En respuesta a «Trombectomía mecánica en el ictus isquémico agudo, conociendo nuestros resultados» / In reply to "Mechanical thrombectomy in acute ischemic stroke, knowing our results"

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Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía / Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: a retrospective analysis and review of the literature

Objetivo: Valorar si la técnica de embolización urgente del aneurisma cerebral y posterior cirugía del hematoma es segura y eficaz en pacientes con hematoma y signos de hipertensión intracraneal por rotura de aneurisma cerebral. Métodos: Se incluyeron 23 pacientes consecutivos con aneurisma cerebral roto y mal estado clínico debido a un hematoma intracraneal, ambos tratamientos completados en las primeras 4 horas del inicio de la clínica. Todos los pacientes presentaban signos clínicos de hipertensión intracraneal y/o alteración del nivel conciencia, incluido coma por deterioro rostrocaudal. Se valoró la eficacia de la técnica mediante el grado de cierre de los aneurismas y el pronóstico de los pacientes un mes después, y la seguridad, mediante el análisis de las complicaciones de los tratamientos. Resultados: El 91,3% de los pacientes tenía un aneurisma localizado en la arteria cerebral media (ACM). Todos los pacientes presentaban un valor de 4 en la escala de Fisher y de IV-V en la escala de Hunt y Hess. El tiempo medio desde la identificación del aneurisma en la tomografía computarizada hasta la embolización del aneurisma fue de 115 minutos. Se usó balón de remodeling en el 78% de los casos, con el que se logró un cierre adecuado en el 82,6% de los pacientes. Durante la cirugía se colocó un drenaje ventricular en 9 (39,1%) pacientes. Al mes, 13 (56,5%) pacientes eran independientes, con una mortalidad del 13%. No existieron resangrados. Conclusión: En nuestra experiencia, el tratamiento combinado mediante embolización del aneurisma y descompresión quirúrgica con evacuación del hematoma es segura y efectiva, y es una alternativa al tratamiento quirúrgico aislado

Objective: To determine whether the urgent embolization of a cerebral aneurysms and posterior surgery on cerebral hematomas is safe and efficacious in patients with hematomas and signs of intracranial hypertension due to the rupture of cerebral aneurysms. Methods: We included 23 consecutive patients in poor clinical condition due to an intracranial hematoma caused by a ruptured cerebral aneurysm who were treated with both embolization and surgery within 4 hours of the onset of symptoms. All patients had clinical signs of intracranial hypertension and / or altered levels of consciousness, including coma due to rostrocaudal deterioration. We evaluated the efficacy of the combined technique by determining the degree of closure of the aneurysms and the patients' prognosis one month after the procedures; we evaluated safety by analyzing the complications of the treatments. Results: All but two of the patients (21/23; 91.3%) had an aneurysm of the middle cerebral artery. All patients scored 4 on the Fisher scale and were classified as Hunt and Hess IV or V. The mean time from the identification of the aneurysm on computed tomography to embolization was 115minutes. A balloon remodeling technique was used in 18 (78%) patients; embolization achieved adequate closure in 19 (82.6%) patients. During surgery, a ventricular drain was placed in 9 (39.1%) patients. One month after treatment, 13 (56.5%) patients were functionally independent and 3 (13%) had died. No episodes of rebleeding were observed. Conclusion: In our experience, combined treatment including embolization of the aneurysm and surgical decompression with evacuation of the hematoma is a safe and effective alternative to surgical treatment alone

Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: a retrospective analysis and review of the literature. / Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía.

OBJECTIVE: To determine whether the urgent embolization of a cerebral aneurysms and posterior surgery on cerebral hematomas is safe and efficacious in patients with hematomas and signs of intracranial hypertension due to the rupture of cerebral aneurysms. METHODS: We included 23 consecutive patients in poor clinical condition due to an intracranial hematoma caused by a ruptured cerebral aneurysm who were treated with both embolization and surgery within 4hours of the onset of symptoms. All patients had clinical signs of intracranial hypertension and / or altered levels of consciousness, including coma due to rostrocaudal deterioration. We evaluated the efficacy of the combined technique by determining the degree of closure of the aneurysms and the patients' prognosis one month after the procedures; we evaluated safety by analyzing the complications of the treatments. RESULTS: All but two of the patients (21/23; 91.3%) had an aneurysm of the middle cerebral artery. All patients scored 4 on the Fisher scale and were classified as Hunt and Hess IV or V. The mean time from the identification of the aneurysm on computed tomography to embolization was 115minutes. A balloon remodeling technique was used in 18 (78%) patients; embolization achieved adequate closure in 19 (82.6%) patients. During surgery, a ventricular drain was placed in 9 (39.1%) patients. One month after treatment, 13 (56.5%) patients were functionally independent and 3 (13%) had died. No episodes of rebleeding were observed. CONCLUSION: In our experience, combined treatment including embolization of the aneurysm and surgical decompression with evacuation of the hematoma is a safe and effective alternative to surgical treatment alone.

