Trombolisis intravenosa en ataque cerebrovascular isquémico agudo en Santa Cruz Bolivia: análisis retrospectivo de los primeros 18 casos / Intravenous thrombolysis in acute ischemic stroke in Santa Cruz Bolivia: retrospective analysis of the first 18 cases

OBJETIVOS: describir la experiencia en la implementación del protocolo de trombolisis i.v. en 18 pacientes con Accidente Cerebrovascular (ACV) isquémico en la Unidad de ACV de la Clínica Foianini, concretamente, entre septiembre de 2013 y julio de 2017. MÉTODOS: el estudio tiene un enfoque cuantitativo, tipo descriptivo y retrospectivo. Se revisó las historias clínicas de los pacientes con diagnóstico de ACV isquémico agudo, que fueron tratados con trombolitico intravenoso (Alteplasa) en el servicio UTAC, entre septiembre de 2013 y julio 2017 en Santa Cruz, Bolivia. RESULTADOS: el Tiempo Síntoma-Puerta alcanzo a 62,7 +/- 38 min, mientras que el Tiempo Puerta-Aguja fue de 53,6 +/- 15 min. y Tiempo Síntoma-Aguja 114,6 +/- 43 min. Se registraron complicaciones en 6 (33,3%). promedio de 4,6 +/- 3 días de internación en la clínica, pasando un promedio de 2,8 +/- 2 días en la Unidad de ACV. La tasa de mortalidad fue de 16,6%. Según la Escala Modficada de Rankin, tuvieron un puntaje de 0-1 mRS. CONCLUSIONES: el tiempo Puerta-Aguja en nuestro establecimiento fue de un promedio de 57 minutos, cumpliendo de esta forma la recomendación de la American Heart Association Guidelines 2013, la cual recalca que éste debe ser <60 min13.

OBJECTIVE: describe the experience in the implementation of the thrombolysis intravenous protocol in eighteen patients with acute ischemic stroke in the Stroke unit from the Foianini Clinic specifically, between September of 2013 and July of 2017. METHODS: the study has a quantitative, descriptive and retrospective approach. The medical record of the patients with the acute ischemic stroke diagnosis treated with intravenous thrombolytic (Alteplasa) in the UTAC service between September of 2013 and July 2017 in Santa Cruz Bolivia was revised. RESULTS: symptoms-Door time reached to 62.7 +/- 38 minutes. While the time Door- needle time was 53.6 +/- 15 minutes and the time symptoms- needle 114.6 +/- 3 days of internment in the clinic, passing out an average of 2.8 +/- 2 days in the stroke unit. The mortality tax was 16.6%. According to the modified Rankin Scale, it had a 0-1 mRS score. CONCLUSIONS: the time Door-needle in our establishment was an average of 57 minutes, fulfilling in this way the recommendation of the American Heart Association Guidelines 2013, which emphasize that it has to be < 60 minutes.

The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.

Mobile device for thrombolysis decisions for telestroke / Dispositivo móvil para decisiones de trombólisis mediante Telestroke

Abstract Aim: This study compares the reliability of brain CT interpretations performed using a diagnostic workstation and a mobile tablet computer in a telestroke context. Methods: A factorial design with 1,452 interpretations was used. Reliability was evaluated using the Fleiss' kappa coefficient on the agreements of the interpretation results on the lesion classification, presence of imaging contraindications to the intravenous recombinant tissue-type plasminogen activator (t-PA) administration, and on the Alberta Stroke Program Early CT Score (ASPECTS). Results: The intra-observer agreements were as follows: good agreement on the overall lesion classification (κ= 0.63, p<0.001), very good agreement on hemorrhagic lesions (κ= 0.89, p<0.001), and moderate agreements on both without acute lesion classification and acute ischemic lesion classification (κ= 0.59 and κ= 0.58 respectively, p<0.001). There was good intra-observer agreement on the dichotomized-ASPECTS (κ= 0.65, p<0.001). Conclusions: The results of our study allow us to conclude that the reliability of the mobile solution for interpreting brain CT images of patients with acute stroke was assured, which would allow efficient and low-cost telestroke services.

