The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial.

BACKGROUND: Early control of elevated blood pressure is the most promising treatment for acute intracerebral haemorrhage. We aimed to establish whether implementing a goal-directed care bundle incorporating protocols for early intensive blood pressure lowering and management algorithms for hyperglycaemia, pyrexia, and abnormal anticoagulation, implemented in a hospital setting, could improve outcomes for patients with acute spontaneous intracerebral haemorrhage. METHODS: We performed a pragmatic, international, multicentre, blinded endpoint, stepped wedge cluster randomised controlled trial at hospitals in nine low-income and middle-income countries (Brazil, China, India, Mexico, Nigeria, Pakistan, Peru, Sri Lanka, and Viet Nam) and one high-income country (Chile). Hospitals were eligible if they had no or inconsistent relevant, disease-specific protocols, and were willing to implement the care bundle to consecutive patients (aged ≥18 years) with imaging-confirmed spontaneous intracerebral haemorrhage presenting within 6 h of the onset of symptoms, had a local champion, and could provide the required study data. Hospitals were centrally randomly allocated using permuted blocks to three sequences of implementation, stratified by country and the projected number of patients to be recruited over the 12 months of the study period. These sequences had four periods that dictated the order in which the hospitals were to switch from the control usual care procedure to the intervention implementation of the care bundle procedure to different clusters of patients in a stepped manner. To avoid contamination, details of the intervention, sequence, and allocation periods were concealed from sites until they had completed the usual care control periods. The care bundle protocol included the early intensive lowering of systolic blood pressure (target <140 mm Hg), strict glucose control (target 6·1-7·8 mmol/L in those without diabetes and 7·8-10·0 mmol/L in those with diabetes), antipyrexia treatment (target body temperature ≤37·5°C), and rapid reversal of warfarin-related anticoagulation (target international normalised ratio <1·5) within 1 h of treatment, in patients where these variables were abnormal. Analyses were performed according to a modified intention-to-treat population with available outcome data (ie, excluding sites that withdrew during the study). The primary outcome was functional recovery, measured with the modified Rankin scale (mRS; range 0 [no symptoms] to 6 [death]) at 6 months by masked research staff, analysed using proportional ordinal logistic regression to assess the distribution in scores on the mRS, with adjustments for cluster (hospital site), group assignment of cluster per period, and time (6-month periods from Dec 12, 2017). This trial is registered at Clinicaltrials.gov (NCT03209258) and the Chinese Clinical Trial Registry (ChiCTR-IOC-17011787) and is completed. FINDINGS: Between May 27, 2017, and July 8, 2021, 206 hospitals were assessed for eligibility, of which 144 hospitals in ten countries agreed to join and were randomly assigned in the trial, but 22 hospitals withdrew before starting to enrol patients and another hospital was withdrawn and their data on enrolled patients was deleted because regulatory approval was not obtained. Between Dec 12, 2017, and Dec 31, 2021, 10 857 patients were screened but 3821 were excluded. Overall, the modified intention-to-treat population included 7036 patients enrolled at 121 hospitals, with 3221 assigned to the care bundle group and 3815 to the usual care group, with primary outcome data available in 2892 patients in the care bundle group and 3363 patients in the usual care group. The likelihood of a poor functional outcome was lower in the care bundle group (common odds ratio 0·86; 95% CI 0·76-0·97; p=0·015). The favourable shift in mRS scores in the care bundle group was generally consistent across a range of sensitivity analyses that included additional adjustments for country and patient variables (0·84; 0·73-0·97; p=0·017), and with different approaches to the use of multiple imputations for missing data. Patients in the care bundle group had fewer serious adverse events than those in the usual care group (16·0% vs 20·1%; p=0·0098). INTERPRETATION: Implementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition. FUNDING: Joint Global Health Trials scheme from the Department of Health and Social Care, the Foreign, Commonwealth & Development Office, and the Medical Research Council and Wellcome Trust; West China Hospital; the National Health and Medical Research Council of Australia; Sichuan Credit Pharmaceutic and Takeda China.

Predictive accuracy of clinicians estimates of death and recovery after acute intracerebral hemorrhage: pre-specified analysis in INTERACT3 study.

