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Resumo Introdução: O acidente vascular cerebral isquêmico tem como tratamento a terapia trombolítica, aplicada ainda na fase aguda, promovendo melhora importante nas sequelas acarretadas por este agravo. Considerando a complexidade da terapia trombolítica, torna-se necessário que os enfermeiros compreendam suas competências para auxiliar no cuidado. Objetivo: Identificar evidências científicas acerca das competências do enfermeiro no cuidado a pacientes com acidente vascular cerebral elegíveis à terapia trombolítica. Metodologia: Revisão integrativa composta por seis etapas em seis etapas (elaboração da questão, busca na literatura, coleta de dados, análise, discussão e apresentação da revisão), realizada nas bases de dados MEDLINE, LILACS, BDENF, IBECS, PubMed, Scopus, Web of Science, Embase e CINAHL. A busca foi realizada entre agosto e setembro de 2022 adotando como critérios de inclusão estudos primários; gratuitos, disponíveis eletronicamente na íntegra; nos idiomas inglês, português e espanhol. Foram obtidos inicialmente 2.830 estudos, os quais passaram por uma seleção, onde foram incluídos aqueles que atendiam os critérios previamente estabelecidos. Resultados: Com base nos doze estudos incluídos nesta revisão identificaram-se competências voltadas à três atividades do cuidado: gestão do cuidado como trabalho em equipe, códigos, fluxos e protocolos, assistência ao paciente antes, durante e após a utilização da terapia trombolítica e educação em saúde para equipe, pacientes e familiares. Conclusão: Os achados desta revisão puderam evidenciar as competências do enfermeiro no cuidado aos pacientes elegíveis a terapia trombolítica, as quais perpassam diferentes áreas de atuação do enfermeiro. Para este estudo prevaleceram as competências assistências, seguida por competências gerenciais.

Resumen Introducción: El accidente cerebrovascular isquémico se trata con terapia trombolítica, aplicada incluso en la fase aguda, que promueve una mejoría significativa de las secuelas provocadas por este padecimiento. Considerando la complejidad de la terapia trombolítica, es necesario que las personas profesionales de enfermería comprendan sus competencias para ayudar en el cuidado. Objetivo: Identificar evidencias científicas sobre las competencias del personal de enfermería en el cuidado de pacientes con accidente cerebrovascular elegibles para terapia trombolítica. Metodología: Revisión integradora que consta de seis etapas (elaboración de la pregunta, búsqueda bibliográfica, recolección de datos, análisis, discusión y presentación de la revisión), realizada en las bases de dados MEDLINE, LILACS, BDENF, IBECS, PubMed, Scopus, Web of Science, Embase y CINAHL. La búsqueda se realizó entre agosto y septiembre de 2022. Los criterio de inclusión fueron: estudios primarios, gratuito, disponible electrónicamente en su totalidad, en inglés, portugués y español. Inicialmente se obtuvieron 2830 estudios, los cuales fueron sometidos a un proceso de selección, que incluyó aquellos que cumplían con los criterios previamente establecidos. Resultados: A partir de los doce estudios incluidos en esta revisión, se identificaron competencias centradas en tres actividades asistenciales: gestión del cuidado como trabajo en equipo, códigos, flujos y protocolos, atención a pacientes antes, durante y después del uso de la terapia trombolítica y educación en salud para personal, pacientes y familias. Conclusión: Los hallazgos de esta revisión pudieron resaltar las competencias de las personas profesionales en enfermería en el cuidado de personas elegibles para terapia trombolítica, que abarcan diferentes áreas de actuación del personal de enfermería. Para este estudio, prevalecieron las habilidades asistenciales, seguidas de las competencias gerenciales.

ABSTRACT Introduction: Ischemic stroke is treated with thrombolytic therapy, applied even in the acute phase, promoting a significant improvement in the after-effects caused by this condition. Considering the complexity of thrombolytic therapy, it is necessary for nurses to understand the skills required to assist in care. Objective: To identify scientific evidence about the competencies of nurses in the care of patients with stroke who are eligible for thrombolytic therapy. Methodology: An integrative review consisting of six stages (elaboration of the question, literature review, data collection, analysis, discussion, and presentation), conducted in MEDLINE, LILACS, BDENF, IBECS, PubMed, Scopus, Web of Science, Embase, and CINAHL databases. The search was carried out between August and September 2022 using primary studies as the inclusion criteria: free of charge, fully available electronically, published in English, Portuguese, or Spanish. Initially, 2.830 studies were obtained, which underwent a selection process that included only those studies that met the previously established criteria. Results: Based on the twelve studies included in this review, competencies focused on three care activities were identified: care management such as teamwork; codes; flows and protocols; patient care before, during, and after the use of thrombolytic therapy; and education health education for staff, patients, and families. Conclusion: The findings of this review highlighted the nurses' competencies in the care of patients eligible for thrombolytic therapy, which encompass different areas of the nurse's work. For this study, assistance competencies prevailed, followed by management competencies.

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The efficacy and safety of dual antiplatelet therapy (DAPT) relative to intravenous (IV) alteplase in patients with acute minor ischemic stroke are insufficiently established. Therefore, we aimed to perform a meta-analysis to compare DAPT with IV alteplase in patients with acute minor stroke. MEDLINE, Embase, and Cochrane were searched for studies comparing DAPT with IV alteplase in patients with minor stroke. Functional and safety outcomes in 90 days were analyzed. Statistical analysis was performed using Rstudio 4.3.1. Subanalyses were performed restricted to non-disabling minor strokes and NIHSS score ≤ 3. PROSPERO (CRD42023440986). We included five studies with a total of 6,340 patients, of whom 4,050 (63.9%) received DAPT. The follow-up period for all included studies was 90 days. There was no significant difference for individual outcomes of mRS 0-1 (OR 1.26; 95% CI 0.85-1.89; p = 0.25), mRS 0-2 (OR 0.99; 95% CI 0.69-1.43; p = 0.97), or all-cause mortality (OR 0.80; 95% CI 0.20-3.13; p = 0.75) between groups. Symptomatic intracranial hemorrhage (sICH) was significantly lower (OR 0.11; 95% CI 0.003-0.36; p < 0.001) in patients treated with DAPT compared with IV alteplase. In terms of mRS 0-1 and mRS 0-2, we found no significant difference in both subgroup analyses. We found no statistically significant difference between DAPT and IV alteplase regarding functional outcome (mRS scores of 0-1 and 0-2) or all-cause mortality at 90 days in patients with minor ischemic stroke. Additionally, DAPT was associated with a significantly lower rate of sICH.

