Real-world setting comparison of bridging therapy versus direct mechanical thrombectomy for acute ischemic stroke: A meta-analysis.

BACKGROUND AND PURPOSE: Intravenous Thrombolysis (IVT) prior to Mechanical Thrombectomy (MT) for Acute Ischaemic Stroke (AIS) due to Large-Vessel Occlusion (LVO) remains controversial. Therefore, the authors performed a meta-analysis of the available real-world evidence focusing on the efficacy and safety of Bridging Therapy (BT) compared with direct MT in patients with AIS due to LVO. METHODS: Four databases were searched until 01 February 2023. Retrospective and prospective studies from nationwide or health organization registry databases that compared the clinical outcomes of BT and direct MT were included. Odds Ratios (ORs) and 95 % Confidence Intervals (CIs) for efficacy and safety outcomes were pooled using a random-effects model. RESULTS: Of the 12 studies, 86,695 patients were included. In patients with AIS due to LVO, BT group was associated with higher odds of achieving excellent functional outcome (modified Rankin Scale score 0-1) at 90 days (OR = 1.48, 95 % CI 1.25-1.75), favorable discharge disposition (to the home with or without services) (OR = 1.33, 95 % CI 1.29-1.38), and decreased mortality at 90 days (OR = 0.62, 95 % CI 0.56-0.70), as compared with the direct MT group. In addition, the risk of symptomatic intracranial hemorrhage did not increase significantly in the BT group. CONCLUSION: The present meta-analysis indicates that BT was associated with favorable outcomes in patients with AIS due to LVO. These findings support the current practice in a real-world setting and strengthen their validity. For patients eligible for both IVT and MT, BT remains the standard treatment until more data are available.

Is time really brain in stroke therapy?: A meta-analysis of mechanical thrombectomy up to 155 h post ictus.

BACKGROUND AND OBJECTIVES: Mechanical thrombectomy (MT) has been established as the gold standard of treatment for patients with Acute Ischemic Stroke (AIS) who present up to 6 h after the onset of the stroke. Recently, the DEFUSE-3 and DAWN trials established the safety of starting the MT procedure up to 16 and 24 h after the patient was last seen well, respectively. The purpose of this study is to assess the safety and functional effects of thrombectomy in individuals with AIS detected at a late stage (> 24 h). MATERIALS AND METHODS: PubMed, Web of Science, Embase, and Cochrane databases were thoroughly searched for research on MT in patients in the extremely late time window after AIS. The primary outcomes were symptomatic cerebral hemorrhage, 90-day mortality, Thrombolysis in Cerebral Infarction (TICI) 2b-3, and Modified Rankin Scale (mRS) 0-2. RESULTS: Our study included fifteen studies involving a total of 1,221 patients who presented with AIS and an extended time window. The primary outcome of interest was the favorable functional outcome, mRS 0-2 at 90 days. The pooled proportion for this outcome was 45% (95% confidence interval 34-58%). Other outcomes included the TICI 2b or 3 (successful recanalization), which was reported in 12 studies and had a 79% incidence in the study population (95% CI 68-87%). Complications included: symptomatic intracranial hemorrhage (sICH), which revealed an incidence of 7% in the study population (95% CI 5-10%); and 90-day mortality, which reported a 27% incidence (95% CI 24-31%). In addition, we conducted a comparative analysis between endovascular treatment and standard medical therapy. CONCLUSION: Our meta-analysis provides evidence that supports the need of further randomized and prospective clinical trials to better assess the effectiveness and safety of MT in these patients.

[Cost-utility analysis: Mechanical thrombectomy plus thrombolysis in ischemic stroke due to large vessel occlusion in the public sector in Chile]. / Análisis de costo utilidad: trombectomía mecánica más trombólisis en accidente vascular cerebral isquémico debido a oclusión de grandes vasos en el sector público en Chile.