INTRODUCTION: Accurately predicting a patient's prognosis is an important component of decision-making in intracerebral hemorrhage (ICH). We aimed to determine clinicians' ability to predict survival, functional recovery, and return to premorbid activities in patients with ICH. METHODS: Pre-specified secondary analysis of the third INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3), an international, multicenter, stepped-wedge cluster randomized controlled trial. Clinician perspectives on prognosis were collected at hospital admission and Day 7 (or before discharge). Prognosis questions were the likelihood of (i) survival at 48 hours and 6 months, (ii) favorable functional outcome (recovery walking and self-care) and (iii) return to usual activities at 6 months. Clinician predictions were compared with actual outcomes. RESULTS: Most clinician participants were from neurosurgery (75%) with a median of 8 working years (IQR 5-14) of experience. Of the 6305 randomized patients who survived 48 hours, 213 (3.4%) were predicted to die (positive predictive value [PPV] 0.99, 95% confidence interval [CI] 0.99-0.99). Of 5435 patients who survived 6 months, 209 (3.8%) were predicted to die (PPV 0.93, 95% CI 0.92-0.93). Predictions on favorable functional outcome (PPV 0.54, 95% CI 0.52-0.56) and satisfied ability to return to usual activities (PPV 0.50, 95% CI 0.49-0.52) were poor. Prediction accuracy varied by working years and region of practice. CONCLUSIONS: In patients with ICH, clinician estimates of death are very good but conversely they are poor in predicting higher levels of functional recovery and activities.

Availability and barriers to access post-stroke rehabilitation in Latin America.

OBJECTIVES: To describe the availability and barriers to access post-stroke rehabilitation services in Latin America. MATERIALS AND METHODS: We conducted a multi-national survey in Latin American countries. The survey consisted of three sections: (1) the national state of post-stroke rehabilitation; (2) the local state of post-stroke rehabilitation; and (3) the coverage and financing of post-stroke services. Stroke leaders from the surveyed countries were involved in developing and disseminating the survey. RESULTS: 261 responses were collected from 17 countries. The mean age of respondents was 42.4 ± 10.1 years, and 139 (54.5 %) of the respondents were male. National clinical guidelines for post-stroke rehabilitation were reported by 67 (25.7 %) of the respondents. However, there were discrepancies between respondents within the same country. Stroke units, physiotherapy, occupational therapy, speech therapy, and neuropsychological therapy services were less common in public than private settings. The main barriers for inpatient and outpatient services included limited rehabilitation facilities, coverage, and rehabilitation personnel. The main source of financing for the inpatient and outpatient services was the national health insurance, followed by out-of-pocket payments. Private and out-of-pocket costs were more frequently reported in outpatient services. CONCLUSIONS: Post-stroke rehabilitation services in Latin American countries are restricted due to a lack of coverage by the public health system and private insurers, human resources, and financial aid. Public settings offer fewer post-stroke rehabilitation services compared to private settings. Developing consensus guidelines, increasing coverage, and using innovative approaches to deliver post-stroke rehabilitation is paramount to increase access without posing a financial burden.

Stroke care and collaborative academic research in Latin America.

OBJECTIVE: A narrative overview of regional academic research collaborations to address the increasing burden and gaps in care for patients at risk of, and who suffer from, stroke in Latin America (LA). MATERIALS AND METHODS: A summary of experiences and knowledge of the local situation is presented. No systematic literature review was performed. RESULTS: The rapidly increasing burden of stroke poses immense challenges in LA, where prevention and manage-ment strategies are highly uneven and inadequate. Clinical research is increasing through various academic consortia and networks formed to overcome structural, funding and skill barriers. However, strengthening the ability to generate, analyze and interpret randomized evidence is central to further develop effective therapies and healthcare systems in LA. CONCLUSIONS: Regional networks foster the conduct of multicenter studies -particularly randomized controlled trials-, even in resource-poor regions. They also contribute to the external validity of international studies and strengthen systems of care, clinical skills, critical thinking, and international knowledge exchange.

Managing Post-Stroke Care During the COVID-19 Pandemic at a Tertiary Care Level Hospital in Peru.

