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Thrombolytic Therapy (thrombolytic + therapy)
Selected AbstractsProsthetic Valve Thrombosis Presenting as an Acute Embolic Myocardial Infarction in a Pregnant Patient: Issues on Anticoagulation Regimens and Thrombolytic TherapyECHOCARDIOGRAPHY, Issue 9 2006Padmini Varadarajan M.D. Mechanical valves are inherently thrombogenic and require meticulous anticoagulation. Pregnancy produces a hypercoagulable state and achieving adequate anticoagulation is difficult. We present a pregnant patient who had a nonobstructive thrombus of mechanical mitral valve causing embolic acute myocardial infarction. Issues surrounding management of anticoagulation and use of thrombolytic therapy during pregnancy are discussed. Education regarding the critical nature of adequate anticoagulation in these patients is important. [source] Combination of T2*W and FLAIR Abnormalities for the Prediction of Parenchymal Hematoma Following Thrombolytic Therapy in 100 Stroke PatientsJOURNAL OF NEUROIMAGING, Issue 4 2009Jens Fiehler MD ABSTRACT INTRODUCTION The objective of our study was to determine whether the combination of hypointense spots ("cerebral microbleeds," CMBs) with a leukoaraiosis is associated with the risk of parenchymal hematoma (PH) after thrombolytic therapy. PATIENTS AND METHODS We analyzed magnetic resonance imaging (MRI) scans acquired within 6 hours after symptom onset from 100 ischemic stroke patients. Multiparametric MRI including a T2*-weighted (T2*w) MRI and fluid attenuated inversion recovery (FLAIR) was performed before thrombolysis in all patients. Initial T2*w imaging was rated by two independent observers for the presence of CMBs smaller than 5 mm. White matter changes were evaluated using an adapted scale of Fazekas and Schmidt. PH was defined in follow-up imaging. FINDINGS A PH was observed in seven per 100 patients. CMBs were detected by observer 1 in 22 and observer 2 in 20 patients. We found a very low sensitivity (0.14) for prediction of PH by the presence of CMBs. We found a concordant increase in the rate of PH when the periventricular hyperintensity in FLAIR was larger than a thin lining. Sensitivity was good-to-perfect (0.86 and 1.00, observers 1 and 2) and specificity was substantial (0.65 and 0.66). Using the combination of a periventricular matter lesion (PVML)>1 and the presence of CMBs did not improve the prediction of PH. DISCUSSION A marked periventricular hyperintensity in FLAIR imaging seems to be associated with a substantially increased risk of PH. A combination of CMBs with leukoaraiosis scores did not appear to be beneficial for prognosis. [source] Thrombolytic Therapy with Tissue Plasminogen Activator for the Treatment of Nonstructural Malfunction of Bileaflet Cardiac Valve ProsthesesARTIFICIAL ORGANS, Issue 5 2002Hideki Teshima Abstract: This study was conducted to determine the effect of thrombolytic therapy with tissue plasminogen activator (t-PA) for nonstructural malfunction of bileaflet cardiac valve prostheses. Twenty-seven patients with bileaflet prosthetic valve malfunction diagnosed by a combination of cineradiography and transthoracic echocardiography were treated with the administration of intravenous t-PA. The treatment resulted in complete success in 55.6% (15 of 27), partial success in 22.2% (6 of 27), and no change in 22.2% (6 of 27). In the complete success and partial success groups, the condition of the patients in 85.7% (18 of 21) of the cases improved within 24 h after the administration of t-PA. Six cases in whom thrombolytic therapy was instituted more than 1 month (ranged from 1 to 38 months, mean 14.7 months) after the diagnosis of prosthetic valve malfunction showed significantly less effectiveness of thrombolytic therapy with t-PA. Only one patient (3.7%) had a major complication (thromboembolism) after t-PA treatment. The results suggest that thrombolytic therapy with t-PA in patients with nonstructural malfunction of bileaflet cardiac valve prostheses is effective with low incidence of complication when the treatment is instituted early after the diagnosis. [source] The economics and practicality of t-PA vs tunnel catheter replacement for hemodialysisHEMODIALYSIS INTERNATIONAL, Issue 1 2005Cairoli O. Kaiser Permanente Introduction:,Thrombolytic therapy is an important treatment modality for thrombosis-related catheter occlusion. Central venous access devices (CAVDs) are essential tools for the administration of many therapeutic modalities, especially for patients requiring lifetime therapy like hemodialysis. There are several reasons to salvage the occluded catheter. Catheter replacement results in an interruption of therapy delivery. This interruption may result in complications such as life-threatening metabolic and physiologic states. In addition, the patient's future access sites for CAVDs may be affected. The data released in the 2001 Annual Report , ESRD Clinical Performance Measures Project (Department of Health and Human Services, December 2001) shows 17% of prevalent patients were dialyzed with a chronic catheter continuously for 90 days or longer. In the pediatric population the data shows that 31% were dialyzed with a chronic catheter. The most common reasons for catheter placement included: no fistula or graft created (42%) and fistula and graft were maturing, not ready to cannulate (17%). Five percent of patients were not candidates for fistula or