New paradigms
12 years of systemic thrombolysis. Stroke Unit, Clinicas Hospital
Keywords:
STROKE, CEREBRAL INFARCTION, SYSTEMIC THROMBOLYSIS, INTRAVENOUS THROMBOLYSIS, INTRACRANIAL HEMORRHAGE, STROKE UNITS, MORTALITY
Abstract
Introduction: Strokes are a health problem and systemic thrombolysis constitutes a reperfusion strategy backed up by significant evidence on its positive therapeutic impact. National reports on its use are scarce.
Objectives: To report and analyze results obtained with this therapeutic approach at the Clinicas Hospital. To establish predictive factors for a good evolution, intracranial hemorrhage and mortality.
Method: Observational, analytical study of thrombolysed patients at Clinicas Hospital (2010-2021). Results: Systemic thrombolysis was performed in 268 patients. Average NIHSS score was 12 points when admitted to hospital.42 % of cases were total anterior circulation infarct (TACI). Cardioembolic ischaemmic stroke was the most frequent etiopahogenesis. 59.3% of patients were discharged with functional independence and 55.2% had minimal neurologic deficit. Symptomatic intracranial hemorrhage and mortality rates were 7.1% and 18.7% respectively. 57% of patients were assisted within ≤60 minutes they showed up at the ER. Thrombolysis percentage in total number of strokes was 18.9%. Age, NIHSS score upon arrival to hospital and admission to the stroke unit were significant variables to predict a good evolution, intracranial hemorrhage and death.
Discussion and conclusions: The large number of cases in the country was reported. Effectiveness and safety parameters for this treatment were comparable to those reported internationally. The good door-to-needle time and thrombolysis rate versus total number of strokes stood out as satisfactory indicators of healthcare quality. Admission to the stroke unit behaved as a predictive factor of functional independence and it protected patients from hospital mortality.
References
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18) Preve F, Gaye A, Hackembruch J. Cohorte de pacientes con ACV isquémico -trombolizados y candidatos a trombectomía mecánica- de la Unidad ACV - Hospital de Clínicas (período marzo 2014-16) - Uruguay. Rev Urug Med Int 2016; 1(2):35-44. Disponible en: https://revistamedicinainterna.uy/index.php/smiu/article/view/98 [Consulta: 12 abril 2022].
19) Gaye Saavedra A, Camejo C, Salamano R, Brunet F, Albisu S. Stroke care organization in public health of Montevideo, Uruguay. J Neurol Sci 2015; 357:e377. doi: 10.1016/j.jns.2015.08.1344.
20) World Stroke Organization. Sociedad Iberoamericana de Enfermedad Cerebrovascular. Certificación de los Centros de ACV en Latinoamérica. Disponible en: https://www.globalstrokealliance.com/certificacion/uruguay/ [Consulta: 16 febrero 2022].
21) Mendez Andrade T, Vidal J, Luna A, Arciere B, Perez Lago C. Primeros 70 pacientes trombolizados con ACV hiperagudo en el Hospital Maciel. (Tema Libre 0168). Rev Urug Med Int 2019; (1):205. Disponible en: https://www.medicinainterna.org.uy/wp-content/uploads/2019/03/RumiNumero01_Marzo2019_V2.pdf [Consulta: 16 febrero 2022].
22) Bartesaghi L, Berrutti C, Rebella M, Boschi J, Crossa R, Cánepa A. Una nueva etapa para el accidente cerebrovascular en Uruguay. Informe preliminar. (Tema Libre 0119) Rev Urug Med Int 2019; (1):158. Disponible en: https://www.medicinainterna.org.uy/wp-content/uploads/2019/03/RumiNumero01_Marzo2019_V2.pdf [Consulta: 16 febrero 2022].
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24) Lyden P. Using the National Institutes of Health Stroke Scale: a cautionary tale. Stroke 2017; 48(2):513-9. doi: 10.1161/strokeaha.116.015434.
25) Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke 2007; 38(3):1091-6. doi: 10.1161/01.STR.0000258355.23810.c6.
26) Buck BH, Akhtar N, Alrohimi A, Khan K, Shuaiba A. Stroke mimics: incidence, aetiology, clinical features and treatment. Ann Med 2021; 53(1):420-36. doi: 10.1080/07853890.2021.1890205.