INTRODUCTION: Several studies demonstrate the therapeutic superiority of thrombolysis plus mechanical thrombectomy versus thrombolysis alone to treat stroke. OBJECTIVE: To analyze the cost-utility of thrombolysis plus mechanical thrombectomy versus thrombolysis in patients with ischemic stroke due to large vessel occlusion. METHODS: Cost-utility analysis. The model used is blended: Decision Tree (first 90 days) and Markov in the long term, of seven health states based on a disease-specific scale, from the Chilean public insurance and societal perspective. Quality-Adjusted Life-Years and costs are evaluated. Deterministic (DSA) and probabilistic (PSA) analyses were carried out. RESULTS: From the public insurance perspective, in the base case, mechanical thrombectomy is associated with lower costs in a lifetime horizon, and with higher benefits (2.63 incremental QALYs, and 1.19 discounted incremental life years), at a Net Monetary Benefit (NMB) of CLP 37,289,874, and an Incremental Cost-Utility Ratio (ICUR) of CLP 3,807,413/QALY. For the scenario that incorporates access to rehabilitation, 2.54 incremental QALYs and 1.13 discounted life years were estimated, resulting in an NMB of CLP 35,670,319 and ICUR of CLP 3,960,624/QALY. In the scenario that incorporates access to long-term care from a societal perspective, the ICUR falls to CLP 951,911/QALY, and the NMB raises to CLP 43,318,072, improving the previous scenarios. In the DSA, health states, starting age, and relative risk of dying were the variables with the greatest influence. The PSA for the base case corroborated the estimates. CONCLUSIONS: Thrombolysis plus mechanical thrombectomy adds quality of life at costs acceptable for decision-makers versus thrombolysis alone. The results are consistent with international studies.

INTRODUCCIÓN: Diversos estudios demuestran la superioridad terapéutica de la trombólisis más trombectomía mecánica, versus trombólisis sola, en el tratamiento del accidente vascular cerebral. OBJETIVOS: Analizar el costo utilidad de la trombólisis más trombectomía versus trombólisis sola en pacientes con accidente vascular cerebral isquémico con oclusión de grandes vasos. MÉTODOS: Evaluación de costo utilidad. Se ha utilizado un modelo mixto: árbol de decisión (primeros 90 días) y Markov en el largo plazo, de siete estados de salud definidos en escala específica de enfermedad, desde la perspectiva del seguro público chileno y societal. Se evalúan costos y años de vida ajustados por calidad. Se realizó análisis de incertidumbre determinístico y probabilístico. RESULTADOS: Bajo la perspectiva de seguro público, en el caso base la trombectomía mecánica se relaciona con menores costos en un horizonte de por vida, con mayores beneficios (2,63 años de vida ajustados por calidad incrementales, y 1,19 años de vida incrementales descontados), a un beneficio monetario neto de $37 289 874 pesos chilenos, y una razón incremental de costo utilidad de $3 807 413 pesos por años de vida ajustados por calidad. Para el escenario que agrega acceso a rehabilitación se estimaron 2,54 años de vida ajustados por calidad incremental y 1,13 años de vida descontados, resultando en un beneficio monetario neto de $35 670 319 pesos y razón incremental de costo utilidad de $3 960 624 pesos por años de vida ajustados por calidad. En el escenario que agrega el efecto de acceso a cuidados de larga duración con perspectiva societal, la razón incremental de costo utilidad cae hasta $951 911 pesos por años de vida ajustados por calidad y el beneficio monetario neto se eleva a $43 318 072 pesos, superando las estimaciones anteriores. En el análisis de incertidumbre determinístico, los estados de salud, edad de inicio de la cohorte y riesgo relativo de morir, fueron las variables con mayor influencia. El análisis de incertidumbre probabilístico para el caso base, corroboró las estimaciones. CONCLUSIONES: La trombólisis más trombectomía mecánica agrega calidad de vida a costos aceptables por el tomador de decisión, versus trombólisis sola. Los resultados son consistentes con los estudios internacionales.

Tratamiento trombolitico en el síndrome coronario agudo con elevación del st / Treatment trombolitico in the sharp coronary syndrome with elevation of the st

RESUMEN Introducción: la cardiopatía isquémica es tan antigua como el hombre. Constituye uno de los problemas de salud más serios a nivel mundial. Entre sus formas clínicas está el infarto agudo de miocardio. Los síndromes isquémicos agudos, representan un espectro clínico continúo sustentado por una fisiopatología común. Objetivo: identificar los factores que causaron retraso en la aplicación del tratamiento trombolítico en los pacientes, los que se traducen en el futuro, en pérdida de calidad de vida, diferentes grados de discapacidad, y hasta del aumento de la mortalidad por esta entidad. Materiales y métodos: se realizó un estudio observacional, con 62 pacientes con criterio de trombolisis atendidos en la Unidad de Cuidados Intensivos del Hospital Docente Clínico Quirúrgico "José Ramón López Tabrane", en el período comprendido entre enero del 2012 y junio del 2014. Se aplicaron métodos empíricos, estadísticos y teóricos. Resultados: de 147 pacientes recibidos con criterios de trombolisis 62 no recibieron el tratamiento trombolítico que representó un 42,2 %. Entre las causas estuvieron falta de entrenamiento de los médicos para la aplicación de dicho tratamiento y la no existencia de transporte para su traslado en el tiempo requerido. Conclusiones: los pacientes no trombolizados con más de 12 h sin diagnóstico con criterio de infacto agudo del miocardo, incidió en el diagnóstico erróneo del médico y valencia de sus propios medios, para llegar a un centro de salud. Con contraindicación absoluta, el accidente vascular isquémico menor de tres meses fue la causante más padecida. Con contraindicación relativa fue la hipertensión arterial no controlada (AU).

