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#31
28.10.2006, 20:52
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Уважаемые коллеги, вот на днях появилась новая инфа об интраартериальном тромболизисе:
Long-Term Effect of Intra-Arterial Thrombolysis in Stroke Krassen Nedeltchev MD; Urs Fischer MD; Marcel Arnold MD; Pietro Ballinari MSc; Tobias Haefeli MD; Liliane Kappeler MD; Caspar Brekenfeld MD; Luca Remonda MD; Gerhard Schroth MD; and Heinrich P. Mattle MD* From Departments of Neurology (K.N., U.F., M.A., L.K., T.H., H.P.M.), Diagnostic and Interventional Neuroradiology (C.B., L.R., G.S.), and Psychology (P.B.), University of Bern, Switzerland. * To whom correspondence should be addressed. E-mail: [Ссылки доступны только зарегистрированным пользователям ] Background and Purpose--Thrombolysis has been shown to improve the 3-month outcome of patients with ischemic stroke, but knowledge of the long-term effect of thrombolysis is limited. Methods--The present study compares the long-term outcome of stroke patients who were treated with intra-arterial thrombolysis (IAT) using urokinase with the outcome of patients treated with aspirin. The modified Rankin Scale (mRS) was used to assess the outcome; 173 patients treated with IAT and 261 patients treated with aspirin from the Bernese Stroke Data Bank were eligible for the study. A matching algorithm taking into account patient age and stroke severity on admission (as measured by the National Institute of Health Stroke Scale [NIHSS]) was used to assemble an IAT and an aspirin group. Results--One hundred and forty-four patients treated with IAT and 147 patients treated with aspirin could be matched and included in the comparative analysis. The median NIHSS score was 14 in each group. At 2 years, 56% of the patients treated with IAT and 42% of the patients treated with aspirin achieved functional independence (mRS, 0 to 2; P=0.037). Clinical outcome was excellent (mRS, 0 to 1) in 40% of the IAT and in 24% of the aspirin patients (P=0.008). Mortality was 23% and 24%, respectively. Conclusions  --The present study provides evidence for a sustained effect of IAT when assessed 2 years after the stroke.
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#32
02.11.2006, 13:43
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Тромболитический вестник открыть можно и нужно. Вот толь 99% инфы там будет на англицком языке. Или это нормально? Тогда в качестве затравки:
 Reperfusion in acute occlusive stroke - Karolinska Stroke Update Consensus Statement 2004  The following Consensus Statement was adopted by the 5th Karolinska Stroke Update meeting on November 15, 2004. The consensus statement was proposed by the chairpersons in the session, Professor Markku Kaste, Helsinki, and Professor Kennedy R Lees, Glasgow, together with the speakers in the session. The statement was then finally approved by the participants of the meeting, after listening to the different presentations. The speakers in this session were Professor Cesare Fieschi, Rome, Dr Geert Vanhooren, Brügge, Associate Professor Nils Wahlgren, Stockholm and Professor Heinrich Mattle, Bern Reperfusion in acute occlusive stroke 1. Intravenous rt-PA within 3 hours after the onset of symptoms in patients with acute ischaemic stroke is a highly effective treatment in selected patients (grade A evidence). The use of rt-PA is supported by results from randomized controlled trials, pooled analysis of six randomized rt-PA trials, meta-analyses and post-approval data. According to meta-analyses, for patients given rt-PA within 3 hours of ischemic stroke at most 1 out of 22 may suffer some form of symptomatic haemorrhage, and 1 out of 100 more will survive as a result of the treatment (grade A evidence). In spite of haemorrhages approximately 1 out of 8 more will be independent according to the pooled analysis (grade A evidence). 2. The pooled analysis of the 2775 patients of the ATLANTIS, ECASS and NINDS rt-PA trials suggests benefit up to 4 ½ hours after the onset of an ischemic stroke but the treatment benefit decreases with the time elapsed before treatment commences. Odds ratios for favourable outcomes with rt-PA in the pooled analysis were 2.8 (95%CI 1.8-4.5) in the 0-90, 1.6 (95%CI 1.1-2.2) in the 91-180, 1.4 (95%CI 1.1-1.9) in the 181-270 and 1.2 (95%CI 0.9-1.5) in the 271-360 minute time windows. Further randomized trials will be required to determine the latest useful time window (grade A evidence). 3. Outside randomized controlled trials, it is recommended that the therapeutic use of intravenous rt-PA should follow published guidelines (with local modifications as appropriate), and the labelling approved by Health Authorities and should be subject to continuous quality control such as SITS collaboration. 