27) Wardlaw JM, Dennis MS, Lindley RI, Sellar RJ, Warlow CP. The validity of a simple clinical classification of acute ischemic stroke. J Neurol 1996; 243(3):274-9. doi: 10.1007/BF00868526.
28) Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24(1):35-41. doi: 10.1161/01.str.24.1.35.
29) Figueroa-Reyes T, Sáenz MD, Mansilla LE, Sánchez VR, Nogales- Gaete J, Delgado B I. Experiencia de trombólisis sistematizada en infarto cerebral agudo en un hospital público de Chile. Rev Méd Chile 2011; 139(9):1118-27. doi: 10.4067/S0034-98872011000900002.
30) Zinkstok SM, Engelter ST, Gensicke H, Lyrer PA, Ringleb PA, Artto V, et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke 2013; 44(4):1080-4. doi: 10.1161/STROKEAHA.111.000126.
31) Saber H, Saver JL. Distributional validity and prognostic power of the National Institutes of Health Stroke Scale in US administrative claims data. JAMA Neurol 2020; 77(5):606-12. doi: 10.1001/jamaneurol.2019.5061.
32) Rost NS, Bottle A, Lee JM, Randall M, Middleton S, Shaw L, et al. Stroke severity is a crucial predictor of outcome: an international prospective validation study. J Am Heart Assoc 2016; 5(1):e002433. doi: 10.1161/jaha.115.002433.
33) Yaghi S, Raz E, Yang D, Cutting S, Mac Grory B, Elkind MS, et al. Lacunar stroke: mechanisms and therapeutic implications. J Neurol Neurosurg Psychiatry 2021; 92(8):823-30. doi: 10.1136/jnnp-2021-326308.
34) Gaye A, Brunet F, Albisu S, Higgie J, Preve F, Camejo P, et al. Ataque Cerebrovascular en jóvenes en la Unidad de ACV del Hospital de Clínicas de Montevideo. AnFaMed 2015; 2(1):70-6.
35) Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013 44(3):870-947. doi: 10.1161/STR.0b013e318284056a.
36) Kamel H. The evolving concept of cryptogenic stroke. Continumm (Minneap Minn) 2020; 26(2):353-62. doi: 10.1212/CON.0000000000000832.
37) Uruguay. Ministerio de Salud Pública. Protocolo Nacional de ACV. Uruguay 2020. Montevideo: MSP, 2020. Disponible en: https://medicinainterna.org.uy/protocolo-nacional-de-acv-uruguay-2020/ [Consulta: 16 febrero 2022].
38) Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, et al. Treatment and outcome of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2017; 48(12):e343-e361. doi: 10.1161/str.0000000000000152.
39) Aguiar de Sousa D, von Martial R, Abilleira S, Gattringer T, Kobayashi A, Gallofré M, et al. Access to and delivery of acute ischaemic stroke treatments: a survey of national scientific societies and stroke experts in 44 European countries. Europ Stroke J 2019; 4(1):13-28. doi: 10.1177/2396987318786023.
40) Chalos V, van der Ende NAM, Lingsma HF, Mulder MJHL, Venema E, Dijkland SA, et al. National Institutes of Health Stroke Scale: an alternative primary outcome measure for trials of acute treatment for ischemic stroke. Stroke 2020; 51(1):282-90. doi: 10.1161/STROKEAHA.119.026791.
2) Comisión Honoraria para la Salud Cardiovascular. Mortalidad por enfermedades del sistema circulatorio en Uruguay, 2020. Montevideo: CHSCV, 2021. Disponible en: https://cardiosalud.org/publicacion/mortalidad-por-enfermedades-del-sistema-circulatorio-en-el-uruguay-2020/ [Consulta: 24 setiembre 2021].
3) Uruguay. Ministerio de Salud Pública. Programa de Prevención de Enfermedades No Transmisibles. Primer Estudio de Carga Global de Enfermedad para el año 2010. Montevideo: MSP, 2010. Disponible en: https://www.gub.uy/ministerio-salud-publica/sites/ministerio-salud-publica/files/documentos/publicaciones/Estudio_de_Carga_Global.pdf [Consulta: 5 mayo 2022].
4) Brunet F, Camejo C, Gaye A, Castro L, Puppo C, Niggemeyer A, et al. Ataque cerebrovascular isquémico en Uruguay: comunicación de los primeros 34 casos trombolizados en el Hospital de Clínicas. Rev Méd Urug 2014; 30(1):37-48. Disponible en: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-03902014000100005&lng=es&nrm=iso&tlng=es [Consulta: 15 setiembre 2021].