Resumen Objetivo: Este estudio compara la confiabilidad de interpretaciones de TAC de cráneo simple realizadas utilizando una estación de trabajo de diagnóstico y un computador tableta en un contexto de teleACV. Métodos: Se utilizó un diseño factorial con 1,452 interpretaciones. La confiabilidad se evaluó utilizando el coeficiente kappa de Fleiss en las concordancias sobre los resultados de la interpretación en la clasificación de la lesión, la presencia de contraindicaciones en la imagen para la administración intravenosa del activador del plasminógeno tisular (AP-t) y con el Alberta Stroke Programme Early CT Score (ASPECTS). Resultados: Se obtuvieron las siguientes concordancias intraobservadores: buena concordancia en la clasificación general de la lesión (κ= 0.63, p<0.001), muy buena concordancia en lesiones hemorrágicas (κ= 0.89, p< 0.001), y concordancia moderada en ambos sin clasificación de lesión aguda y clasificación de lesión isquémica aguda (κ= 0.59 y κ= 0.58 respectivamente, p<0.001). Hubo una buena concordancia intraobservadores en el ASPECTS dicotomizado (κ= 0.65, p<0.001). Conclusiones: Los resultados de nuestro estudio permiten concluir que la confiabilidad de la solución móvil para la interpretación de imágenes de TAC de cráneo simple de pacientes con accidente cerebrovascular agudo (ACV) estaba garantizada, lo que permitiría servicios de teleACV eficientes y de bajo costo.

Management of Acute Submacular Hemorrhage with Intravitreal Injection of Tenecteplase, Anti-vascular Endothelial Growth Factor and Gas

PURPOSE: To evaluate the visual and anatomical outcomes for neovascular age-related macular degeneration with submacular hemorrhage after intravitreal injections of tenecteplase (TNK), anti-vascular endothelial growth factor (VEGF) and expansile gas. METHODS: This study was a retrospective clinical case series following 25 eyes of 25 patients. All patients received a triple injection using 0.05 mL TNK (50 µg), 0.05 mL anti-VEGF and 0.3 mL of perfluoropropane gas. Retreatment with anti-VEGF was performed as needed. Preoperative and postoperative best-corrected visual acuity and central retinal thickness were analyzed. RESULTS: The mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved significantly from 1.09 ± 0.77 at baseline to 0.52 ± 0.60 at 12 months (p < 0.001). The mean central retinal thickness also improved significantly from 545 ± 156 at baseline to 266 ± 107 at 12 months (p < 0.001). A visual improvement of 0.3 logarithm of the minimum angle of resolution unit or more was achieved in 15 eyes (60%). During the 12 postoperative months, an average of 4.04 intravitreal anti-VEGF injections was applied. CONCLUSIONS: A triple injection of TNK, anti-VEGF, and a gas appears to be safe and effective for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration.

Lean thinking turns ‘time is brain’ into reality / Pensamento enxuto faz ‘tempo é cérebro’ virar realidade

Intravenous rt-PA is an effective recanalizing treatment for ischemic stroke within 4 and half hours from its onset (Onset-to-Treatment [OTT]), with the best result seen in those treated within 90 minutes OTT. Yet few patients currently are treated in this time frame. From the standpoint of process improvement or a lean thinking perspective, there is a potential opportunity to reduce the time by eliminating non-value-added steps in each element of the stroke survival chain. The reduction in one time element does not necessarily shift the OTT under 90 minutes. Most likely, the reduction in OTT requires a coordinated approach to track and improve all elements of OTT, from the patient’s ability to recognize the onset of stroke up to delivery of medication. Shortening this total time should be a considered an indicator of quality improvement in acute stroke care.

Tratamento intravenoso com rt- PA é eficaz na recanalização do acidente vascular cerebral isquêmico (AVCI) no prazo de até 4 horas e meia de seu início (OTT), com o melhor resultado visto naqueles tratados dentro de 90 minutos OTT. Apesar disso, poucos são tratados neste período de tempo. Do ponto de vista da melhoria de processos ou uma perspectiva de pensamento enxuto, há uma oportunidade potencial para reduzir o tempo ao eliminar etapas que não agregam valor em cada elemento da cadeia de sobrevivência do paciente com acidente vascular cerebral. A diminuição da OTT requer uma abordagem coordenada em conjunto para controlar e melhorar todos os elementos de OTT, a capacidade do paciente para reconhecer o início do icto até à administração da medicação. Encurtar esse tempo total deve ser um considerado um indicador da melhoria da qualidade no atendimento AVCI agudo.

