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1.
JAMA ; 324(17): 1765-1776, 2020 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-33141212

RESUMO

Importance: Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. Observations: PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin. Conclusions and Relevance: Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.


Assuntos
Extremidade Inferior/irrigação sanguínea , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/terapia , Fatores Etários , Biomarcadores/sangue , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Estilo de Vida , Ilustração Médica , Síndrome Pós-Trombótica/etiologia , Valor Preditivo dos Testes , Fatores de Risco , Fatores Sexuais , Avaliação de Sintomas , Trombectomia/métodos , Trombofilia/complicações , Trombofilia/genética , Ultrassonografia , Filtros de Veia Cava , Tromboembolia Venosa/sangue , Tromboembolia Venosa/etiologia , Varfarina/uso terapêutico
2.
Anesth Analg ; 131(4): 1124-1134, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925333

RESUMO

Acute ischemic stroke is a neurological emergency with a high likelihood of morbidity, mortality, and long-term disability. Modern stroke care involves multidisciplinary management by neurologists, radiologists, neurosurgeons, and anesthesiologists. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend thrombolytic therapy with intravenous (IV) alteplase within the first 3-4.5 hours of initial stroke symptoms and endovascular mechanical thrombectomy within the first 16-24 hours depending on specific inclusion criteria. The anesthesia and critical care provider may become involved for airway management due to worsening neurologic status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning, to facilitate mechanical thrombectomy, or to manage critical care of stroke patients. Existing data are unclear whether the mechanical thrombectomy procedure is best performed under general anesthesia or sedation. Retrospective cohort trials favor sedation over general anesthesia, but recent randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over general anesthesia. Regardless of anesthesia type, a critical element of intraprocedural stroke care is tight blood pressure management. At different phases of stroke care, different blood pressure targets are recommended. This narrative review will focus on the anesthesia and critical care providers' roles in the management of both perioperative stroke and acute ischemic stroke with a focus on anesthetic management for mechanical thrombectomy.


Assuntos
Anestesia , Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Humanos , Assistência Perioperatória
3.
Stroke ; 51(10): 2951-2959, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32895016

RESUMO

BACKGROUND AND PURPOSE: The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice. METHODS: Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used. RESULTS: Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts. CONCLUSIONS: In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.


Assuntos
Anestesia Local , Isquemia Encefálica/cirurgia , Sedação Consciente/métodos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento
4.
Stroke ; 51(10): 3174-3181, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32912096

RESUMO

The use of mechanical thrombectomy for the treatment of acute childhood arterial ischemic stroke with large vessel occlusion is increasing, with mounting evidence for its feasibility and safety. Despite this emerging evidence, clear guidelines for patient selection, thrombectomy technique, and postprocedure care do not exist for the pediatric population. Due to unique features of stroke in children, neurologists and interventionalists must consider differences in patient size, anatomy, collateral vessels, imaging parameters, and expected outcomes that may impact appropriate patient selection and timing criteria. In addition, different causes of stroke and comorbidities in children must be considered and may alter the safety and efficacy of thrombectomy. To optimize the success of endovascular intervention in children, a multidisciplinary team should take into account these nuanced considerations when determining patient eligibility, developing a procedural approach, and formulating a postprocedure neurological monitoring and therapeutic plan.


Assuntos
Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Isquemia Encefálica/diagnóstico por imagem , Criança , Humanos , Imagem por Ressonância Magnética , Seleção de Pacientes , Acidente Vascular Cerebral/diagnóstico por imagem , Resultado do Tratamento
5.
Stroke ; 51(10): 2934-2942, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32933420

