Tratamiento trombolítico con tPA en el ictus isquémico

Abstract

Background and purpose. Treatment of acute ischemic stroke within three hours with intravenous tissue-type plasminogen activator (tPA) was approved by the European Drug Agency in 2002. We present the development of an internal organization system that has permitted thrombolytic treatment in our center, without previous experience. We also analyze the influence of individual and collective acquired experience and of the activation of an out-of-hospital stroke code (OSC) on the delays to onset of treatment, number of patients treated and outcome. We analyzed the treatment procedures, safety and efficacy of intravenous tPA in in-hospital strokes (IHSs) compared with out-of-hospital strokes (OHSs). Material and method. Development of the thrombolysis educational program, of the internal organization system, and combined care protocols among the participating services. Prospective registry of patients with ischemic stroke treated with intravenous tPA within the period 1/2004 – 12/2007. We collected demographic data, risk factors for cerebrovascular disease, glycemia and systolic blood pressure previous to treatment, stroke assessment scales score (NIHSS), antiaggregant or anticoagulant therapy previous to treatment, stroke etiology, stroke location, activation of OSC, time to treatment, symptomatic hemorrhagic transformation, three months mortality and functional independency at three months and one year. Comparison of results between patients treated during the four years of study, patients treated by experienced or inexperienced neurologist, patients treated with or without activation of OSC and between IHSs and OHSs. Results. A total of 140 patients were treated (mean age: 67.1 + 14.6 years), 48.5% men and 51.4% women. Mean NIHSS pretreatment: 14 (4-26). Door-toneedle time was 79 + 21 minutes in 2004, 64 + 22 minutes in 2005, 63 + 26 in 2006 and 56 + 24 in 2007 (p = 0.01). Experienced neurologist started thrombolysis sooner (door-to-needle time: 55 + 19 minutes vs 70 + 23, p= 0.004). Activation of the OSC reduced door-to-needle time (52 + 20 minutes vs 61 + 20; p = 0.0216) and door-to-computed tomography scan time (21 + 10 minutes vs 31 + 17; p = 0.0027). Among 140 treated, 20 were IHSs. In-hospital delays were significantly longer in IHSs for door-to-computed tomography scan time (42.2 + 23.2 vs 26.6 + 18.3 minutes, p = 0.0019), door-to-needle time (88.2 + 29.7 vs 58 + 21.2 minutes, p < 0.0001) and computed tomography-totreatment time (54.1 + 23.2 vs 43.1 + 26.1 minutes, p = 0.02). No differences were observed in safety or efficacy. Conclusions. Individual and collective acquired experience and the activation of an OSC can lower in-hospital delays. This contributes to increase the number of patients eligible for thrombolysis. In-hospital procedures for thrombolysis proceed more slowly in IHSs than in OHSs. Thrombolytic therapy is safe and effective even when it is applied by inexperienced neurologist if strict guidelines are followed.