4. In most open studies the safety and efficacy of intravenous rt-PA in routine clinical practice is comparable to randomized studies. A meta-analysis of 12 post-approval open series with 2639 patients treated within 3 hours revealed comparable rates of symptomatic haemorrhages (5.2 vs 6.4 % in the NINDS trial), of favourable outcome as defined by mRS 0-1 pts (37.1 vs 39% in the NINDS trial) and of initial stroke severity as defined by the baseline NIHSS (14 vs 14 in the NINDS trial). 5. Thrombolysis within 3 hours is now widely approved by Health Authorities. The evidence strongly supports that rt-PA is made available for routine clinical use to treat stroke patients in adequately resourced and experienced centres. However, there is an obvious need for continuous education and for trained stroke specialists to guarantee safe and efficient use of thrombolysis. The development of hospital services designed to deliver early thrombolysis 24 hours a day for acute ischemic stroke is encouraged. If the local hospital is not able to provide it there should be a referral system designated to deliver thrombolysis. 6. The approval of rt-PA in ischemic stroke by the European Union Health Authorities in 2002 was conditional. The first condition was that all treated patients should be included in the Safe Implementation of Thrombolysis in Stroke - The Monitoring Study register (SITS-MOST). The second condition was a double-blind, randomized, placebo-controlled trial of IV rt-PA in ischemic stroke where thrombolysis is initiated between 3 and 4 hours after stroke onset (ECASS III). 7. The heterogeneity for good outcome in meta-analyses of treatment > 3 hours implies that more data are needed on how to identify the patients most likely to benefit and least likely to be harmed by thrombolysis. The role of patient characteristics, stroke severity, stroke subtype, vascular lesions, stroke pathophysiology, concomitant disease, and drug treatments should be further evaluated in future trials, meta-analyses, phase IV studies and the SITS register. 8. It is recommended that some future trials of safety and efficacy of thrombolysis should assess modern imaging techniques as a part of the protocol to help in patient selection and in monitoring of the effects of therapy. Extended ischemic oedema as detected by CT should militate against the use of thrombolysis (grade B evidence). MR diffusion and perfusion weighted imaging may reveal brain tissue at risk that can be salvaged with thrombolysis in individual patients within a 3-hour time window and possibly rather longer (grade C evidence). Other imaging modalities including perfusion CT, MR angiography, SPECT and TCD may be useful in selecting patients, in assessing arterial pathology and in monitoring the effects of therapy (grade C evidence). However, further data from randomized trials incorporating these new imaging modalities are required as although each may provide extra prognostic information, they may also increase time to treatment and hence reduce the benefit of rt-PA. 9. The limitation of the 3-hour time window and age limits are the major factors which prevent wider application of thrombolysis in ischemic stroke. ECASS III, IST-3, EPITHET and DIAS II aim at extending the time window. This may have an important public health impact in Europe. It is recommended that new thrombolytic agents, wider time windows and age limits, and thrombolysis together with ultrasound and/or neuroprotective agents, should be evaluated in future randomized trials to try to extend the effectiveness and to limit the risks of thrombolysis. 10. Another factor that prevented the wider application of thrombolysis in ischemic stroke is the concern that brain haemorrhage may harm the patient. In the pooled analysis (ATLANTIS, ECASS and NINDS), the rate of large space occupying haematoma (PH) was 1.1% in the placebo group and 5.9% in the rt-PA group. Despite this 5.4 fold risk, rt-PA significantly increased the overall chance of not being disabled or dead after stroke. From meta-analysis, the true increase in risk is probably lower, at under 4-fold. In addition, closer examination of the data shows that not all of these haemorrhages were symptomatic. Many were incidental findings with no impact on clinical status of the patients. Accordingly, the definition of symptomatic brain haemorrhage should fulfil the following criteria: 'Clinical deterioration by > 4 points on NIHSS (or equivalent) combined with brain haemorrhage without other pathology, or clinical deterioration by > 4 points on NIHSS (or equivalent) combined with cerebral haemorrhage within an ischemic lesion where any mass effect is largely attributable to the haemorrhage. A small haemorrhage within a large space-occupying infarction should not be considered as “symptomatic haemorrhage” but rather “ischemic edema”, and data should be collected on ischemic edema in future trials.' 