RESUMO

BACKGROUND AND PURPOSE: Post hoc analyses of randomized controlled clinical trials evaluating mechanical thrombectomy have suggested that admission-to-groin-puncture (ATG) delays are associated with reduced reperfusion rates. Purpose of this analysis was to validate this association in a real-world cohort and to find associated factors and confounders for prolonged ATG intervals. METHODS: Patients included into the BEYOND-SWIFT cohort (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the Solitaire FR With the Intention for Thrombectomy; https://www.clinicaltrials.gov; Unique identifier: NCT03496064) were analyzed (n=2386). Association between baseline characteristics and ATG was evaluated using mixed linear regression analysis. The effect of increasing symptom-onset-to-admission and ATG intervals on successful reperfusion (defined as Thrombolysis in Cerebral Infarction [TICI] 2b-3) was evaluated using logistic regression analysis adjusting for potential confounders. RESULTS: Median ATG was 73 minutes. Prolonged ATG intervals were associated with the use of magnetic resonance imaging (+19.1 [95% CI, +9.1 to +29.1] minutes), general anesthesia (+12.1 [95% CI, +3.7 to +20.4] minutes), and borderline indication criteria, such as lower National Institutes of Health Stroke Scale, late presentations, or not meeting top-tier early time window eligibility criteria (+13.8 [95% CI, +6.1 to +21.6] minutes). There was a 13% relative odds reduction for TICI 2b-3 (adjusted odds ratio [aOR], 0.87 [95% CI, 0.79-0.96]) and TICI 2c/3 (aOR, 0.87 [95% CI, 0.79-0.95]) per hour ATG delay, while the reduction of TICI 2b-3 per hour increase symptom-onset-to-admission was minor (aOR, 0.97 [95% CI, 0.94-0.99]) and inconsistent regarding TICI 2c/3 (aOR, 0.99 [95% CI, 0.97-1.02]). After adjusting for identified factors associated with prolonged ATG intervals, the association of ATG delay and lower rates of TICI 2b-3 remained tangible (aOR, 0.87 [95% CI, 0.76-0.99]). CONCLUSIONS: There is a great potential to reduce ATG, and potential targets for improvement can be deduced from observational data. The association between in-hospital delay and reduced reperfusion rates is evident in real-world clinical data, underscoring the need to optimize in-hospital workflows. Given the only minor association between symptom-onset-to-admission intervals and reperfusion rates, the causal relationship of this association warrants further research. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064.


Assuntos
Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Acidente Vascular Cerebral/diagnóstico por imagem , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento
7.
BMC Neurol ; 20(1): 358, 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-32972381

RESUMO

BACKGROUND: The novel coronavirus (COVID-19) global pandemic is associated with an increased incidence of acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO). The treatment of these patients poses unique and significant challenges to health care providers requiring changes in existing protocols. CASE PRESENTATION: A 54-year-old COVID-19 positive patient developed sudden onset left hemiparesis secondary to an acute right middle cerebral artery occlusion (National Institutes of Health Stroke Scale (NIHSS) score = 11). Mechanical thrombectomy (MT) was performed under a new protocol specifically designed to maximize protective measures for the team involved in the care of the patient. Mechanical Thrombectomy was performed successfully under general anesthesia resulting in TICI 3 recanalization. With regards to time metrics, time from door to reperfusion was 60 mins. The 24-h NIHSS score decreased to 2. Patient was discharged after 19 days after improvement of her pulmonary status with modified Rankin Scale = 1. CONCLUSION: Patients infected by COVID-19 can develop LVO that is multifactorial in etiology. Mechanical thrombectomy in a COVID-19 confirmed patient presenting with AIS due to LVO is feasible with current mechanical thrombectomy devices. A change in stroke workflow and protocols is now necessary in order to deliver the appropriate life-saving therapy for COVID-19 positive patients while protecting medical providers.


