 20(3): 131-136, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30585869

RESUMO

AIMS: The aim of this study was to evaluate the safety and efficacy of the EkoSonic Endovascular System (EKOS) in patients with acute pulmonary embolism (APE) at high or intermediate-high risk and contraindication to systemic fibrinolysis. METHODS: This is a retrospective study including consecutive patients admitted due to high-risk or intermediate-high-risk APE and treated by EKOS because of an absolute or relative contraindication to systemic fibrinolysis. The primary efficacy end-point was the change from baseline to 72 h in right to left ventricular dimension ratio [right ventricular/left ventricular (RV/LV) ratio]; pulmonary embolic burden using the Qanadli Index; and systolic pulmonary arterial pressure (SPAP). The primary safety end-point was the occurrence of bleeding (GUSTO classification) within 72 h. RESULTS: Eighteen patients (5 men, 13 women; mean age 74 ±â€Š12.7 years) affected by high-risk APE (n = 5; 27.8%) or intermediate-high-risk APE (n = 13; 72.2%) were included. A significant reduction of mean RV/LV ratio (1.38 ±â€Š0.3 vs. 0.97 ±â€Š0.16; P < 0.0005); Qanadli Index [27.06 ±â€Š2.6 vs. 18.8 ±â€Š7.8 (P < 0.001) and SPAP (71.1 ±â€Š12 vs. 45.2 ±â€Š16 mmHg; P < 0.001)] was observed within 72 h after EKOS. Five bleeding events occurred: one fatal and four moderates; three out of them led to the access site hematoma, two due to pre-existing active bleeding. CONCLUSION: EKOS is an effective tool to treat patients with APE at high or intermediate-high risk and contraindication to fibrinolysis. It is a relatively safe therapy considering the critical conditions and high bleeding risk of the receiving population.


Assuntos
Procedimentos Endovasculares/instrumentação , Fibrinolíticos/efeitos adversos , Trombólise Mecânica/instrumentação , Embolia Pulmonar/terapia , Terapia Trombolítica/efeitos adversos , Terapia por Ultrassom/instrumentação , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Contraindicações de Medicamentos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Hemodinâmica , Hemorragia/etiologia , Humanos , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Terapia por Ultrassom/efeitos adversos , Terapia por Ultrassom/mortalidade , Função Ventricular Esquerda , Função Ventricular Direita
6.
Clin Neuroradiol ; 29(1): 153-160, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29260256

RESUMO

BACKGROUND: Mechanical thrombectomy (MT) of basilar artery occlusions (BAO) is a subject of debate. We investigated the clinical outcome of MT in BAO and predictors of a favorable outcome. MATERIAL AND METHODS: A total of 104 MTs of BAO (carried out between 2010 and 2016) were analyzed. Favorable outcome as a modified Rankin scale (mRS) ≤ 2 at 90 days was the primary endpoint. The influence of the following variables on outcome was investigated: number of detectable posterior communicating arteries (PcoAs), patency of basilar tip, completeness of BAO and posterior circulation Alberta Stroke Program early computed tomography score (PC-ASPECTS). Secondary endpoints were technical periprocedural parameters including symptomatic intracranial hemorrhage (sICH). RESULTS: The favorable clinical outcome at 90 days was 25% and mortality was 43%. The rate of successful reperfusion, i.e. modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was 82%. Presence of bilateral PcoAs (area under the curve, AUC: 0.81, odds ratio, OR: 4.2, 2.2-8.2; p < 0.0001), lower National Institute of Health Stroke Scale (NIHSS) on admission (AUC: 0.74, OR: 2.6, 1.3-5.2; p < 0.01), PC-ASPECTS ≥ 9 (AUC: 0.72, OR: 4.2, 1.5-11.9; p < 0.01), incomplete BAO (AUC: 0.66, OR: 2.6, 1.4-4.8; p < 0.001), and basilar tip patency (AUC: 0.66, OR: 2.5, 1.3-4.8; p < 0.01) were associated with a favorable outcome. Stepwise logistic regression analysis revealed that the strongest predictors of favorable outcome at 90 days were bilateral PcoAs, low NIHSS on admission, and incomplete BAO (AUC: 0.923, OR: 7.2, 3-17.3; p < 0.0001). CONCLUSION: The use of MT for BAO is safe with high rates of successful reperfusion. Aside from baseline NIHSS and incomplete vessel occlusion, both known predictors of favorable outcome in anterior circulation events, we found that collateral flow based on the presence or absence of PcoAs had a decisive prognostic impact.