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#33
02.11.2006, 13:46
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Продолжаю, все не влезло:
11. IA thrombolysis is experimental and has not been approved in any country. Intra-arterial thrombolysis with r-proUK reduced disability in patients with occluded M1 or M2 segments of the middle cerebral artery within 6-hour time window in PROACT I and II (grade B evidence). The drug is not available in Europe. Open series have suggested that urokinase may be equally effective and safe as r-proUK. IA thrombolysis has also been used in basilar artery occlusions although IV thrombolysis may be equally effective due to faster delivery of the drug. Large trials to assess IA treatment beyond 3 h and trials to compare IV and IA thrombolysis and their combination are needed. 12. Various mechanical means of clot removal and angioplasty are under investigation. The safety and efficacy of these endovascular techniques including stent protected angioplasty in acute stroke need further assessment. 13. Thrombolysis for stroke in children, in patients older than 80 years, in carotid dissections, and in those with basilar artery occlusions needs further studies although case series suggest that it may have similar utility in those over 80 years of age as in younger patients, in basilar artery occlusions as in anterior circulation strokes, and in carotid dissections. 14. The present guidelines may need updating in many aspects of acute stroke care during thrombolysis. In the pooled analysis (ATLANTIS, ECASS and NINDS) every 10 mg/dl increase of blood sugar reduced odds ratios of good outcome (modified Rankin scale 0-1) by 0.98 and increased odds ratios for a bad outcome (modified Rankin scale 5-6) by 1.04 (grade B evidence). Open studies have revealed similar relationships between admission hyperglycemia and outcome in patients treated with thrombolytics. Accordingly, more active blood glucose control seems indicated in connection with thrombolysis. 15. Neither the pooled analysis (ATLANTIS, ECASS and NINDS) nor the reanalysis of the NINDS t-PA trial allowed assessment of the effect of blood pressure or its management on outcome but there are several case series which strongly suggest that it may not be desirable to reduce blood pressure without good clinical reason such as heart failure or hypertensive encephalopathy. When the occluded artery reopens the blood pressure declines, but if it does not recanalize, the blood pressure remains elevated to ensure perfusion in ischemic penumbra, and then an aggressive reduction of blood pressure may reduce the chances of good outcome. The SITS-MOST register may give an answer to some of these open questions but ongoing randomized trials may also contribute in this respect. 16. The impact of antiplatelet treatment prior to stroke on the risk of symptomatic haemorrhage following stroke needs to be studied further. Existing data do not indicate an increased risk of symptomatic haemorrhage (grade B evidence). Furthermore, the safety and efficacy of post-thrombolytic antithrombotic treatment and anticoagulation to prevent reocclusion need to be analysed in randomized trials. 17. The public should be educated of the value of early expert assessment and treatment. 18. Thrombolysis in stroke should be widely available. Our task is now to increase rapid response to stroke. It is equally important to develop a well-functioning stroke triage and an in-hospital stroke care pathway.