OBJECTIVES: To understand the hospital-to-outpatient care transition and how the discharge process of stroke patients is managed; and to identify potential opportunities to improve these processes, while contrasting pre- and during COVID-19 experiences in Peru. METHODS: A qualitative study was conducted between February and March 2021 consisting of in-depth interviews of patients with stroke, their caregivers and healthcare personnel regarding stroke care at a national tertiary referral center for stroke care in Lima, Peru. We explored the following phases of the patients' journeys: pre-hospitalization, emergency room, hospitalization, discharge process and post-discharge. For each phase, we explored experiences, feelings and expectations using thematic analysis. RESULTS: We conducted a total of 11 interviews with patients or caregivers and 7 with health care personnel and found disruption in the continuity of care for patients with stroke. Mainly, caregivers and patients referred to problems related to communication with healthcare personnel and an absence of training to provide post-discharge care at home. Potential solutions included increasing human resources and caregiver participation in care, implementation of electronic healthcare records, improving the referral system and reinforcing telemedicine services. CONCLUSION: The continuity of care of patients with stroke was negatively affected during the COVID-19 pandemic. In LMICs, the impact was likely greater due to the already weak and fragmented healthcare systems. The COVID-19 pandemic presents an opportunity to improve post-stroke care services, and address patients' experiences and feelings by developing solutions in a participatory manner.

Adherence to American Heart Association/American Stroke Association Clinical Performance Measures in a Peruvian Neurological Reference Institute.

BACKGROUND: Little is known about adherence to American Heart Association/American Stroke Association (AHA/ASA) stroke performance measures in developing countries like Peru. AIMS: We assessed adherence and determined factors associated with adherence to the AHA/ASA stroke performance measures at a reference center for neurological diseases in Lima, Peru. METHODS: We conducted a retrospective chart review of 150 stroke patients admitted to the Neurological Institute of Neurological Science from 2014 to 2016 to ascertain adherence to 15 different AHA/ASA stroke performance measures. Adherence was measured as a simple proportion, with both single and composite measures. Associations were analyzed with nonparametric statistics and multivariate logistic regression. RESULTS: Mean adherence to AHA/ASA stroke performance measures was 47%. We observed a statistically significant relationship between adherence to ischemic stroke performance measures and being married (OR = 3.78, 95% CI: 1.05-13.55), as well as an inverse relationship with an onset of symptoms of greater than 4.5 h prior to arrival at the hospital compared to those with ≤ 4.5 h (OR = 0.14, 95% CI: 0.02-0.97). Compared to patients with a lower National Institutes of Health Stroke Scale (NIHSS) score (<13), those with a score of ≥13 were less likely to have good adherence (OR = 0.11, 95% CI: 0.04-0.31). CONCLUSIONS: The mean composite measure of adherence to internationally recognized standards of stroke management in our Peruvian institution was below the level needed for an achievement award by AHA/ASA. An intervention targeted toward stroke prevention and training could lead to improved outcomes of stroke patients in Peru.

Challenges of Thrombolysis in a Developing Country: Characteristics and Outcomes in Peru.

BACKGROUND: The availability of intravenous tissue plasminogen activator (IV-tPA) remains limited worldwide, especially in low-income countries, where the burden of disability due to ischemic stroke is the highest. AIMS: To evaluate outcomes and safety of IV-tPA at the only Peruvian reference institute for neurologic diseases. METHODS: We conducted a prospective, observational study of stroke patients who received IV-tPA between 2009 and 2016. We assessed characteristics associated with good outcome (modified Rankine scale 0-2) at 3 months using a multivariate regression model; and factors correlated with clinical improvement (delta National Institute of Health Stroke Scale (NIHSS)) using linear regression. RESULTS: Only 1.98% (39/1,1962) of patients presenting with ischemic stroke received IV-tPA. Nearly half (41%) were younger than 60 years, 56.4 % were men, and most strokes were cardioembolic (46.2%). The majority (64.1%) were treated within 3-4.5 hours. The median NIHSS on admission and discharge was 9 and 4, respectively; 42.1% of patients had an mRS of 0-1 at 3 months. Three patients (7.7%) developed hemorrhagic conversion, and 1 patient died (2.6%). Patients with good outcomes had lower pretreatment systolic blood pressure (138.9 versus 158.1 mm Hg, P < .007), fewer complications during hospitalization (5 versus 9 events, P < .001), shorter hospital stay (14 versus 21 days, P < .03) and, paradoxically, longer last known well -to-door times (148.3 versus 105 minutes, P < .0022). Clinical improvement was associated with shorter door-to-tPA times and obesity. CONCLUSIONS: Our findings indicate that IV-tPA has similar safety and outcomes compared to developed countries. All internal metrics (door-to-tPA, door-to-CT, and CT-to-tPA time) improved over time, highlighting areas for future implementation science studies to further expedite the administration of IV-tPA.