SUMMARY Introduction: The Ischemic Cardiopatía is as old as the man. One constitutes from the most serious problems of health to world level and enter their clinical forms the sharp heart attack of miocardio is (IMA), causing in the world population a third of the deaths. The sharp ischemic syndromes SIAs represents a continuous clinical spectrum sustained by a fisiopatología común. Objective: He/she was carried out an observational, descriptive and traverse study, in 62 patients with trombolisis approach assisted in the UCIE of the Surgical Clinical Educational Hospital José Ramón López Tabrane, in the period understood between January of 2012 and June of the 2014.Se they applied the empiric, statistical and theoretical methods. Materials and method: identify the factors that caused delay in the application of the treatment trombolítico in this patients, which are translated in the future in loss of quality of life, different discapacidad grades and until of the increase of the mortality for this entity. Among the causes that were they were: the non training of the doctors for the application of this treatment and the not existence of transport for their transfer in the required time. Conclusion: In patient non trombolizados with more than twelve hours without diagnostic of IMA (19,4%) with approach impacted the doctor's erroneous diagnosis and valency of their own means to arrive to a center of health. With absolute contraindication, the Ischemic Vascular Accident smaller than three months was the causing one more suffered. With relative contraindication it was the arterial hypertension not controlled (AU).

Fragmentación mecánica y trombólisis guiada por catéter en la embolia pulmonar de riesgo intermedio / Mechanical fragmentation and catheter-guided thrombolysis in intermediate risk pulmonary embolism

La tromboembolia pulmonar aguda (TEPA) sigue siendo una importante causa de morbilidad y mortalidad a nivel mundial. Su diagnóstico, estratificación de riesgo y tratamiento precoz son fundamentales, siendo su pilar la anticoagulación. En pacientes de bajo riesgo cardiovascular, el pronóstico es excelente y solo basta con la administración de anticoagulantes. No obstante, debido al pobre pronóstico de los pacientes con riesgo elevado (descompensación hemodinámica), el enfoque terapéutico es más agresivo, utilizándose trombolíticos sistémicos que disminuyen la mortalidad pero incrementan el riesgo de complicaciones hemorrágicas mayores. En el TEPA de riesgo intermedio (evidencia de falla de ventrículo derecho, sin descompensación hemodinámica), la relación riesgo-beneficio del tratamiento con trombolíticos es más equilibrada por lo que la decisión es controvertida. La fragmentación mecánica con trombólisis dirigida por catéter es una alternativa con potenciales beneficios. Presentamos dos casos de TEPA de riesgo intermedio, en los que se realizó fragmentación mecánica y trombólisis dirigida por catéter.

Acute pulmonary thromboembolism remains a significant cause of morbidity and mortality worldwide. Its diagnosis, risk stratification and early treatment are essential. The mainstay of treatment is anticoagulation. In patients with low cardiovascular risk, the prognosis is excellent and the treatment consists only of the administration of anticoagulants. Due to the poor prognosis of patients with high risk (hemodynamic decompensation), the approach is more aggressive using systemic thrombolytics, which reduce mortality but increase the risk of major hemorrhagic complications. In the intermediate-risk patients (evidence of right ventricular failure, without hemodynamic decompensation), the risk-benefit relationship of thrombolytic treatment is more balanced, so the choice is controversial. Mechanical fragmentation with catheter-directed thrombolysis is an alternative with potential benefits. We present two cases of intermediate-risk acute pulmonary thromboembolism to whom mechanical fragmentation and catheter-directed thrombolysis was applied.

[Mechanical fragmentation and catheter-guided thrombolysis in intermediate risk pulmonary embolism]. / Fragmentación mecánica y trombólisis guiada por catéter en la embolia pulmonar de riesgo intermedio.

Acute pulmonary thromboembolism remains a significant cause of morbidity and mortality worldwide. Its diagnosis, risk stratification and early treatment are essential. The mainstay of treatment is anticoagulation. In patients with low cardiovascular risk, the prognosis is excellent and the treatment consists only of the administration of anticoagulants. Due to the poor prognosis of patients with high risk (hemodynamic decompensation), the approach is more aggressive using systemic thrombolytics, which reduce mortality but increase the risk of major hemorrhagic complications. In the intermediate-risk patients (evidence of right ventricular failure, without hemodynamic decompensation), the risk-benefit relationship of thrombolytic treatment is more balanced, so the choice is controversial. Mechanical fragmentation with catheter-directed thrombolysis is an alternative with potential benefits. We present two cases of intermediate-risk acute pulmonary thromboembolism to whom mechanical fragmentation and catheter-directed thrombolysis was applied.