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OBJECTIVE: In complicated parapneumonic effusion or Empyema, approximately 25% of patients require surgical intervention which can be associated with a mortality risk of almost 20%. However, the use combination of rt-tPA and DNase in elderly patients with prohibitive surgical risk has improved outcomes. The main goal of our study is to highlight the utility of intrapleural thrombolysis in patients with prohibitive risk for surgery. METHODS: A retrospective record review study of patients (n=23) with complicated parapneumonic pleural effusion or empyema treated with tPA and DNase from January 1st of 2015 to March 18th, 2019 at VACHCS. Data collected to describe the outcome of intrapleural thrombolytics included demographic, pleural fluid analysis, surgical risk assessment, diagnosis and initiation treatment day, doses, chest imaging, drainage rate, chest tube size and average days in place, inflammatory markers, microbiology, antibiotics, and complications. RESULTS: Only 21.7% of patients were considered surgical candidates. Seventy-four percent had a 30-day post-surgical mortality risk of > 2.5% using the National Surgery Office (NSO) risk calculator. Post-operative inpatient stay was 99.7% and estimated post operative ICU stay average was >80%. Primary outcome (pleural drainage improvement) obtained in 73.9%. Most common serious complications included sepsis (52.2%) and nonserious was residual hydropneumothorax (47.8%). CONCLUSION: This study demonstrates that administration of intrapleural thrombolytics through a percutaneous pleural catheter achieved successful drainage safely and without the need for surgical interventions in a selected group of advanced age, elderly patients with pleural infections who were deemed to be high surgical risk.

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Abstract The authors report the case of a 71-year-old woman presented to the Emergency Department with acute ischemic stroke. She was treated with rt-PA and interventional endovascular revascularization and developed rapidly progressing angioedema that led to emergency intubation. The standard treatment was not very effective and the swelling improved after infusion of fresh frozen plasma. Angioedema after rt-PA infusion could be a life-threatening emergency that requires quick airway management by skilled professionals. As this condition is triggered by several factors, such as unregulated histamine and bradykinin production, the traditional treatment recommended by the guidelines may not be sufficient and the use of FFP can be considered as a safe and valuable aid.

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Abstract Background Seizures after stroke can negatively affect the prognosis of ischemic stroke and cause a decrease in quality of life. The efficacy of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) treatment in acute ischemic stroke has been demonstrated in many studies, and IV rt-PA treatment has been increasingly used around the world. The SeLECT score is a useful score for the prediction of late seizures after stroke and includes the severity of stroke (Se), large artery atherosclerosis (L), early seizure (E), cortical involvement (C), and the territory of the middle cerebral artery (T). However, the specificity and sensitivity of the SeLECTscore have not been studied in acute ischemic stroke patients that received IV rt-PA treatment. Objective In the present study, we aimed to validate and develop the SeLECT score in acute ischemic stroke patients receiving IV rt-PA treatment. Methods The present study included 157 patients who received IV thrombolytic treatment in our third-stage hospital. The 1-year seizure rates of the patients were detected. SeLECT scores were calculated. Results In our study, we found that the SeLECT score had low sensitivity but high specificity for predicting the likelihood of late seizure after stroke in patients administered IV rt-PA therapy. In addition to the SeLECT score, we found that the specificity and sensitivity were higher when we evaluated diabetes mellitus (DM) and leukoaraiosis. Conclusion We found that DM was an independent risk factor for late seizures after stroke in a patient group receiving thrombolytic therapy, and late seizures after stroke were less frequent in patients with leukoaraiosis.

Resumo Antecedentes As convulsões após o AVC podem afetar negativamente o prognóstico do AVC isquêmico e causar uma diminuição na qualidade de vida. A eficácia do tratamento com ativador do plasminogênio tecidual recombinante (rt-PA) intravenoso (IV) no AVC isquêmico agudo foi demonstrada em muitos estudos, e o tratamento com rt-PA IV tem sido cada vez mais usado em todo o mundo. A pontuação SeLECT é uma pontuação útil para a previsão de convulsões tardias após AVC e inclui a gravidade do AVC (Se), aterosclerose de grandes artérias (L), convulsão precoce (E), envolvimento cortical (C) e o território do meio artéria cerebral (T). No entanto, a especificidade e a sensibilidade do escore SeLECT não foram estudadas em pacientes com AVC isquêmico agudo que receberam tratamento IV com rt-PA. Objetivo No presente estudo, objetivamos validar e desenvolver o escore SeLECT em pacientes com AVC isquêmico agudo recebendo tratamento IV com rt-PA. Métodos O presente estudo incluiu 157 pacientes que receberam tratamento trombolítico IV em nosso hospital de terceiro estágio. As taxas de convulsão de 1 ano dos pacientes foram detectadas. Os escores SeLECT foram calculados. Resultados Em nosso estudo, descobrimos que o escore SeLECT apresentou baixa sensibilidade, mas alta especificidade para prever a probabilidade de convulsão tardia após AVC em pacientes que receberam terapia IV com rt-PA. Além do escore SeLECT, descobrimos que a especificidade e a sensibilidade foram maiores quando avaliamos diabetes mellitus (DM) e leucoaraiose. Conclusão Descobrimos que DM foi um fator de risco independente para convulsões tardias após AVC em um grupo de pacientes recebendo terapia trombolítica, e convulsões tardias após AVC foram menos frequentes em pacientes com leucoaraiose.

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INTRODUCTION: Major depressive disorder (MDD) is a severe mental health condition that affects millions of people worldwide. Etiologically, several factors may play a role in its development. Previous studies have reported elevated plasminogen activator inhibitor-1 (PAI-1) levels in patients with depression, suggesting that PAI-1 levels might be linked to the etiology of MDD. METHODS: We systematically searched the following online databases: MEDLINE, Scopus, and Web of Science up to September 10, 2020, to identify studies in which PAI-1 levels were reported in subjects with MDD. Subsequently we used RevMan 5.3 to perform a meta-analysis of data extracted from the included studies using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PICO criteria for the search and analysis. RESULTS: Six studies that reported mean ± standard deviation (SD) were included in the analysis, with a total of 507 MDD patients and 3,453 controls. The overall standardized mean difference (SMD) was 0.27 (95% confidence interval [95% CI] 0.01-0.53). PAI-1 serum levels were 0.27 SDs higher in MDD patients than in controls. The test for overall effect was significant (z = 2.04, p = 0.04). Substantial heterogeneity was detected among the studies, demonstrated by the inconsistency test (I² = 72%) and the chi-square test (χ² = 18.32; p = 0.003). CONCLUSIONS: This systematic review and meta-analysis showed that MDD might be related to elevated PAI-1 levels. We propose larger prospective clinical studies to further investigate this clinical correlation and validate the clinical significance of these observations.