Activador del plasminógeno tisular recombinante en el manejo de trombos cardiacos en recién nacidos / Recombinant tissue plasminogen activator for the management of intracardiac thrombi in newborns

Introducción: La incidencia de trombos cardíacos en recién nacidos (RN) ha aumentado con el uso de catéteres venosos centrales. La trombólisis con activador del plasminógeno tisular recombinante (rTPA) se ha utilizado como alternativa a la heparina en trombos gigantes con riesgo vital y de embolización. Nuestro objetivo fue describir la respuesta y las complicaciones relacionadas con el uso del rTPA en el manejo de trombos cardíacos con riesgo vital en RN. Pacientes y método: Estudio retrospectivo de 8 RN, 7 prematuros, con trombos cardíacos en los cuales se utilizó rTPA. Se analizó la edad gestacional y al diagnóstico, peso, sexo, enfermedades asociadas, hemograma, niveles de fibrinógeno, dímero D, tiempo parcial de tromboplastina activada y de protrombina, antes y al término de la infusión de rTPA. El diagnóstico del trombo se realizó por ecocardiografía doppler. La indicación de rTPA fue trombo mayor de 10 mm o que ocupara más del 50% de la cavidad donde se localizaba; aumento del tamaño a pesar del tratamiento con heparina, aspecto fragmentado y lobulado con riesgo embólico pulmonar o sistémico o que comprometiera la función valvular o cardíaca. Resultados: Cuatro hombres; peso promedio de 1.580 g. La principal enfermedad fue la sepsis (7/8), se usó catéter venoso central en todos, la vena cava superior fue la localización más frecuente, con tiempo promedio de instalación previo al diagnóstico de 12 días. En 7/8 RN los trombos se ubicaron en la aurícula derecha, con un tamaño entre 7 a 20 mm. Tres pacientes recibieron heparina de bajo peso molecular previo al uso de rTPA, se realizaron entre uno a 5 ciclos con rTPA. En 4 pacientes se logró resolución completa del trombo a los 3,5 días en promedio. No hubo embolia ni fallecidos. Cuatro pacientes presentaron hemorragia intracraneana grado I, sin secuelas en el seguimiento. Conclusión: Este estudio constituye la primera serie de neonatos tratados con rTPA en Chile, lográndose la resolución completa del trombo en un 50% de los RN y parcial en el resto, permitiendo con ello disminuir el riesgo vital secundario a este proceso patológico.

Introduction: The incidence of cardiac thrombi in newborns has increased with the use of central venous catheters. Thrombolysis with recombinant tissue plasminogen activator (rTPA) has been used as an alternative to heparin in life threatening giant thrombus and embolization. The aim of this study is to describe the response and complications related to the use of rTPA in the management of life- threatening cardiac thrombi in newborns. Patients and method: The medical records of 8 newborn were reviewed in a retrospective study, of whom 7 were preterm with cardiac thrombi, and rTPA was used in all of them. Results: The patients included 4 males with a mean weight of 1580 gr. The principal pathology was sepsis (7/8), all of them used venous central catheter. The superior vena cava was the most frequent location, with a mean time of installation before the diagnosis of 12 days. RN 7/8 thrombi were located in the right atrium with a size between 7 to 20 mm. Three patients received low molecular weight heparin prior to using rTPA. They received between 1 to 5 cycles with rTPA. In 4 patients complete resolution of the thrombus was achieved in a mean of 3.5 days. Four patients had intracranial haemorrhage grade I, without sequelae at follow-up. There were no deaths or embolism. Conclusion: This study is the first series of infants treated with rTPA in Chile, and where its use has quickly achieved complete resolution of the thrombus in 50% of cases, and partially in the others, thus reducing the secondary life-threatening risk of this disease.

Subconjunctival and topical application of recombinant tissue plasminogen activator in rabbits / Uso tópico e subconjuntival de ativador de plasminogênio tecidual recombinante em coelhos

Purpose: To quantify fibrin degradation products after topical and subconjunctival administration of recombinant tissue plasminogen activator in rabbits. Methods: Fibrin formation was induced in the anterior chamber in 25 rabbits. Subsequently, five rabbits received an injection of r-TPA (positive control) in the anterior chamber, another 10 received a subconjunctival injection of r-TPA, and the remaining 10 received instillations of topical r-TPA. Afterwards, samples of aqueous humor were collected and semi-quantitative analysis of fibrin degradation products (FDP) was performed. Results: No statistical differences were noted between the treatment and control groups at any time point. Fibrin degradation products semi-quantification showed statistical improvement in the control group and the subconjunctival group. Conclusion: Fibrin degradation products were observed in the anterior chamber after subconjunctival administration of r-TPA. However, it was probably not sufficient to cause fibrin degradation. Topical r-TPA did not effectively absorb anterior chamber fibrin. .