La tromboembolia pulmonar aguda (TEPA) sigue siendo una importante causa de morbilidad y mortalidad a nivel mundial. Su diagnóstico, estratificación de riesgo y tratamiento precoz son fundamentales, siendo su pilar la anticoagulación. En pacientes de bajo riesgo cardiovascular, el pronóstico es excelente y solo basta con la administración de anticoagulantes. No obstante, debido al pobre pronóstico de los pacientes con riesgo elevado (descompensación hemodinámica), el enfoque terapéutico es más agresivo, utilizándose trombolíticos sistémicos que disminuyen la mortalidad pero incrementan el riesgo de complicaciones hemorrágicas mayores. En el TEPA de riesgo intermedio (evidencia de falla de ventrículo derecho, sin descompensación hemodinámica), la relación riesgo-beneficio del tratamiento con trombolíticos es más equilibrada por lo que la decisión es controvertida. La fragmentación mecánica con trombólisis dirigida por catéter es una alternativa con potenciales beneficios. Presentamos dos casos de TEPA de riesgo intermedio, en los que se realizó fragmentación mecánica y trombólisis dirigida por catéter.

Mechanical thrombectomy for reperfusion of acute ischemic stroke in a Stroke Unit in Argentina.

OBJECTIVE: Stroke is an important cause of morbidity and mortality worldwide. Reperfusion therapy with intravenous tissue plasminogen activator (IV-tPA) was first implemented in 1996. More recently, endovascular reperfusion with mechanical thrombectomy (MT) demonstrated a robust beneficial effect, extending the 4.5 h time window. In our country, there are difficulties to achieve the implementation of both procedures. Our purpose is to report the early experience of a Comprehensive Stroke Center in the use of MT for acute stroke. METHODS: Analysis of consecutive patients from January 2015 to September 2018, who received reperfusion treatment with MT. Demographic data, treatment times, previous use of IV-tPA, site of obstruction, recanalization, outcomes and disability after stroke were assessed. RESULTS: We admitted 891 patients with acute ischemic stroke during this period. Ninety-seven received IV-tPA (11%) and 27 were treated with MT (3%). In the MT group, mean age was 66.0±14.5 years. Median NIHSS before MT was 20 (range:14‒24). The most prevalent etiology was cardioembolic stroke (52%). Prior to MT, 16 of 27 patients (59%) received IV-tPA. Previous tPA treatment did not affect onset to recanalization time or door-to-puncture time. For MT, door-to-puncture time was 104±50 minutes and onset to recanalization was 289±153 minutes. Successful recanalization (mTICI grade 2b/3) was achieved in 21 patients (78%). At three-month follow-up, the median NIHSS was 5 (range:4‒15) and mRS was 0‒2 in 37%, and ≥3 in 63%. CONCLUSIONS: With adequate logistics and strict selection criteria, MT can be implemented in our population with results like those reported in large clinical trials.

Mechanical thrombectomy for reperfusion of acute ischemic stroke in a Stroke Unit in Argentina / Trombectomía mecánica para la reperfusión en el accidente cerebrovascular agudo en una Unidad Cerebrovascular de Argentina

Abstract Stroke is an important cause of morbidity and mortality worldwide. Reperfusion therapy with intravenous tissue plasminogen activator (IV-tPA) was first implemented in 1996. More recently, endovascular reperfusion with mechanical thrombectomy (MT) demonstrated a robust beneficial effect, extending the 4.5 h time window. In our country, there are difficulties to achieve the implementation of both procedures. Objective: Our purpose is to report the early experience of a Comprehensive Stroke Center in the use of MT for acute stroke. Methods: Analysis of consecutive patients from January 2015 to September 2018, who received reperfusion treatment with MT. Demographic data, treatment times, previous use of IV-tPA, site of obstruction, recanalization, outcomes and disability after stroke were assessed. Results: We admitted 891 patients with acute ischemic stroke during this period. Ninety-seven received IV-tPA (11%) and 27 were treated with MT (3%). In the MT group, mean age was 66.0±14.5 years. Median NIHSS before MT was 20 (range:14‒24). The most prevalent etiology was cardioembolic stroke (52%). Prior to MT, 16 of 27 patients (59%) received IV-tPA. Previous tPA treatment did not affect onset to recanalization time or door-to-puncture time. For MT, door-to-puncture time was 104±50 minutes and onset to recanalization was 289±153 minutes. Successful recanalization (mTICI grade 2b/3) was achieved in 21 patients (78%). At three-month follow-up, the median NIHSS was 5 (range:4‒15) and mRS was 0‒2 in 37%, and ≥3 in 63%. Conclusions: With adequate logistics and strict selection criteria, MT can be implemented in our population with results like those reported in large clinical trials.

