The second part of these Guidelines covers the topics of antiplatelet, anticoagulant, and statin therapy in acute ischemic stroke, reperfusion therapy, and classification of Stroke Centers. ...Information on the classes and levels of evidence used in this guideline is provided in Part I. A translated version of the Guidelines is available from the Brazilian Stroke Society website (www.sbdcv.com.br).
Sonothrombolysis has recently been considered an emerging modality for the treatment of stroke. The purpose of the present paper was to review randomized clinical studies concerning the effects of ...sonothrombolysis associated with tissue plasminogen activator (tPA) on acute ischemic stroke.
Systematic searches for literature published between January 1996 and July 2011 were performed for studies regarding sonothrombolysis combined with tPA for acute ischemic stroke. Only randomized controlled trials were included. Data extraction was based on ultrasound variables, patient characteristics, and outcome variables (rate of intracranial hemorrhages and arterial recanalization).
Four trials were included in this study; 2 trials evaluated the effect of transcranial Doppler (TCD) ultrasonography on sonothrombolysis, and 2 addressed transcranial color-coded duplex (TCCD) ultrasonography. The frequency of ultrasound waves varied from 1.8 to 2 MHz. The duration of thrombus exposure to ultrasound energy ranged from 60 to 120 minutes. Sample sizes were small, recanalization was evaluated at different time points (60 and 120 minutes), and inclusion criteria were heterogeneous. Sonothrombolysis combined with tPA did not lead to an increase in symptomatic intracranial hemorrhagic complications. Two studies demonstrated that patients treated with ultrasound combined with tPA had statistically significant higher rates of recanalization than patients treated with tPA alone.
Despite the heterogeneity and the limitations of the reviewed studies, there is evidence that sonothrombolysis associated with tPA is a safe procedure and results in an increased rate of recanalization in the setting of acute ischemic stroke when wave frequencies and energy intensities of diagnostic ultrasound systems are used.
OBJETIVO: Dada a ausência de estudos de séries brasileiras de pacientes com dissecção arterial cervical espontânea, com o objetivo de descrever os fatores de risco, sintomas precedentes, ...manifestações clínicas, resultados da investigação, tratamento e evolução. MÉTODO: realizamos a análise retrospectiva dos prontuários e laudos radiológicos angiografia digital(AD), ressonância magnética(RM) e ângio-ressonância(ARM) dos pacientes com esse diagnóstico atendidos no Serviço de Neurologia do HC/USP entre 1997 e 2003. RESULTADOS: 48 pacientes (24 homens), média de idade 37,9 anos; 26 pacientes com dissecção carotídea (DC) unilateral, 15 com vertebral (DV) unilateral e 7 com multiarterial, todos com déficits neurológicos. Os principais fatores de risco para doença vascular foram hipertensão arterial, tabagismo e dislipidemia. Mais de 80% apresentaram pelo menos um sintoma precedente, na maioria cefaléia têmporo-parietal. Cervicalgia foi referida por 44% dos pacientes com DV e por 3,4% dos com DC. O tempo médio entre o primeiro sintoma e o déficit foi 5,4 dias para as DC e 13,5 para as DV. AD foi o principal método diagnóstico (93%), associado a RM e ARM em 42% dos casos. Em 3 pacientes a RM cervical com supressão de gordura foi isoladamente suficiente. 75% dos pacientes receberam anticoagulação. Dois pacientes fizeram trombólise endovenosa sem complicações. A evolução foi boa, exceto por dois óbitos (DC bilateral). CONCLUSÃO: Os resultados são semelhantes aos da literatura, exceto pela baixa freqüência de cervicalgia nos casos de DC e pelo predomínio de cefaléia têmporo-parietal nas dissecções arteriais cervicais. Fatores de risco para doença vascular isquêmica foram frequentes.
OBJETIVE: To report a Brazilian series of spontaneous cervical arterial dissections, risk factors, warning symptoms, clinical manifestations, diagnostic tests, treatment and prognosis. METHOD: We performed the retrospective analysis of clinical and neuroradiological records (MRI, A-MRI and Angiography) of patients with this diagnosis who were evaluated in a tertiary hospital for the period of 1997-2003. RESULTS: 48 patients (24 men) with median age 37.9 years: 26 patients with unilateral internal carotid dissection (ICAD), 15 with unilateral vertebral artery dissection (VAD) and 7 with multivessel dissections. All patients presented neurological deficits. Hypertension, smoking and dyslipidemia were the main risk factors. More than 80% of patients presented at least one initial symptom, most of them temporoparietal headache. 44% of patients with VAD and only 3.4% of patients with ICAD had neck pain. The median interval between the onset of symptom and the appearance of neurological deficit was 5.4 days for ICAD and 13.5 days for VAD. Five patients with ICAD presented preceding TIA. Angiography was performed in 93% of patients. In 42% of these patients, MRI and A-MRI were associated. In three patients the diagnosis was made just through cervical MRI. 75% of patients received anticoagulation. Two patients received intravenous thrombolytic therapy with no complications. Prognosis was good for all patients but two patients with bilateral ICAD died. CONCLUSION: Our results are similar to the literature, except for the low frequency of neck pain in ICAD patients and predominance of temporoparietal headache in cervical artery dissection patients. Vascular risk factors were commonly found.
