Treatment of ischemic stroke with r-tPA: implementation challenges in a tertiary hospital in Brazil

Tosta, Elza Dias; Rebello, Letícia C; Almeida, S; Neiva, Márcia Silva Santos

doi:10.1590/0004-282x20140021

Cited by 5 publications

(7 citation statements)

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“…(26) Frequency of symptomatic hemorrhagic transformation was greater in comparison to other studies. Al-Khaled et al (20) found 6%; Tong et al, (15) 5%; Tosta et al (7) and Cougo-Pinto et al (21) found a frequency of 6%. The higher frequency of hemorrhagic transformation in this study can be explained by higher NIHSS scores and the presence of comorbidities such as atrial fibrillation and heart disease.…”

Section: Discussionmentioning

confidence: 94%

“…The difference between time windows in Brazilian and international studies is noteworthy. In a Brazilian study by Tosta et al (7) the mean time window was 118 minutes. In the most important Brazilian study conducted at 19 hospitals with 2,407 stroke patients, the mean time window was 12.9 hours.…”

Section: Discussionmentioning

confidence: 98%

“…(6) The main clinical outcomes associated with this treatment are: significantly improved National Institute of Health Stroke Scale NIHSS score, hospital discharge, low occurrence of symptomatic hemorrhagic transformation, and low treatment-related deaths. (7,8) In Brazil, intravenous thrombolysis for ischemic stroke is conducted in several hospitals. However, there are few national reports on the demographic and clinical characteristics of patients submitted to this treatment.…”

Section: Introductionmentioning

confidence: 99%

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Desfechos clínicos de pacientes com acidente vascular cerebral isquêmico após terapia trombolítica

et al. 2016

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Objective: To analyze outcomes and associated factors in ischemic stroke patients submitted to thrombolytic therapy. Methods: This was a retrospective cohort study of ischemic stroke patients submitted to thrombolytic therapy. Comorbidities, neurologic deficits and time of thrombolysis were described. The chi-squared test was used to assess association among comorbidities, time of thrombolysis, and occurrence of hemorrhagic transformation. Results: There was a high frequency of comorbidities. Mean neurological deficit score was 15 points. Mean time window was 98 minutes and needle-to-door time, 89.9 minutes. Hemorrhagic transformation was observed in 20 patients. Bivariate analysis revealed that hemorrhagic transformation was associated with greater neurologic deficit score, atrial fibrillation and heart disease. Neurologic deficit fell from 51% to 12.5% between admission and discharge. Conclusion: Thrombolytic therapy presented positive outcomes, regardless of long thrombolysis time and high neurologic deficit scores. ResumoObjetivo: Analisar desfechos e fatores associados em pacientes com acidente vascular cerebral isquêmico após terapia trombolítica. Métodos: Estudo do tipo coorte retrospectivo de pacientes com acidente vascular cerebral isquêmico submetidos à terapia trombolítica. Foram descritas as comorbidades; os défices neurológicos e os tempos de atendimento. Utilizou-se o teste qui quadrado para associação entre comorbidades, tempos de atendimento e ocorrência de transformação hemorrágica. Resultados: Houve elevada frequência de comorbidades. Défices neurológicos pontuaram média de 15 pontos. A janela de tempo obteve média de 98 minutos e o tempo porta-agulha, 89,8 minutos. Observouse transformação hemorrágica em 20 pacientes. Na análise bivariada, a ocorrência de transformação hemorrágica esteve associada com maior défice neurológico, fibrilação atrial e cardiopatia. Houve redução dos défices neurológicos de 51% para 12,5 entre a admissão e alta. Conclusão: A terapia trombolítica apresentou resultados positivos, apesar de tempos de atendimento elevados e pacientes com défices neurológicos com elevada pontuação.

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Section: Discussionmentioning

confidence: 94%

Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

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Desfechos clínicos de pacientes com acidente vascular cerebral isquêmico após terapia trombolítica

et al. 2016

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“…Previous studies showed a 42% decrease of CVA incidence in high income and more than 100% increase in low and middle income countries (4). Treatment of acute CVA is one of the most challenging medical health problems and many studies have been conducted in this regard during the last 10to15 years (5). Standard protocols have been designed for appropriate treatment of acute ischemic CVA with recombinant tissue plasminogen activator (rt-PA).…”

Section: Introductionmentioning

confidence: 99%

Recombinant Tissue Plasminogen Activator Administration in Patients With Cerebrovascular Accident; A Case Series