Resumen El accidente cerebrovascular isquémico (ACVi) es una importante causa de morbi-mortalidad a nivel mundial. La reperfusión con trombólisis endovenosa es utilizada desde 1996. Más recientemente, la reperfusión con trombectomía mecánica (TM) ha demostrado un beneficio consistente extendiendo la ventana terapéutica. En nuestro país existen dificultades para que su implementación sea una práctica habitual. Objetivo: Reportamos la experiencia de un Centro Integral de Neurología Vascular en el uso de TM como tratamiento del ACVi agudo. Métodos: Análisis retrospectivo de pacientes consecutivos desde enero 2015 a septiembre 2018, que recibieron reperfusión con TM. Se registraron datos demográficos, tiempos de tratamiento, uso de rtPA, sitio de obstrucción, recanalización, severidad del evento y discapacidad. Resultados: Se evaluaron 891 pacientes con ACVi en este periodo. 97 recibieron rtPA (11%) y 27 recibieron TM (3%). En el grupo TM, la edad promedio fue 66 años (±14.5). Mediana de NIHSS previo a TM: 20 (RIC 14‒24). La etiología más frecuente fue cardioembolia (52%). Previo a TM, 16 pacientes (59%) recibieron rtPA endovenoso. No hallamos efecto del rtPA en tiempo de recanalización por TM o tiempo puerta-punción. Para la TM, el tiempo puerta-punción fue 104±50 minutos y el tiempo entre inicio de síntomas-recanalización fue 289±153 minutos. En 21 pacientes (78%) se logró recanalización exitosa (TICI 2B/3). En el seguimiento a tres meses, el mRS fue 0‒2 en el 37% y ≥3 en el 63%. Conclusión: Una logística adecuada y un estricto criterio de selección ha posibilitado el uso de TM en nuestra población, obteniendo resultados similares a aquellos reportados en los estudios clínicos publicados.

Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke: Primary Results of the STRATIS Registry.

BACKGROUND AND PURPOSE: Mechanical thrombectomy with stent retrievers has become standard of care for treatment of acute ischemic stroke patients because of large vessel occlusion. The STRATIS registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) aimed to assess whether similar process timelines, technical, and functional outcomes could be achieved in a large real world cohort as in the randomized trials. METHODS: STRATIS was designed to prospectively enroll patients treated in the United States with a Solitaire Revascularization Device and Mindframe Capture Low Profile Revascularization Device within 8 hours from symptom onset. The STRATIS cohort was compared with the interventional cohort of a previously published SEER patient-level meta-analysis. RESULTS: A total of 984 patients treated at 55 sites were analyzed. The mean National Institutes of Health Stroke Scale score was 17.3. Intravenous tissue-type plasminogen activator was administered in 64.0%. The median time from onset to arrival in the enrolling hospital, door to puncture, and puncture to reperfusion were 138, 72, and 36 minutes, respectively. The Core lab-adjudicated modified Thrombolysis in Cerebral Infarction ≥2b was achieved in 87.9% of patients. At 90 days, 56.5% achieved a modified Rankin Scale score of 0 to 2, all-cause mortality was 14.4%, and 1.4% suffered a symptomatic intracranial hemorrhage. The median time from emergency medical services scene arrival to puncture was 152 minutes, and each hour delay in this interval was associated with a 5.5% absolute decline in the likelihood of achieving modified Rankin Scale score 0 to 2. CONCLUSIONS: This largest-to-date Solitaire registry documents that the results of the randomized trials can be reproduced in the community. The decrease of clinical benefit over time warrants optimization of the system of care. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02239640.

The direct first pass aspiration technique in the treatment of acute ischemic stroke resulting from large vessel occlusions.

METHODS: Recanalization was assessed using the modified thrombolysis in cerebral infarction (mTICI) score. Neurological outcomes were assessed using the National Institutes of Health Stroke Scale and modified Rankin Scale. RESULTS: Fifteen patients were evaluated. The mTICI score was 2b-3 in 80%, and it was 3 in 60% of patients. No intracranial hemorrhage was seen. At three months, modified Rankin Scale scores ≤ 2 were observed in 60% of patients and the mortality rate was 13.3%. CONCLUSIONS: The ADAPT appears to be a safe, effective, and fast recanalization strategy for treatment of acute ischemic stroke resulting from large vessel occlusions.