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The authors report the case of a 71-year-old woman presented to the Emergency Department with acute ischemic stroke. She was treated with rt-PA and interventional endovascular revascularization and developed rapidly progressing angioedema that led to emergency intubation. The standard treatment was not very effective and the swelling improved after infusion of fresh frozen plasma. Angioedema after rt-PA infusion could be a life-threatening emergency that requires quick airway management by skilled professionals. As this condition is triggered by several factors, such as unregulated histamine and bradykinin production, the traditional treatment recommended by the guidelines may not be sufficient and the use of FFP can be considered as a safe and valuable aid.

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Abstract Introduction Major depressive disorder (MDD) is a severe mental health condition that affects millions of people worldwide. Etiologically, several factors may play a role in its development. Previous studies have reported elevated plasminogen activator inhibitor-1 (PAI-1) levels in patients with depression, suggesting that PAI-1 levels might be linked to the etiology of MDD. Methods We systematically searched the following online databases: MEDLINE, Scopus, and Web of Science up to September 10, 2020, to identify studies in which PAI-1 levels were reported in subjects with MDD. Subsequently we used RevMan 5.3 to perform a meta-analysis of data extracted from the included studies using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PICO criteria for the search and analysis. Results Six studies that reported mean ± standard deviation (SD) were included in the analysis, with a total of 507 MDD patients and 3,453 controls. The overall standardized mean difference (SMD) was 0.27 (95% confidence interval [95% CI] 0.01-0.53). PAI-1 serum levels were 0.27 SDs higher in MDD patients than in controls. The test for overall effect was significant (z = 2.04, p = 0.04). Substantial heterogeneity was detected among the studies, demonstrated by the inconsistency test (I2 = 72%) and the chi-square test (χ2 = 18.32; p = 0.003). Conclusion This systematic review and meta-analysis showed that MDD might be related to elevated PAI-1 levels. We propose larger prospective clinical studies to further investigate this clinical correlation and validate the clinical significance of these observations.

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Abstract Background Stroke is a major cause of disability worldwide and a neurological emergency. Intravenous thrombolysis and mechanical thrombectomy are effective in the reperfusion of the parenchyma in distress, but the impossibility to determine the exact time of onset was an important cause of exclusion from treatment until a few years ago. Objectives To review the clinical and radiological profile of patients with unknown-onset stroke, the imaging methods to guide the reperfusion treatment, and suggest a protocol for the therapeutic approach. Methods The different imaging methods were grouped according to current evidence-based treatments. Results Most studies found no difference between the clinical and imaging characteristics of patients with wake-up stroke and known-onset stroke, suggesting that the ictus, in the first group, occurs just prior to awakening. Regarding the treatment of patients with unknown-onset stroke, four main phase-three trials stand out: WAKE-UP and EXTEND for intravenous thrombolysis, and DAWN and DEFUSE-3 for mechanical thrombectomy. The length of the therapeutic window is based on the diffusion weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch, core-penumbra mismatch, and clinical core mismatch paradigms. The challenges to approach unknown-onset stroke involve extending the length of the time window, the reproducibility of real-world imaging modalities, and the discovery of new methods and therapies for this condition. Conclusion The advance in the possibilities for the treatment of ischemic stroke, while guided by imaging concepts, has become evident. New studies in this field are essential and needed to structure the health care services for this new scenario.

Resumo Antecedentes O acidente vascular cerebral (AVC) é uma das principais causas de incapacidade em todo o mundo, e uma emergência neurológica. A trombólise intravenosa e a trombectomia mecânica são eficazes na reperfusão do parênquima em sofrimento, mas a impossibilidade de determinar o tempo exato de início era uma causa importante de exclusão ao tratamento até alguns anos atrás. Objetivos Revisar o perfil clínico-radiológico dos pacientes com AVC de tempo indeterminado, os métodos de imagem para guiar o tratamento de reperfusão, e sugerir um protocolo para a abordagem terapêutica. Métodos Os diferentes métodos de imagem foram agrupados de acordo com os tratamentos atuais baseados em evidências. Resultados A maioria dos estudos não encontrou diferença entre as características clínicas e de imagem dos pacientes com AVC reconhecido ao despertar e AVC de tempo definido, o que sugere que o icto, no primeiro grupo, ocorre próximo ao acordar. Quanto ao tratamento do AVC de tempo indeterminado, quatro grandes estudos na fase três sobressaem: WAKE-UP e EXTEND para trombólise intravenosa, e DAWN e DEFUSE-3 para trombectomia mecânica. A ampliação da janela terapêutica fundamenta-se nos paradigmas de incompatibilidade da imagem ponderada de difusão-recuperação da inversão atenuada por fluidos (diffusion weighted imaging-fluid-attenuated inversion recovery, DWI-FLAIR, em inglês), do núcleo isquêmico e penumbra, e clínico-radiológico. Os desafios na abordagem do AVC de tempo indeterminado envolvem a ampliação da janela terapêutica, a reprodutibilidade das modalidades de imagem no mundo real, e a identificação de novos métodos e tratamentos para essa condição. Conclusão É evidente o avanço nas possibilidades de tratamento do AVC isquêmico guiado pelos conceitos de imagem. Novos estudos nesse campo são essenciais, com necessidade de estruturar os serviços de saúde para esse novo cenário.