Objetivo: Quantificar produtos de degradação de fibrina (PDF) após uso tópico e subconjunctival de ativador de plasminogênio tecidual recombinante (r-TPA) em coelhos. Métodos: Formação de fibrina foi induzida na câmara anterior em 25 coelhos. Cinco coelhos foram submetidos a injeção intracameral de r-TPA (controle positivo). Dez coelhos foram submetidos a injeção subconjuntival de r-TPA e dez coelhos foram submetidos a instilação tópica de r-TPA. Amostras de humor aquoso foram coletados e uma análise quantitativa dos produtos de degradação de fibrina foi realizada. Resultados: Não foi observado diferença estatisticamente significativa na degradação de fibrina em nenhum dos momentos estudados quando comparados com o controle. Porém foi observado diferença estatisticamente significante na quantificação do produtos de degradação de fibrina no grupo controle e no grupo subconjuntival. Conclusão: Produtos de degradação de fibrina foi observado nas amostras do grupo subconjunctival, porém, provavelmente não foi suficiente para degradar a fibrin presente. r-TPA tópico não foi efetivo em absorver fibrina na câmara anterior. .

Predictive factors for anterior chamber fibrin formation after vitreoretinal surgery / Fatores preditivos para formação de fibrina na câmara anterior após cirurgia vitreorretiniana

Purpose: The aim of this study was to investigate possible predictive factors related to anterior chamber fibrin formation after vitreoretinal surgery in a large series of patients. Methods: The data of 185 eyes of 185 patients submitted to vitreoretinal surgery was reviewed. The following variables were evaluated: the postoperatively presence of fibrin, age, diabetes mellitus, the vitrectomy system gauge (20, 23 or 25 gauge), the type of vitreous substitute, the influence of prior surgical procedures and the combination with cataract extraction. To evaluate predictive factors for anterior chamber fibrin formation, univariate analysis was performed. A multivariate stepwise logistic regression model was adjusted to investigate factors associated with fibrin formation (p<0.05). Results: Fibrinoid anterior chamber reaction was found in 12 (6.4%) patients. For multivariate logistic regression analysis, balanced salt solution (BSS), the chance of fibrin occurrence was 5 times greater (odds ratio 4.83, CI 95% 1.302 - 17.892; p=0.019), while combination with phacoemulsification increased the chance of fibrin formation by 20 times (odds ratio 20, CI 95% 2.480 - 161.347; p=0.005). No significant difference was found regarding other variables. Conclusion: Anterior chamber fibrin formation is an unwanted complication after vitreoretinal surgery. Factors such as combined performance of phacoemulsification and the use of balanced salt solution as a vitreous substitute may predispose the occurrence of this complication. .

Objetivo: Avaliar os possíveis fatores relacionados à formação de fibrina na câmara anterior após cirurgia vitreorretiniana em uma grande série de casos. Métodos: Foi realizado um estudo retrospectivo, observacional, caso-controle, onde os dados de 185 olhos de 185 pacientes submetidos à cirurgia vitreorretiniana foram avaliados. Os seguintes dados foram analisados: presença ou não de fibrina na câmara anterior na primeira semana de pós-operatório, idade, presença ou não de diabetes mellitus, calibre do sistema de vitrectomia utilizado (20,23 ou 25 gauge), substituto vítreo, a influência de cirurgias oftalmológicas prévias e a realização de cirurgia de catarata combinada. Para avaliação dos fatores preditivos para formação de fibrina, a análise univariada foi realizada. O modelo de regressão logística multivariada foi utilizado para investigar os fatores associados com a formação de fibrina (p<0,05). Resultados: A presença de fibrina na câmara anterior foi encontrada em 12 (6,4%) pacientes. Pela análise de regressão logística multivariada, o uso de solução salina balanceada (BSS) como substituto vítreo, a chance da presença de fibrina foi 5 vezes maior (odds ratio 4,83, IC 95% 1,302 - 17,892; p=0,019), enquanto que a realização de cirurgia facoemulsificação combinada aumentou a chance de formação de fibrina 20 vezes (odds ratio 20, IC 95% 2,480 - 161,347; p=0,005). Nenhuma diferença estatisticamente significativa foi encontrada para as outras variáveis. Conclusão: A formação de fibrina na câmara é uma complicação indesejada após cirurgia vitreorretiniana. Fatores como realização de cirurgia de facoemulsificação combinada e ...