graft placement as all sites had been exhausted. Methods:,A short study was done in our medical center to evaluate the results of t-PA vs. changing the tunnel catheter. On an average a catheter costs about $400.00. If you add the cost of specialty personnel such as an interventional radiologist, radiology technician, radiology nurse, and the ancillaries such as the room, sutures, gauze, and tape, the total could reach $2000.00 easily. CathfloÔ Activase® costs around $60.00 for a single dose. T-PA was reconstituted by pharmacy personnel in single vials containing 2 mg/2 ml. Now with Cathflo, vials are stored in the renal clinic's refrigerator and when the need arises, the RN reconstitutes the medication. The RN, using established protocols, will instill Cathflo in the catheter following the volume requirements of the various tunnel catheters. After the t-PA is placed, the patient is sent home with instructions to return to their dialysis center the next day (arrangements are made by the RN as needed). In seventeen patients (17) with tunnel catheter malfunctions due to inadequate flow, not related to placement, t-PA was used. Of those 17 patients 2 were unable to use their catheter on their next dialysis treatment date, yielding an 88% success rate. This compares with clinical trials in which there is an 83% success rate with a dwell time of 4 hours, or an 89% rate on patients having a 2 hour dwell time (t-PA was repeated a second time if flow was not successfully restored. Results:,15/17 patients in our retrospective study showed that Cathflo worked successfully in restoring blood flow. Two catheters needed to be exchanged. The cost savings were significant when we compared the average cost of an exchange ($2000) versus using t-PA ($170 including nursing time). Conclusion:,Cathflo is not just safe and practical to use but also cost effective. [source] Thrombolytic therapy for acute ST-segment elevation myocardial infarction: Should it be given to all patients prior to urgent PCI?CLINICAL CARDIOLOGY, Issue 3 2006C. Richard M.D., M.A.C.C. Editor-in-Chief No abstract is available for this article. [source] Thrombolytic therapy in morbidly obese patientsCLINICAL CARDIOLOGY, Issue 6 2004C. Richard Conti M.D., M.A.C.C. Editor-in-Chief No abstract is available for this article. [source] Cardiac hypertrophy and failure: lessons learned from genetically engineered miceACTA PHYSIOLOGICA, Issue 1 2001Y. Takeishi Congestive heart failure is a major and growing public health problem. Because of improved survival of myocardial infarction patients produced by thrombolytic therapy or per-cutaneous revascularization it represents the only form of cardiovascular disease with significantly increased incidence and prevalence. Clinicians view this clinical syndrome as the final common pathway of diverse pathologies such as myocardial infarction and haemodynamic overload. Insights into mechanisms for heart failure historically derived from physiological and biochemical studies which identified compensatory adaptations for the haemodynamic burden associated with the pathological condition including utilization of the Frank Starling mechanism, augmentation of muscle mass, and neurohormonal activation to increase contractility. Therapy has largely been phenomenological and designed to prevent or limit the deleterious effects of these compensatory processes. More recently insights from molecular and cell biology have contributed to a more mechanistic understanding of potential causes of cardiac hypertrophy and failure. Many different analytical approaches have been employed for this purpose. These include the use of conventional animal models which permit serial observation of the onset and progression of heart failure and a sequential analysis of underlying biochemical and molecular events. Neonatal murine cardiomyocytes have been a powerful tool to examine in vitro subcellular mechanisms devoid of the confounding functional effects of multicellular preparations and heterogeneity of cell type. Finally, significant progress has been made by utilizing tissue from human cardiomyopathic hearts explanted at the time of orthotopic transplantation. Each of these methods has significant advantages and disadvantages. Arguably the greatest advance in our understanding of cardiac hypertrophy and failure over the past decade has been the exploitation of genetically engineered mice as biological reagents to study in vivo the effects of alterations in the murine genome. The power of this approach, in principle, derives from the ability to precisely overexpress or ablate a gene of interest and examine the phenotypic consequences in a cardiac specific post-natal manner. In contrast to conventional animal models of human disease which employ some form of environmental stress, genetic engineering involves a signal known molecular perturbation which produces the phenotype. [source] Prosthetic Valve Thrombosis Presenting as an Acute Embolic Myocardial Infarction in a Pregnant Patient: Issues on Anticoagulation Regimens and Thrombolytic TherapyECHOCARDIOGRAPHY, Issue 9 2006Padmini Varadarajan M.D. Mechanical valves are inherently thrombogenic and require meticulous anticoagulation. Pregnancy produces a hypercoagulable state and achieving adequate anticoagulation is difficult. We present a pregnant patient who had a nonobstructive thrombus of mechanical mitral valve causing embolic acute myocardial