Assuntos
Arteriopatias Oclusivas/cirurgia , Artéria Basilar/cirurgia , Trombólise Mecânica/métodos , Idoso , Área Sob a Curva , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/mortalidade , Artéria Basilar/diagnóstico por imagem , Artérias Cerebrais/diagnóstico por imagem , Circulação Colateral , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Hemorragias Intracranianas , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/mortalidade , Análise Multivariada , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Reperfusão , Fatores de Tempo , Resultado do Tratamento
7.
World Neurosurg ; 119: e941-e946, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30103058

RESUMO

BACKGROUND: Although elderly patients have generally worse outcomes after acute ischemic stroke, they may derive significant incremental benefit from thrombectomy as compared with medical management. Although several case series for octogenarians have been reported, data for nonagenarians are scarce. METHODS: A prospectively maintained institutional mechanical thrombectomy database was reviewed for nonagenarians who underwent thrombectomy between January 2013 and July 2017. Patient demographic data and clinical history data were extracted, and clinical and radiographic outcomes were assessed. Univariate analysis was used to determine correlation between treatment and radiographic data and outcome. RESULTS: During the study period, 30 patients ≥90 years old underwent mechanical thrombectomy. Median National Institutes of Health Stroke Scale score on presentation was 20. Successful reperfusion (Thrombolysis In Cerebral Infarction 2b/3) was achieved in 27 patients (90%). One patient (3%) was discharged to home, and 9 patients (30%) were discharged to a rehabilitation facility. The 90-day mortality was 70%. Six patients (21%) returned to living at home. All 6 patients had successful reperfusion after the procedure; average infarct burden on postthrombectomy neuroimaging was 1.5 cm3, and infarct volume was <7 cm3 in all cases. Final infarct volume of <10 cm3 was a strong predictor of whether a patient returned to live at home (P = 0.002), with a trend toward better outcome as assessed by modified Rankin Scale (P = 0.076). CONCLUSIONS: Large vessel thrombectomy in nonagenarians is safe and offers patients a chance at returning to functional baseline. All patients returning home in our cohort had successful recanalization and minimal stroke burden after thrombectomy.


Assuntos
Infarto Cerebral/terapia , Trombólise Mecânica/métodos , Atividades Cotidianas , Idoso de 80 Anos ou mais , Infarto Cerebral/mortalidade , Infarto Cerebral/patologia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Trombólise Mecânica/mortalidade , Alta do Paciente/estatística & dados numéricos , Estudos Prospectivos , Recuperação de Função Fisiológica , Retratamento , Estudos Retrospectivos , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/terapia , Reabilitação do Acidente Vascular Cerebral , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
8.
J Stroke Cerebrovasc Dis ; 26(12): 3004-3008, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28843804

RESUMO

BACKGROUND: Intra-arterial alteplase (IA tPA) is commonly used during mechanical thrombectomy for acute ischemic stroke in patients with large-vessel occlusion, but specific indications and applications for its use remain undefined. METHODS: We analyzed 40 patients who underwent stent-retriever mechanical thrombectomy, 28 of whom received adjunctive IA tPA. To our knowledge, this is the largest cohort with this concomitant treatment reported in the literature in the post-mechanical thrombectomy trial era. RESULTS: Between patients with and without IA tPA, rates of hemorrhagic conversion, neurologic outcome, and mortality were equivalent, with a trend toward improved angiographic revascularization observed in the IA tPA group. CONCLUSIONS: IA tPA is a safe adjunct to mechanical thrombectomy, and more investigation is warranted to understand ideal indications and dosage methodologies.