Clinical experience with alteplase in the management of intracardiac and major cardiac vessels thrombosis in pediatrics: a case series

Experience with alteplase in pediatric patients is limited and recommendations are extrapolated from adult data. Comprehensive guidelines on the management of thromboembolic events in this group are lacking. We assessed the efficacy and safety of alteplase [recombinant tissue plasminogen activator] in the management of intracardiac and major cardiac vessel thrombosis in pediatric patients. All pediatric patients, 14 years of age and younger, with intracardiac or major cardiac vessel thrombus who were treated with alteplase from 1997 to 2004 at our tertiary care institute were identified through the pharmacy database. Patient data were retrospectively evaluated for the efficacy and safety of altepase. Five cases were eligible out of nineteen who received alteplase. Patient ages ranged from 40 days to 13 years. The initial dose of alteplase ranged from 0.3 to 0.6 mg/kg followed by a continuous infusion in three patients with a dosage range between 0.05 and 0.5 mg/kg/hr, while intermittent infusion was used in the other two patients. The duration of therapy ranged from 2 to 4 days. By the end of the treatment, two patients had complete resolution of thrombus and one had partial resolution. Two patients failed to respond and had "old" thrombus. Major bleeding events were reported in three patients. The rest had minor bleeding events. Alteplase may effectively dissolve intracardiac thrombi, particularly when freshly formed. Continuous infusion for a long duration appears to be associated with an increased risk of major bleeding. Optimal dose and duration of infusion are still unknown

Spontaneous splenic rupture in a patient receiving thrombolytic therapy / Ruptura esplênica espontânea em paciente submetida a terapia trombolítica

We describe the case of a 67-year-old female patient with a history of femoral-distal bypass graft with sudden onset of unremitting leg pain, who had recently received tissue plasminogen activator (t-PA). The patient reported non-compliance with her warfarin regimen. Angiography revealed occlusion of the bypass graft. Infusion of t-PA was performed via a right femoral artery approach. On hospital day two, the patient developed nausea and abdominal pain with associated hypotension. A CT scan showed a massive intra-abdominal and pelvic free fluid consistent with blood. The spleen was enlarged and fluid noted around the liver. At laparotomy, a grade III splenic laceration at the hilum was identified and a splenectomy performed. The patient recovered completely. Although rare, spontaneous splenic rupture should be considered in the differential diagnosis of patients undergoing thrombolytic therapy who develop signs of hemodynamic instability.

Descrevemos o caso de uma paciente de 67 anos com histórico de enxerto fêmoro-distal com início súbito de dor repetitiva em membro inferior e que havia recebido ativador de plasminogênio tecidual (AP-t) recentemente. A paciente relatou não adesão ao seu tratamento com warfarina. A angiografia revelou oclusão do enxerto. O AP-t foi administrado via artéria femoral direita. No segundo dia de hospitalização, a paciente apresentou náuseas e dor abdominal com hipotensão associada. Uma tomografia computadorizada revelou a existência de um fluido pélvico e intra-abdominal livre em grande quantidade, com suspeita de que fosse sangue. O baço estava crescido, e o fluido foi observado em torno do fígado. A laparotomia identificou uma laceração grau III no hilo esplênico, e uma esplenectomia foi realizada. A paciente teve recuperação completa. Embora rara, a ruptura esplênica espontânea deve ser considerada no diagnóstico diferencial de pacientes submetidos a terapia trombolítica que apresentem sinais de instabilidade hemodinâmica.

Angioedema orolingual após infusão de alteplase no tratamento de acidente vascular cerebral: relato de caso / Orolingual angioedema after alteplase infusion for treatment of brain stroke: case report

O angioedema é uma reação inflamatória local potencialmente grave. Estudos evidenciam uma incidência destes casos após uso de alteplase entre 0,02% e 5,1%. Relatamos um caso de acidente vascular cerebral isquêmico agudo tratado com alteplase que evoluiu com angioedema e piora clínica. Este paciente teve expressiva melhora neurológica com posterior declínio clínico após o angioedema. O mecanismo inflamatório neste caso pode ter desempenhado papel determinante na reoclusão.

Angioedema is a potentially severe local inflammatory reaction. There is an incidence of 0.02% to 5.1% in patients treated with alteplase. We report a case of acute ischemic stroke that was treated with alteplase and presented a life threatening allergic reaction. This patient had an important neurologic improvement in the beginning, but this benefit was lost after angioedema. The inflammatory mechanism that causes angioedema is sometimes decisive in re-occlusion.

Late results of catheter-directed recombinant tissue plasminogen activator fibrinolytic therapy of iliofemoral deep venous thrombosis