Assuntos
Infecções por Coronavirus/complicações , Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/cirurgia , Equipamento de Proteção Individual , Pneumonia Viral/complicações , Trombectomia/métodos , Betacoronavirus , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Angiografia Cerebral , Angiografia por Tomografia Computadorizada , Serviços Médicos de Emergência , Feminino , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Intubação Intratraqueal , Pessoa de Meia-Idade , Pandemias , Reperfusão , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento , Resultado do Tratamento
8.
J Neurointerv Surg ; 12(11): 1045-1048, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32989032

RESUMO

BACKGROUND: We aimed to compare the outcome of acute ischemic stroke (AIS) patients who received endovascular thrombectomy (EVT) with confirmed COVID-19 to those without. METHODS: We performed a retrospective analysis using the Vizient Clinical Data Base and included hospital discharges from April 1 to July 31 2020 with ICD-10 codes for AIS and EVT. The primary outcome was in-hospital death and the secondary outcome was favorable discharge, defined as discharge home or to acute rehabilitation. We compared patients with laboratory-confirmed COVID-19 to those without. As a sensitivity analysis, we compared COVID-19 AIS patients who did not undergo EVT to those who did, to balance potential adverse events inherent to COVID-19 infection. RESULTS: We identified 3165 AIS patients who received EVT during April to July 2020, in which COVID-19 was confirmed in 104 (3.3%). Comorbid COVID-19 infection was associated with younger age, male sex, diabetes, black race, Hispanic ethnicity, intubation, acute coronary syndrome, acute renal failure, and longer hospital and intensive care unit length of stay. The rate of in-hospital death was 12.4% without COVID-19 vs 29.8% with COVID-19 (P<0.001). In mixed-effects logistic regression that accounted for patient clustering by hospital, comorbid COVID-19 increased the odds of in-hospital death over four-fold (OR 4.48, 95% CI 3.02 to 6.165). Comorbid COVID-19 was also associated with lower odds of a favorable discharge (OR 0.43, 95% CI 0.30 to 0.61). In the sensitivity analysis, comparing AIS patients with COVID-19 who did not undergo EVT (n=2139) to the AIS EVT patients with COVID-19, there was no difference in the rate of in-hospital death (30.6% vs 29.8%, P=0.868), and AIS EVT patients had a higher rate of favorable discharge (32.4% vs 47.1%, P=0.002). CONCLUSION: In AIS patients treated with EVT, comorbid COVID-19 infection was associated with in-hospital death and a lower odds of favorable discharge compared with patients without COVID-19, but not compared with AIS patients with COVID-19 who did not undergo EVT. AIS EVT patients with COVID-19 were younger, more likely to be male, have systemic complications, and almost twice as likely to be black and over three times as likely to be Hispanic.


Assuntos
Isquemia Encefálica/complicações , Isquemia Encefálica/cirurgia , Infecções por Coronavirus/complicações , Procedimentos Endovasculares/estatística & dados numéricos , Pneumonia Viral/complicações , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/cirurgia , Trombectomia/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Procedimentos Endovasculares/métodos , Grupos Étnicos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Reabilitação do Acidente Vascular Cerebral/estatística & dados numéricos , Trombectomia/métodos , Resultado do Tratamento , Adulto Jovem
9.
Neurology ; 95(17): e2331-e2342, 2020 10 27.
Artigo em Inglês | MEDLINE | ID: mdl-32847948

RESUMO

OBJECTIVE: To test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], NCT03496064). METHODS: In 2,011 patients (49.7% female, median age 73 years [61-81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4-6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5-6 as futile. RESULTS: MRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio [aOR] 1.048, 95% confidence interval [CI] 0.677-1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4-6 including 393/1,489 (26%) FR mRS 5-6. CT-based selection was associated with increased rates of FRs compared to MRI (44% [41%-47%] vs 29% [25%-32%], p < 0.001; aOR 1.77 [95% CI 1.25-2.51]). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT. CONCLUSIONS: CT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.


