Thrombolysis Experience in Costa Rica Compared Against Individual Patient Data from two Randomized Controlled Trials.

OBJECTIVES: We sought to compare thrombolysis outcomes from the Costa Rican Stroke Registry Program (CRSRP) with published individual patient data from NINDS and CLOTBUST-ER trials using matching and outcome modeling from randomized clinical trials (RCTs). MATERIALS AND METHODS: A retrospective observational study matching subjects on baseline characteristics, from the CRSRP, the control arm of CLOTBUST-ER, and the interventional arm of NINDS trials. Day 7-10/discharge modified Rankin Score (mRS), and early mortality was compared between matched subjects. A mortality model derived from RCTs was developed, and outcomes were compared at similar baseline NIHSS scores. CRSRP symptomatic hemorrhage (SICH) rate was compared with an Ibero-American cohort (IAC). RESULTS: Of 540 CRSRP patients, 351 received rt-PA under 3 hours and were matched with NINDS subjects yielding 292 pairs; 161 CRSRP subjects treated within 4.5 hours were matched with CLOTBUST-ER subjects resulting in 151 pairs. The proportion of patients achieving excellent outcomes (mRS 0-1) did not differ between CRSRP and either NINDS or CLOTBUST-ER (CRSRP vs NINDS: 36.6% vs 32.9%, p=0.3; CRSRP vs CLOTBUST-ER: 26.5% vs 24.5%, p=0.8). Mortality was higher for CRSRP vs CLOTBUST-ER (7.3% vs 0.7%, p=0.006), but not vs NINDS (6.5% vs 4.5%, p=0.4). A pooled mortality model derived from 15 RCTs representing 4410 patients (R2=0.39) showed CRSRP and NINDS within expected mortality, while CLOTBUST-ER showed lower than expected mortality. CRSRP SICH rate equaled IAC (5.7% vs 5.7%; p=0.9). CONCLUSIONS: Functional outcomes and SICH of thrombolysed Costa Rican patients compared favorably with published datasets, with a potential increase in early mortality.

Evento cerebrovascular isquémico en el adulto joven / Ischemic stroke in a young adult

El evento cerebrovascular isquémico es un desorden multifactorial, en el que contribuyen factores genéticos y ambientales. A pesar de que se reconoce un aumento del riesgo de eventos cerebrovasculares cuando existe una historia familiar positiva (de hasta un 75 por ciento en ciertos estudios), no se conoce la contribución exacta que tiene la genética en el desarrollo de eventos cerebrales isquémicos en el paciente joven. El papel que desempeña la predisposición genética sobre la ocurrencia de estos eventos, difiere según la edad y el tipo de eventos. Los factores genéticos se conjugan con los factores de riesgo convencionales como hipertensión arterial, diabetes y niveles de homocisteína, que a su vez interactúan con el ambiente en el desarrollo de arterosclerosis. La homocisteína por sí sola, ha sido considerada un factor aterogónico en enfermedades cardiovasculares y cerebrovasculares. Se refiere el caso de un paciente de 49 años conocido sano, quien presenta un evento cerebrovascular isquémico de la circulación cerebral anterior, con un valor en la escala para derrame del Instituto Nacional de Salud de 7 puntos al ingreso y una mutación heterocigota del gen de la metiltetrahidrofolato reductasa (región de mutación C677T)...