Resultados y evolución funcional de pacientes críticos con ictus isquémico sometidos a trombectomía mecánica / Results and functional outcomes of acute ischemic stroke patients who underwent mechanical thrombectomy admitted to intensive care unit

OBJETIVO: Estudiar los resultados y las complicaciones del tratamiento endovascular (TEV) en pacientes con ictus isquémico agudo ingresados en una unidad de cuidados intensivos (UCI). Analizar los factores que podrían influir en la mortalidad y en el grado de discapacidad al alta y un año después del ictus. DISEÑO: Estudio prospectivo observacional. Ámbito: UCI polivalente. Hospital de tercer nivel. PACIENTES: Sesenta pacientes adultos. Muestra consecutiva. INTERVENCIONES: Ninguna. Variables de interés: Datos epidemiológicos, tiempo desde la clínica inicial hasta el TEV, resultado angiográfico, tiempo de estancia en UCI, días de ventilación mecánica, complicaciones neurológicas, National Institutes of Health Stroke Scale (NIHSS) al ingreso y al alta de UCI, escala de Rankin modificada (mRS) al año de evolución. RESULTADOS: Edad media 68,90±8,84años. Mediana de tiempo hasta el TEV: 180min. Mediana NIHSS al ingreso: 17,5; al alta: 3. Flujo distal en el 90% de los casos. Mediana estancia en UCI: 3días. Ventilación mecánica: 81,7%. Independencia funcional (mRS≤2) 50% al año del ictus. Fallecimientos: 22 (36,6%); 8 (13,3%) en la UCI y el resto durante el primer año. CONCLUSIONES: Las variables asociadas a un peor estado funcional fueron la transformación hemorrágica sintomática, la ausencia de recanalización y las complicaciones durante el procedimiento. La transformación hemorrágica y la hidrocefalia se asociaron a mayor mortalidad. Se consiguió flujo distal en la mayoría de los casos, con una baja tasa de complicaciones. La mitad de los pacientes alcanza independencia funcional al año del ictus

PURPOSE: To study the results and complications of endovascular treatment (EVT) in acute ischemic stroke patients admitted to Intensive Care Unit (ICU). To analyse the possible factors related to mortality and level of disability at ICU discharge and one year after stroke. DESIGN: Observational prospective study. SETTING: Mixed ICU. Third level hospital. PATIENTS: Sixty adult patients. Consecutive sample. INTERVENTIONS: None. Variables of interest: Epidemiological data, time from symptom onset to EVT, angiographic result, length of stay, days on mechanical ventilation, neurological complications, National Institutes of Health Stroke Scale (NIHSS) at ICU admission and discharge, modified Rankin scale score (mRS) at one year. RESULTS: Mean age 68,90±8,84years. Median time from symptom onset to EVT: 180minutes. Median NIHSS at admission: 17,5; at discharge: 3. Distal flow was achieved in 90% of cases. Median ICU stay: 3 days. Mechanical ventilation: 81,7.%. Functional independence (mRS≤2) 50% at one year. Deaths: 22 (36,6%) of which 8 (13,3%) died during UCI stay and the rest during the first year. CONCLUSIONS: The factors relating to a worse functional outcome were symptomatic hemorrhage transformation, lack of recanalization and complications during EVT. The factors relating to mortality were symptomatic hemorrhage and hydrocephalus. Distal flow was achieve in most cases with a low complication rate. Half of the patients presented functional independence one year after the stroke

Results and functional outcomes of acute ischemic stroke patients who underwent mechanical thrombectomy admitted to intensive care unit. / Resultados y evolución funcional de pacientes críticos con ictus isquémico sometidos a trombectomía mecánica.