Stroke Care and Application of Thrombolysis in Ibero-America: Report From the SITS-SIECV Ibero-American Stroke Register

Background and Purpose: Standardized registries may provide valuable data to further improve stroke care. Our aim was to obtain updated information about characteristics of stroke patients and management of stroke across the Ibero-American countries, using a common in-hospital registry (Safe Implementation of Treatments in Stroke­Sociedad Iberoamericana de Enfermedades Cerebrovasculares) as a basis for further quality improvement. Methods: Data for this study were entered into the Safe Implementation of Treatments in Stroke registry from September 2009 to December 2013 by 58 centers in 14 countries. Data included demographics, risk factors, onset-to-door time, National Institutes of Health Stroke Scale score, stroke subtype, ischemic stroke etiology, treatments, 3-month mortality, and modified Rankin Scale score. Time to treatment was also recorded for patients treated with thrombolysis. Results: Five thousand four hundred one patients were registered; median age, 65 years; 46% women; 3915 (72.5%) ischemic strokes; 686 (13.7%) hemorrhagic strokes; 213 (4.3%) subarachnoid hemorrhages; 414 (8.3%) transient ischemic attacks; and 31 (0.6%) cerebral vein thrombosis. The most prevalent risk factors were hypertension (71.3%), dyslipidemia (35.2%), and diabetes mellitus (23.6%). Atrial fibrillation was present in 15.1%. Three hundred one ischemic strokes were treated with intravenous thrombolysis (IVT; 7.7%). Patients undergoing IVT were more severely affected (median baseline National Institutes of Health Stroke Scale score, 11 versus 6). The rate of symptomatic intracerebral hemorrhages after IVT was 5.7%. At 3 months, 60.3% of IVT-treated patients and 59.1% of untreated patients were independent (modified Rankin Scale score, 0­2). Mortality was 11.4% in treated and 12.8% in untreated patients. Conclusions: Safe Implementation of Treatments in Stroke­Sociedad Iberoamericana de Enfermedades Cerebrovasculares is the largest registry of a general stroke population and the first study to evaluate the level of IVT use in Ibero-America. It provides valuable information that may help to improve the quality of stroke care in the Ibero-American region.

Predictors of functional outcome among stroke patients in Lima, Peru.

BACKGROUND: Because of the aging population in low- and middle-income countries, cerebrovascular disease is expected to remain a leading cause of death. Little has been published about stroke in Peru. We conducted a retrospective cohort study of hospitalized stroke patients at a referral center hospital in Lima, Peru to explore factors associated with functional outcome among stroke patients. METHODS: We identified 579 patients hospitalized for ischemic stroke or intracerebral hemorrhage stroke at the National Institute of Neurologic Sciences in Lima, Peru in 2008 and 2009. A favorable outcome was defined as a modified Rankin scale score of ≤ 2 at discharge. RESULTS: The mean age was 63.3 years; 75.6% had ischemic stroke; the average duration of stay was 17.3 days. At hospital discharge, 231 (39.9%) had a favorable outcome. The overall mortality rate was 5.2%. In multivariate models, the likelihood of having a favorable outcome decreased linearly with increasing age (P = .02) and increasing National Institutes of Health Stroke Scale (NIHSS) score (P = .02). Favorable outcome was also associated with male gender (relative risk [RR] 1.2; 95% confidence interval [CI] 1.0-1.5) and divorced status (RR 1.3; 95% CI 1.1-1.7). Patients on Salud Integral de Salud (SIS; public assistance-type insurance; RR 0.7; 95% CI 0.5-1.0) were also less likely to have a favorable outcome. CONCLUSIONS: Favorable outcome after stroke was independently associated with younger age, a lower NIHSS score, male gender, being divorced, and not being on SIS insurance. These findings suggest that additional study of worse functional outcomes in patients with SIS insurance be conducted and confirm the importance of risk adjustment for age, stroke severity (according to the NIHSS scale), and other socioeconomic factors in outcomes studies. Future studies should preferentially assess outcome at 30 days and 6 months to provide more reliable comparisons and allow additional study of Peruvian end-of-life decision-making and care.