Assuntos
Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Hemorragia Cerebral/etiologia , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/mortalidade , Tomografia Computadorizada por Raios X , Falha de Tratamento , Resultado do Tratamento
10.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 31(4): 173-183, jul.-ago. 2020. ilus
Artigo em Inglês | IBECS | ID: ibc-193898

RESUMO

OBJECT: The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. METHODS: A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. RESULTS: Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. CONCLUSIONS: Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients


OBJETIVO: La variedad y la complejidad de las enfermedades neurovasculares tratadas con neurocirugía endovascular ha aumentado drásticamente en los últimos años. Muchos aneurismas continúan siendo difíciles de tratar de forma segura. Los enfoques de transcirculación (contralateral y/o retrógrada) a través del círculo de Willis son alternativas útiles para el tratamiento endovascular de lesiones difíciles. Presentamos una serie de casos de pacientes tratados con técnicas de transcirculación no convencionales. MÉTODOS: Se trató a un total de 6 pacientes que inicialmente se creía que no eran aptos para el tratamiento endovascular: 4 pacientes con 5 aneurismas, un paciente con un ictus de la arteria cerebral media (ACM) y un paciente con un meningioma que requería embolización preoperatoria. Se tomó la decisión de tratar a estos pacientes con métodos de transcirculación. Todos los pacientes fueron tratados por un solo especialista. Se localizaron y trataron un aneurisma en el segmento cavernoso de la arteria carótida interna (ACI), otro en la arteria vertebral, 2 en el segmento paraclinoideo de la ACI y otro en una malformación arteriovenosa cerebelosa de un vaso nutriente. RESULTADOS: Cinco de los 6 pacientes (83%) alcanzaron una recuperación neurológica completa. Se trataron 3 aneurismas hasta una oclusión completa, un aneurisma se dejó con un pequeño relleno de cuello residual y otro aneurisma no pudo ser tratado. Un paciente fue sometido a una trombectomía mecánica de un émbolo en la ACM y el relleno de la ACM se restauró después del tratamiento. Un paciente se sometió a embolización completa del riego vascular profundo de un meningioma. CONCLUSIONES: Aunque muchas enfermedades neurovasculares siguen sin ser adecuadas para el tratamiento endovascular, los enfoques de transcirculación pueden permitir el tratamiento seguro y exitoso de lesiones difíciles en pacientes seleccionados


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Procedimentos Endovasculares/instrumentação , Doenças Arteriais Intracranianas/diagnóstico por imagem , Doenças Arteriais Intracranianas/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Trombectomia/métodos , Embolização Terapêutica/instrumentação
13.
Stroke ; 51(9): 2630-2638, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32772684

RESUMO

BACKGROUND AND PURPOSE: To quantify workflow metrics in patients receiving stroke imaging (noncontrast-enhanced computed tomography [CT] and CT-angiography) in either a computed-tomography scanner suite (CT-Transit [CTT]) or an angio-suite (direct transfer to angio-suite-[DTAS]-using flat-panel CT) before undergoing mechanical thrombectomy. METHODS: Prospective, single-center investigator initiated randomized controlled trial in a comprehensive stroke center focusing on time from imaging to groin puncture (primary end point) and time from hospital admission to final angiographic result (secondary end point) in patients receiving mechanical thrombectomy for anterior circulation large vessel occlusion after randomization to the CTT or DTAS pathway. RESULTS: The trial was stopped early after the enrollment of n=60 patients (CTT: n=34/60 [56.7 %]; DTAS: n=26/60 [43.3%]) of n=110 planned patients because of a preplanned interim analysis. Time from imaging to groin puncture was shorter in DTAS-patients (in minutes, median [interquartile range]: CTT: 26 [23-32]; DTAS: 19 [15-23]; P value: 0.001). Time from hospital admission to stroke imaging was shorter in patients randomized to DTAS (CTT: 12 (7-18); DTAS: 21 (15-25), P value: 0.007). Time from hospital admission to final angiographic reperfusion was comparable between patient groups (CTT: 78 [58-92], DTAS: 80 [66-118]; P value: 0.067). CONCLUSIONS: This trial showed a reduction in time from imaging to groin-puncture when patients are transferred directly to the angiosuite for advanced stroke-imaging compared with imaging in a CT scanner suite. This time saving was outweighed by a longer admission to imaging time and could not translate into a shorter time to final angiographic reperfusion in this trial.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/cirurgia , Angiografia por Tomografia Computadorizada , Determinação de Ponto Final , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes , Estudos Prospectivos , Reperfusão , Tempo para o Tratamento , Tomografia Computadorizada por Raios X , Fluxo de Trabalho
14.
J Neurointerv Surg ; 12(11): 1039-1044, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32843359

RESUMO

BACKGROUND: In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS: A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS: 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION: We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.