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#35
06.11.2006, 12:54
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Цитата:
 По сабжу. Я несколько дней сижу и буквально "чешу репу" не знаю что бы такого примечательного выслать (а предварительно найти ) сюда. Однако определенно тема должна развиваться, люди должны знать о методике.
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#37
06.11.2006, 13:31
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Цитата:
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#38
07.11.2006, 14:39
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А чего "одобрялка" не работает? (это к последнему сообщению).
Начинать ТЛТ ИИ - большой гемор, но, все же, НАЧИНАТЬ -ТО надо!!! Или мы скатимся уже к уровню обезьян (поймите правильно, уважаемые коллеги, никаких персоналий, никого не хочу оскорбить!!!).
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#39
08.11.2006, 15:33
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Цитата:
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#41
08.11.2006, 15:58
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Цитата:
. На частные вопросы отвечу с удовольствием. 
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#42
08.11.2006, 22:41
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Цитата:
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#43
10.11.2006, 14:14
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Как мне кажется, обнадеживающие данные именно для нашей медицины:
An Expedited Code Stroke Protocol Is Feasible and Safe Justin A. Sattin MD; Scott E. Olson MD; Lin Liu PhD; Rema Raman PhD; and Patrick D. Lyden MD* Background and Purpose--Stroke recovery critically depends on timely reperfusion. In July 2003, we set a benchmark onset-to-treatment time of 2 hours and instituted an expedited code stroke protocol to accomplish this. We aim to show that the protocol is feasible and safe. Methods--The expedited protocol includes: Benchmark onset-to-treatment within 2 hours; in-person triage of all code stroke patients; unmixed tissue plasminogen activator at the bedside during evaluation; no delays pending coagulation tests, chest x-ray, or stool guiac unless specifically indicated; and no delays pending formal CT interpretation or written consent. Results--Between July 2003 and June 2005, we evaluated 781 patients and treated 103 of 781 (13.2%) with intravenous recombinant tissue plasminogen activator within 3 hours. Of these, we treated 49 of 103 (47.6%) within 2 hours of symptom onset, and 54 of 103 (52.4%) between 2 and 3 hours. The overall risk of symptomatic intracerebral hemorrhage was 4 of 103 (3.9%; 95% CI, 1.1%, 9.6%), and not significantly different from 6.4% (P=0.42). The hemorrhage risks in those treated within 2 hours of symptom onset and those treated between 2 and 3 hours were not significantly different from each other or from 6.4%. Conclusions--The expedited code stroke protocol is feasible and appears safe. Further study is warranted to confirm its safety and determine whether it results in better clinical outcomes.
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#44
11.11.2006, 15:02
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А вот и небольшая ложка дегтя в нашу бочку с актилизе:
Long-Term Effect of Intra-Arterial Thrombolysis in Stroke Background and Purpose--Thrombolysis has been shown to improve the 3-month outcome of patients with ischemic stroke, but knowledge of the long-term effect of thrombolysis is limited. Methods--The present study compares the long-term outcome of stroke patients who were treated with intra-arterial thrombolysis (IAT) using urokinase with the outcome of patients treated with aspirin. The modified Rankin Scale (mRS) was used to assess the outcome; 173 patients treated with IAT and 261 patients treated with aspirin from the Bernese Stroke Data Bank were eligible for the study. A matching algorithm taking into account patient age and stroke severity on admission (as measured by the National Institute of Health Stroke Scale [NIHSS]) was used to assemble an IAT and an aspirin group. Results--One hundred and forty-four patients treated with IAT and 147 patients treated with aspirin could be matched and included in the comparative analysis. The median NIHSS score was 14 in each group. At 2 years, 56% of the patients treated with IAT and 42% of the patients treated with aspirin achieved functional independence (mRS, 0 to 2; P=0.037). Clinical outcome was excellent (mRS, 0 to 1) in 40% of the IAT and in 24% of the aspirin patients (P=0.008). Mortality was 23% and 24%, respectively. Conclusions--The present study provides evidence for a sustained effect of IAT when assessed 2 years after the stroke
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Линейный вид