Spinal Dural Arteriovenous Fistula: A Mimic of Demyelinating Disease and Radiculopathy.

Spinal dural arteriovenous fistula (SDAVF) is characterized by an abnormal connection between a radicular artery and the venous plexus producing spinal cord venous congestion. It manifests with nonspecific sensory and motor symptoms. We present three cases of SDAVF with different forms of presentation; in two cases, an autoimmune etiology was considered, and in the third case, the initial diagnosis was chronic radiculopathy. In all three cases, a serpentine enhancement was observed after the gadolinium in the dorsal region of the spinal cord corresponded to flow voids in T2-weighted images, which guided the diagnosis. SDAVF should be considered in atypical clinical presentations of radiculopathies or spinal cord syndromes, especially spinal conus or epicone syndrome. Likewise, it should be part of the differential diagnosis of spinal cord presentations of demyelinating diseases such as multiple sclerosis or neuromyelitis optica spectrum disorders.

Burden of Stroke and Population-Attributable Fractions of Risk Factors in Latin America and the Caribbean.

Background Stroke burden characterization studies in low- and middle-income countries are scarce. We estimated the burden of stroke and its risk factors in Latin America and the Caribbean (LAC). Methods and Results We extracted GBD (Global Burden of Disease) study 2019 data on overall stroke and 3 subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) for 20 LAC countries. We estimated absolute and age-standardized rates of disability-adjusted life years, years of life lost, years lived with disability, and deaths. The population-attributable fractions of 17 risk factors were estimated. All analyses were performed at regional and national levels by stroke subtype, sex, and age subgroups. In 2019, the LAC region had the fourth largest stroke burden worldwide (6.8 million disability-adjusted life years), predominantly attributable to premature deaths (89.5% of disability-adjusted life years). Intracerebral hemorrhage was the primary cause of the overall stroke burden (42% of disability-adjusted life years), but ischemic stroke was the leading cause of disability (69% of total years lived with disability). Haiti and Honduras had the highest age-standardized rates. Older adults and men had the largest burdens, although women had the highest rate of disability. Socioeconomic development level did not influence the burden. The major risk factor clusters were metabolic (high systolic blood pressure [population-attributable fraction=53%] and high body mass index [population-attributable fraction=37%]), which were more influential in hemorrhagic events, women, and older adults. Household air pollution was an important risk factor in low-income countries in LAC. Conclusions The stroke burden and stroke-related mortality in LAC are higher than the worldwide averages. However, stroke is a highly preventable disease in this region. Up to 90% of the burden could be reduced by targeting 2 modifiable factors: blood pressure and body mass index. Further research and implementation of primary and secondary prevention interventions are needed, as well as integrated national stroke care programs for acute, subacute, and rehabilitation management in LAC.

Bullying Victimization Among Peruvian Children: The Predictive Role of Parental Maltreatment.

Bullying among schoolchildren is increasingly being recognized as a major problem. Although previous studies have examined parental maltreatment as a risk factor for bullying, the evidence on this topic remains limited in Latin America. The aim of this study was then to measure the prevalence of bullying victimization among a nationally representative sample of Peruvian children and to test the association between bullying victimization and parental maltreatment in Peru. This study used a pooled data set from the 2013 and 2015 Peru National Surveys on social relations. Participants were Peruvian children aged from 9 years to 11 years in the fourth, fifth, and sixth grade of primary in both public and private schools nationwide. The results indicated that almost one third of Peruvian children have experienced physical bullying and nearly half of them psychological bullying. However, only a small percentage reported experiencing bullying very frequently. Furthermore, it was found that parental maltreatment in any form-physical or psychological-was strongly and positively associated with physical and psychological bullying victimization. The results also showed that the probabilities of being physically or psychologically bullied were higher among children who experienced physical or psychological parental maltreatment than among children who have not experienced such violence. The probabilities of being bullied were even higher among children who experienced both types of parental maltreatment. Consistent with previous research, these findings suggest that the relationship that children establish with their parents will largely determine how they interact with their peers.