et al. 2015

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Background: Cerebrovascular accident (CVA), as a debilitating neurological impairment, is one of the most common causes of death in adults. It is observed that CVA is less well-documented in the developing countries compared to the developed ones and most of the available data are based on case series. Objectives: The current study aimed to evaluate the effectiveness, feasibility, outcome, and safety of intravenous recombinant tissue plasminogen activator (IV rt-PA) administration in patients with acute ischemic cerebrovascular accident (CVA). Patients and Methods: All CVA patients referred three hours after onset of symptoms to the emergency department (ED) of Shohadaye Tajrish Hospital, Tehran, Iran, from February 2012 to March 2014 were included. The following data were collected using specific check list: demographic data, chief complaint, signs and symptoms, medical history, risk factors, focused neurologic examination, and the National Institutes of Health CVA Scale (NIHSS). Then, all patients received 0.9 mg/kg of rt-PA as a bolus intravenous dose and intravenous infusion under close monitoring in the ED. Outcomes were categorized as good (complete reversal of focal neurologic deficit), not bad (partial reversal of focal neurologic deficit), death, and unknown (missed follow up). Data were analyzed by STATA software version 11. Results: Fifteen patients with the mean age of 56.7 ± 18.9 years included in the study (male 66.7%). The most common chief complaints were left side hemiplegia (46.67%), right side hemiplegia (40%), and decreased level of consciousness (13.33%), respectively. The most common affected vascular territory was medial cerebral artery (MCA) (86.67%). There was no significant relationship between age (P = 0.06), gender (P = 0.08), NIHSS score (P = 0.07), location of infarct (P > 0.99) and mean time from admission to beginning the drug administration (P = 0.55) with the outcomes. The outcome in 26.7% of the patients was favorable and death (two of four) happened due to intra cranial hemorrhage (ICH) as rt-PA side effects. Conclusions: It seems that intravenous rt-PA administered three hours after CVA is bemeficial in patients with CVA and by reducing the early evaluation time and brain imaging can overcome the CVA complications. However, any conclusion from this study is limited by the small population under study.

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“…Whether Berlin's experience can be generalized is open to debate 22 . In Brazil there are other challenges to overcome first, from the patients' ability to react 23 to tertiary hospital setup 24 .…”

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confidence: 99%

Lean thinking turns ‘time is brain’ into reality

Johnson²

2015

Arq. Neuro-Psiquiatr.

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Thrombolysis with intravenous rt-PA is an effective recanalizing treatment for ischemic stroke within 4 and half hours from its onset 1 . It is clear that by providing the treatment earlier the outcome is better with fewer complications 2,3 . A pooled study 4 demonstrated that short stroke-onset-to-treatment time (OTT) with rt-PA had better functional outcomes (modified Rankin Scale, mRS, score of 0 to 1) than patients treated beyond the 90 minute OTT, with odds of 2.8 (95%CI 1.8-4.5) for OTT between 0 to 90 min in comparison to odds of 1.6 (1.1-2.2) for OTT between 91 to 180 min. A more recent pooled reanalysis with additional data showed similar findings 5 ; the number of patients needed to treat (NNT) to achieve an mRS score of 0 to 1 for OTT within 90 minutes is 4.5, whereas the NNT doubled to 9 for OTT between 91-180, and to 14 for OTT between 181-270 minutes.Therefore, the goal for an optimal treatment should be to target an OTT under 90 minutes, as pictured in Figure 1. Based on the recommended American Heart Association (AHA) stroke guideline (the text and references 6,7 in Figure 1 are derived from it 8 ), the time limits for pre-hospital (30 minutes) plus hospital care (60 minutes) fill up the 90 minute window. Experience has demonstrated that process improvement can lower the time spent in the pre-hospital 9 and hospital 10,11,12,13 phases, and educational awareness campaigns can improve stroke recognition and time to seek help 8 . Therefore, combining best practices and available technologies, it is possible to respond within 90 minutes. The strategy and plan of action require commitment from the stakeholders, including society and in particular patients at risk. We need to move forward to interpret the 60 minute door to needle recommendation as more than a time to attain. The door-to-needle time needs to AbstrActIntravenous rt-PA is an effective recanalizing treatment for ischemic stroke within 4 and half hours from its onset (Onset-to-Treatment [OTT]), with the best result seen in those treated within 90 minutes OTT. Yet few patients currently are treated in this time frame. From the standpoint of process improvement or a lean thinking perspective, there is a potential opportunity to reduce the time by eliminating non-value-added steps in each element of the stroke survival chain. The reduction in one time element does not necessarily shift the OTT under 90 minutes. Most likely, the reduction in OTT requires a coordinated approach to track and improve all elements of OTT, from the patient's ability to recognize the onset of stroke up to delivery of medication. Shortening this total time should be a considered an indicator of quality improvement in acute stroke care.Keywords: stroke, thrombolysis, quality, safety. resumoTratamento intravenoso com rt-PA é eficaz na recanalização do acidente vascular cerebral isquêmico (AVCI) no prazo de até 4 horas e meia de seu início (OTT), com o melhor resultado visto naqueles tratados dentro de 90 minutos OTT. Apesar disso, poucos são tratados neste período de ...

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Treatment of ischemic stroke with r-tPA: implementation challenges in a tertiary hospital in Brazil

Abstract: Tratamento do acidente vascular cerebral isquêmico com r-tPA: o desafio da implantação em um hospital terciário no Brasil The results of our study are similar to those reported in the literature, although we have been dealing with difficulties, such as the lack of a stroke unit.

Cited by 5 publications

References 12 publications

Desfechos clínicos de pacientes com acidente vascular cerebral isquêmico após terapia trombolítica

Desfechos clínicos de pacientes com acidente vascular cerebral isquêmico após terapia trombolítica

Recombinant Tissue Plasminogen Activator Administration in Patients With Cerebrovascular Accident; A Case Series

Lean thinking turns ‘time is brain’ into reality

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