Assuntos
Isquemia Encefálica/terapia , Fibrinolíticos/administração & dosagem , Trombólise Mecânica/métodos , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intra-Arteriais , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
9.
J Thromb Thrombolysis ; 44(2): 203-209, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28702769

RESUMO

Recent clinical trials demonstrated that mechanical thrombectomy (MT) using second-generation endovascular devices has beneficial effects in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, it remains controversial if intravenous thrombolysis (IVT) prior to MT is superior compared to direct mechanical thrombectomy (DMT). The aims of this study were to compare short and long-term outcomes between IVT + MT and DMT patients. We prospectively recruited AIS patients with LVO in the anterior or posterior circulation eligible for MT with and without prior IVT. Modified Rankin Scale (mRS) and mortality were assessed at baseline, at discharge, 90-days and 1-year after stroke. Favorable outcome was defined as a mRS score ≤2. Of the 66 patients included, 33 (50%) were in IVT + MT group and 33 (50%) were in DMT group. Except for a higher prevalence of patients using anticoagulants at admission in DMT group, baseline characteristics did not differ in the two groups. Procedural characteristics were similar in IVT + MT and DMT group. Rate of favorable outcome was significantly higher in IVT + MT patients than DMT ones both 90-days (51.5 vs. 18.2%; p = 0.004) and 1-year (51.5 vs. 15.2%; p = 0.002) after stroke. DMT patients were six times more likely to die during the 1-year follow-up compared to IVT + MT patients. This study suggests that bridging therapy may improve short and long-term outcomes in patients eligible for endovascular treatment. Further studies with larger patient numbers and randomized design are needed to confirm our findings.


Assuntos
Trombólise Mecânica/métodos , Trombectomia/métodos , Terapia Trombolítica/métodos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/terapia , Feminino , Humanos , Masculino , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Estudos Prospectivos , Acidente Vascular Cerebral/terapia , Trombectomia/mortalidade , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento
10.
Stroke ; 48(2): 361-366, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28070000

RESUMO

BACKGROUND AND PURPOSE: The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke. METHODS: We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay. RESULTS: Among 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models. CONCLUSIONS: Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care.


Assuntos
Anestesia Geral/mortalidade , Isquemia Encefálica/mortalidade , Sedação Consciente/mortalidade , Trombólise Mecânica/mortalidade , Acidente Vascular Cerebral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Anestesia Geral/tendências , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Estudos de Coortes , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/tendências , Pessoa de Meia-Idade , New York/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
11.
Stroke ; 48(2): 342-347, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28008095

RESUMO

BACKGROUND AND PURPOSE: Intracranial carotid artery calcification (ICAC) is a surrogate marker of intracranial arteriosclerosis, which may impact the revascularization and clinical outcome of acute stroke patients who undergo mechanical thrombectomy. METHODS: We included 194 patients admitted to our Stroke Unit between January 2009 and September 2015 who underwent mechanical thrombectomy for an anterior circulation occlusion. ICAC was quantified in both intracranial carotid arteries on the nonenhanced computed tomographic scan that was acquired before thrombectomy. Complete arterial revascularization was defined as a Thrombolysis in Cerebral Infarction ≥2b on the final angiographic examination. Poor functional outcome was defined as a modified Rankin Scale score of >2 at 90 days. We assessed the independent effect of ICAC volume on complete arterial revascularization, functional outcome, and mortality using logistic regression models adjusted for relevant confounders. RESULTS: ICAC was present in 164 (84.5%) patients, with a median volume of 87.1 mm3 (25th-75th quartile: 18.9-254.6 mm3). We found that larger ICAC volumes were associated with incomplete arterial revascularization (adjusted odds ratio per unit increase in ln-transformed ICAC volume 0.73 [95% confidence interval, 0.57-0.93]) and with poorer functional outcome (adjusted odds ratio per unit increase in ln-transformed ICAC volume 1.31 [95% confidence interval, 1.04-1.66]). CONCLUSIONS: A larger amount of ICAC before mechanical thrombectomy in acute stroke patients is an indicator of worse postprocedural arterial revascularization and poorer functional outcome.