infarction. Issues surrounding management of anticoagulation and use of thrombolytic therapy during pregnancy are discussed. Education regarding the critical nature of adequate anticoagulation in these patients is important. [source] Abciximab Treatment for Obstructive Prosthetic Aortic and Mitral Valve Thrombosis in the Presence of Large Thrombi, Cardiogenic Shock, and Acute Evolving Embolic StrokeECHOCARDIOGRAPHY, Issue 1 2004Atiar M Rahman M.D., Ph.D. Obstructive thrombosis of left-sided mechanical prosthetic valves is a life-threatening complication. Intravenous thrombolytic therapy is contraindicated due to risk of clot embolization and surgical treatment is often required for hemodynamically unstable patients. We report for the first time the successful use of abciximab in the management of a patient in cardiogenic shock with multiple prosthetic valve obstructive thrombosis and evolving embolic stroke. Serial Doppler echocardiography and cinefluoroscopy demonstrated resolution of thrombi, improvements in transvalvular gradients and improvement in leaflet motion. This observation suggests abciximab should be considered as a therapeutic option in the treatment of obstructed prosthetic heart valves. (ECHOCARDIOGRAPHY, Volume 21, January 2004) [source] Effect of daytime, weekday and year of admission on outcome in acute ischaemic stroke patients treated with thrombolytic therapyEUROPEAN JOURNAL OF NEUROLOGY, Issue 4 2010M. Jauss Background:, Since doubts were raised, if a challenging medical procedure such as acute stroke treatment including thrombolysis with recombinant tissue plasminogen activator (rTPA) is available with identical standard and outcome 24 h and 7 days a week our aim was to examine if acute stroke patients defined by onset-admission time (OAT) of , 3 h were treated differently or had distinct outcome when admitted during off duty hours (day versus night and weekend versus weekdays) and if any differences in treatment or outcome were apparent when comparing patients admitted in the year 2003 with patients admitted in the year 2006. Methods:, We analyzed 2003,2006 data of a prospective registry and grouped patients by time, day, and year of admission. The evaluation was limited to patients that were diagnosed with ischaemic stroke and with OAT of , 3 h. Medical and sociodemographic items, use of thrombolytic treatment, complications during clinical course and place of discharge were obtained. Clinical state on admission and discharge was assessed using the modified Rankin scale. Comparison with chi-square test, t -test and logistic regression was performed. Results:, Patient's characteristics, rate of thrombolysis, and outcome were independent from time or day of admission. Proportion of patients with good clinical state at discharge increased significantly from 2003 to 2006 together with a higher rate of rTPA treatment without increase of intracranial hemorrhage. Proportion of patients discharged in good clinical condition after rTPA treatment increased from 34% to 44%. Conclusions:, Stroke treatment in potential candidates for thrombolytic therapy revealed no impairment on weekend or at night already in 2003. During 4 years, it was possible to increase rate of rTPA treatment from 8.9% to 21.8% without increment of complications or death, confirming that rTPA is safe and can be implemented with full daily and weekly coverage. [source] The response to IV rt-PA in very old stroke patientsEUROPEAN JOURNAL OF NEUROLOGY, Issue 3 2008M. Gómez-Choco The use of rtPA in stroke patients aged >80 years remains controversial and it is debated whether there are sex-based differences in the response to rtPA. We assessed the clinical value of thrombolytic therapy in patients aged >80 years (elderly group) in comparison with a non-elderly group, and evaluated the existence of sex differences in the response to rtPA. All consecutive patients (n = 157) treated with rtPA were prospectively assessed since July 2001, including 49 elderly patients who fulfilled the National Institute of Neurological Disorders and Stroke (NINDS) criteria. Changes of the National Institute of Health Stroke Scale (NIHSS) score at 1 h, 24 h, and 7 days after rtPA administration, favourable outcome at day 90 [(modified Rankin Scale) mRS 0,1, or 2 if mRS = 2 before the stroke], symptomatic bleedings, and death rates were compared between elderly and non-elderly patients. Using logistic regression, baseline NIHSS score [odds ratio (OR) 0.59, 95% confidence interval (CI) 0.41,0.84] was an independent predictor of favourable outcome, but not sex (OR 0.72, 95% CI 0.33,1.56), or age >80 years (OR 0.74, 95% CI 0.32,1.70). The rates of clinical improvement, mortality, or symptomatic CNS bleeding were also unrelated to age and sex. In conclusion, the response to IV rtPA is not impaired in elderly stroke patients and male and female are equally responsive. [source] Electrocardiographic ST-segment Elevation: Correct Identification of Acute Myocardial Infarction (AMI) and Non-AMI Syndromes by Emergency PhysiciansACADEMIC EMERGENCY MEDICINE, Issue 4 2001William J. Brady MD Abstract. Objective: To determine the emergency physician's (EP's) ability to identify the cause of ST-segment elevation (STE) in a hypothetical chest pain patient. Methods: Eleven electrocardiograms (ECGs) with STE were given to EPs; the patient in each instance was a 45-year-old male with a medical history of hypertension and diabetes