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SUMMARY Objective : This study aimed at: 1) Assessment of the frequency of stroke and related mortality rate in patients hospitalized for COVID-19 in two major hospital referral centers in Peru; 2) Exploration of factors associated to mortality and dependency in these patients; 3) Comparisons of frequency of admissions of stroke patients and reperfusion treatments in similar periods of time prior to (2019) and during the pandemia occurrence. Material and Methods : A retrospective cohort study was conducted in two of the largest referral hospital centers for COVID-19 in Peru. The study included patient victims of stroke and COVID-19, hospitalized between April and August 2020. Demographic, clinical and laboratory data, radiological findings, and severity levels measured by the NIHSS scale were collected. Poisson regression models to evaluate associated factors to mortality and dependency were applied. Results : A 31% reduction of admissions for stroke, and of 81% of intravenous reperfusion treatment, respectively, were found in 2020 when compared with 2019. 1.37% of the patients with COVID-19 experienced a stroke, with an overall mortality rate of 40.6%, and a dependency rate of 68.3% at discharge time (Rankin > 2). An age increase of 10 years was found in mortality, associated with a 29% increase in mortality risk. As well, having hypertension, chronic kidney disease, inflammatory markers (D dimer and ferritin) and the severity of the stroke were associated with mortality. Finally, the severity of stroke, lymphopenia, and inflammatory markers (D dimer and fibrinogen) were associated with greater risk of dependency. Conclusions : The care system of stroke patients was affected by the COVID-19 pandemic in two of Perú's major public hospitals. There was a decrease in admissions and reperfusion treatments of stroke cases, and 1.37% of patients with COVID-19 presented a stroke. Age, hypertension, chronic kidney disease, inflammatory markers and severity of stroke were associated with mortality in these patients.

RESUMEN Objetivo : Los objetivos del presente trabajo fueron: 1) Evaluar la frecuencia de accidente cerebrovascular (ACV) y de la tasa de mortalidad en pacientes hospitalizados por COVID-19 en dos importantes centros hospitalarios de referencia en Perú, 2) Exploración de factores asociados a mortalidad y dependencia en estos pacientes, 3) Comparar la frecuencia de admisiones de pacientes con ACV y de los tratamientos de reperfusión en tiempo de pandemia y en periodos previos (2019). Material y Métodos : Se realizó un estudio retrospectivo en dos de los mayores centros hospitalarios de referencia en Perú, incluyendo pacientes con ACV y COVID-19 hospitalizados entre abril y agosto del 2020. Se recolectó información demográfica, clínica y de laboratorio, hallazgos radiológicos y niveles de severidad medidos por la escala NIHSS, y se utilizó un modelo de regresión de Poisson para evaluar los factores asociados a mortalidad y dependencia. Resultados : Se encontró una disminución del 31% de admisiones hospitalarias de pacientes con ACV (ictus) y del 81% de los tratamientos de reperfusión endovenosa en el 2020 con respecto al 2019. Un 1.37% de pacientes con COVID-19 experimentaron ACV, con una mortalidad global de 40.6% y dependencia al alta del 58.3% (rankin >2). Un incremento de 10 años en edad se asoció con un aumento del 29% en el riesgo de mortalidad. Hipertensión arterial, enfermedad renal crónica, marcadores inflamatorios (Dímero D y ferritina) y la gravedad del ictus se encontraron asociados con mortalidad. La gravedad del ictus, la linfopenia y los marcadores inflamatorios (Dimero D y fibrinógeno) estuvieron asociados a un mayor riesgo de dependencia. Conclusión : El sistema de atención de ACVs se vio afectado por la pandemia del COVID-19 en dos de los centros hospitalarios públicos más grandes del Perú. Se encontró una disminución en las admisiones hospitalarias y en los tratamientos de reperfusión de estos pacientes durante la pandemia. Edad, hipertensión, enfermedad renal crónica, marcadores inflamatorios y gravedad del ictus fueron factores asociados con la mortalidad de pacientes con COVID-19 y ACV.

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RESUMEN INTRODUCCIÓN: La evaluación de la calidad de la atención del ataque cerebrovascular (ACV) es una prioridad para los sistemas de salud, debido a su relación con la disminución de la discapacidad y la muerte. En este estudio se analizan los marcadores de calidad en ACV en un hospital de referencia en Nariño, Colombia. OBJETIVO: Evaluar los marcadores de calidad de atención en ACV en el Hospital Universitario Departamental de Nariño E. S. E., entre junio del 2018 y diciembre del 2019. Como referencia se comparó con los registros de Colombia en la plataforma RES-Q. MATERIALES Y MÉTODOS: Estudio descriptivo retrospectivo de pacientes con ACV atendidos intrahospitalariamente. La recolección de datos se realizó mediante la plataforma RES-Q, en tanto que el análisis se efectuó por medio de estadísticos descriptivos y frecuencias absolutas y relativas y las diferencias con pruebas analíticas. RESULTADOS: Se evaluaron 457 pacientes con predominio de ACV isquémico y se llevó a cabo trombólisis endovenosa al 7,2% en el 2018 y al 9,2 % en el 2019, el 27,7 % con tiempo puerta aguja menor a 60 minutos en el 2018 y el 42,8 % en el 2019. Entre los marcadores de calidad, se encontró mejoría en realización de NIHSS, evaluación de disfagia en las primeras 24 horas, realización de doppler carotideo en los primeros siete días. En comparación con Colombia, se encontró un porcentaje inferior en trombólisis endovenosa y trombectomía. La mayoría de los indicadores de atención en ACV es similar al promedio nacional. CONCLUSIONES: La mejoría en el cumplimiento de marcadores de calidad en ACV refleja el impacto de programas de atención en ACV. El monitoreo de los parámetros de calidad permite generar programas para fortalecer la atención integral del ataque cerebrovascular en la región.

ABSTRACT INTRODUCTION: The evaluation of the quality of care for Stroke is a priority for health systems, given its relationship with disability and death. In this study, Stroke quality markers are analyzed in stroke in a referral hospital in Narino, Colombia. OBJECTIVE: To evaluate the markers of quality of care in stroke in the Hospital Departamental Universitario de Narino E.S.E between June 2018 and December 2019. As a reference, the outcomes were compared with the Colombian registries on RES-Q platform. MATERIALS AND METHODS: A retrospective descriptive study of patients treated in-hospital with stroke, data collection was performed using the RES-Q platform. The analysis was carried out using descriptive statistics and absolute and relative frequencies and the differences with analytical tests. RESULTS: 457patients were evaluated, with ischemic stroke predominance, endovenous thrombolysis was performed in 7.2 % in 2018, and 9.2 % in 2019, 27.7 % of patients had door to needle time less than 60 minutes in 2018 and 42.8 % in 2019. Among the quality markers evaluated, an improvement was found in the performance of NIHSS, dysphagia evaluation, and carotid doppler performance in ischemic stroke. Compared with Colombian registry, a lower percentage was found in endovenous thrombolysis and thrombectomy. Most of Stroke Care Markers are similar to national average. CONCLUSIONS: The improvement in compliance of standard of Stroke Care Quality Markers reflects the impact of stroke care programs. The monitoring of quality parameters allows the generation of comprehensivestroke care programs in the region.