Assuntos
Doenças das Artérias Carótidas/mortalidade , Artéria Carótida Interna , Revascularização Cerebral/mortalidade , Arteriosclerose Intracraniana/mortalidade , Trombólise Mecânica/mortalidade , Calcificação Vascular/mortalidade , Idoso , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/terapia , Artéria Carótida Interna/diagnóstico por imagem , Revascularização Cerebral/tendências , Feminino , Humanos , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/terapia , Masculino , Trombólise Mecânica/tendências , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/terapia
14.
World Neurosurg ; 88: 320-326, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26746334

RESUMO

OBJECTIVES: Venous thromboembolism (VTE) is a serious complication after intracranial meningioma surgery. To what extent systemic prophylaxis with pharmacotherapy is beneficial with respect to VTE risk, or associated with increased risk of bleeding and postoperative hemorrhage, remains debated. The current study aimed to clarify the risk/benefit ratio of prophylactic pharmacotherapy initiated the evening before craniotomy for meningioma. METHODS: In a Scandinavian population-based cohort, we conducted a retrospective review of 979 operations for intracranial meningioma between 2007 and 2013 at 3 neurosurgical centers with population-based referral. We compared 2 different treatment strategies analyzing frequencies of VTE and proportions of postoperative intracranial hematomas requiring surgery or intensified subsequent observation or care (intensive care unit or other intensified observation or treatment). One neurosurgical center favored preoperative prophylaxis with low-molecular-weight heparin (LMWH) (LMWH routine group) in addition to mechanical prophylaxis, and 2 centers favored mechanical prophylaxis with LMWH only given as needed in cases of delayed mobilization (LMWH as needed group). RESULTS: In the LMWH routine group, VTE was diagnosed after 24/626 operations (3.9%), and VTE was diagnosed after 11/353 (3.1%) operations in the LMWH as needed group (P = 0.56). Clinically relevant postoperative hematomas occurred after 57/626 operations (9.1%) in the LMWH routine group compared with 23/353 (6.5%) in the LMWH as needed group (P = 0.16). Surgically evacuated postoperative hematomas occurred after 19/626 operations (3.0%) in the LMWH routine group compared with 8/353 operations (2.3%) in the LMWH as needed group (P = 0.26). CONCLUSIONS: There is no benefit of routine preoperative LMWH starting before intracranial meningioma surgery. Neither could we for primary outcomes detect a significant increase in clinically relevant postoperative hematomas secondary to this regimen. We suggest that as needed perioperative administration of LMWH, reserved for patients with excess risk because of delayed mobilization, is effective and also appears to be the safest strategy.


Assuntos
Heparina de Baixo Peso Molecular/administração & dosagem , Trombólise Mecânica/mortalidade , Meningioma/mortalidade , Meningioma/cirurgia , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/prevenção & controle , Causalidade , Terapia Combinada/métodos , Terapia Combinada/mortalidade , Comorbidade , Feminino , Humanos , Masculino , Trombólise Mecânica/estatística & dados numéricos , Neoplasias Meníngeas/mortalidade , Neoplasias Meníngeas/cirurgia , Pessoa de Meia-Idade , Noruega/epidemiologia , Complicações Pós-Operatórias/mortalidade , Pré-Medicação , Cuidados Pré-Operatórios , Prevalência , Medição de Risco , Fatores de Risco , Taxa de Sobrevida , Suécia/epidemiologia
15.
Eur Radiol ; 26(6): 1742-50, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26370945

RESUMO

BACKGROUND: Multiple studies have shown a clinical benefit of thrombectomy in acute ischaemic stroke, but most of them excluded octogenarians. The purpose of this study was to compare the outcomes between octogenarians and younger patients after thrombectomy. MATERIALS AND METHODS: One hundred and sixty-six patients with large cerebral artery occlusion and consecutive thrombectomy were evaluated and divided into two patient age groups: younger than 80 years and older than 80 years. We compared recanalization rates, complications experienced, disability, death after discharge and at a 90-day follow-up between these age groups. RESULTS: Sixty-eight percent of octogenarians and 72 % of younger patients were registered with successful recanalization (p = 1.0). There was no significant difference in symptomatic intracerebral haemorrhage between the groups (p = 0.32). However, octogenarians had a significantly lower rate of good clinical outcome (24 % vs. 48 %; p = 0.008) and a higher mortality rate (36 % vs. 12 %; p = 0.0013). CONCLUSION: Octogenarians have a lower chance of good clinical outcome and a higher mortality rate despite successful recanalization. Nevertheless, 24 % of octogenarians were documented with mRS ≤2. As this age group of octogenarians will grow prospectively, careful patient selection should be mandatory when considering octogenarians for thrombectomy. KEY POINTS: • Careful patient selection for thrombectomy should be mandatory in octogenarians. • Octogenarians have a higher mortality rate despite successful recanalization. • Nearly one-third of octogenarians were documented with a good clinical outcome.


