RESUMEN
In children, arterial ischemic stroke is a much less understood disease compared to in adults due to its lower frequency and different aetiology. However, it is also a serious disease, with a high incidence of severe and permanent sequelae that exceeds 50% of total cases. The acute management of postnatal arterial ischaemic stroke (MNAIS) has changed drastically in recent years, chiefly on account of recanalization treatments (thrombolysis and endovascular therapies). These treatments, which used to not be recommended in childhood, are increasingly implemented in everyday clinical practice. Although the evidence from studies carried out in children is not of high quality due to their retrospective design and the small number of reported cases, they support the hypothesis that these treatments are as safe and effective as they are in adults as long as appropriate eligibility criteria are applied and they are used within a certain time from the onset of symptoms (therapeutic window). This article reviews the MNAIS based on the current scientific evidence. Since the efficacy of these treatments is highly dependent on their early initiation, a paediatric stroke code needs to be in place as an extension of the stroke code applied to adults. It has started to be introduced in Spain since 2019, although there are still large areas of the country where it has yet to be applied.
Asunto(s)
Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Niño , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Isquemia Encefálica/complicaciones , Terapia Trombolítica/efectos adversos , Trombectomía/efectos adversos , Estudios Retrospectivos , Accidente Cerebrovascular Isquémico/complicacionesAsunto(s)
Isquemia Encefálica/clasificación , Isquemia Encefálica/etiología , Accidente Cerebrovascular/clasificación , Accidente Cerebrovascular/etiología , Isquemia Encefálica/diagnóstico , Humanos , Arteriosclerosis Intracraneal/clasificación , Arteriosclerosis Intracraneal/complicaciones , Arteriosclerosis Intracraneal/diagnóstico , Embolia Intracraneal/clasificación , Embolia Intracraneal/complicaciones , Embolia Intracraneal/diagnóstico , Fenotipo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/diagnósticoRESUMEN
BACKGROUND AND PURPOSE: Evidence is accumulating regarding the prognostic influence of hyperglycemia in patients with acute ischemic stroke. However, the level associated with poor outcome is unknown. Our objectives were to establish the capillary glucose threshold with the highest predictive accuracy of poor outcome and to evaluate its hypothetical value in influencing functional outcome by adjusting for other well-known prognostic factors in acute stroke. METHODS: The authors conducted a multicenter, prospective, and observational cohort study of 476 patients with ischemic stroke within less than 24 hours from stroke onset. Capillary finger-prick glucose and stroke severity were determined on admission and 3 times a day during the first 48 hours. Poor outcome (modified Rankin Scale >2) was evaluated at 3 months. RESULTS: The receiver operating characteristic curves showed the predictive value of maximum capillary glucose at any time within the first 48 hours with an area under the curve of 0.656 (95% CI, 0.592 to 0.720; P<0.01) and pointed to 155 mg/dL as the optimal cutoff level for poor outcome at 3 months (53% sensitivity; 73% specificity). This point was associated with a 2.7-fold increase (95% CI, 1.42 to 5.24) in the odds of poor outcome after adjustment for age, diabetes, capillary glucose on admission, infarct volume, and baseline stroke severity and with a 3-fold increase in the risk of death at 3 months (hazard ratio, 3.80; 95% CI, 1.79 to 8.10). CONCLUSIONS: Hyperglycemia >or=155 mg/dL at any time within the first 48 hours from stroke onset, and not only the isolated value of admission glycemia, is associated with poor outcome independently of stroke severity, infarct volume, diabetes, or age.
Asunto(s)
Glucemia/metabolismo , Accidente Cerebrovascular/metabolismo , Enfermedad Aguda , Anciano , Biomarcadores , Capilares/metabolismo , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Curva ROC , Accidente Cerebrovascular/clasificación , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: Our aim is to review the association between blood pressure and stroke and analyse data from randomized controlled trials involving diverse therapies, especially those regarding the renin-angiotensin system. In addition, an overview of stroke pathogenesis is given and its relationship with treatment action mechanisms reviewed. RECENT FINDINGS: Stroke is a leading cause of death worldwide. In addition, many survivors of stroke suffer different degrees of disability. Because of the ageing of the global population, especially in regions of rapid economic growth, stroke will remain the second leading cause of death and in terms of disability it will be among the five most important causes in both developing and developed countries. High blood pressure is the most important risk factor for stroke, either ischemic or haemorrhagic, and established hypertension is the most prevalent modifiable risk factor. Data from controlled trials of blood-pressure-lowering treatment have demonstrated that treatment considerably lowers the risk of stroke within a few years of starting treatment. However, there exists controversy about the most efficient treatment regimen for primary and secondary prevention of stroke among the different blood-pressure-lowering treatments. SUMMARY: Debate rages as to whether the benefits of treating high blood pressure are simply determined by the quality of blood-pressure control, or whether the choice of drug therapy adds or detracts from the expected benefits of blood-pressure reduction. The desirable future interventional comparative studies should consent to determine specific effects of drug classes on cardiovascular risk in the absence of the confounding effect of a relevant blood-pressure reduction that may counteract the potential blood-pressure-independent benefits of specific drug classes.