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RESUMEN INTRODUCCION: El ataque cerebrovascular (ACV) de etiología isquémica es una patología cuya incidencia y mortalidad aumentaron en la última década. Cuando se maneja oportunamente, mediante trombólisis como terapia inicial, mejora su desenlace y funcionalidad. En el departamento del Tolima (Colombia) no hay registros de esta patología y en el país la bibliografía al respecto es limitada. El objetivo de este estudio es evaluar los desenlaces clínicos del manejo agudo con r-tPA en los pacientes que presentaron ACV isquémico en dos instituciones de la ciudad de Ibagué, capital de dicho departamento, entre junio del 2019 y junio del 2020, e identificar los tiempos de atención hospitalaria y las principales variables asociadas con el grupo de pacientes que fallecieron. MATERIALES Y METODOS: Estudio descriptivo de corte transversal del manejo del ACV isquémico con r-tPA, en el que se describen las variables sociodemográficas, la escala NIHSS como evaluación neurológica inicial, los tiempos de atención (inicio-aguja, puerta-tac y puerta-aguja), los desenlaces postoperatorios y el Rankin modificado al egreso. RESULTADOS: Se incluyeron 38 pacientes con una media de 67,37 años, el 60,53 % fueron mujeres. La escala NIHSS al ingreso fue 13,47 puntos (DE 5,24). Los tiempos de atención fueron 183 minutos (DE 72,63) inicio-aguja, 41 minutos (RIQ 17-72) puerta-TAC y 101,50 minutos (RIQ 77 - 137,25) puerta-aguja. La mortalidad fue del 23,68 %. CONCLUSION: La mortalidad y el desenlace funcional del ACV en nuestra población fueron similares a los reportados en la literatura nacional e internacional, sin embargo, es preciso implementar protocolos de atención del infarto cerebral para incrementar el número de pacientes con desenlace favorable, acortando los tiempos de atención en toda la cadena del tratamiento adecuado del infarto cerebral.

ABSTRACT INTRODUCTION: Ischemic stroke is a growing disease in the last decade, increasing both its incidence and its mortality. However, timely thrombolysis management as initial therapy can improve both disease progression as well as an individual's functionality. In Tolima, there are no registries of this disease and in Colombia in general, the literature is limited. The objective of this study is to investigate the clinical outcomes of the acute management of ischemic stroke using r-tPA as well as identifying in-hospital treatment times, at two institutions in Ibague between 2019 and 2020. METHODS AND MATERIALS: Using a cross-sectional descriptive study, we describe the management of ischemic stroke using r-tPA, describing sociodemographic variables, NIHSS scale as the initial neurological evaluation, in-hospital treatment times (symptoms-to-needle, door-to-TAC, door-to-needle), the clinical outcomes, and lastly the modified Rankin score upon discharge. RESULTS: We included 38 patients with median age of 67,37 years, 60,53 % were females. The initial average NIHSS scale upon admission was 13,47 (DE 5,24). In-hospital attention time averages were: symptoms-to-needle 183 minutes (DE 72,63), door-to-CAT 41 minutes (RIQ 17-72), and door-to-needle 101,50 minutes (RIQ 77-137,25). Overall the rate of mortality was 23,68 %. CONCLUSIONS: Mortality and functionality outcomes of the stroke population observed was similar to previously reported, both nationally and internationally. However, protocols should be implemented for the timely ischemic stroke management to improve the number of patients with favorable outcomes, by reducing the in-hospital attention times in all areas of the management chain.

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A embolia pulmonar, uma doença com risco de vida, é prevalente em todo o mundo, afetando grande porcentagem da população e representando uma das principais causas de morte cardiovascular. Para reduzir sua mortalidade e morbidade e melhorar os desfechos, é fundamental uma estratificação precoce do risco. Há uma ampla variação na gravidade de uma embolia pulmonar, desde leve até com risco de vida. Quando um paciente tem uma embolia pulmonar de alto risco e está em choque ou parada cardíaca, é razoável realizar trombólise sistêmica ou embolectomia de emergência, mas a anticoagulação isolada tem ótimos resultados na embolia pulmonar de baixo risco. Há várias estratégias para aproveitar os benefícios da trombólise e minimizar seus riscos, mas a experiência clínica com essas novas estratégias de intervenção é limitada. A equipe de resposta à embolia pulmonar, composta de cardiologista intervencionista, radiologista intervencionista, cirurgião cardíaco, radiologista especializado em imagem cardíaca e intensivista, pode ajudar a determinar o tipo de intervenção em um determinado paciente. Este artigo traz um esboço das terapias intervencionistas endovasculares atuais e seu contexto.

This life-threatening condition, known as pulmonary embolism, is prevalent throughout the world, affecting a large percentage of population and representing one of the leading causes of cardiovascular death. To reduce mortality and morbidity and improve outcomes, early risk stratification is critical. There is a wide range in the severity of a pulmonary embolism, from mild to life-threatening. When a patient has a high-risk pulmonary embolism and is in shock or cardiac arrest, emergency systemic thrombolysis or embolectomy is reasonable, but anticoagulation alone has great results in low-risk pulmonary embolism. Multiple strategies exist to capture the benefits of thrombolysis while minimizing its risks, but clinical experience with such novel intervention strategies is limited. The pulmonary embolism response team comprises interventional cardiologist, interventional radiologist, cardiac surgeon, cardiac radiologist, and critical care specialist, can help determine the type of intervention in a given patient. This article provides an outline of current endovascular interventional therapies and their context.