The direct first pass aspiration technique in the treatment of acute ischemic stroke resulting from large vessel occlusions / Técnica de aspiração primária no tratamento do acidente vascular cerebral isquêmico por oclusões de grandes vasos

ABSTRACT Mechanical thrombectomy using stent retrievers is the standard treatment for acute ischemic stroke that results from large vessel occlusions. The direct aspiration first pass technique (ADAPT) has been proposed as an efficient, fast, and cost-effective thrombectomy strategy. The aim of this study was to assess the safety and efficacy of ADAPT. Methods Recanalization was assessed using the modified thrombolysis in cerebral infarction (mTICI) score. Neurological outcomes were assessed using the National Institutes of Health Stroke Scale and modified Rankin Scale. Results Fifteen patients were evaluated. The mTICI score was 2b-3 in 80%, and it was 3 in 60% of patients. No intracranial hemorrhage was seen. At three months, modified Rankin Scale scores ≤ 2 were observed in 60% of patients and the mortality rate was 13.3%. Conclusions The ADAPT appears to be a safe, effective, and fast recanalization strategy for treatment of acute ischemic stroke resulting from large vessel occlusions.

RESUMO A trombectomia mecânica com stent retrievers é o tratamento padrão ouro do acidente vascular cerebral isquêmico agudo (AVCi) por oclusão de grandes artérias. A técnica de aspiração primária (ADAPT) tem sido proposta como uma estratégia de trombectomia rápida e com boa custo-efetividade. O objetivo deste estudo foi avaliar a segurança e eficácia da técnica ADAPT. Métodos A recanalização foi avaliada utilizando a escala mTICI. Os desfechos neurológicos foram avaliados utilizando as escalas do NIHSS e mRS. Resultados Quinze pacientes foram avaliados. Foram obtidas taxas de mTICI = 2b-3 em 80% e TICI = 3 em 60% dos pacientes. Não ocorreram hemorragias intracranianas. Em 3 meses as taxas de mRS≤2 e mortalidade foram respectivamente 60% e 13.3%. Conclusão A técnica ADAPT parece ser uma estratégia de recanalização rápida, segura e efetiva para o tratamento do AVC por oclusão de grandes artérias.

[Mechanical and pharmacomechanical trombolysis in deep venous thrombosis with no clinical response to conventional treatment]. / Trombolisis mecánica y fármaco-mecánica en el tratamiento de trombosis venosa profunda sin respuesta clínica con tratamiento médico convencional.

BACKGROUND: Conventional treatment of deep vein thrombosis (DVT) is anticoagulation, bed rest and limb elevation. Proximal DVT patients with persisting edema, pain and cyanosis of extremities despite of conventional therapy may develop ischemia. Direct treatment of thrombosis becomes necessary. AIM: To report our experience with mechanical trombolysis of proximal lower extremity DVT. MATERIAL AND METHODS: Retrospective review of medical records of proximal DVT patients treated with thrombolysis between March 2012 and August 2015. Thirteen patients, 14 limbs, median age 34 years (22-85), 8 women, were admitted with pain and swelling of recent onset; one patient with venous gangrene. All patients initially received heparin in therapeutic doses without clinical improvement. RESULTS: In all 13 cases, mechanical thrombolysis was performed using AngioJet®, and associated with single dose thrombolytic agent in 9. Additional angioplasty for residual stenosis was performed in 12 (7 stents) and IVCF were implanted in 8. All patients were subsequently anticoagulated. Early outcomes with disappearance of pain and decrease of edema, with no mortality or bleeding complications. The patient with foot gangrene required amputation. CONCLUSIONS: Mechanical thrombolysis with a single dose of a thrombolytic agent is safe and effective in patients with proximal DVT with an unfavorable evolution.

Experience on Mechanical Thrombectomy for Acute Stroke Treatment in a Brazilian University Hospital.