mellitus with the chief complaint of chest pain. The EP was asked to determine the cause of the STE and, if due to acute myocardial infarction (AMI), to decide whether thrombolytic therapy (TT) would be administered (the patient had no contraindication to such treatment). Rates of TT administration were determined; appropriate TT administration was defined as that occurring in an AMI patient, while inappropriate TT administration was defined as that in the non-AMI patient. Results: Four hundred fifty-eight EPs completed the questionnaire; levels of medical experience included the following: postgraduate year 2-3, 193 (42%); and attending, 265 (58%). The overall rate of correct interpretation of the study ECGs was 94.9% (4,782 correct interpretations out of 5,038 instances). Acute myocardial infarction with typical STE, ventricular paced rhythm, and right bundle branch block were never misinterpreted. The remaining conditions were misinterpreted with rates ranging between 9% (left bundle branch block, LBBB) and 72% (left ventricular aneurysm, LVA). The overall rate of appropriate thrombolytic agent administration was 83% (1,525 correct administrations out of 1,832 indicated administrations). The leading diagnosis for which thrombolytic agent was given inappropriately was LVA (28%), followed by benign early repolarization (23%), pericarditis (21%), and LBBB without electrocardiographic AMI (5%). Thrombolytic agent was appropriately given in all cases of AMI except when associated with atypical STE, where it was inappropriately withheld 67% of the time. Conclusions: In this survey, EPs were asked whether they would give TT based on limited information (ECG). Certain syndromes with STE were frequently misdiagnosed. Emergency physician electrocardiographic education must focus on the proper identification of these syndromes so that TT may be appropriately utilized. [source] The hospital costs of care for stroke in nine European countriesHEALTH ECONOMICS, Issue S1 2008David Epstein Abstract Stroke is a major cause of mortality and morbidity, but the reasons for differences in costs of care within and between countries are not well understood. The HealthBASKET project used a vignette methodology to compare the mean costs and prices of hospital care across providers in nine European Union countries. Data on resource use, unit costs and prices of care for female stroke patients without co-morbidity were collected from a sample of 50 hospitals. Mean costs for each provider were analysed using multiple regression. Sensitivity analysis explored the effects on cost of using official exchange rates, purchasing power parity (PPP) and proportion of national income per capita. The mean cost of a hospital episode per patient for stroke at PPP was ,3813 (standard error 227) with an additional day in hospital typically associated with 6.9% (95% CI: 4,9%) higher costs and thrombolysis associated with 41% higher costs (10,73%). After adjusting for explanatory factors, about 76% of the variation in cost could be attributed to between-country differences, and the extent of this variation was sensitive to the method of currency conversion. There was considerable variation in the care pathways within and between countries, including differences in the availability of stroke units and access to rehabilitative services, but only the length of stay and use of thrombolytic therapy were significantly associated with higher cost. The vignette methodology appears feasible, but further research needs to consider access to healthcare over a longer follow up and to include both costs and outcomes. Copyright © 2008 John Wiley & Sons, Ltd. [source] Thrombelastometry-guided thrombolytic therapy in massive pulmonary artery embolismACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 9 2010A. PLOPPA We report a case of a patient who suffered a massive pulmonary embolism with cardiac arrest on post-operative day 4 after a Whipple operation. Despite thrombolytic therapy with the recommended maximal bolus of 50 mg recombinant tissue type plasminogen activator (rt-PA), thrombelastometry showed no signs of fibrinolysis and cardiogenic shock persisted, after only a transient hemodynamic improvement. Not until a repeat bolus of 25 mg rt-PA and an infusion of 50 mg/h did thrombelastometry demonstrate complete fibrinolysis. Although only residual emboli were seen on computed tomography, the patient died secondary to refractory right heart failure. This demonstrates that the standard dosing of thrombolytics may fail in a subgroup of patients, and suggests that thrombelastometry may be useful for early dose adjustment when standard dosing regimens fail. [source] The Effect of Dementia on Outcomes and Process of Care for Medicare Beneficiaries Admitted with Acute Myocardial InfarctionJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2004Frank A. Sloan PhD Objectives: To determine differences in mortality after admission for acute myocardial infarction (AMI) and in use of noninvasive and invasive treatments for AMI between patients with and without dementia. Design: Retrospective chart review. Setting: Cooperative Cardiovascular Project. Patients: Medicare patients admitted for AMI (N=129,092) in 1994 and 1995. Measurements: Dementia noted on medical chart as history of dementia, Alzheimer's disease, chronic confusion, or senility. Outcome measures included mortality at 30 days and 1-year postadmission; use