Carotid Web Diagnosed by Ultrasound Carotid Duplex in a Patient With Ischemic Stroke.

Carotid web (CW) is an atypical form of intimal fibromuscular dysplasia that occurs at the level of the carotid bulb. It is associated with ischemic strokes. The first report of this association was in 1967 and it is currently known to represent a significant percentage of cryptogenic stroke. We report the case of a young female patient with a history of transient ischemic attack who presented a cerebral infarction of the territory of the left middle cerebral artery. The diagnosis of CW was suggested by the findings of the ultrasound carotid duplex and was confirmed by digital subtraction angiography. Likewise, brain magnetic resonance angiography showed an incipient alteration in the morphology of the wall of the left internal carotid artery in its intracranial segment. Aspirin treatment was started and there was no recurrence up to two years of follow-up. CW represents a diagnostic challenge; it should be suspected in young adults with ischemic stroke. In them, studies of the supra-aortic vessels should be performed. Ultrasound carotid duplex can be a useful diagnostic tool.

Evidence-based appraisal of blood pressure reduction in spontaneous intracerebral hemorrhage: A scoping review and overview.

BACKGROUND AND AIM: There is a current debate on the best approach for blood pressure (BP) reduction in patients with spontaneous intracerebral hemorrhage (ICH). Through this scoping review, we aimed to examine how research on reducing BP in ICH patients has been conducted and to clarify the evidence on which approach is the best (intensive vs. standard BP reductions). METHODS: We performed a scoping review and overview of reviews of the literature. We systematically searched clinical practice guidelines (CPGs), systematic reviews (SRs), and randomized controlled trials (RCTs) that compared intensive versus standard BP reduction. We searched in three databases from inception until March 2020. Two independent authors conducted the study selection, data extraction, quality assessment, and overlapping analysis of SRs. We performed a description and critical appraisal of the current body of evidence. RESULTS: We included three CPGs (with moderate to high quality); all of them recommended intensive reduction in specific clinical settings. We included eight SRs (with high overlap and critically low quality): two supported intensive reduction and four supported its safety, but not effectiveness. One SR reported that patients with intensive reduction had a significant risk of renal adverse events. We included seven RCTs (with limitations in randomization process); trials with large population did not found significant differences in mortality and disability. One RCT reported a significantly higher number of renal adverse events. CONCLUSIONS: CPGs support the use of intensive BP reduction; however, most recent SRs partially supported or did not support it due to the association with renal events. It seems the range goal between 140 and 180 mmHg could be safe and equally effective than intensive reduction. We recommend further research in serious and non-serious events promoted by intensive reduction and outcomes homogenization across studies to ensure correct comparison.

Diagnostic Value of Thunderclap Headache and Convexal Subarachnoid Hemorrhage for Reversible Cerebral Vasoconstriction Syndrome: A Case Report.

Reversible cerebral vasoconstriction syndrome (RCVS) is an underdiagnosed cause of convexal subarachnoid hemorrhage, characterized by thunderclap headache associated with focal and segmental intracranial vasoconstriction. It can appear complications such as intracerebral hemorrhage, seizures, posterior reversible leukoencephalopathy, or ischemic stroke. Our objective is to present the case of a 51-year-old woman with an RCVS diagnosis, who had a normal digital subtraction angiography at the illness onset. We highlight the high diagnostic value of thunderclap headache and convexal subarachnoid hemorrhage. We also highlight the importance of repeating the angiographic studies in the second week when there is strong diagnostic suspicion.

INTEnsive care bundle with blood pressure reduction in acute cerebral hemorrhage trial (INTERACT3): study protocol for a pragmatic stepped-wedge cluster-randomized controlled trial.