BACKGROUND: Brazil is a developing country struggling to reduce its extreme social inequality, which is reflected on shortage of health-care infrastructure, mainly to the low-income class, which depends exclusively on the public health system. In Brazil, less than 1% of stroke patients have access to intravenous thrombolysis in a stroke unit, and constraints to the development of mechanical thrombectomy in the public health system increase the social burden of stroke. OBJECTIVE: Report the feasibility of mechanical thrombectomy as part of routine stroke care in a Brazilian public university hospital. METHODS: Prospective data were collected from all patients treated for acute ischemic stroke with mechanical thrombectomy from June 2011 to March 2016. Combined thrombectomy was performed in eligible patients for intravenous thrombolysis if they presented occlusion of large artery. For those patients ineligible for intravenous thrombolysis, primary thrombectomy was performed as long as there was no evidence of significant ischemia for anterior circulation stroke (Alberta Stroke Program Early CT score >6) within a 6-hour time window, and also for those patients with wake-up stroke or posterior circulation stroke, regardless of the time of symptoms onset. RESULTS: A total of 161 patients were evaluated, resulting in an overall successful recanalization rate of 76% and symptomatic intracranial hemorrhage rate of 6.8%. At 3 months, 36% of the patients had modified Rankin Scale score less than or equal to 2. The overall mortality rate was 23%. CONCLUSION: Our study, the first ever large series of mechanical thrombectomy in Brazil, demonstrates acceptable efficacy and safety results, even under restricted conditions outside the ideal scenario of trial studies.

Trombolisis mecánica y fármaco-mecánica en el tratamiento de trombosis venosa profunda sin respuesta clínica con tratamiento médico convencional / Mechanical and pharmacomechanical trombolysis in deep venous thrombosis with no clinical response to conventional treatment

Background: Conventional treatment of deep vein thrombosis (DVT) is anticoagulation, bed rest and limb elevation. Proximal DVT patients with persisting edema, pain and cyanosis of extremities despite of conventional therapy may develop ischemia. Direct treatment of thrombosis becomes necessary. Aim: To report our experience with mechanical trombolysis of proximal lower extremity DVT. Material and Methods: Retrospective review of medical records of proximal DVT patients treated with thrombolysis between March 2012 and August 2015. Thirteen patients, 14 limbs, median age 34 years (22-85), 8 women, were admitted with pain and swelling of recent onset; one patient with venous gangrene. All patients initially received heparin in therapeutic doses without clinical improvement. Results: In all 13 cases, mechanical thrombolysis was performed using AngioJet®, and associated with single dose thrombolytic agent in 9. Additional angioplasty for residual stenosis was performed in 12 (7 stents) and IVCF were implanted in 8. All patients were subsequently anticoagulated. Early outcomes with disappearance of pain and decrease of edema, with no mortality or bleeding complications. The patient with foot gangrene required amputation. Conclusions: Mechanical thrombolysis with a single dose of a thrombolytic agent is safe and effective in patients with proximal DVT with an unfavorable evolution.

International Survey on the Management of Wake-Up Stroke.

BACKGROUND: Patients who wake up having experienced a stroke while asleep represent around 20% of acute stroke admissions. According to international guidelines for the management of acute stroke, patients presenting with wake-up stroke are not currently eligible to receive revascularization treatments. In this study, we aimed to assess the opinions of stroke experts about the management of patients with wake-up stroke by using an international multicenter electronic survey. METHOD: This study consisted of 8 questions on wake-up stroke treatment. RESULTS: Two hundred invitations to participate in the survey were sent by e-mail. Fifty-nine participants started the survey, 4 dropped out before completing it, and 55 completed the full questionnaire. We had 55 participants from 22 countries. CONCLUSIONS: In this study, most stroke experts recommended a recanalization treatment for wake-up stroke. However, there was considerable disagreement among experts regarding the best brain imaging method and the best recanalization treatment. The results of ongoing randomized trials on wake-up stroke are urgently needed.

Trombectomía mecánica en el ICTUS: experiencia con trevo en Hospital Provincial Clínico Barcelona / Mechanical thrombectomy in stroke: experience with trevo at Hospital Provincial Clinic Barcelona

Objectives: to report our experience, the efficiency, safety and results of endovascular mechanical thrombectomy with the Trevo device in acute ischemic cerebral stroke. Materials and Methods: we performed a retrospective study of 145 acute ischemic stroke patients treated with mechanical throm-bectomy using the Trevo system, between october 2008 and march 2012. 87.3percent in anterior circulation and 12.7 percent in posterior circulation. Results: mean age at presentation was 67 years (range 21-82, 54.5 percent males). The NIHSS presentation baseline was 17 (range, 18-22). The median interval from the onset of symptoms to arterial punction was 263 minutes (173-296). Satisfactory recanalization defined TICI (2-3) in 91 percent with 45 percent showing a good functional prognosis (mRS 0-2) at 90 days. 23 percent mortality at 90 days with 11 percent intracerebral haemorrage. Conclusions: in our experience, endovascular treatment of acute ischemic stroke with the Trevo device is safe and effective.

