[Thrombolysis in cerebral ischemia].
Thrombolytic treatment with rt-PA is the first effective step in the therapeutic management of acute ischemic infarction. The benefit of rt-PA was clearly demonstrated in the NINDS study which showed a reduction in mortality or dependence in 13% of the cases. However, a reduction of only 3-5% as observed in the ECASS-II study is clinically relevant. In both the individual analysis and metaanalysis, the rt-PA studies indicate that despite a high frequency of symptomatic hemorrhages, mortality or morbidity do not increase and the clinical evolution improves. We believe that, at present, the question is not whether thrombolysis is effective in acute infarction, but whether we have well trained physicians in well equipped centers to provide this treatment adequately and safely. The patients admitted to stroke units within the first six hours should be considered for thrombolysis with rt-PA after careful evaluation of the inclusion and exclusion criteria. In Spain, however, rt-PA should be exclusively administered in accredited centers which have obtained authorization to perform its compassive use. In these cases, treatment with rt-PA should be carefully adjusted to the recommendations published by the AHA, it should be indicated by neurologists who are experts in the management of ictus, and administered in patients who may be closely monitored in stroke units. Hospitals without these possibilities should promote a radical change in stroke management. In these centers, neurologists, in collaboration with radiologists, internists and emergency physicians, should develop protocols of clinical performance, reorganize the priorities of the emergency departments, and familiarize themselves with CT findings and with the treatment criteria. The results of the metaanalysis of the finalized studies will allow better definition of the groups of patients at high risk of developing cerebral hemorrhage, and those in whom rt-PA may be more effective. The potential risks and benefits of rt-PA should be individually evaluated and discussed with the patient and relatives before initiation of treatment. However, the existence of severe potential complications should not invalidate the benefit of thrombolytic treatment, similar to the fact that the severe surgical complications of carotid endarterectomy (5%) have not obscured the clear benefits of this intervention on the long term prognosis of the patients.
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Sección de Neurología, Hospital Universitari de Girona Doctor Josep Trueta. adavalose@meditex.es
D001921:Brain / Q000098:blood supply*; D002545:Brain Ischemia / Q000188:drug therapy*; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans
D005343:Fibrinolytic Agents
Trombólisis en la isquemia cerebral.