5) Correction to: Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019; 50(12):e440-e441. doi: 10.1161/STR.0000000000000215. Erratum for: Stroke 2019 Oct 30; STR0000000000000211.
6) Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6(1):I-LXII. doi: 10.1177/2396987321989865.
7) Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Eng J Med 2018; 378(1):11-21. doi: 10.1056/NEJMmoa1706442.
8) Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018; 378(8):708-18. doi: 10.1056/NEJMoa1713973.
9) Langhorne P, Ramachandra S; Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database Syst Rev 2020; 4(4):CD000197. doi: 10.1002/14651858.CD000197.pub4.
10) Zivin JA. Acute stroke therapy with tissue plasminogen activator (tpa) since it was approved by the U.S. Food and Drug Administration (FDA). Ann Neurol 2009; 66(1):6-10. doi: 10.1002/ana.21750.
11) National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333(24):1581-7. doi: 10.1056/NEJM199512143332401.
12) Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359(13):1317-29. doi: 10.1056/NEJMoa0804656.
13) Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, et al. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med 2018; 379(7):611-22. doi: 10.1056/NEJMoa1804355.
14) Campbell BC, Mitchell PJ, Yan B, Parsons MW, Christensen S, Churilov, et al. A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA). Int J Stroke 2014; 9(1):126-32. doi: 10.1111/ijs.12206.
15) Demeestere J, Wouters A, Christensen S, Lemmens R, Lansberg MG. Review of perfusion imaging in acute ischemic stroke: from Time to tissue. Stroke 2020; 51(3):1017-24. doi: 10.1161/STROKEAHA.119.028337.
16) Camejo C, Legnani C, Gaye A, Arciere B, Brumett F, Castro L, et al. Unidad de ACV en el Hospital de Clínicas: comportamiento clínico-epidemiológico de los pacientes con ACV (2007-2012). Arch Med Int 2015; 37(1):30-5. Disponible en: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-423X2015000100006 [Consulta: 15 marzo 2022].
17) Gaye A, Brunet F, Albisu S, Camejo C, Rocha V. Diez años del registro de la unidad ACV Hospital de Clínicas (Trabajo 11). Rev Urug Med Int 2018; (2):61. Disponible en: https://www.medicinainterna.org.uy/wp-content/uploads/2018/06/Rumi_N%C2%B02_2018.pdf [Consulta: 12 abril 2022].
18) Preve F, Gaye A, Hackembruch J. Cohorte de pacientes con ACV isquémico -trombolizados y candidatos a trombectomía mecánica- de la Unidad ACV - Hospital de Clínicas (período marzo 2014-16) - Uruguay. Rev Urug Med Int 2016; 1(2):35-44. Disponible en: https://revistamedicinainterna.uy/index.php/smiu/article/view/98 [Consulta: 12 abril 2022].
19) Gaye Saavedra A, Camejo C, Salamano R, Brunet F, Albisu S. Stroke care organization in public health of Montevideo, Uruguay. J Neurol Sci 2015; 357:e377. doi: 10.1016/j.jns.2015.08.1344.
20) World Stroke Organization. Sociedad Iberoamericana de Enfermedad Cerebrovascular. Certificación de los Centros de ACV en Latinoamérica. Disponible en: https://www.globalstrokealliance.com/certificacion/uruguay/ [Consulta: 16 febrero 2022].
21) Mendez Andrade T, Vidal J, Luna A, Arciere B, Perez Lago C. Primeros 70 pacientes trombolizados con ACV hiperagudo en el Hospital Maciel. (Tema Libre 0168). Rev Urug Med Int 2019; (1):205. Disponible en: https://www.medicinainterna.org.uy/wp-content/uploads/2019/03/RumiNumero01_Marzo2019_V2.pdf [Consulta: 16 febrero 2022].
22) Bartesaghi L, Berrutti C, Rebella M, Boschi J, Crossa R, Cánepa A. Una nueva etapa para el accidente cerebrovascular en Uruguay. Informe preliminar. (Tema Libre 0119) Rev Urug Med Int 2019; (1):158. Disponible en: https://www.medicinainterna.org.uy/wp-content/uploads/2019/03/RumiNumero01_Marzo2019_V2.pdf [Consulta: 16 febrero 2022].
23) Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20(7):864-70. doi: 10.1161/01.str.20.7.864.
24) Lyden P. Using the National Institutes of Health Stroke Scale: a cautionary tale. Stroke 2017; 48(2):513-9. doi: 10.1161/strokeaha.116.015434.
25) Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke 2007; 38(3):1091-6. doi: 10.1161/01.STR.0000258355.23810.c6.
26) Buck BH, Akhtar N, Alrohimi A, Khan K, Shuaiba A. Stroke mimics: incidence, aetiology, clinical features and treatment. Ann Med 2021; 53(1):420-36. doi: 10.1080/07853890.2021.1890205.
27) Wardlaw JM, Dennis MS, Lindley RI, Sellar RJ, Warlow CP. The validity of a simple clinical classification of acute ischemic stroke. J Neurol 1996; 243(3):274-9. doi: 10.1007/BF00868526.
28) Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24(1):35-41. doi: 10.1161/01.str.24.1.35.
29) Figueroa-Reyes T, Sáenz MD, Mansilla LE, Sánchez VR, Nogales- Gaete J, Delgado B I. Experiencia de trombólisis sistematizada en infarto cerebral agudo en un hospital público de Chile. Rev Méd Chile 2011; 139(9):1118-27. doi: 10.4067/S0034-98872011000900002.
30) Zinkstok SM, Engelter ST, Gensicke H, Lyrer PA, Ringleb PA, Artto V, et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke 2013; 44(4):1080-4. doi: 10.1161/STROKEAHA.111.000126.
31) Saber H, Saver JL. Distributional validity and prognostic power of the National Institutes of Health Stroke Scale in US administrative claims data. JAMA Neurol 2020; 77(5):606-12. doi: 10.1001/jamaneurol.2019.5061.
32) Rost NS, Bottle A, Lee JM, Randall M, Middleton S, Shaw L, et al. Stroke severity is a crucial predictor of outcome: an international prospective validation study. J Am Heart Assoc 2016; 5(1):e002433. doi: 10.1161/jaha.115.002433.
33) Yaghi S, Raz E, Yang D, Cutting S, Mac Grory B, Elkind MS, et al. Lacunar stroke: mechanisms and therapeutic implications. J Neurol Neurosurg Psychiatry 2021; 92(8):823-30. doi: 10.1136/jnnp-2021-326308.
34) Gaye A, Brunet F, Albisu S, Higgie J, Preve F, Camejo P, et al. Ataque Cerebrovascular en jóvenes en la Unidad de ACV del Hospital de Clínicas de Montevideo. AnFaMed 2015; 2(1):70-6.
35) Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013 44(3):870-947. doi: 10.1161/STR.0b013e318284056a.
36) Kamel H. The evolving concept of cryptogenic stroke. Continumm (Minneap Minn) 2020; 26(2):353-62. doi: 10.1212/CON.0000000000000832.
37) Uruguay. Ministerio de Salud Pública. Protocolo Nacional de ACV. Uruguay 2020. Montevideo: MSP, 2020. Disponible en: https://medicinainterna.org.uy/protocolo-nacional-de-acv-uruguay-2020/ [Consulta: 16 febrero 2022].
38) Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, et al. Treatment and outcome of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2017; 48(12):e343-e361. doi: 10.1161/str.0000000000000152.
39) Aguiar de Sousa D, von Martial R, Abilleira S, Gattringer T, Kobayashi A, Gallofré M, et al. Access to and delivery of acute ischaemic stroke treatments: a survey of national scientific societies and stroke experts in 44 European countries. Europ Stroke J 2019; 4(1):13-28. doi: 10.1177/2396987318786023.
40) Chalos V, van der Ende NAM, Lingsma HF, Mulder MJHL, Venema E, Dijkland SA, et al. National Institutes of Health Stroke Scale: an alternative primary outcome measure for trials of acute treatment for ischemic stroke. Stroke 2020; 51(1):282-90. doi: 10.1161/STROKEAHA.119.026791.
Published
2023-02-15
How to Cite
1.
Gaye Saavedra A, Méndez T, Décima R, Vidal J, Pérez G, Preve Cocco F, Cassella R. New paradigms. Rev. Méd. Urug. [Internet]. 2023Feb.15 [cited 2024Dec.18];39(1):e202. Available from: https://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/1010
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