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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com

WORLD EMERGENCY MEDICINE SOCIETIES

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sábado, 30 de abril de 2011

Una nueva estrategia para la apoplejía isquémica

Received December 1, 2010
Accepted January 20, 2011 Stroke. 2011Published online before print April 28, 2011, doi: 10.1161/STROKEAHA.110.610147

A New Therapeutic Strategy for Acute Ischemic Stroke

Sequential Combined Intravenous tPA-Tenecteplase for Proximal Middle Cerebral Artery Occlusion Based on First Results in 13 Consecutive Patients
Didier Smadja, MD; Nicolas Chausson, MD; Julien Joux, MD; Martine Saint-Vil, MD; Aïssatou Signaté, MD; Mireille Edimonana, MD; Séverine Jeannin, MD; Blaise Bartoli, MD; Mathieu Aveillan, MD; Philippe Cabre, MD; Stéphane Olindo, MD

From the Department of Neurology and Stroke Center (D.S., N.C., J.J., M.S.V., A.S., M.E., S.J., P.C., S.O.) and Department of Neuroradiology and Interventional Radiology (B.B., M.A.), University Hospital of Fort-de-France, Jeune Equipe 2503 (D.S., P.C., S.O.), Antilles-Guyane University, Martinique, French West Indies.

Correspondence to Didier Smadja, MD, Department of Neurology and Stroke Center, University Hospital of Fort-de-France, BP 632, 97261 Fort-de-France Cedex, Martinique, French West Indies. E-mail didier.smadja@chu-fortdefrance.fr -->
Abstract
Background and Purpose—Intravenous tissue-type plasminogen activator (IV tPA) frequently fails to recanalize proximal middle cerebral artery (MCA-M1) obstructions, preventing favorable outcomes. Only neurointerventional procedures prevail in these cases, but well-equipped centers remain scarce. A new therapeutic strategy consisting of a second IV thrombolysis with low-dose tenecteplase was applied.
Methods—Consecutive patients with an MCA-M1 occlusion that did not reopen at the end of IV tPA perfusion received IV tenecteplase (0.1 mg/kg). Partial or complete thrombolysis in myocardial infarction recanalization (Thrombolysis In Myocardial Infarction grade 2/3) and intracerebral hemorrhage were assessed by magnetic resonance imaging {approx}24 hours later. Clinical outcomes at 3 months were evaluated with the modified Rankin score.
Results—Among 40 patients with MCA-M1 occlusions who received IV tPA, 13 were treated according to the protocol of sequential combined IV thrombolytics. Baseline National Institutes of Health Stroke Scale score was 15. At a mean of 16.8 hours after IV thrombolysis, the recanalization rate was 100% (2 with Thrombolysis In Myocardial Infarction grade 2, 11 with Thrombolysis In Myocardial Infarction grade 3). Intracerebral hemorrhage occurred in 4 of 13 (31%) patients, with no symptomatic hemorrhage. Good clinical outcomes (modified Rankin score=0/1) were achieved in 9 of 13 (69%) patients. Functional outcomes were very similar to those of 13 patients with early IV-tPA recanalization. Among 4 patients treated as protocol violations, 1 presented with a lack of recanalization and a parenchymal hematoma type 2.
Conclusions—For patients with MCA-M1 occlusions treated with IV tPA but without early recanalization, a second bolus of IV tenecteplase (0.1 mg/kg) may be a relatively safe, effective, and easy option in carefully selected cases, but additional studies are needed to confirm these findings.