Evolución clínica tras el tratamiento trombolítico intravenoso con activador del plasminógeno tisular recombinante en el ictus isquémico. Factores pronósticos

Abstract

Introduction: Intravenous(IV) thrombolysis with recombinant tisular plasminogen activator (rt-PA) is the only approved treatment for the acute ischemic stroke. The cinical evolution after this treatment could be variable. Patients(Method: Theaim of this study was to analyze the different clinical evolutions in patients 48 hours after IV thrombolysis trying to identify prognostic factors. We took four groups: patients remaining stable after treatment, without clinical changes or changes less than 4 points NIHSS (group I); patients with clinical improvement, or decrease >- 4 pints NIHSS (group 2); patients with clinical worsening, or increase >- 4 points in the NIHSS (group 3); and patients with worsening after initial improvement, or initial decrease >- 4 points NIHSS and posterior worsening>- 4 points NIHSS. We analyzed previous cerebrovascular risk factors (smoking, artrial hypertension, hyperlipemia cardiopathy…): admission parmeters (glycemia, blood pressure…); neuroimaging (basa CT, angio-CT and perfusion-CT) at admission and worsening: and clinical and functional status (NIHSS, Bl and mRS). Results/Conclusions: Beween January 2000- october 2005, 136 patients fulfilled crieria to IV thrombolysis (57 females, 79 males): 11,8% (group 1), 67% (group 2), 13% (group 3) and 8% (group 4). Of the patients with initial improvement, 10,8% had posterior worsening. The mechanism of stroke (TOAST criteria) was: 18% large vessel, 3% small vessel, 48% cardioembolic, 15% another actiology and 19% undetermined. Female sex, peripheral vascular disease and no hyperlipemia were associated at group 3. Tobacco and no valvulopathy were associated at group 2. No occlusion in the admission angio-TC and penumbra > core in the admission perfusion-CT were associated with better prognostic. Nevertheless 25% patients with penumbra> core had worsening after initial improvement. Persistent oclusion in angio-TC was associated with group 3. Causes of worsening were symptomatic intracranial haemorrhage (sICH) (mortality RR igual 30), intracranial oedema (mortality RR igual 29) and reoclusion/new (mortality RR igual 4). Patients with sICH had a mortality RR igual 9,6.In comparison to group 2, group 3 patients had a mortality RR igual 43,6, and group 4 had a mortality RR igual 14,7.