PURPOSE: To evaluate the efficacy of catheter-directed low-dose recombinant tissue-type plasminogen activator infusion in the treatment of iliofemoral deep venous thrombosis and prevention of post-thrombotic syndrome. METHOD: Eighteen patients (out of 260 evaluated) with acute iliofemoral deep venous thrombosis and no previous evidence of venous insufficiency were prospectively selected for thrombolytic therapy. Catheter-directed low-dose recombinant tissue-type plasminogen activator (1 mg/h) was infused into the thrombotic segments. RESULTS: Effective fibrinolysis was achieved in 14 of 18 cases, with correlation between effective fibrinolysis and major/complete resolution of acute signs and symptoms (P <.01). There were no episodes of major complications. Four patients presented with early rethrombosis (1 to 8 weeks). Individuals were followed for a period up to 131 weeks (average, 85.2). The incidence of clinical signs and symptoms of venous insufficiency and duplex-scan findings of valvular reflux was significantly lower in the patients in which lytic therapy succeeded and patency was kept, compared with patients experiencing acute therapeutic failure or rethrombosis (P <.01). CONCLUSIONS: Low-dose recombinant tissue-type plasminogen activator fibrinolytic therapy is safe and effective in the treatment of acute iliofemoral venous thrombosis. The late evolution as revealed clinically and by ultrasound was superior in patients for whom lytic therapy was effective.

OBJETIVOS: Avaliar a eficácia da infusão seletiva por cateter do ativador de plasminogênio tecidual recombinante em baixas doses no tratamento da trombose venosa iliacofemoral e na prevenção da síndrome pós-trombótica. MÉTODO: Dezoito pacientes (de 260 avaliados) portadores de trombose venosa profunda iliacofemoral sem evidência prévia de insuficiência venosa foram selecionados para terapia fibrinolítica e submetidos a infusão seletiva por cateter do ativador de plasminogênio tecidual recombinante na dose de 1mg/dl nos segmentos venosos trombóticos. RESULTADOS: Quatorze pacientes apresentaram fibrinólise efetiva; observamos correlação entre o grau de melhora clínica observado e a redução percentual do volume trombótico (P<.01). Não houve episódios de complicações graves. Quatro pacientes apresentaram retrombose precoce (1 a 8 semanas). Os pacientes foram seguidos por um período de até 131 semanas (média 85.2). A incidência de sinais e sintomas clínicos de insuficiência venosa e os achados ecográficos de refluxo valvular foram significativamente menores nos pacientes em que a terapia fibrinolítica foi efetiva e a perviedade mantida ao longo do período de seguimento, na comparação com os casos de falha aguda ou de retrombose precoce (P<.01). CONCLUSÕES: A terapia fibrinolítica da trombose venosa iliacofemoral com ativador de plasminogênio tecidual recombinante seletivo em baixas doses demonstrou-se eficaz e segura. A evolução clínica e ecográfica tardia foi superior nos pacientes em que a terapia lítica foi efetiva.

Revascularização clínica e intervencionista no acidente vascular cerebral isquêmico agudo: opinião nacional / Clinical and interventional revascularization in the acute ischemic stroke: national opinion

Este artigo apresenta as conclusões sobre revascularização clínica e intervencionista no acidente vascular cerebral isquêmico agudo, um dos temas discutidos na reunião "Opinião Nacional sobre o Tratamento do AVC". Tratou-se de reunião promovida e coordenada pela Sociedade Brasileira de Doenças Cerebrovasculares, com neurologistas especializados em doenças cerebrovasculares, que analisaram e discutiram as evidências e experiências atuais sobre o uso de trombólise e técnicas intervencionistas em pacientes com acidente vascular cerebral isquêmico agudo.

Resultados a corto plazo de angioplastía de rescate en pacientes con infarto agudo de miocardio con trombólisis fallida / Short-term results of rescue angioplasty in patients with acute myocardial infarction and failure of thrombolysis treatment

El objetivo es describir nuestra experiencia, resultados clínicos y angiográficos inmediatos en pacientes con IAM sometidos a angioplastía coronaria transluminal percutánea de rescate (ACTPR). Material y métodos: Tipo de estudio; retrospectivo, observacional, transversal y descriptivo con seguimiento a 30 días. De enero de 2001 a julio de 2004 se realizaron 3,238 procedimientos de ACTP con aplicación de stent a pacientes con diagnóstico de cardiopatía isquémica por aterosclerosis coronaria, se seleccionó a 32 pacientes que representan el 0.98%, con edad de 47 a 79 años promedio de 63, 24 (75%) del sexo masculino, con hipertensión arterial sistémica 29 (90.6%), diabetes mellitus 18 (56.3%), hipercolesterolemia 11 (34.4%), tabaquismo 24 (75%), con antecedentes de angina inestable 9 (28.1%) y con infarto miocardio previo 2 (6.3%). La localización del IAM: anterior extenso 14 (43.8%), anteroseptal en 6 (18.8%), postero-inferior en 5 (15.6%), Pl con extensión eléctrica y/o hemodinámica en VD en 4 (12.5%), lateral en 1 (3.1%). Se trombolizaron en un tiempo promedio 3.19 horas (rango 2-7) con estreptoquinasa 19 (59.4%) y con rTPA 13 (40.6%), la CPK-MB pico (U) promedio de 348 ± 240. Con Killip Kimball (KK) 1 en cinco (15.6%), II 16 (50%), III 5 (15.6%) y IV 6 (18.8%) éstos manejados con balón intraaórtico de contrapulsación. Resultados: Llevados a sala de hemodinamia en un tiempo de 6 a 24 h encontrando flujo TIMI 0 en 16 (50%), TIMI 1 en diez (31.2%), TIMI 2 en seis (18.8%), promedio de vasos enfermos de 1.9. Se implantó stent en 27 (84.3%). Éxito angiográfico post ACTP más stent TIMI 3 en 24 (75%). Complicaciones: En 9(28.1%), en 7 (21.8%) con no reflujo y en 1 (3.1%) disección de la arteria coronaria relacionada con el IAM, 6 (18.7%) que fallecieron, en 4 (12.5%) con choque cardiogénico; 3 (9.3%) la ACTPR fue fallida. Conclusión: La ACTPR es un procedimiento de alto riesgo y pese a ello es una buena alternativa de tratamiento en pacientes con trombólisis fallida.