Assuntos
Infecções por Coronavirus , Pandemias , Pneumonia Viral , Acidente Vascular Cerebral/terapia , Trombectomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , Procedimentos Endovasculares , Feminino , Mortalidade Hospitalar , Humanos , Vida Independente , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reperfusão , Trombectomia/métodos , Resultado do Tratamento , Fluxo de Trabalho
15.
Stroke ; 51(8): 2488-2494, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32684141

RESUMO

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MTB) is a reference treatment for acute ischemic stroke, with several endovascular strategies currently available. However, no quantitative methods are available for the selection of the best endovascular strategy or to predict the difficulty of clot removal. We aimed to investigate the predictive value of an endovascular strategy based on radiomic features extracted from the clot on preinterventional, noncontrast computed tomography to identify patients with first-attempt recanalization with thromboaspiration and to predict the overall number of passages needed with an MTB device for successful recanalization. METHODS: We performed a study including 2 cohorts of patients admitted to our hospital: a retrospective training cohort (n=109) and a prospective validation cohort (n=47). Thrombi were segmented on noncontrast computed tomography, followed by the automatic computation of 1485 thrombus-related radiomic features. After selection of the relevant features, 2 machine learning models were developed on the training cohort to predict (1) first-attempt recanalization with thromboaspiration and (2) the overall number of passages with MTB devices for successful recanalization. The performance of the models was evaluated on the prospective validation cohort. RESULTS: A small subset of radiomic features (n=9) was predictive of first-attempt recanalization with thromboaspiration (receiver operating characteristic curve-area under the curve, 0.88). The same subset also predicted the overall number of passages required for successful recanalization (explained variance, 0.70; mean squared error, 0.76; Pearson correlation coefficient, 0.73; P<0.05). CONCLUSIONS: Clot-based radiomics have the ability to predict an MTB strategy for successful recanalization in acute ischemic stroke, thus allowing a potentially better selection of the MTB strategy, as well as patients who are most likely to benefit from the intervention.


Assuntos
Isquemia Encefálica/cirurgia , Revascularização Cerebral/métodos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Trombose/cirurgia , Idoso , Isquemia Encefálica/diagnóstico por imagem , Estudos de Coortes , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Trombose/diagnóstico por imagem , Resultado do Tratamento
16.
BMC Neurol ; 20(1): 283, 2020 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-32682406

RESUMO

BACKGROUND: Although stent retriever (SR) is recommended as a frontline device of endovascular treatment (EVT) for embolic large artery occlusion causing acute ischemic stroke, contact aspiration (CA) device showed similar efficacy in the recent trials. However, the efficacy of the both devices as first-line therapy for intracranial atherosclerotic stenosis (ICAS)-related large vessel occlusion has not yet been established. Therefore, we compared the immediate effects and final outcomes of SR and CA as first-line devices for treating ICAS-related occlusions. METHODS: We retrospectively analyzed the data of patients who underwent EVT for acute ischemic stroke from the registry of three Korean hospitals. Patients with ICAS-related occlusion who were treated within 24 h of onset of the symptoms were included. We investigated immediate reperfusion performance, immediate safety outcomes, and 3-month clinical outcomes for the two first-line devices. RESULTS: Of the 720 registered patients, 111 were eligible for this study. Forty-nine patients (44.1%) used SR and 62 (55.9%) used CA as the first-line device. Achieving successful reperfusion immediately after first-line thrombectomy was more frequent in the SR group than that in the CA group (77.6% vs. 43.5%, p = 0.001), with fewer additional rescue treatments (12.2% vs. 59.7%, p < 0.001). The incidence of iatrogenic dissection or rupture was lower in the SR group than that in the CA group (8.2% vs. 29.0%, p = 0.012). After additional rescue treatments, however, the final successful reperfusion rate did not differ between the two groups (SR 87.8% vs. CA 77.4%, p = 0.247), and there was no significant difference in the 3-month good outcomes (modified Rankin Scale, p = 0.524). CONCLUSIONS: First-line SR thrombectomy showed higher immediate reperfusion and less vessel injury for ICAS-related occlusions than CA. However, there was no significant difference in the final reperfusion status or 3-month outcomes from additional rescue treatments.