Assuntos
Procedimentos Endovasculares/métodos , Trombólise Mecânica/métodos , Acidente Vascular Cerebral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Hemorragia Cerebral/etiologia , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/cirurgia , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Trombólise Mecânica/mortalidade , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Estudos Prospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/mortalidade , Tempo para o Tratamento , Resultado do Tratamento
16.
J Invest Surg ; 29(2): 106-11, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26366836

RESUMO

OBJECTIVES: Mechanical thrombectomy (MT) is a promising treatment for acute ischemic stroke (AIS). But the results of completed trials were contradictory. Hence, we performed a meta-analysis to evaluate the efficacy and safety of MT in treating AIS. METHODS: Literatures were searched in the databases including Pubmed, Cochrane Library, Web of Science and Ovid-SP. The bias and quality of publications with randomized controlled trials (RCTs) were assessed with the Cochrane collaboration's tool for assessing risk of bias. RESULTS: Totally 16 publications matched the inclusion criteria, including seven independent RCTs and 2043 AIS patients. The results showed that the recanalization rate and the modified Rankin score of 0-2 at 90 days after treatment were better in MT combining standard care group, but the mortality had no significant difference, even the incidence of intracerebral hemorrhage during follow-up period was worse, as compared with standard care group. CONCLUSION: MT combining standard care would be an effective and promising treatment for AIS patients according to the present study.


Assuntos
Fibrinolíticos/uso terapêutico , Trombólise Mecânica , Viés de Publicação , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/etiologia , Humanos , Incidência , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do Tratamento
17.
Neuroradiology ; 58(2): 147-53, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26494464

RESUMO

INTRODUCTION: No previous study has investigated the relationship between intravenous tissue plasminogen activator (IV t-PA) and intracranial hemorrhage (ICH) according to the location of vessel occlusion. The aim of the present study was to investigate the relationship between preprocedural IV t-PA and endovascular treatment (EVT) and ICH according to the location of occlusion using data from the nationwide prospective registry of acute cerebral large vessel occlusion (LVO), the RESCUE-Japan Registry. METHODS: Among 1442 patients with acute LVO enrolled in the registry, we examined 410 patients who received EVT. Patients were divided into the following four groups according to the location of occlusion: the internal carotid artery (ICA), middle cerebral artery first division (M1), middle cerebral artery second division (M2), and vertebral artery (VA)/basilar artery (BA) groups. RESULTS: A total of 399 patients in whom the occlusion was located in these vessels were finally included. Any ICH (aICH) was identified in 127 (30.9%) patients, and symptomatic ICH (sICH) was identified in 20 (4.9%). Preprocedural IV t-PA did not increase the incidence of aICH in any group and tended to increase the incidence of sICH in only the M2 group. In multivariate analysis of the M2 group, IV t-PA was an independent risk factor for sICH. CONCLUSION: Preprocedural IV t-PA did not increase the incidence of ICH in total, but could increase the incidence of sICH in those with M2 occlusion. IV t-PA before EVT may be an independent risk factor for sICH in patients with M2 occlusion.


Assuntos
Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/cirurgia , Hemorragias Intracranianas/mortalidade , Trombólise Mecânica/mortalidade , Pré-Medicação/mortalidade , Ativador de Plasminogênio Tecidual/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Causalidade , Angiografia Cerebral/estatística & dados numéricos , Comorbidade , Procedimentos Endovasculares , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Incidência , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Injeções Intravenosas , Hemorragias Intracranianas/diagnóstico por imagem , Japão/epidemiologia , Masculino , Trombólise Mecânica/estatística & dados numéricos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Pré-Medicação/estatística & dados numéricos , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Taxa de Sobrevida , Avaliação de Sintomas
18.
Radiologe ; 56(1): 9-11, 2016 Jan.
Artigo em Alemão | MEDLINE | ID: mdl-26696536

RESUMO

BACKGROUND: The publications of five prospective randomized trials have made 2015 a milestone in the development of stroke therapy. Up till then, IV rtPA had been the only evidence-based recanalizing treatment for ischemic stroke. AIM: In this article we review the results of five trials: MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, and REVASCAT.