PURPOSE: To study the results and complications of endovascular treatment (EVT) in acute ischemic stroke patients admitted to Intensive Care Unit (ICU). To analyse the possible factors related to mortality and level of disability at ICU discharge and one year after stroke. DESIGN: Observational prospective study. SETTING: Mixed ICU. Third level hospital. PATIENTS: Sixty adult patients. Consecutive sample. INTERVENTIONS: None. VARIABLES OF INTEREST: Epidemiological data, time from symptom onset to EVT, angiographic result, length of stay, days on mechanical ventilation, neurological complications, National Institutes of Health Stroke Scale (NIHSS) at ICU admission and discharge, modified Rankin scale score (mRS) at one year. RESULTS: Mean age 68,90±8,84years. Median time from symptom onset to EVT: 180minutes. Median NIHSS at admission: 17,5; at discharge: 3. Distal flow was achieved in 90% of cases. Median ICU stay: 3 days. Mechanical ventilation: 81,7.%. Functional independence (mRS≤2) 50% at one year. Deaths: 22 (36,6%) of which 8 (13,3%) died during UCI stay and the rest during the first year. CONCLUSIONS: The factors relating to a worse functional outcome were symptomatic hemorrhage transformation, lack of recanalization and complications during EVT. The factors relating to mortality were symptomatic hemorrhage and hydrocephalus. Distal flow was achieve in most cases with a low complication rate. Half of the patients presented functional independence one year after the stroke.

Evaluation of a real-time PCR assay for rectal screening of OXA-48-producing Enterobacteriaceae in a general intensive care unit of an endemic hospital.

Carbapenemase-producing Enterobacteriaceae are increasing worldwide. Rectal screening for these bacteria can inform the management of infected and colonized patients, especially those admitted to intensive care units (ICUs). A laboratory developed, qualitative duplex real-time polymerase chain reaction assay for rapid detection of OXA-48-like and VIM producing Enterobacteriaceae, performed on rectal swabs, was designed and evaluated in an intensive care unit with endemic presence of OXA-48. During analytical assay validation, no cross-reactivity was observed and 100% sensitivity and specificity were obtained for both blaOXA-48-like and blaVIM in all spiked clinical samples. During the clinical part of the study, the global sensitivity and specificity of the real-time PCR assay for OXA-48 detection were 95.7% and 100% (P=0.1250), respectively, in comparison with culture; no VIM-producing Enterobacteriaceae were detected. Clinical features of patients in the ICU who were colonized or infected with OXA-48 producing Enterobacteriaceae, including outcome, were analyzed. Most had severe underlying conditions, and had risk factors for colonization with carbapenemase-producing Enterobacteriaceae before or during ICU admission, such as receiving previous antimicrobial therapy, prior healthcare exposure (including long-term care), chronic disease, immunosuppression and/or the presence of an intravascular catheter and/or mechanical ventilation device. The described real-time PCR assay is fast (~2-3hours, if DNA extraction is included), simple to perform and results are easy to interpret, features which make it applicable in the routine of clinical microbiology laboratories. Implementation in endemic hospitals could contribute to early detection of patients colonized by OXA-48 producing Enterobacteriaceae and prevention of their spread.

Supervivencia de las paradas cardiacas extrahospitalarias atendidas por una unidad de vigilancia intensiva móvil de Asturias en 2010 / Survival of out-hospital cardiac arrests attended by a mobile intensive care unit in Asturias (Spain) in 2010