of aspirin, beta-blocker, angiotensin-converting enzyme (ACE) inhibitor, thrombolytic therapy, cardiac catheterization, coronary angioplasty, and cardiac bypass surgery compared by dementia status. Results: Dementia was associated with higher mortality at 30 days (relative risk (RR)=1.16, 95% confidence interval (CI)=1.09,1.22) and at 1-year postadmission (RR=1.18, 95% CI=1.13,1.23). There were few to no differences in the use of aspirin and beta-blockers between patients with and without a history of dementia. Patients with a history of dementia were less likely to receive ACE inhibitors during the stay (RR=0.89, 95% CI=0.86,0.93) or at discharge (RR=0.90, 95% CI=0.86,0.95), thrombolytic therapy (RR=0.82, 95% CI=0.74,0.90), catheterization (RR=0.51, 95% CI=0.47,0.55), coronary angioplasty (RR=0.58, 95% CI=0.51,0.66), and cardiac bypass surgery (RR=0.41, 95% CI=0.33,0.50) than patients without a history of dementia. Conclusion: The results imply that the presence of dementia had a major effect on mortality and care patterns for this condition. [source] A Time-to-Treatment Analysis in the Medicine Versus Angiography in Thrombolytic Exclusion (MATE) TrialJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 4 2001F.A.C.C., F.A.C.P, M.P.H., PETER A. MCCULLOUGH M.D. Patients with acute coronary syndromes who are considered ineligible for thrombolytic therapy are at high risk of recurrent ischemia and death. This trial randomized 201 patients to triage angiography in the first 24 hours of hospital admission versus conventional medical care. Of the 165 patients who underwent angiography that was either protocol-driven or on the basis of physician preference, those who underwent angiography within 6 hours of symptom onset had a reduction in early and late adverse events. The rates of in-hospital recurrent ischemia were 15.4%, 15.4%, 17.5%, 32.4%, and 38.5%, respectively (P = 0.01 for trend), and rates of cumulative recurrent myocardial infarction or death were 0%, 12.8%, 10.0%, 11.8%, and 7.7%, respectively (P = 0.48 for trend) for patients who underwent angiography at 0,6, 6,12, 12,24, 24,48, and over 48 hours, respectively from symptom onset. Future trials of invasive versus conservative therapy should focus on performing angiography within 6 hours of symptom onset. [source] Signaling, delivery and age as emerging issues in the benefit/risk ratio outcome of tPA For treatment of CNS ischemic disordersJOURNAL OF NEUROCHEMISTRY, Issue 2 2010William M. Armstead J. Neurochem. (2010) 113, 303,312. Abstract Stroke is a leading cause of morbidity and mortality. While tissue-type plasminogen activator (tPA) remains the only FDA-approved treatment for ischemic stroke, clinical use of tPA has been constrained to roughly 3% of eligible patients because of the danger of intracranial hemorrhage and a narrow 3 h time window for safe administration. Basic science studies indicate that tPA enhances excitotoxic neuronal cell death. In this review, the beneficial and deleterious effects of tPA in ischemic brain are discussed along with emphasis on development of new approaches toward treatment of patients with acute ischemic stroke. In particular, roles of tPA-induced signaling and a novel delivery system for tPA administration based on tPA coupling to carrier red blood cells will be considered as therapeutic modalities for increasing tPA benefit/risk ratio. The concept of the neurovascular unit will be discussed in the context of dynamic relationships between tPA-induced changes in cerebral hemodynamics and histopathologic outcome of CNS ischemia. Additionally, the role of age will be considered since thrombolytic therapy is being increasingly used in the pediatric population, but there are few basic science studies of CNS injury in pediatric animals. [source] Combination of T2*W and FLAIR Abnormalities for the Prediction of Parenchymal Hematoma Following Thrombolytic Therapy in 100 Stroke PatientsJOURNAL OF NEUROIMAGING, Issue 4 2009Jens Fiehler MD ABSTRACT INTRODUCTION The objective of our study was to determine whether the combination of hypointense spots ("cerebral microbleeds," CMBs) with a leukoaraiosis is associated with the risk of parenchymal hematoma (PH) after thrombolytic therapy. PATIENTS AND METHODS We analyzed magnetic resonance imaging (MRI) scans acquired within 6 hours after symptom onset from 100 ischemic stroke patients. Multiparametric MRI including a T2*-weighted (T2*w) MRI and fluid attenuated inversion recovery (FLAIR) was performed before thrombolysis in all patients. Initial T2*w imaging was rated by two independent observers for the presence of CMBs smaller than 5 mm. White matter changes were evaluated using an adapted scale of Fazekas and Schmidt. PH was defined in follow-up imaging. FINDINGS A PH was observed in seven per 100 patients. CMBs were detected by observer 1 in 22 and observer 2 in 20 patients. We found a very low sensitivity (0.14) for prediction of PH by the presence of CMBs. We found a concordant increase in the rate of PH when the periventricular hyperintensity in FLAIR was larger than a thin lining. Sensitivity was good-to-perfect (0.86 and 1.00, observers 1 and 2) and specificity was substantial (0.65 and 0.66). Using the combination of a periventricular matter lesion (PVML)>1 and the presence of CMBs did not improve the prediction of PH. DISCUSSION A marked periventricular hyperintensity in FLAIR imaging seems to be associated with a