Assuntos
Trombólise Mecânica/mortalidade , Trombólise Mecânica/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/cirurgia , Medicina Baseada em Evidências , Humanos , Duração da Cirurgia , Prevalência , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Taxa de Sobrevida , Resultado do Tratamento
19.
Clin Neuroradiol ; 26(2): 169-75, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25164695

RESUMO

PURPOSE: The treatment mode in acute vertebrobasilar occlusion (VBO) remains uncertain. We analyzed efficacy and safety of intravenous glycoprotein IIb/IIIa inhibitor (IV GPI) plus subsequent intra-arterial thrombolysis with or without additional endovascular mechanical therapy (percutaneous transluminal angioplasty/stenting or thrombus aspiration) and sought treatment factors that predict good clinical outcome. METHODS: We retrospectively analyzed 120 cases of patients with angiographically proven acute VBO. Multivariate logistic regression was used to identify independent predictors for clinical outcome and included level of consciousness, age, sex, time to angiography, GPI agent, admission mode, occlusion type, recanalization success, and endovascular treatment mode. Clinical follow-up was dichotomized in no to moderate disability (modified Rankin scale (mRS) 0-3) vs. severe disability or death (mRS 4-6). RESULTS: Median National Institutes of Health stroke scale (NIHSS) score on admission was 32, and mean NIHSS score was 24. A total of 49 patients (41 %) developed no to moderate disability (mRS 0-3), and 39 patients (33 %) died. Thrombolysis in myocardial infarction 2/3 recanalization success was achieved in 97 patients (80.8 %). Symptomatic intracerebral hemorrhages occurred in 11 patients (9 %). Mild impairment of consciousness (p < 0.001) and embolic occlusion type (p = 0.01) were significant predictors of favorable outcome. Clinical outcome in recanalized patients was better, but not statistically significant (p = 0.055). CONCLUSIONS: Our results indicate that combined therapy with IV GPI and subsequent endovascular therapy may be a valid treatment strategy in acute VBO. With this treatment approach, a preserved vigilance before treatment and an embolic occlusion type are associated with no to moderate disability.


Assuntos
Trombólise Mecânica/mortalidade , Inibidores da Agregação de Plaquetas/administração & dosagem , Insuficiência Vertebrobasilar/mortalidade , Insuficiência Vertebrobasilar/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares , Feminino , Alemanha/epidemiologia , Humanos , Integrina beta3/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/farmacologia , Glicoproteína IIb da Membrana de Plaquetas/efeitos dos fármacos , Pré-Medicação/métodos , Pré-Medicação/mortalidade , Prevalência , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Insuficiência Vertebrobasilar/diagnóstico por imagem
20.
Nervenarzt ; 86(10): 1226-35, 2015 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-26440630

RESUMO

OBJECTIVE: To determine the importance of mechanical thrombectomy (MT) in the treatment of ischemic stroke. MATERIAL AND METHODS: Analysis and comparison of randomized controlled trials (RCT) of MT versus i.v. thrombolysis (IVT) considering pathophysiological and logistic aspects. RESULTS: The use of MT is more effective than IVT for internal carotid artery terminus (ICAT), M1 segment and tandem occlusions, i.e. proximal internal carotid artery (ICA) occlusion or stenosis, even in patients older than 75-80 years of age. Due to the small sample sizes this question cannot be answered for patients with M2 occlusions. It is still uncertain whether MT is needed in patients with a low National Institutes of Health stroke scale (NIHSS) score, whether IVT is needed before MT and what type of imaging should be performed. Approximately one third of eligible patients currently undergo MT in Germany. Results from RCTs with stent retrievers for patients with vertebrobasilar artery occlusions are lacking. CONCLUSION: After becoming established as a first-line therapy for patients with ICAT, M1 segment and tandem occlusions, the effectiveness of MT with stent retrievers has to proven in patients with more distal occlusions, low NIHSS scores and even vertebrobasilar artery occlusions.


Assuntos
Trombólise Mecânica/mortalidade , Complicações Pós-Operatórias/mortalidade , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/cirurgia , Ativador de Plasminogênio Tecidual/administração & dosagem , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Medicina Baseada em Evidências , Feminino , Fibrinolíticos/administração & dosagem , Alemanha/epidemiologia , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Prevalência , Fatores de Risco , Distribuição por Sexo , Taxa de Sobrevida , Resultado do Tratamento
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