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OBJECTIVE: To describe existing pediatric acute stroke protocols to better understand how pediatric centers might implement such pathways within the context of institution-specific structures. STUDY DESIGN: We administered an Internet-based survey of pediatric stroke specialists. The survey included questions about hospital demographics, child neurology and pediatric stroke demographics, acute stroke response, imaging, and hyperacute treatment. RESULTS: Forty-seven surveys were analyzed. Most respondents practiced at a large, freestanding children's hospital with a moderate-sized neurology department and at least 1 neurologist with expertise in pediatric stroke. Although there was variability in how the hospitals deployed stroke protocols, particularly in regard to staffing, the majority of institutions had an acute stroke pathway, and almost all included activation of a stroke alert page. Most institutions preferred magnetic resonance imaging (MRI) over computed tomography (CT) and used abbreviated MRI protocols for acute stroke imaging. Most institutions also had either CT-based or magnetic resonance-based perfusion imaging available. At least 1 patient was treated with intravenous tissue plasminogen activator (IV-tPA) or mechanical thrombectomy at the majority of institutions during the year before our survey. CONCLUSIONS: An acute stroke protocol is utilized in at least 41 pediatric centers in the US and Canada. Most acute stroke response teams are multidisciplinary, prefer abbreviated MRI over CT for diagnosis, and have experience providing IV-tPA and mechanical thrombectomy. Further studies are needed to standardize practices of pediatric acute stroke diagnosis and hyperacute management.

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Objetivo: Identificar os fatores de risco associados ao déficit neurológico em pessoas vítimas de acidente vascular cerebral isquêmico. Métodos: Trata-se de um estudo retrospectivo descritivo quantitativo realizado em um hospital no interior de Minas Gerais Brasil. Os dados foram coletados em 52 prontuários, através de um instrumento contendo variáveis sociodemográficas, clínicas e janelas de tempo de tratamento. Para avaliação do déficit neurológico utilizou-se National Institutes of Health Stroke Scale. Os testes de Shapiro-Wilk, Quiquadrado de Pearson, T Student e McNemar foram utilizados para a análise estatística. O nível de significância foi de 0,05. Resultados: Na admissão hospitalar houve prevalência do déficit neurológico moderado, e na alta hospitalar, o déficit neurológico leve. O valor do déficit neurológico na admissão hospitalar e alta hospitalar foram, respectivamente 13,10 (±7,2) e 7,58 (±8,3), p = (0,000). O período de internação foi de 7,78 dias para os indivíduos com déficit neurológico leve/moderado e 11,67 dias para déficit neurológico grave (p=0,044). O tempo de janela porta agulha foi 38 minutos nos pacientes com déficit neurológico leve/moderado e 55,3 minutos para o déficit neurológico grave (p=0,025). Conclusão: Destaca-se a influência da condição neurológica no tempo de internação e a importância do atendimento ágil por parte da equipe. (AU)

Objective: To identify the risk factors associated with neurological deficit in people who victims of ischemic stroke. Methods: This is a retrospective quantitative descriptive study carried out in a hospital in the interior of Minas Gerais Brazil. Data were collected from 52 medical records, using an instrument containing sociodemographic and clinical variables and treatment time windows. To assess neurological deficit, the National Institutes of Health Stroke Scale was used. The Shapiro-Wilk, Pearson Chi- square, T Student and McNemar testes were used for statistical analysis. The significance level was 0,05. Results: At hospital admission there was a prevalence of moderate neurological deficit, and at hospital discharge, mild neurological deficit. Neurological deficit values at hospital admission and discharge werw respectively 13,10 (±7,2) and 7,58 (±8,3), p = (0,000). The hospital stay was 7,78 days for individuals with mild/moderate neurological deficit and 11,67 days for severe neurological deficit (p=0,044). The needle door window time was 38 minutes for patients with mild/moderate neurological deficit and 55,3 minutes for severe neurological deficit (p=0,025). Conclusion: The influence of the neurological condition on the length of stay and the importance of prompt care by the team are highlighted. (AU)

Objetivo: Identificar los factores de riesgo asociados al déficit neurológico en personas víctimas de ictus isquémico. Métodos: Se trata de un estudio cuantitativo descriptivo retrospectivo realizado en un hospital del interior de Minas Gerais Brasil. Se recolectaron datos de 52 historias clínicas, utilizando un instrumento que contiene variables sociodemográficas y clínicas y ventanas de tiempo de tratamiento. Para evaluar el déficit neurológico, se utilizó la National Institutes of Health Stroke Scale. Para el análisis estadístico se utilizaron las pruebas de Shapiro-Wilk, Chi-cuadrado de Pearson, T de Student y McNemar. El nivel de significancia fue 0.05. Resultados: al ingreso hospitalario prevaleció déficit neurológico moderado y al alta hospitalaria déficit neurológico leve. Los valores de déficit neurológico al ingreso y al alta hospitalaria fueron respectivamente 13,10 (± 7,2) y 7,58 (± 8,3), p = (0,000). La estancia hospitalaria fue de 7,78 días para individuos con déficit neurológico leve / moderado y de 11,67 días para déficit neurológico severo (p = 0,044). El tiempo de ventana de la puerta de la aguja fue de 38 minutos para pacientes con déficit neurológico leve / moderado y de 55,3 minutos para déficit neurológico severo (p = 0,025). Conclusión: Se destaca la influencia de la afección neurológica en la duración de la estadía y la importancia de una atención inmediata por parte del equipo. (AU)

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Abstract The development of stable cell lines producing recombinant proteins is very time-consuming and laborious. One of the practical approaches successfully performed is Fluorescence-Activated Cell Sorting (FACS). A mutated chimeric tissue plasminogen activator (mt-PA) was developed by removing the first three domains of t-PA, insertion of GHRP sequence and mutation toward resistance to plasminogen activator inhibitor-1 (PAI-1). In the current study, a new stable CHO-DG44 cell line producing mt-PA was developed by two sequential clonal selections: FACS and clonal-selection by limiting dilution. Furthermore, the expression was more evaluated using two different expression media. Finally, the high-producing clones were selected based on the dot blot and amidolytic activity test. The transfection efficiency of CHO-DG44 cells was 38% as measured by flow cytometry on green fluorescent protein (GFP). After performing FACS on stable cell pools, the expression yield was increased to fifty-fold. In terms of growth profile, CD-DG44 showed higher viability and cell density results than ProCHO5 medium. The expression of mt-PA was significantly higher in CD-DG44 than in ProCHO5, 765 and 280 IU/mL, respectively. Our data indicated that selection of an appropriate expression medium played a critical role in the development of potent producing stable cells by FACS.