Assuntos
Arteriosclerose Intracraniana/cirurgia , Stents , Trombectomia/instrumentação , Trombectomia/métodos , Idoso , Isquemia Encefálica/complicações , Feminino , Humanos , Arteriosclerose Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Reperfusão , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Trombectomia/efeitos adversos , Resultado do Tratamento
17.
BMC Neurol ; 20(1): 284, 2020 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-32689957

RESUMO

BACKGROUND: Compared with embolic occlusions, intracranial atherosclerotic stenosis (ICAS)-related large vessel occlusions (LVOs) often require rescue treatment following mechanical thrombectomy (MT). Herein, we hypothesized that local tirofiban infusion can be effective and safe for remnant stenosis in LVO during endovascular treatment and can improve clinical outcomes. METHODS: This observational multicenter registry study (January 2011 to February 2016) included patients with ICAS who underwent endovascular treatment for LVO within 24 h after stroke onset. An underlying fixed focal stenosis at the occlusion site observed on cerebral angiography during and after MT was retrospectively determined as a surrogate marker of ICAS. Procedural and clinical outcomes were compared between the tirofiban and non-tirofiban groups. RESULTS: Of 118 patients, 59 received local tirofiban infusion. Compared to the non-tirofiban group, patients were older (non-tirofiban group versus tirofiban group; median, 63 years vs. 71 years, p = 0.015) and the onset-to-puncture time was longer (median, 275 min vs. 395 min, p = 0.036) in the tirofiban group. The median percent of residual stenosis prior to rescue treatment tended to be higher in the tirofiban group (80 [71-86] vs. 83 [79-90], p = 0.056). Final reperfusion success (modified Treatment In Cerebral Ischemic 2b-3) was more frequent (42.4%vs. 86.4%, p = 0.016) and post-procedure parenchymal hematoma type 2 and/or thick subarachnoid hemorrhages were less frequent (15.3%vs. 5.1%, p = 0.068) in the tirofiban group. The frequency of favorable outcomes 3 months after endovascular treatment (modified Rankin Scale 0-2) was significantly higher in the tirofiban group (32.2% vs. 52.5%, p = 0.025), and tirofiban administration was an independent predictor of favorable outcomes (odds ratio, 2.991; 95% confidence interval, 1.011-8.848; p = 0.048). CONCLUSIONS: Local tirofiban infusion can be a feasible adjuvant treatment option for patients with ICAS-LVO.


Assuntos
Transtornos Cerebrovasculares/cirurgia , Arteriosclerose Intracraniana/cirurgia , Tirofibana/uso terapêutico , Fatores Etários , Idoso , Estudos de Casos e Controles , Angiografia Cerebral , Transtornos Cerebrovasculares/complicações , Transtornos Cerebrovasculares/diagnóstico por imagem , Feminino , Humanos , Arteriosclerose Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Trombectomia/métodos , Fatores de Tempo , Resultado do Tratamento
18.
Lancet ; 396(10244): 129-142, 2020 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-32653056

RESUMO

Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.


