Registro prospectivo de ictus intrahospitalarios
- Autores: Rocío Vera Lechuga
- Directores de la Tesis: Jaime Masjuan Vallejo (dir. tes.)
- Lectura: En la Universidad de Alcalá ( España ) en 2012
- Idioma: español
- Tribunal Calificador de la Tesis: Agustín Albillos Martínez (presid.), Luis Manzano Espinosa (secret.), Manuel Barón Rubio (voc.), José Vivancos Mora (voc.), Antonio Carmelo Gil Nuñez (voc.)
- Materias:
- Enlaces
- Resumen
- español
Antecedentes: Los ictus intrahospitalarios (IIH) son frecuentes, suponen entre el 4.4 y el 15% del total de ictus. Tienen mayor gravedad y peor pronóstico. Se han observado retrasos en su atención, lo que supone una desventaja en el tratamiento de estos enfermos dada la importancia de la atención precoz en el ictus.
Material y Método: Se ha realizado un registro prospectivo de pacientes con IIH de dos años estudiando sus características, etiología y tratamiento. También se han estudiado los pacientes con infarto cerebral intrahospitalario que han sido tratados con trombolisis intravenosa (iv) en la Unidad de Ictus del Hospital Ramón y Cajal desde 2004 hasta 2007 y comparado con los que fueron tratados por un infarto cerebral extrahospitalario.
Resultados y Conclusiones: Las incidencia de IIH en el hospital Ramón y Cajal es de 236 casos/ingresados/año. El 11% del total de ictus tratados fueron IIH. Hubo 155 IIH: 109 infartos, 28 AITs, 18 hemorragias cerebrales. Las neoplasias, la cirugía o intervencionismo en los días previos y las retirada de los antitrombóticos previos son muy frecuentes entre los pacientes con IIH. Los IIH tratados con trombolisis iv podrían haber sido el doble de no haber sido por el retraso en avisar a neurología. El porcentaje de pacientes con contraindicaciones para tratamiento con trombolisis iv es elevado. Solo un paciente se benefició de tratamiento endovascular. La trombolisis iv es segura y eficaz en los IIH. Las mortalidad de los IIH es elevada (21.9%), sobretodo en el grupo de pacientes hemorragia cerebral (66.1%).
- English
Background and purpose: in-hospital strokes (IHS) are relatively frequent. Previous studies have shown that 4.4% to 15% of all strokes occur in patients who are already admitted to hospitals. IHS have higher mortality and medical complications, poorer functional status at discharge and increased need for post-discharge rehabilitation care than outhospital strokes (OHS). Associated comorbidities, higher rate of cardioembolic strokes and greater stroke severity may explain their worse prognosis. Avoidable delays in neurological assessment have been demonstrated and may become a significant disadvantage for these patients. We study the clinical characteristics, quality of neurological care, delays in assessment, rate of thrombolysis, mortality and functional outcome of IHS. On the other hand, we analyzed time to treatment intervals, safety and efficacy of intravenous thrombolysis with tPA in IHS compared with OHS.
Material and method: prospective registry of patients with consecutive IHS during their admission in our hospital within the period 7/2007 – 6/2009. Demographic and clinical characteristics, admission diagnosis, patient location, stroke mechanism, quality of care, thrombolytic therapy, in-hospital mortality and three month mortality and functional outcome were recorded. IHS incidence in our hospital has been also determined. Besides, we have compared IHS and OHS thrombolysed patients since 2004 (when treatment with intravenous tPA in acute ischemic stroke was first used in our hospital) until 2010, using our stroke unit thrombolysis registry.
Results: Anual incidence of IHS in our hospital was 236 cases /100.000 hospitalized patients /year. Eleven percent of the patients who were treated for a stroke in the hospital during the registry, had had an IHS. We included 155 IHS patients (109 ischemic strokes, 28 transient ischemic attacks and 18 cerebral haemorrhages). Mean age was 73±13.1 years. Cardiac sources of embolism were present in 90 (58 %), withdrawal of antithrombotic drugs in 54 (34.8%) and active cancers in 19 (12.3%).
Cardioembolic stroke was the most common subtype of IS (55.9%). Fourty three (27.7%) patients were admitted to Cardiology or Cardiac Surgery departments. Only 67 patients (43.2%) were evaluated by a neurologist within three hours of stroke onset. Sixteen patients received treatment with tPA (14.7%). On the other hand, 17 patients could not be treated because of a delay in contacting the neurologist (15.6%). Recent major surgical procedures (32.2%) and treatment with anticoagulants and INR>1.7 (19.4%) were the most frequent exclusion criteria for intravenous thrombolysis in patients with ischemic stroke, apart from time window. Only one patient (0.9%) was treated with interventional neuroradiology procedures. During hospitalization, 34 patients died (21.9%), 30 of them (88%) because of the stroke or its complications. After three months, only 54 (38.4%) patients were functionally independent. Intravenous thrombolytic registry analysis showed no significant differences in treatment safety and efficacy in IHS compared to OHS. Twenty four (51.1%) of IHS and only 25 (5.2%) of OHS were treated within 90 minutes from stroke onset (p<0.001). Inhospital delays were significantly longer in IHS for door-to-computed tomography time (45±25 vs 27±18, p<0.001) and computer tomograhy-to-treatment time (41±25 vs 33±29, p<0.001).
Conclusions: Cardioembolic IS was the most frequent subtype of IHS. Cardiac sources of embolism, active cancers and withdrawal of antithrombotic drugs constituted especial risk factors for IHS. A significant proportion of patients were treated with thrombolysis. However, delays in contacting the neurologist excluded a proportion of patients from treatment. Recent surgery and anticoagulant therapies exclude many patients with IHS from thrombolysis with intravenous tPA. Interventional neuroradiology procedures could compensate this disadvantage. IHS mortality was high, mostly due to stroke. Thrombolysis is safe and effective in IHS. However, in-hospital procedures for thrombolysis are slower in IHS than in OHS. Stroke training programs for medical staffs, especially in cardiovascular departments, might improve the detection of candidates for revascularization therapies.
- español