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RESUMEN INTRODUCCIÓN: El ataque cerebrovascular (ACV) es la segunda causa de muerte y tercera causa de discapacidad en el mundo. La trombólisis intravenosa, como tratamiento agudo del ACV isquémico ha demostrado reducir discapacidad y mortalidad; sin embargo, está directamente ligado al tiempo de administración y un adecuado programa hospitalario. Mediante este trabajo se evalúan los tiempos de atención en trombólisis intravenosa en el Hospital Universitario Departamental de Nariño E.S.E, como institución de referencia departamental en Colombia. MATERIALES Y MÉTODOS: Estudio descriptivo transversal retrospectivo, incluyó pacientes con ACV isquémico que recibieron trombólisis intravenosa entre 2014 y 2019. El análisis se realizó mediante estadísticos descriptivos, y frecuencias absolutas y relativas. Para evaluar las diferencias se dividió en tres periodos de atención. RESULTADOS: Se evaluaron 50 pacientes, con edad promedio 67,6 años, 58% hombres. En 70% se observó una disminución mayor a 3 puntos NIHSS post-trombólisis. El 58 % tuvo escala modificada Rankin (mRS) 0 a 1. Hubo una diferencia significativa entre las medianas del tiempo Puerta-TAC con 36,5 (n=10, 2014-2015 ), 34,5 (n=16, 2016-2017) y 16 minutos (n=24, 2018-2019). Y en el tiempo Puerta-Aguja fue de 154,8; 98,2 y 79,9 minutos en los mismos periodos. En 45,8% el tiempo Puerta-Aguja fue menor a 60 minutos en el tercer periodo. CONCLUSIONES: Se evidencia aumento del número de pacientes que reciben trombólisis intravenosa a través de los años evaluados, así como disminución en tiempo Puerta-TAC y Puerta-Aguja, como marcadores de mejoría en la atención clínica.

ABSTRACT INTRODUCTION: Stroke is the second leading cause of death and third of disability in the world. Intravenous Thrombolysis as a treatment for acute ischemic stroke has been shown to reduce disability and mortality; however, it is directly linked to administration time and adequate stroke care attention. Through this work, the times of attention in thrombolysis are evaluated at the Hospital Universitario Departamental de Narino E.S.E, as a local reference institution in Colombia. METHODS: A retrospective descriptive study included patients with ischemic stroke who received intravenous thrombolysis between 2014 and 2019. The analysis was performed using descriptive statistics and absolute and relative frequencies. To assess the differences, it was divided into three attention periods. RESULTS: 50 patients were evaluated, with an average age of 67.6 years, 58% men. In 70% a decrease greater than 3 NIHSS points was observed post-thrombolysis. The 58% had mRS 0-1. There was a difference between the medians in the Door-CT time with 36.5 (n = 10, 2014-2015), 34.5 (n = 16, 2016-2017) and 16 minutes (n = 24, 2018-2019). And in the Door-Needle time was 154.8; 98.2 and 79.9 minutes in the same periods. In 45.8%, the Door-Needle time was less than 60 minutes in the third period. CONCLUSIONS: There is evidence of an increase in the number of patients receiving intravenous thrombolysis throughout the years evaluated, as well as a decrease in Door-CT and Door-Needle times, as markers of improvement in clinical care.

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Introducción: el tratamiento con activador recombinante del plasminógeno tisular (siglas en inglés rt-PA), aplicado vía intravenosa (IV) es el procedimiento de primera línea en casos de evento vascular cerebral (EVC) en una ventana de 4,5 horas a partir del inicio de los síntomas y con bajo riesgo de transformación hemorrágica del infarto cerebral. El personal de enfermería es un elemento clave para el tratamiento de las personas que han padecido un EVC y se encuentra en su etapa aguda. La fibrinólisis con alteplasa (rt-PA) se ha establecido como tratamiento de primera línea para los casos de ictus isquémico, la administración de este fármaco, control y seguimiento de estos pacientes idealmente debe realizarse por el personal de enfermería en las unidades de ictus. Objetivo: investigar el nivel de conocimiento del personal de enfermería en la administración del activador recombinante del plasminógeno tisular (rt-PA) en el servicio de urgencias en una institución de tercer nivel. Material y métodos: se realizó un estudio descriptivo y transversal en el Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez de la Ciudad de México, con un muestreo por conveniencia, participaron 33 profesionales de enfermería que laboran en el servicio de urgencias, se observaron las 24 horas del día. Se tomó en cuenta a enfermeras de todas las categorías, excluyendo a personal médico, camilleros y enfermeras suplentes. Se aplicó un instrumento para evaluar el conocimiento sobre enfermedad vascular isquémica e intervenciones de enfermería en el cuidado inmediato y mediato en la administración del fármaco activador tisular de plasminógeno (rt-PA). Resultados: llama la atención que sólo 58 % del personal de enfermería conozca el tiempo vital para recuperar al cerebro, otro dato que alarma es que el 30 % no tiene claro el concepto de ictus y al ser una institución de especialidad neurológica de debe establecer un programa de capacitación para establecer intervenciones oportunas con (rt-PA) para reducir secuelas o daño neurológico. Discusión: el papel del personal de enfermería en unidades especializadas en afecciones neurológicas a los pacientes con ictus es proporcionar un cuidado de calidad, eficaz y eficiente, además de participar en la valoración integral del paciente y en la administración del actilyse cuando se trata de una terapia fibrinolítica. En consecuencia, la enfermera debe estar formada sobre los cuidados que requiere este tipo de pacientes, las complicaciones propias de la patología, tratamiento y efectos secundarios del mismo. Proponer un plan de cuidados integral, porque ya el personal tiene conocimientos al respecto de la enfermedad y la aplicación del activador tisular, pero sería interesante implementar para los profesionales en formación, sin olvidar la elaboración de una propuesta como guía de actuación. Conclusión: los cuidados que el personal de enfermería lleva a cabo deben ser especializados en constante actualización y capacitación para ser capaces de detectar y prevenir las complicaciones del proceso patológico y tratamiento.