The present study is aimed at describing the short-term assessment of clinical and angiographic results in patients with acute myocardial infarction treated with rescue percutaneous transluminal coronary angioplasty (RPTCA). Methods: We reviewed retrospectively, from January 2001 to July 2004, the interventional procedures performed in patients with coronary heart disease. From a total of 3,258 patients we selected 32 (0.98%) with acute myocardial infarction and failure of thrombolysis treatment, which were treated with RPTCA to relief the symptoms. Average age was 63 years (range 47-79), there were 24 men (75%); hypertension in 29 (90.6%); diabetes mellitus in 18 (56.3%); currently smoking 24 (75%); dyslipidemia in 11 (34.4%); unstable angina in 9 (28.1%); previous myocardial infarction in 2 (6.3%). The area related to the infarction was anterior and lateral in 14 (43.8%), anteroseptal in 6 (18.8%), postero-inferior in 5 (15.6%) with electric and hemodynamic involvement in 4 (12.5%), lateral in 1(3.1 %). Thrombolysis treatment was delivered in 3.19 hours (range 2-7 hours) with streptokinasein 19 (59.4%) and rTPA in 13 (40.6%). The evaluated serum marker was CPK-MB with the highest level of 348 ± 240 U/L. Killip Kimball (KK) class was established as follows: KKI in 5 (15.6%), II in 16 (50%), III in 5 (15.6%), and IV in 6 (18.8%). Patients with cardiogenic shock were treated with intra-aortic balloon counterpulsation. Results: Time between symptoms and arrival to the cath lab was 11 hours (range 6-24 hours). TIMI flow was: TIMI 0 in 16(50%). TIMI 1 in 10 (31.2%), TIMI 2 in 6 (18.8%). The number of vessels with a significant lesion was 1.9 (range 1-4). Stents were placed in 27 (84.3%) patients. Angiographic success post-angioplasty was achieved in 24 (75%); there were 9 complications (28.1%), no reflow in 7 (21.8%), coronary dissection in 1 (3.1%). Six patients died (18.7%) and 4 of them (12.5%) were in cardiogenic shock. Conclusion: RPT-CA is a high-risk procedure, being an acceptable treatment option for patients with thrombolysis failure.

Activador del plasminógeno tisular intravenoso en el tratamiento del infarto cerebral agudo: factibilidad, seguridad y eficacia en los primeros dos años de práctica clínica / Intravenous tissue plasminogen activator in acute ischemic stroke: feasibility, safety and efficacy in the first 2 years of clinic practice

Background: The only effective therapy for the treatment of acute ischemic stroke is the infusion of tissue plasminogen activator in the first three hours after the onset of symptoms. Aim: To report the experience with tissue plasminogen activator infusion in the treatment of acute ischemic stroke. Patients and methods: Ten males and 10 females, aged 52 to 85 years old with an acute ischemic stroke, admitted within 89 min after the onset of symptoms were studied. Tissue plasminogen activator was infused following the guidelines designed by the National Institute of Neurological Disorders and Stroke (NINDS). Patients were assessed according to Rankin scale after three months of follow up. Results: All patients had normal CAT scans. The delay between the onset of symptoms and the infusion ranged from 75 to 180 min. One patient had a gastrointestinal bleeding due to a gastric ulcer and one patient had a fatal intracranial hemorrhage. After three months of follow up, 38 percent of patients had a good recuperation (Rankin 0 to 1), 33 percent had a mild to moderate disability (Rankin 2 or 3) and 14 percent had a moderate to severe disability (Rankin 4). There was a 15 percent mortality. Conclusions: This series show that treatment of acute ischemic stroke with tissue plasminogen activator is feasible and safe. The obtained results are similar to those reported abroad

