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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2020; 78(11): 681-686
DOI: 10.1590/0004-282X20200048
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Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience

Dosis reducida de alteplase en el accidente cerebrovascular isquémico después del estudio Enchanted y sus determinantes, una experiencia de un solo centro
Alejandro Michel Brunser 
1   Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Departamento de Urgencia, Santiago, Chile.
2   Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile.
,
Enrico Mazzon 
2   Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile.
,
Gabriel Cavada
3   Clínica Alemana de Santiago, Unidad de Investigación y Ensayos Clínicos, Departamento Científico Docente, Santiago, Chile.
,
Eloy Mansilla 
4   Servicio de Neurología, Hospital Clínico Herminda Martin de Chillán, Servicio de Salud Ñuble, Chillán, Chile.
,
Alexis Rojo
4   Servicio de Neurología, Hospital Clínico Herminda Martin de Chillán, Servicio de Salud Ñuble, Chillán, Chile.
,
Juan Almeida
2   Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile.
,
Verónica Viviana Olavarría 
2   Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile.
,
Paula Muñoz-Venturelli 
2   Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile.
,
Pablo Manuel Lavados 
2   Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile.
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Abstract

Background: Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. Objective: We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. Methods: Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. Results: 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient's age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37‒14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98‒32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81‒357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37‒14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10‒0.40) remained independently associated. Conclusions: Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.

RESUMEN

Introducción: Dosis reducidas de trombolitico (LrtPA) podrían no ser inferiores en muerte/discapacidad. Objetivo: Evaluar el porcentaje de pacientes tratados con LrtPA en nuestro centro después del ensayo ENCHANTED, y los factores asociados con el uso de esta dosis. Métodos: Estudio prospectivo de pacientes consecutivos con infarto cerebral ingresados ​entre junio de 2016 y noviembre de 2018. Resultados: 160 pacientes fueron tratados con trombólisis intravenosa, 50% mujeres; edad media 65,4±18,5 años. 48 casos (30%) recibieron LrtPA. En el análisis univariado, LrtPA se asoció con la edad del paciente (p=0,000), escala de Rankin modificadas (mRS) (p<0,000), hipertensión arterial (p=0,076), diabetes mellitus (p=0,021), hipercolesterolemia (p=0,19), tabaquismo (p=0,06), fibrilación auricular (p=0,10), antecedentes de enfermedad coronaria (p=0,06), tratamiento previo con antiplaquetarios (p<0,000), International Normalized Ratio-INR (p=0,18), recuento de plaquetario (p=0,045), leucoaraiosis en neuroimagen (p<0,003), contraindicaciones para el tratamiento trombolítico (p=0,000) y tratamiento endovascular (p=0,027). Las hemorragias previas relevantes fueron determinantes para el tratamiento con LrtPA. El diagnóstico al alta de imitador de accidente cerebrovascular fue significativo (p=0,02) para el tratamiento con dosis estándar. El análisis multivariado demostró que mRS (OR: 2,21; IC95% 1,37‒14,19), tratamiento antiplaquetario previo (OR: 11,41; IC95% 3,98‒32,7), contraindicaciones para trombólisis (OR: 56,1; IC95% 8,81‒357,8), leucoaraiosis (OR: 4,41; IC95% 1,37‒14,1) y un diagnóstico de imitador de accidente cerebrovascular (OR: 0,22; IC95% 0,1‒0,40) fueron asociados con la dosis recibida. Conclusiones: LrtPA está restringido al 30% de nuestros pacientes. Los criterios para tomar esta decisión se basan en variables que podrían aumentar el riesgo de hemorragia cerebral/sistémica o excluir al paciente del tratamiento con fármacos líticos.

Keywords:

Acute Stroke - Therapeutic Thrombolysis - Thrombolytic Therapy

Palabras clave:

Accidente Cerebrovascular - Terapia Trombolítica - Terapia Trombolítica

Authors’ contributions:

AMB: developed the study idea, collected the data, participated in the statistical calculations and wrote the manuscript. GC: participated in the statistical calculations approve the final manuscript. EM: collected the data, and approve the final manuscript. EM, AR, JA, VVO, PMV and PML: developed the study idea, collected the data, and approve the final manuscript.


Supplementary material



Publikationsverlauf

Eingereicht: 25. Oktober 2019

Angenommen: 12. April 2020

Artikel online veröffentlicht:
10. Juli 2023

© 2020. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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