substantially increased risk of PH. A combination of CMBs with leukoaraiosis scores did not appear to be beneficial for prognosis. [source] Aortic Dissection Presenting as an Acute Ischemic Stroke for ThrombolysisJOURNAL OF NEUROIMAGING, Issue 3 2005Ken Uchino MD ABSTRACT Thrombolysis for the treatment of acute ischemic stroke requires careful selection of patients. The authors report a case of aortic dissection presenting with acute ischemic stroke for which emergent ultrasonographic evaluation was helpful in the diagnosis and subsequent treatment. The patient presented with acute middle cerebral artery ischemic stroke symptoms and complained of bilateral ear and chest pain. Chest x-ray, cardiac enzymes, and transthoracic echocardiogram were normal, and she was considered for thrombolytic therapy. Carotid ultrasound revealed right common carotid occlusion that led to the diagnosis of aortic dissection, confirmed by chest computed tomography. An experienced sonographer with skills to perform rapid intra- and extracranial examinations may help to change the treatment plan for acute stroke patients. [source] Intravenous administration of melatonin reduces the intracerebral cellular inflammatory response following transient focal cerebral ischemia in ratsJOURNAL OF PINEAL RESEARCH, Issue 3 2007Ming-Yang Lee Abstract:, We have previously shown that exogenous melatonin improves the preservation of the blood,brain barrier (BBB) and neurovascular unit following cerebral ischemia,reperfusion. Recent evidence indicates that postischemic microglial activation exaggerates the damage to the BBB. Herein, we explored whether melatonin mitigates the cellular inflammatory response after transient focal cerebral ischemia for 90 min in rats. Melatonin (5 mg/kg) or vehicle was given intravenously at reperfusion onset. Immunohistochemistry and flow cytometric analysis were used to evaluate the cellular inflammatory response at 48 hr after reperfusion. Relative to controls, melatonin-treated animals did not have significantly changed systemic cellular inflammatory responses in the bloodstream (P > 0.05). Melatonin, however, significantly decreased the cellular inflammatory response by 41% (P < 0.001) in the ischemic hemisphere. Specifically, melatonin effectively decreased the extent of neutrophil emigration (Ly6G-positive/CD45-positive) and macrophage/activated microglial infiltration (CD11b-positive/CD45-positive) by 51% (P < 0.01) and 66% (P < 0.01), respectively, but did not significantly alter the population composition of T lymphocyte (CD3-positive/CD45-positive; P > 0.05). This melatonin-mediated decrease in the cellular inflammatory response was accompanied by both reduced brain infarction and improved neurobehavioral outcome by 43% (P < 0.001) and 50% (P < 0.001), respectively. Thus, intravenous administration of melatonin upon reperfusion effectively decreased the emigration of circulatory neutrophils and macrophages/monocytes into the injured brain and inhibited focal microglial activation following cerebral ischemia,reperfusion. The finding demonstrates melatonin's inhibitory ability against the cellular inflammatory response after cerebral ischemia,reperfusion, and further supports its pleuripotent neuroprotective actions suited either as a monotherapy or an add-on to the thrombolytic therapy for ischemic stroke patients. [source] Carboxypeptidase U (TAFIa) activity is induced in vivo in ischemic stroke patients receiving thrombolytic therapyJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 1 2008J. L. WILLEMSE No abstract is available for this article. [source] ,2 -Antiplasmin plays a significant role in acute pulmonary embolismJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 8 2003H. Matsuno Summary., The importance of pulmonary embolism (PE) due to venous thrombosis is recognized in the treatment of vascular diseases. We have investigated the physiological effects of plasmin generation in experimental acute PE using mice deficient in plasminogen (Plg,/,) or ,2 -antiplasmin (,2 -AP,/,). PE was induced by continuous induction of venous thrombus in the left jugular vein by endothelial injury due to photochemical reaction. The mortality of wild-type mice was 68.8% at 2 h after the initiation of venous thrombosis and it was significantly reduced in ,2 -AP,/, mice (41.7%). In contrast, Plg,/, mice did not survive. Histological evidence of thromboembolism in the lung was obtained in all mice. However, whereas a strict thromboembolism was observed in Plg,/, mice, only a few thrombi were detected in the lungs of ,2 -AP,/, mice. Plasma fibrinogen levels measured in mice were not different. When ,2 -AP was infused in ,2 -AP,/, mice, the mortality was indistinguishable from wild-type mice. Tissue-type plasminogen activator (tPA) did not reduce the mortality due to acute PE in wild-type mice. However, in ,2 -AP,/, mice, tPA (0.52 mg kg,1) significantly decreased the mortality compared with that of ,2 -AP,/, mice without tPA. The bleeding time was not significantly prolonged in either type of mice treated with tPA. The lack of plasminogen increases the mortality due to acute PE while a lack of ,2 -AP decreases the mortality rate, which can be further reduced by tPA administration. Therefore, the combination of inhibition of ,2 -AP with thrombolytic therapy could be beneficial in the treatment of acute PE. [source] Evaluation of Emergency Air Evacuation of Critically Ill