Objetivo Determinar los tiempos de asistencia, características extrahospitalarias e intrahospitalarias y supervivencia de las paradas cardiacas atendidas por una UVI móvil, al igual que los factores implicados en la supervivencia al ingreso y al alta hospitalaria. Diseño Estudio observacional retrospectivo desde el 1 de enero de 2010 al 31 de diciembre de 2010, con un seguimiento de un año desde la PCR. Ámbito Área sanitaria IV del Principado de Asturias, con 342.020 habitantes en 2010.PacientesSe incluyeron todos los pacientes que sufrieron una PCR en 2010 y fueron atendidos por la UVI móvil. Variables principales Datos demográficos, causa de la PCR, intervención por testigos, tiempos de asistencia y supervivencia al ingreso, al alta y un año después. Resultados Se atendieron un total de 177 paradas cardiacas. En 120 se indicó el soporte vital avanzado (SVA), siendo 66 de ellas (55%) de causa presumiblemente cardiaca. Recuperaron el pulso 63 pacientes (52,5%), llegando 51 de ellos con vida al hospital (42,5%). Se les dio el alta a 13 pacientes (10,8%). Al año 11 (9,2%) seguían vivos y 9 de ellos (7,5%) tenían una cerebral performance category (CPC) de 1. El ritmo inicial de fibrilación ventricular (FV) y los tiempos cortos en la asistencia se relacionaron con la supervivencia. Conclusiones La supervivencia fue superior a la publicada al ingreso al hospital y similar a la del alta. Como factores relacionados se encontraron los tiempos de asistencia y el ritmo inicial. La reanimación por el testigo fue escasa y no se usaron desfibriladores semiautomáticos (DEA) públicos (AU)

Objective To evaluate attendance timings, out- and in-hospital characteristics, and survival of cardiac arrests attended by an advanced life support unit in Asturias (Spain) in 2010. Factors related to survival upon admission and at discharge were also analyzed. Design A retrospective, observational trial was carried out involving a cohort of out-hospital cardiac arrests (OHCA) occurring between 1 January 2010 and 31 December 2010, with one year of follow-up from OHCA. Setting Health Care Area IV of the Principality of Asturias, with a population of 342,020 in 2010.PatientsAll patients with OHCA and attended by an advanced life support unit were considered. Main variables Demographic data, the etiology of cardiac arrest, bystander cardiopulmonary resuscitation (CPR), attendance timings and survival upon admission, at discharge and after one year. Results A total of 177 OHCA were included. Of these, 120 underwent CPR by the advanced life support team. Sixty-six of these cases (55%) were caused by presumed heart disease. A total of 63 patients (52.5%) recovered spontaneous circulation, and 51 (42.5%) maintained circulation upon admission to hospital. Thirteen patients (10.8%) were discharged alive. After one year, 11 patients were still alive (9.2%) - 9 of them (7.5%) with a Cerebral Performance Category (CPC) score of 1. Ventricular fibrillation and short attendance timings were related to increased survival. Conclusions The survival rate upon admission was better than in other series and similar at discharge. Initial rhythm and attendance timings were related. Public automated external defibrillators (AED) were not used, and bystander CPR was infrequent (AU)

[Survival of out-hospital cardiac arrests attended by a mobile intensive care unit in Asturias (Spain) in 2010]. / Supervivencia de las paradas cardiacas extrahospitalarias atendidas por una unidad de vigilancia intensiva móvil de Asturias en 2010.

OBJECTIVE: To evaluate attendance timings, out- and in-hospital characteristics, and survival of cardiac arrests attended by an advanced life support unit in Asturias (Spain) in 2010. Factors related to survival upon admission and at discharge were also analyzed. DESIGN: A retrospective, observational trial was carried out involving a cohort of out-hospital cardiac arrests (OHCA) occurring between 1 January 2010 and 31 December 2010, with one year of follow-up from OHCA. SETTING: Health Care Area IV of the Principality of Asturias, with a population of 342,020 in 2010. PATIENTS: All patients with OHCA and attended by an advanced life support unit were considered. MAIN VARIABLES: Demographic data, the etiology of cardiac arrest, bystander cardiopulmonary resuscitation (CPR), attendance timings and survival upon admission, at discharge and after one year. RESULTS: A total of 177 OHCA were included. Of these, 120 underwent CPR by the advanced life support team. Sixty-six of these cases (55%) were caused by presumed heart disease. A total of 63 patients (52.5%) recovered spontaneous circulation, and 51 (42.5%) maintained circulation upon admission to hospital. Thirteen patients (10.8%) were discharged alive. After one year, 11 patients were still alive (9.2%) - 9 of them (7.5%) with a Cerebral Performance Category (CPC) score of 1. Ventricular fibrillation and short attendance timings were related to increased survival. CONCLUSIONS: The survival rate upon admission was better than in other series and similar at discharge. Initial rhythm and attendance timings were related. Public automated external defibrillators (AED) were not used, and bystander CPR was infrequent.