![PART 1
•291 patients with acute ischemic stroke were randomly assigned, within 3 hours after the
onset of the stroke, to either intravenous rt-PA or placebo.
•The primary end point was the rate at 24 hours of either complete neurologic recovery or
neurologic improvement, as indicated by an improvement of at least 4 points (NIHSS)
•In this part of the trial, no significant difference (51% and 46%, respectively; relative risk
with rt-PA, 1.1; 95% confidence interval [CI], 0.8 to 1.6; P = 0.56).
PART 2
•additional 333 patients were enrolled
•primary end point was the rate of complete or nearly complete recovery at 90 days
•favorable outcome was significantly greater with intravenous rt-PA than with placebo (odds ratio,
1.7; 95% CI, 1.2 to 2.6; P = 0.008).
•sustained at 6 months and at 1 year.12
• In 1996, the Food and Drug Administration (FDA) approved the use of
intravenous rt-PA](https://image.slidesharecdn.com/revisionstroke-160711154446/85/Revision-stroke-4-320.jpg)
Revision stroke
- 1. Terapia Fibrinolitica en Ictus Cerebral Dr. Ivan Chavez Mostajo Medicina Interna 2015
- 2. How Do Stroke Units Improve Patient Outcomes? A Collaborative Systematic Review of the Randomized Trials Stroke Unit Trialists’ Collaboration Correspondence to P. Langhorne, PhD, MRCP, Academic Section of Geriatric Medicine, 3rd Floor, Center Block, Royal Infirmary, Glasgow G4 0SF, Scotland. E- mail P.Langhorne@clinmed.gla.ac.uk Analisis sistematico de 12 estudios (1611 pacientes) . Disminucion de fallecimientos 1 a 4 semanas Conclusions Organized inpatient stroke unit care probably benefits a wide range of stroke patients in a variety of different ways, ie, reducing death from secondary complications of stroke and reducing the need for institutional care through a reduction in disability.
- 4. PART 1 •291 patients with acute ischemic stroke were randomly assigned, within 3 hours after the onset of the stroke, to either intravenous rt-PA or placebo. •The primary end point was the rate at 24 hours of either complete neurologic recovery or neurologic improvement, as indicated by an improvement of at least 4 points (NIHSS) •In this part of the trial, no significant difference (51% and 46%, respectively; relative risk with rt-PA, 1.1; 95% confidence interval [CI], 0.8 to 1.6; P = 0.56). PART 2 •additional 333 patients were enrolled •primary end point was the rate of complete or nearly complete recovery at 90 days •favorable outcome was significantly greater with intravenous rt-PA than with placebo (odds ratio, 1.7; 95% CI, 1.2 to 2.6; P = 0.008). •sustained at 6 months and at 1 year.12 • In 1996, the Food and Drug Administration (FDA) approved the use of intravenous rt-PA
- 6. Three additional randomized trials showed no benefit of intravenous rt-PA as compared with placebo. •European Cooperative Acute Stroke Study (ECASS) •ECASS II •Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) t > 6 HRS ECASS III •821 patients •at 90 days outcomes (52.4% vs. 45.2%; odds ratio, 1.34; 95% CI, 1.02 to 1.76; P = 0.04). •Disability 3 and 4.5 hours
- 15. Manejo Pre-Hospitalario Pacientes deben ser enviados al mas alto nivel de complejidad en el menor tiempo posible Tiempo evento a despacho de equipo <90 segundos Tiempo de respuesta <26 minutos Transporte inmediato
- 20. Protocolo de evaluacion de emergencias para pacientes con sospecha de Stroke (Class I; Level of Evidence B). •El objetivo se completa cuendo el tiempo puerta – intervention es de < 60 min •Se debe designar el equipo Capacitado de Stroke que incluye medicos, enfermeras, bioquimicos , radiologo. Enfasis en evaluacion clinica cuidadosa incluyendo examen neurologico Escalas de stroke NIHSS (Class I; Level of Evidence B) Hemograma, tiempos de coagulacion y quimica sanguinea, solo la medicion de glucemia precede el inicio de rtPA (Class I; Level of Evidence B). Electrocardiograma, su toma no retrasa el inicio de rtPA (Class I; Level of Evidence B) Troponinas, su toma no retrasa el inicio de rtPA (Class I; Level of Evidence C) Rx Torax, en Stroke hiperagudo sin evidencia de patologi cardiac o pulmonary, uso incierto. No debe retrasar inicio de rtPA (Class IIb; Leve of Evidence B).
- 21. Estudios de imagen de Emergencia deben ser realizados antes de cualquier terapia especifica de Stroke (Class I; Level of Evidence A). • TC simple de cerebro (TCS) prove la informacion necesaria en la mayor parte de los casos. Ambos TC o RM excluyen hemorragia intracerebral y determinan si la isquemia esta (Class I; Level of Evidence A) Terapia Fibrinolitica endovenosa esta indicada ante evidencia de cambios isquemicos tempranos (Class I; Level of Evidence A). Estudios de Imagen
- 22. Estudios no invasivos estan recomendados durante la evaluacion inicial, si se considera fibrinolisis o trombectomia mecanica, sin retrasar inicio de rtPA (Class I; Level of Evidence A). Candidatos a Fibrinolisis, la interpretacion de las imagenes cerebrales deberan hacerse en menos de 45 minutos por medicos con experiencia en la lectura de TC o RM (Class I; Level of Evidence C). Si la Hipodensidad de Frank en TC simple involucra mas de 1/3 ACM, decision de fibrinolisis debe ser retrasada por riesgo de sangrado (Class III; Level of Evidence A)
- 23. Terapia Reperfusion rtPA intravenoso (0.9 mg/kg max 90 mg) es recomendado en Stroke con menos de 3 hrs de evolución (Class I; Level of Evidence A). En pacientes elegibles para rtPA la terapia es dependiente de tiempo • Puerta – Aguja < 60 minutos (Class I; Level of Evidence A). Uso de rtPA es razonable en Px cuya PA puede ser bajada (<185/110 mm Hg) con agentes antihipertensivos antes de el inicio de rtPA intravenoso. (Class I; Level of Evidence B). (
- 27. rtPA intravenoso (0.9 mg/kg max 90 mg) es recomendado en Stroke con 3 a 4.5 hrs de evolución (Class I; Level of Evidence B).