Patients from Cruise ShipsJOURNAL OF TRAVEL MEDICINE, Issue 6 2001Laurence D. Prina Background: The study objectives were to assess the ship physician's diagnostic accuracy in making the decision to air evacuate critically ill patients from cruise ships, to determine the outcome of these patients, and the overall benefit of air evacuation. Methods: From October 1999 to May 2000, we performed a prospective study of critically ill patients coming from cruise ships in the Caribbean and transported to our institution by air ambulance. Demographics, initial diagnosis, and treatment on board were collected by the triage officer at the time of the cruise physician's first call. In route complications and flight team composition were obtained from the air ambulance monitoring log. Patients were followed-up in the hospital for complications, outcome, and final diagnosis. Results: A consecutive series of 104 patients were considered for analysis. There were 65 men and 39 women (mean age: 68.7 years). Cruise physician's diagnosis was correct in more than 90% of the cases. Internal medicine and surgical conditions represented 80.8% and 19.2% of the cases respectively, falling mainly into three categories: cardiac (34.6%), neurological (20.2%), and digestive (14%). Two cardiac arrests and 1 ventricular fibrillation were successfully resuscitated and 5 of 15 myocardial infarctions received thrombolytic therapy on board. Air transfers were warranted in 96.1% of the cases and physician presence in the flight was considered appropriate in 97.6%. In route complications and mortality rate were 5.8% and 2.9% respectively, related to serious cardiac events. Among the 98 hospitalized patients, 10 patients developed new complications and 5 died. The overall mortality rate was 7.7%. Conclusion: The cruise industry appears off to a good start in the medical treatment of passengers needing air evacuation to a land based medical facility. There is room for improvement and adoption of American College of Emergency Physicians (ACEP) and International Council of Cruise Lines (ICCL) Health Care Guidelines are meaningful first steps. Analysis of Caribbean medical facilities and implementation of active telemedicine conferencing represent alternatives to air evacuation that need to be studied. [source] Review article: portal vein thrombosis , new insights into aetiology and managementALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2005G. J. M. Webster Summary Portal vein thrombosis may occur in the presence or absence of underlying liver disease, and a combination of local and systemic factors are increasingly recognized to be important in its development. Acute and chronic portal vein thrombosis have traditionally been considered separately, although a clear clinical distinction may be difficult. Gastrooesophageal varices are an important complication of portal vein thrombosis, but they follow a different natural history to those with portal hypertension related to cirrhosis. Consensus on optimal treatment continues to be hampered by a lack of randomized trials, but recent studies demonstrate the efficacy of thrombolytic therapy in acute thrombosis, and the apparent safety and benefit of anticoagulation in patients with chronic portal vein thrombosis. [source] Acute Stroke Care at Rural Hospitals in Idaho: Challenges in Expediting Stroke CareTHE JOURNAL OF RURAL HEALTH, Issue 1 2006James G. Gebhardt MD ABSTRACT:,Context: Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. Purpose: To provide a snapshot of stroke care at rural hospitals in Idaho and to investigate the experiences of these hospitals in expediting stroke care. Methods: Using a standard questionnaire, a telephone survey of hospital staff at 21 rural hospitals in Idaho was performed. The survey focused on acute stroke care practices and strategies to expedite stroke care. Findings: The median number of stroke patients treated per year was 23.3. Patient delays were reported by 77.8% of hospitals, transport delays by 66.7%, in-hospital delays by 61.1%, equipment delays by 22.2%, and ancillary services delays by 61.1%. Approximately 67% of hospitals had implemented a clinical pathway for stroke and 80.0% had provided staff with stroke-specific training. No hospitals surveyed had a designated stroke team, and only 33.3% reported engaging in quality improvement efforts to expedite stroke care. Thrombolytics (tPA) were available and indicated for stroke at 55.6% of the hospitals surveyed. Conclusions: Rural hospitals in Idaho face many difficult challenges as they endeavor to meet the 3-hour deadline for thrombolytic therapy, including limited resources and experience in acute stroke care, and many different types of prehospital and in-hospital delays. [source] Early magnetic resonance imaging findings in patients receiving tissue plasminogen activator predict outcome: Insights into the pathophysiology of acute stroke in the thrombolysis era,ANNALS OF NEUROLOGY, Issue 1 2004Julio A. Chalela MD We measured ischemic brain changes with diffusion and perfusion MRI in 42 ischemic stroke patients before and 2 hours (range approximately 1.5 to 4.5 hours) after standard intravenous tissue plasminogen activator (tPA) therapy. The median time from stroke onset to tPA was 131 minutes. Clinical and MRI variables (change in perfusion and/or diffusion weighted lesion volume) were compared between those with excellent outcome defined as 3-month