[Intravenous thrombolytic treatment in acute ischemic stroke: initial results in the Complejo Hospitalario Universitario de Albacete]

AIM

To analyze the safety profile and clinical outcome of patients with acute cerebral ischemia who received open treatment with tissue plasminogen activator (rt-PA) in a hospital without previous experience.

PATIENTS AND METHODS

This prospective and observational study were realized from January 2004 to January 2007. A total of 1,704 consecutive patients with ischemic stroke were attended. 72 of them (4.2%) were treated with rt-PA within 3 hours from the symptoms onset. We analyzed age, vascular risk factors, initial and 24 hours neurological state by the National Institute of Health Stroke Scale (NIHSS), incidence of intracerebral hemorrhage and mortality and independence at 90 days. Patients were treated by neurologist and stroke monitoring was performed in the emergency area.

RESULTS

Baseline median NIHSS was 16. At 24 hours, 53% of patients had improved = or > 4 points in the NIHSS and 33% showed = or > 10 points improvement or total recovery. The median time from stroke onset to rt-PA treatment was 160 minutes. Symptomatic intracerebral hemorrhage occurred in two patients (2.7%). Overall mortality at 90 days was 9.7%, but was due to hemorrhagic brain complications only in one case. At three months, 51% of patients were independent according to the modified Rankin scale.

CONCLUSIONS

Treatment of acute ischemic stroke within three hours with intravenous rt-PA is safe and is associated with favorable outcome when it is applied by neurologists following approved protocols even in hospitals without previous experience.

[Benefit of the implementation of on-call neurology physicians in a general hospital]

INTRODUCTION

Most Spanish hospitals have no oncall neurologist (OCN) for emergency patients. This study was designed to highlight the benefits in patient management when an OCN system is implemented.

METHODS

We conducted a prospective study in the University Hospital of Albacete during the first year of OCN implementation (2004). We also compared stroke patients admissions from emergency department (ED) in 2004 with respect to 2003.

FINDINGS

OCN attended 2,745 patients (7.6 per day), 73.1% of these calls coming from ED between 3 PM and 10 PM. Acute stroke was the most frequent consultation. A total of 118 calls were made to determine the need for thrombolytic therapy and 323 emergency neurosonologic examinations were performed by the OCN during the duty. A total of 44.8% of the attended patients were admitted and 30.1% were referred to outpatient clinics. Our hospital had a significant decrease (12.3%) in stroke patients admissions over 2004 compared with 2003 despite an actual increase of total admissions in the neurological ward. The mean hospital stay of stroke patients was shorter in the neurology department than in the internal medicine one.

CONCLUSIONS

OCN improves the quality of attention to the neurological patient, reduces the number of unnecessary hospital admissions and increases the status of the neurological department. Implementation of on-call neurology physicians for 24 hours is necessary in all those sites that provide care to emergency patients and have neurology services.

[Thrombolytic treatment in stroke in patients with intracardiac thrombus: presentation of one case]

Intravenous tissue plasminogen activator (t-PA) is a recent proven effective treatment for acute ischemic stroke patients. However, the use of t-PA in some special settings is controversial. One of these is the presence of a cardiac thrombus, given that the use of t-PA could potentially accelerate breakup of the thrombus and cause additional embolisms. The authors describe the case of a cardiological patient with a cardiac thrombus who was given IV t-PA for acute stroke treatment without complications. We discuss the necessity or not of a 24 hours delay before anticoagulants administration in these special patients.

[Unusual bulbar infarct and occlusion of the vertebral artery]

INTRODUCTION

Isolated bulbar infarcts are infrequent. Because of the vascular anatomy the lateral region is the most commonly affected, and in this clinical disorder the various signs and symptoms are grouped together as the so-called Wallenberg's syndrome. Since the introduction of magnetic resonance (MR) it has been possible to correlate the extent and site of the laterobulbar area involved with the most probable vascular topography and etiopathogenesis.

CLINICAL CASE

We describe the case of a 69 year old female patient with all the symptoms of Wallenberg's syndrome and two potential causes of stroke (emboliogenic cardiopathy and atherothrombotic vascular occlusion), in whom MR showed the presence of an isolated bulbar lesion of unusual morphology which had previously been described as being of thrombotic origin.

CONCLUSIONS

In spite of the small area of the brain involved, in laterobulbar infarcts MR permits definition of different topographic patterns of ischemic lesions. Some of these patterns have been correlated with the specific aetiology of an infarct. Therefore there is twice the importance of cerebral MR in cases of suspicion of lateral bulbar ischaemia, since it not only assists in diagnosis and its clinicopathological correlations, but also, as in our case, helps to have a clinical suspicion of the most likely etiopathogenesis of the stroke.