Assuntos
Encéfalo/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Amilose/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/prevenção & controle , Encéfalo/irrigação sanguínea , Encéfalo/patologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/cirurgia , Hemorragia Cerebral/complicações , Hemorragia Cerebral/tratamento farmacológico , Hemorragia Cerebral/fisiopatologia , Hemorragia Cerebral/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Intervenção Médica Precoce/métodos , Endarterectomia das Carótidas/métodos , Procedimentos Endovasculares/métodos , Forame Oval Patente/cirurgia , Humanos , Pessoa de Meia-Idade , Seleção de Pacientes , Imagem de Perfusão/métodos , Polímeros/uso terapêutico , Recidiva , Acidente Vascular Cerebral/epidemiologia , Succinatos/uso terapêutico , Trombectomia/métodos , Terapia Trombolítica/métodos , Tomografia Computadorizada por Raios X/métodos
19.
BMC Cardiovasc Disord ; 20(1): 314, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32611362

RESUMO

BACKGROUND: Coronary artery aneurysm (CAA) is a potential cause of infarction. During the outbreak of coronavirus disease 2019 (COVID-19), home isolation and activity reduction can lead to hypercoagulability. Here, we report a case of sudden acute myocardial infarction caused by large CAA during the home isolation. CASE PRESENTATION: During the outbreak of coronavirus disease 2019 (COVID-19),a 16-year-old man with no cardiac history was admitted to CCU of Tang du hospital because of severe chest pain for 8 h. The patient reached the hospital its own, his electrocardiogram showed typical features of anterior wall infarction, echocardiography was performed and revealed local anterior wall dysfunction, but left ventricle ejection fraction was normal, initial high-sensitivity troponin level was 7.51 ng/mL (<1.0 ng/mL). The patient received loading dose of aspirin and clopidogrel bisulfate and a total occlusion of the LAD was observed in the emergency coronary angiography (CAG). After repeated aspiration of the thrombus, TIMI blood flow reached level 3. Coronary artery aneurysm was visualized in the last angiography. No stent was implanted. Intravascular ultrasound (IVUS) was performed and the diagnosis of coronary artery aneurysm was further confirmed. The patient was discharged with a better health condition. CONCLUSIONS: Coronary artery aneurysm is a potential reason of infarction, CAG and IVUS are valuable tools in diagnosis in such cases, during the outbreak of coronavirus disease 2019 (COVID-19), home isolation and activity reduction can lead to hypercoagulability, and activities at home should be increased in the high-risk patients.


Assuntos
Infarto Miocárdico de Parede Anterior , Aneurisma Coronário , Angiografia Coronária/métodos , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Trombectomia/métodos , Ultrassonografia de Intervenção/métodos , Adolescente , Infarto Miocárdico de Parede Anterior/diagnóstico , Infarto Miocárdico de Parede Anterior/etiologia , Infarto Miocárdico de Parede Anterior/fisiopatologia , Infarto Miocárdico de Parede Anterior/cirurgia , Betacoronavirus/isolamento & purificação , China/epidemiologia , Aneurisma Coronário/complicações , Aneurisma Coronário/diagnóstico por imagem , Ecocardiografia/métodos , Eletrocardiografia/métodos , Humanos , Masculino , Pandemias , Medição de Risco , Fatores de Risco , Resultado do Tratamento
20.
Korean J Parasitol ; 58(3): 309-313, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32615744

RESUMO

Human sparganosis is a zoonotic disease caused by infection and migration of the plerocercoid of Spirometra spp. Although sparganosis were reported from most parts of the body, the sparganum parasitizing inside cerebral artery is remarkably uncommon. We report a case of cerebral intravascular sparganosis in an elderly patient with acute ischemic stroke who was diagnosed by retrieving sparganum during mechanical thrombectomy. Finally, the parasites were identified as Spirometra erinaceieuropaei using multiplex PCR and cox1 gene sequencing.


Assuntos
Artérias Cerebrais/parasitologia , Esparganose/parasitologia , Plerocercoide/isolamento & purificação , Spirometra/isolamento & purificação , Trombectomia/métodos , Idoso de 80 Anos ou mais , Animais , Grupo com Ancestrais do Continente Asiático , Humanos , Masculino , Esparganose/diagnóstico por imagem , Esparganose/transmissão , Plerocercoide/genética , Spirometra/genética , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia
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