O uso intravenoso do ativador tecidual do plasminogênio está aprovado para o tratamento do acidente vascular cerebral isquêmico há alguns anos e estão publicadas diretrizes e recomendações para o seu ...uso. O atendimento hospitalar precisa ser organizado a fim de tornar esse tratamento exeqüível e seguro, alcançando os resultados esperados. O objetivo deste estudo foi verificar a exeqüibilidade e a segurança do tratamento trombolítico intravenoso nos pacientes tratados pela Clínica Neurológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, assim como avaliar as características desses pacientes, sua evolução clínica, as complicações do tratamento e os preditores prognósticos. Também foi avaliado o desempenho do atendimento hospitalar, através da análise do tempo das diversas etapas do atendimento, em quatro diferentes grupos de pacientes com base no local do primeiro atendimento médico. Foram tratados 51 pacientes entre Junho de 1998 e Agosto de 2005, primeiramente atendidos no Pronto Socorro de Neurologia (22 pacientes), Instituto do Coração (22 pacientes) e enfermarias do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (3 pacientes), assim como no Hospital Universitário (4 pacientes). Os tempos do atendimento, representados por suas respectivas medianas, foram: entre o ictus e a admissão (55 minutos); entre a admissão e a análise da tomografia computadorizada de crânio (35 minutos); entre a admissão e o início do tratamento trombolítico (90 minutos) e entre o ictus e o início do tratamento trombolítico (160 minutos). De uma maneira geral, o desempenho do atendimento melhorou durante o período do estudo. Entretanto, a análise comparativa dos grupos revelou que os tempos entre a admissão e a análise da tomografia computadorizada de crânio e entre a admissão e o início do tratamento trombolítico foram maiores no Instituto do Coração (p = 0,002 e p = 0,01, respectivamente) do que no Pronto Socorro de Neurologia e Hospital Universitário. O principal mecanismo causador do acidente vascular cerebral isquêmico foi embolia de origem cardíaca (54%). A maioria dos pacientes tratados chegou ao hospital com déficits neurológicos graves (mediana 17 na Escala de AVC do NIH). Resultado funcional excelente em 3 meses, definido como pontuações 0 ou 1 na Escala de Rankin modificada, foi observado em 29% dos casos e hemorragia cerebral sintomática em 6% dos casos. Em conclusão, o tratamento trombolítico intravenoso com ativador tecidual do plasminogênio no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo foi exeqüível e seguro. A intensidade do déficit neurológico na admissão, mensurada pela Escala de AVC do NIH e a redução igual ou maior que quatro pontos nesta escala em 24 horas foram preditores prognósticos independentes.
Intravenous use of tissue plasminogen activator has been approved for acute ischemic stroke treatment for some years and guidelines and recommendations about its use have been published. Hospital attendance needs to be organized in order to become this treatment feasible and safe, reaching the expected results. The objective of this study was verify feasibility and safety of intravenous thrombolytic therapy in patients who were treated at Neurology Department of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo as well evaluating characteristics of these patients, their clinical outcome, complications of therapy and outcome predictors. Hospital attendance performance was also evaluated through time analysis of several steps of attendance in four different patient groups based on the place of the first medical attendance. Fifty one patients were treated between June 1998 and August 2005, primarily attended at Neurology Emergency Department (22 patients), Heart Institute (22 patients) and wards of Central Institute of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (3 patients) as well at University Hospital (4 patients). Attendance times, represented by its median were: between symptoms onset and hospital admission (55 minutes); between hospital admission and computed cranial tomography analysis (35 minutes); between hospital admission and thrombolytic therapy onset (90 minutes) and between symptoms onset and thrombolytic therapy onset (160 minutes). As a general rule, hospital attendance performance improved during study period. However, comparative analysis of groups disclosed that time between hospital admission and computed cranial tomography analysis as well time between hospital admission and thrombolytic therapy onset were longer at Heart Institute (p = 0,002 and p = 0,01, respectively) than at Neurology Emergency Department and University Hospital. The main acute ischemic stroke mechanism was cardiac emboli (54%). Most of treated patients arrived at hospital with serious neurologic impairment (NIH Stroke Scale median 17). Excellent functional outcome in 3 months, defined as scoring 0 or 1 by modified Rankin Scale was observed in 29% and symptomatic cerebral hemorrhage in 6% of the cases. In conclusion, intravenous thrombolytic therapy with tissue plasminogen activator at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo was feasible and safe. The intensity of the neurological impairment at hospital admission, as measured by NIH Stroke Scale, and four-point or more score reduction on this scale at 24 hours were independent outcome predictors.
Timectomia robótica para miastenia gravis Sardenberg, Rodrigo Afonso da Silva; Abadalla, Ricardo Zugaib; Abreu, Igor Renato Louro Bruno ...
Jornal brasileiro de pneumologia,
10/2011, Letnik:
37, Številka:
5
Journal Article
PDF