modified Rankin score (mRS) of 0 to 1 and those with incomplete recovery (mRS >1). In multivariate logististic regression analysis, the most powerful independent predictor for excellent outcome was improved brain perfusion: hypoperfusion volume on mean transit time (MTT) map decrease >30% from baseline to 2-hour post tPA scan (p=0.009; odds ratio [95% confidence interval], 20.7 [2.1-203.9]). Except for age < 70 years, no other baseline clinical or imaging variable was an independent predictor of outcome. We propose MTT lesion volume decrease more than 30% 2 hours after tPA as an early marker of long-term clinical benefit of thrombolytic therapy. [source] Thrombolytic Therapy with Tissue Plasminogen Activator for the Treatment of Nonstructural Malfunction of Bileaflet Cardiac Valve ProsthesesARTIFICIAL ORGANS, Issue 5 2002Hideki Teshima Abstract: This study was conducted to determine the effect of thrombolytic therapy with tissue plasminogen activator (t-PA) for nonstructural malfunction of bileaflet cardiac valve prostheses. Twenty-seven patients with bileaflet prosthetic valve malfunction diagnosed by a combination of cineradiography and transthoracic echocardiography were treated with the administration of intravenous t-PA. The treatment resulted in complete success in 55.6% (15 of 27), partial success in 22.2% (6 of 27), and no change in 22.2% (6 of 27). In the complete success and partial success groups, the condition of the patients in 85.7% (18 of 21) of the cases improved within 24 h after the administration of t-PA. Six cases in whom thrombolytic therapy was instituted more than 1 month (ranged from 1 to 38 months, mean 14.7 months) after the diagnosis of prosthetic valve malfunction showed significantly less effectiveness of thrombolytic therapy with t-PA. Only one patient (3.7%) had a major complication (thromboembolism) after t-PA treatment. The results suggest that thrombolytic therapy with t-PA in patients with nonstructural malfunction of bileaflet cardiac valve prostheses is effective with low incidence of complication when the treatment is instituted early after the diagnosis. [source] Percutaneous rheolytic thrombectomy for large pulmonary embolism: A promising treatment optionCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 1 2007Manish S. Chauhan MD Abstract Background: Pulmonary embolism (PE) is a common cardiovascular disease with significant mortality. Some patients with large PE are not eligible for current treatment options such as thrombolysis or surgical embolectomy. We report our experience of percutaneous rheolytic thrombectomy (PRT) using the AngioJet system combined with adjunctive local thrombolytic therapy and inferior vena cava (IVC) filter placement to treat massive or submassive PE in patients ineligible for current treatment options. Methods and Results: Of the 14 consecutive patients ineligible for thrombolysis or embolectomy treated with PRT, 10 patients had massive PE (6 patients were hypotensive and 4 patients had intractable hypoxemia) and 4 patients had submassive PE. Adjunctive local thrombolysis was performed in 5 patients. An IVC filter was placed in 11 patients. Angiographic success based on Miller score was achieved in 13 patients (92.9%). Procedure success was obtained in 12 patients (85.7%). Procedural mortality occurred in one patient who presented in cardiogenic shock (7.1%) and non-fatal hemoptysis occurred in 1 patient (7.1%). Total in-hospital mortality occurred in 3 patients (21.4%). On a mean follow-up of 9 months, all 11 survivors had noted significant improvement in symptoms without recurrence. Conclusions: Percutaneous rheolytic thrombectomy using the AngioJet may be a treatment option for patients with massive or submassive PE who may not be eligible for thrombolytic therapy or surgical embolectomy. © 2007 Wiley-Liss, Inc. [source] Treatment of ischemic stroke complicating cardiac catheterization with systemic thrombolytic therapyCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 3 2005Rod Serry MD Abstract Ischemic stroke is a rare but serious complication of cardiac catheterization. We report a case in which systemic thrombolytic therapy was successfully utilized in treating a patient with a cerebellar stroke, leading to obtundation during elective cardiac catheterization. Underlying bilateral vertebrobasilar disease with thrombotic embolization to the basilar artery was postulated to be the pathophysiological basis for the stroke and subsequent success of thrombolytic treatment in this patient. As the consequences of this rare complication are severe, systemic thrombolytic therapy should be considered for patients suffering an acute ischemic stroke during cardiac catheterization or percutaneous coronary intervention. © 2005 Wiley-Liss, Inc. [source] Rescue angioplasty after failed intra-arterial thrombolysis in acute middle cerebral artery stroke: A case reportCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 3 2004Pinky Agarwal MD Abstract Intra-arterial thrombolysis is increasingly being used in the treatment of acute ischemic stroke with a failure rate of recanalization as high as 66%. We describe a case of acute ischemic stroke secondary to occlusion of the middle cerebral artery that failed intra-arterial thrombolytic therapy but responded to rescue balloon angioplasty. Catheter Cardiovasc Interv 2004;62:396,400. © 2004 Wiley-Liss, Inc. [source] | |||||||||||||||||||||||||||||||