Introduction: recombinant tissue plasminogen activator (rt-PA) therapy, given intravenously (IV), is the first-line procedure in cases of cerebral vascular event (CVE) within 4.5 hours of symptom onset and with low risk of haemorrhagic transformation of cerebral infarction. Nurses are a key element in the management of people who have suffered a stroke and are in the acute stage. Fibrinolysis with alteplase (rt-PA) has been established as the first-line treatment for ischaemic stroke, and the administration of this drug, control and follow-up of these patients should ideally be carried out by nurses in stroke units. Objective: to investigate the level of nursing staff knowledge in the administration of recombinant tissue plasminogen activator (rt-PA) in the emergency department of a tertiary care institution. Material and methods: a descriptive, cross-sectional study was carried out at the Manuel Velasco Suárez National Institute of Neurology and Neurosurgery in Mexico City, with convenience sampling. 33 nursing professionals working in the emergency department participated, and 24 hours a day were observed. All categories of nurses were considered, excluding medical staff, orderlies and substitute nurses. An instrument was used to assess knowledge of ischaemic vascular disease and nursing interventions in immediate and intermediate care in the administration of tissue plasminogen activator (rt-PA). Results: It is striking that only 58 % of nursing staff are aware of the vital time to recover the brain, another alarming fact is that 30 % are not clear about the concept of stroke and, being a neurological speciality institution, a training programme should be established to establish timely interventions with (rt-PA) to reduce sequelae or neurological damage. Discussion: the role of nurses in units specialising in neurological disorders in stroke patients is to provide quality, effective and efficient care, in addition to participating in the comprehensive assessment of the patient and in the administration of actilyse in the case of fibrinolytic therapy. Consequently, the nurse must be trained in the care required by this type of patient, the complications of the pathology, treatment and its side effects. Propose a comprehensive care plan, because the staff already has knowledge of the disease and the application of the tissue activator, but it would be interesting to implement it for professionals in training, without forgetting the development of a proposal as a guide for action. Conclusion: the care carried out by nursing staff must be specialised and constantly updated and trained in order to be able to detect and prevent complications of the pathological process and treatment.

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Exercise intensity modulates postprandial lipemia. However, its effect on hemostatic and pro- and anti-inflammatory markers in the postprandial state is still unknown. Eleven young males performed a 2-day trial on different conditions: (i) REST: rest for 45 min; (ii) MIE: moderate-intensity exercise; and (iii) HIE: heavy-intensity exercise. Experimental conditions were performed in the evening. On the following morning, blood samples were taken in the fasted state (0 h) and at 1, 3, and 5 h after the consumption of a high-fat meal (HFM). Interleukin-10 (IL-10) levels were higher in the HIE vs. MIE trial at 0 and 1 h (p < 0.033) and IL-10 incremental area under the curve (iAUC) was greater in the MIE (p = 0.027) and HIE (p = 0.045) trials vs. REST. Lower levels of anti-coagulation factor VII (FVII) were observed at 1 h in the MIE condition vs. REST (p = 0.043). In comparison with REST, MIE improved hemostatic (FVII) and anti-inflammatory markers (IL-10 iAUC) whereas HIE enhanced IL-10 in the postprandial state. Regardless of the exercise intensity, aerobic exercise mitigates the deleterious consequences of an HFM. Novelty: Prior aerobic exercise at moderate-intensity attenuates next day's postprandial FVII and IL-10 levels whereas exercise performed at heavy-intensity increases IL-10 levels. Moderate-intensity exercise may be more beneficial to improve hemostatic (FVII) and anti-inflammatory (IL-10) responses while heavy-intensity exercise may improve anti-inflammatory (IL-10) levels only.

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Objetivo: Analisar o custo-efetividade da trombólise com alteplase no tratamento de acidente vascular isquêmico (AVCi) agudo em até 4,5 horas após início dos sintomas em comparação com tratamento clínico conservador, sob a perspectiva do Sistema Único de Saúde (SUS) no Brasil. Métodos: Construiu-se um modelo de Markov para simular o tratamento de AVCi agudo e suas consequências em curto e longo prazo. Foram conduzidas análises de custo-efetividade (anos de vida ganhos, AVG) e custo-utilidade (anos de vida ajustados pela qualidade de vida, QALY), considerando um horizonte temporal de tempo de vida. Parâmetros de eficácia e segurança foram obtidos em uma metanálise de dados individuais, considerando tratamento em até 3 horas e 3-4,5 horas. Os custos agudos e crônicos foram obtidos por análise secundária de dados de um hospital público brasileiro e expressos em reais (R$). Foram conduzidas análises de sensibilidade determinística e probabilística. Utilizou-se como limiar de disposição a pagar (LDP) 1 PIB (produto interno bruto) per capita para 2019 no Brasil (R$ 31.833,50). Resultados: O tratamento com alteplase vs. conservador resultou em incremento de 0,22 AVG, 0,32 QALY e R$ 4.320,12 em custo, com razão de custo-efetividade incremental (RCEI) estimada em R$ 19.996,43/AVG e R$ 13.383,64/QALY. Ambas as estimativas foram mais sensíveis a variações na efetividade e nos custos de tratamento agudo com alteplase. Para RCEI/AVG e RCEI/QALY, 70,7% e 93,1% das simulações na análise de sensibilidade probabilística estavam abaixo do LDP, respectivamente. Conclusões: O tratamento com alteplase até 4,5 horas após o início dos sintomas tem elevada probabilidade de ser custo-efetivo na perspectiva do SUS.

Objective: To assess the cost-effectiveness of thrombolysis with alteplase for the treatment of acute ischemic stroke up to 4.5 hours after the onset of symptoms as compared to conservative medical treatment from the perspective of the Brazilian Public Health System. Methods: A Markov model was used to simulate the treatment of acute stroke and the associated short- and long-term consequences. Cost-effectiveness (life-years gained, LYG) and cost-utility (quality-adjusted life years, QALY) analyses were performed considering a lifetime horizon. Efficacy and safety parameters were obtained from a meta-analysis of individual data, considering treatment within 3 hours and 3-4.5 hours after the onset of symptoms. Acute and chronic costs were derived from a secondary analysis of data obtained from a Brazilian public hospital and expressed in Brazilian reais (R$). Probabilistic and deterministic sensitivity analyses were performed. The willingness to pay threshold (WPT) was established as 1 GDP per capita for 2019 in Brazil (R$ 31,833.50). Results: Treatment with alteplase vs. conservative medical treatment was associated with an increase of 0.22 in LYG, 0.32 in QALY, and R$ 4,320.12 in cost. The incremental cost-effectiveness ratio (ICER) was estimated as R$ 19,996.43/LYG and R$ 13,383.64/QALY. Variations in effectiveness and costs of acute alteplase treatment had the greatest impact on sensitivity analyses. Considering ICER/LYG and ICER /QALY, 70.7% and 93.1% of the simulations in probabilistic sensitivity analysis were below the WPT, respectively. Conclusions: Treatment with alteplase up to 4.5 hours after the onset of symptoms has a high probability of being cost-effective from the perspective of the Brazilian Public Health System.

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