Objetivos: reportar nuestra experiencia, eficacia, seguridad y resultados del tratamiento endovascular mediante trombectomía mecánica con el dispositivo Trevo en el ictus cerebral isquémico agudo. Materiales y Métodos: realizamos un estudio retrospectivo de 145 pacientes con infarto cerebral isquémico agudo tratados mediante trombectomía mecánica con el dispositivo Trevo entre octubre del 2008 y marzo del 2012. 87,3 por ciento circulación anterior y 12,7 por ciento circulación posterior. Resultados: la edad media de presentación fue 67 años (rango 21-82; 54,5 por ciento sexo masculino). El NIHSS basal de presentación fue de 17 (rango, 18-22). La mediana desde el inicio de los síntomas a punción arterial fue de 263 minutos (173-296). Recanalización satisfactoria (TICI 2-3) del 91 por ciento con un 45 por ciento de buen pronóstico funcional (mRS de 0-2) a los 90 días. Mortalidad de 23 por ciento a los 90 días con 11 por ciento de sangrado intracerebral. Conclusiones: en nuestra experiencia, el tratamiento endovascular del ictus isquémico agudo con el dispositivo Trevo es seguro y eficaz.

Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population

OBJECTIVE: Large vessel occlusion in acute ischemic stroke is associated with low recanalization rates under intravenous thrombolysis. We evaluated the safety and efficacy of the Solitaire AB stent in treating acute ischemic stroke. METHODS: Patients presenting with acute ischemic stroke were prospectively evaluated. The neurological outcomes were assessed using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Time was recorded from the symptom onset to the recanalization and procedure time. Recanalization was assessed using the thrombolysis in cerebral infarction score. RESULTS: Twenty-one patients were evaluated. The mean patient age was 65, and the National Institutes of Health Stroke Scale scores ranged from 7 to 28 (average 17±6.36) at presentation. The vessel occlusions occurred in the middle cerebral artery (61.9%), distal internal carotid artery (14.3%), tandem carotid occlusion (14.3%), and basilarartery (9.5%). Primary thrombectomy, rescue treatment and a bridging approach represented 66.6%, 28.6%, and 4.8% of the performed procedures, respectively. The mean time from symptom onset to recanalization was 356.5±107.8 minutes (range, 80-586 minutes). The mean procedure time was 60.4±58.8 minutes (range, 14-240 minutes). The overall recanalization rate (thrombolysis in cerebral infarction scores of 3 or 2b) was 90.4%, and the symptomatic intracranial hemorrhage rate was 14.2%. The National Institutes of Health Stroke Scale scores at discharge ranged from 0 to 25 (average 6.9±7). At three months, 61.9% of the patients had a modified Rankin Scale score of 0 to 2, with an overall mortality rate of 9.5%. CONCLUSIONS: Intra-arterial thrombectomy with the Solitaire AB device appears to be safe and effective. Large randomized trials are necessary to confirm the benefits of this approach in acute ischemic stroke.

Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population.

OBJECTIVE: Large vessel occlusion in acute ischemic stroke is associated with low recanalization rates under intravenous thrombolysis. We evaluated the safety and efficacy of the Solitaire AB stent in treating acute ischemic stroke. METHODS: Patients presenting with acute ischemic stroke were prospectively evaluated. The neurological outcomes were assessed using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Time was recorded from the symptom onset to the recanalization and procedure time. Recanalization was assessed using the thrombolysis in cerebral infarction score. RESULTS: Twenty-one patients were evaluated. The mean patient age was 65, and the National Institutes of Health Stroke Scale scores ranged from 7 to 28 (average 17 ± 6.36) at presentation. The vessel occlusions occurred in the middle cerebral artery (61.9%), distal internal carotid artery (14.3%), tandem carotid occlusion (14.3%), and basilarartery (9.5%). Primary thrombectomy, rescue treatment and a bridging approach represented 66.6%, 28.6%, and 4.8% of the performed procedures, respectively. The mean time from symptom onset to recanalization was 356.5 ± 107.8 minutes (range, 80-586 minutes). The mean procedure time was 60.4 ± 58.8 minutes (range, 14-240 minutes). The overall recanalization rate (thrombolysis in cerebral infarction scores of 3 or 2b) was 90.4%, and the symptomatic intracranial hemorrhage rate was 14.2%. The National Institutes of Health Stroke Scale scores at discharge ranged from 0 to 25 (average 6.9 ± 7). At three months, 61.9% of the patients had a modified Rankin Scale score of 0 to 2, with an overall mortality rate of 9.5%. CONCLUSIONS: Intra-arterial thrombectomy with the Solitaire AB device appears to be safe and effective. Large randomized trials are necessary to confirm the benefits of this approach in acute ischemic stroke.