Evaluación retrospectiva del uso de activador tisular del plasminógeno (rt-PA) en el manejo del infarto agudo de miocardio en el servicio de urgencias de la Clínica Shaio

Objetivo: Evaluar el uso de activador tisular del plasminógeno recombinante (rt-PA) en los pacientes con IAM que ingresaron por el servicio de urgencias. Materiales y métodos: Estudio descriptivo retrospectivo de corte transversal en donde se tomaron todos los pacientes con diagnóstico de IAM al ingreso en urgencias durante el período comprendido entre enero de 1996 hasta julio de 1997 en los cuales se utilizó la terapia trombolítica con rt-PA. Se administró el esquema acelerado de rt-PA seguido por infusión de heparina para mantener PTT entre 50 y 70 segundos por 24 a 48 horas. Las indicaciones para administrar rt-PA fueron: edad menor de 75 años, infarto de localización anterior y tiempo de evolución menor de 6 horas. La recolección de la información se realizó a partir de la historia clínica. Las variables estudiadas fueron edad, sexo, tipo de infarto, localización, clasificación de killip, tiempo de evolución al momento de la consulta, uso, tipo y causa de exclusión de trombosis con rt-AP. permeabilidad de la arteria relacionada con el infarto, realización de angioplastia, requerimiento de cirugía (electiva o de urgencia), complicaciones y mortalidad antes de la intervención con angioplastia electiva o cirugía. Resultados: De un total de 458 pacientes con diagnóstico de IAM se realizó terapia de recanalización en 206 pacientes (44.5 por ciento), 12 con angioplastia primaria (6 por ciento), 146 (70.5 por ciento) con STK y 48 (23.5 por ciento) con rt-PA. De estos pacientes 42 (87.5 por ciento) fueron hombres y 6 (12.5 por ciento) mujeres. Las edades estuvieron entre 42 años el más joven y 75 años el de mayor edad, con un promedio de 60-17 años. El tiempo promedio de consulta a urgencias después del inicio de los síntomas fue de 4.9 horas. Ningún paciente entró con Killip IV, 3 (6.5 por ciento) Killip I, 14 (29 por ciento) en Killip II yb 31 (64.5 por ciento) en Killip III. La principal causa de exclusión de trombólisis con rt-PA fue la consulta fuera de tiempo > 6 horas. Se presentó un caso de hemorragia de vías digestivas clasificada como menor ya que no requirió transfusión. De las complicaciones secundarias al IAM se presentó choque en 4 (8.3 por ciento), arritmia ventricular en 3 (6.2 por ciento); pericarditis en 2 (4.15 por ciento); angina post IAM en 1 (2.5 por ciento); insuficiencia mitral en 1 (2.5 por ciento); trombo intracavitario 1 (2.5 por ciento). La mortalidad entre los pacientes trombolizados...

Fator tecidual ativador de plasminogênio (rt-PA) em oftalmologia: casos clínicos / Tissue plasminogen activador in ophthalmology: cases report

Este trabalho apresenta e discute 10 casos clínicos em que o rt-PA foi injetado na câmara anterior na dose de 25mcg com a finalidade de dissolver as membranas de fibirina e diminuir as complicaçöes fibrinoproliferativas no pós-operatório de facectomias, cirurgias filtrantes e vitrectomias; acelerar a reabsorçäo de hifemas; e facilitar a retirada de membranas neovasculares sub-retinianas no per-operatório de vitrectomias. Todos os pacientes apresentavam membrana de fibrina na câmara anterior resistente ao tratamento máximo com antiinflamatórios. Dos 10 casos, 7 apresentaram bom resultado clínico (receberam a injeçäo do 6§ ao 20§ dia após a cirurgia, realizada nas seguintes situaçöes: vitrectomias, transplantes de córnea à quente, facoemulsificaçäo em uveíte, membranectomia subretiniana macular, trabeculectomia e facectomia em criança) e três näo apresentaram dissoluçäo da fibrina (receberam a injeçäo do 7§ ao 30§ dia, e nas seguintes indicaçöes: pós-sutura de córnea em trauma perfurante, pós facectomia em catarata traumática e por hifema pós-vitrectomia. Os resultados deste estudo confirmaram que o tempo de pós-operatório e as características biomicroscópicas da membrana säo importantes no efeito fibrinolítico do rt-PA na câmara anterior mostrou-se eficiente e sem efeito colateral