Intravenous rtPA versus mechanical thrombectomy in acute ischemic stroke: A historical cohort in Joinville, Brazil

Abstract

Groundbreaking results concerning ischemic stroke (IS) hyperacute treatment worldwide were published in 2014 and 2015. We aimed to compare functional status after 3 months in patients treated with intra-arterial thrombectomy (IAT) and those treated with intravenous thrombolysis (IVT) alone in Joinville, Brazil.From the Joinville Stroke Registry, we extracted and compared all consecutive IVT patients treated with r-tPA within 4.5 h in the period 2009–2011 versus all consecutive IAT treated within 6 h with the Solitaire FR device plus IVT in the period 2012–2014.We registered 82 patients in the IVT group and 31 patients in the IAT group. At hospital admission, patients in the IAT group were significantly younger (p < 0.001), had a higher educational level (p = 0.001), had a slightly higher prevalence of atrial fibrillation (p = 0.057) and had more severe strokes measured by the NIH stroke scale (p = 0.011). After 90 days, 45% of patients in the IAT group and 27% in the IVT group were independent (0–1 points) according to the modified Rankin scale (adjusted odds ratio: 4.53; 95% CI: 1.22 to 16.75). Symptomatic hemorrhage was diagnosed in 10% of patients in both groups (p = 1.0). The 90-day case-fatality was 39% (32/82) in the IVT group and 26% (8/31) in the IAT group (p = 0.27). In this small cohort, a greater rate of functional independence was achieved in patients treated with IAT plus IVT, compared with patients treated with IVT lysis alone. Our “real-world” findings are consistent with results of controlled, randomized clinical trials.

<b>Estimation of water consumption in multifamily residential buildings

“…Joinville is an industrial city (Cabral et al, 2016) with 562,151 inhabitants and is the biggest city of the state, with a MHDI equal to 0.809 (Instituo Brasileiro de Geografia e Estatistica [IBGE], 2016). The climate can be classified as of warm temperature, completely humid, with hot summer (Rubel & Kottek, 2010).…”

Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke

“…Despite being one of the leading causes of mortality in the country, stroke has been severely neglected, with very poor stroke awareness in the population and very low rates of treatment with intravenous thrombolysis 10,11 . Unfortunately, Brazil is a country of great economic inequalities, with some stroke units in the private and public hospitals, especially in the wealthier regions of the country, presenting similar thrombolysis rates to those of tertiary stroke centers of developed countries 11,12,13 . These services routinely perform endovascular treatment for stroke and were able to develop a triage and quality control system, with some centers even being certified by international institutions such as the Joint Commission to PAO: proximal arterial occlusions; NIHSS: National Institutes of Health Stroke Scale; IV TPA: intravenous tissue plasminogen activator; MR CLEAN: multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands; EXTEND-IA: extending the time for thrombolysis in emergency neurological deficits -intra-arterial; ESCAPE: endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times; SWIFT-PRIME: solitaire with the Intention for thrombectomy as primary endovascular treatment; REVASCAT: randomized trial of revascularization with solitaire FR device versus best medical therapy in the treatment of acute stroke due to anterior circulation large vessel occlusion presenting within eight hours of symptom onset; IC ICA: intracranial segment of the internal carotid artery; M1 and M2: first and second segments of the MCA; EC ICA: extracranial segment of the internal carotid artery; Tmax: time to maximum; CBF: cerebral blood flow; ASPECTS: Alberta stroke program early CT score; CT: computed tomography; MCA: middle cerebral artery; CTA: CT angiography; CTP: CT perfusion; CBV: cerebral blood volume; DWI: diffusion weighted imaging; Solitaire FR: solitaire stent-retriever device.…”

Norberto Cabral: A Pioneer in Stroke Research in Brazil Leaves a Huge Legacy for Latin America

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well as a researcher and clinical neurologist at the Hospital Municipal São José and Neurological Clinic in Joinville.As one of the most distinguished Brazilian stroke researchers, he started the JOINVASC in 2005, a population-based registry in the city of Joinville, one of the largest stroke databases in the world, providing information to plan the stroke assistance in his city, and also establishing important knowledge about stroke [1][2][3][4][5][6][7][8][9][10][11].With his persistence, leadership and expertise, he put Joinville on the Brazilian and world map, showing the work of his group in the first stroke unit created in Brazil (1997) [1]. He always followed what he preached: "who has numbers has argument, who has information has power."

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“…Disagreeing with social injustices, he always defended those who had no voice to defend themselves, striving for better public health for all. His determination and his tireless work leave us a huge legacy of fundamental studies that supported stroke research and planning of stroke care in Brazil [1,[3][4][5][6][7][9][10][11][12][13], including the most important population-based study on stroke on a national level performed through the National Research Network of the Ministry of Health.With important models in his professional life, he was strongly influenced by Valery Feigin, Peter Sandercock and Joanna Wardlaw as well as his friends, researchers from Chile, Pablo Lavados and Claudio…”

“…As one of the most distinguished Brazilian stroke researchers, he started the JOINVASC in 2005, a population-based registry in the city of Joinville, one of the largest stroke databases in the world, providing information to plan the stroke assistance in his city, and also establishing important knowledge about stroke [1][2][3][4][5][6][7][8][9][10][11].…”