BACKGROUND: Early intensive blood pressure (BP) lowering remains the most promising treatment for acute intracerebral hemorrhage (ICH), despite discordant results between clinical trials and potential variation in the treatment effects by approach to control BP. As the third in a series of clinical trials on this topic, the INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) aims to determine the effectiveness of a goal-directed care bundle protocol of early physiological control (intensive BP lowering, glycemic control, and pyrexia treatment) and reversal of anticoagulation, in acute ICH. METHODS: INTERACT3 is a pragmatic, international, multicenter, stepped-wedge (4 phases/3 steps), cluster-randomized controlled trial to determine the effectiveness of a multifaceted care package in adult (age ≥ 18 years) patients (target 8360) with acute ICH (< 6 h of onset) recruited from 110 hospitals (average of 19 consecutive patients per phase) in low- and middle-income countries. After a control phase, each hospital implements the intervention (intensive BP lowering, target systolic < 140 mmHg; glucose control, target 6.1-7.8 mmol/L and 7.8-10.0 mmol/L in those without and with diabetes mellitus, respectively; anti-pyrexia treatment to target body temperature ≤ 37.5 °C; and reversal of anticoagulation, target international normalized ratio < 1.5 within 1 h). Information will be obtained on demographic and baseline clinical characteristics, in-hospital management, and 7-day outcomes. Central trained blinded assessors will conduct telephone interviews to assess physical function and health-related quality of life at 6 months. The primary outcome is the modified Rankin scale (mRS) at 6 months analyzed using ordinal logistic regression. The sample size of 8360 subjects provides 90% power (α = 0.05) to detect a 5.6% absolute improvement (shift) in the primary outcome of the intervention versus control standard care, with various assumptions. DISCUSSION: As the largest clinical trial in acute ICH, INTERACT3 is on schedule to provide an assessment of the effectiveness of a widely applicable goal-directed care bundle for a serious condition in which a clearly proven treatment has yet to be established. TRIAL REGISTRATION: ClinicalTrials.gov NCT03209258. Registered on 1 July 2017. Chinese Trial Registry ChiCTR-IOC-17011787. Registered on 28 June 2017.

Disección cervical: a propósito de un caso / Dissection of the vertebral artery: a case report

La disección cervical es una entidad poco estudiada y diagnosticada como variante de infarto cerebral, sobretodo en el adulto joven; es, sin embargo, relativamente frecuente y debe formar parte del diagnóstico diferencialen pacientes jóvenes con infarto cerebral de mecanismo embólico. Se presenta el caso clínico de una paciente coninfarto cerebral en diferentes territorios vasculares: varios estudios de ayuda diagnóstica resultaron en la detecciónde compromiso de la arteria vertebral izquierda por disección arterial, mediante protocolos especiales de resonanciamagnética cervical.

Cervical dissection is a poorly studied and diagnosed entity, a variant of cerebral infarction particularly foundamong young adults. It is, however, relatively frequent and should be suspected as a differential diagnosis in young patients with history of an embolic stroke. The clinical case of a patient with cerebral infarction of different vascular territories is presented: various diagnostic studies resulted in the detection of involvement of the left vertebral artery by arterial dissection, by special protocols of cervical magnetic resonance.

Factores asociados a mortalidad en pacientes con infarto cerebral del Instituto Nacional de Ciencias Neurológicas: Enero 2008 - diciembre 2009 / Factors associated to mortality in patients with cerebral infarction at the Instituto Nacional de Ciencias Neurólogicas: January 2008 - December 2009

Objetivos: Explorar los factores asociados a mortalidad en pacientes con infarto cerebral que fueron hospitalizados en el Instituto Nacional de Ciencias Neurológicas. Material y Métodos: Se revisaron las historias clínicas de pacientes con diagnóstico de infarto cerebral hospitalizados en el Instituto Nacional de Ciencias Neurológicas, durante Enero del 2008 hasta Diciembre del 2009. Se describen las variables demográficas y clínicas de los pacientes, además se utilizó el modelo de regresión logística para explorar los factores asociados a mortalidad en los pacientes. Resultados: Se analizaron 461 historias clínicas de pacientes con infarto cerebral. El promedio de edad fue de 67 años, el 56% fueron hombres. La mortalidad fue del 7,6%, IC 95% (5,3-10,4); los factores asociados a mortalidad que tuvieron significancia estadística fueron: el déficit sensitivo OR=2,7, cefalea OR=2,75, trastorno de conciencia OR=12, escala NIHSS al ingreso OR=1,25 y el territorio vascular anterior OR=2,65. Conclusiones: en éste estudio exploratorio los factores asociados a mortalidad intrahospitalaria por infarto cerebral fueron la presencia de déficit sensitivo, cefalea, pérdida de conciencia, déficit neurológico severo y territorio vascular de la circulación anterior.

Objectives: To explore associated factors to mortality of patients with cerebral infarction. Methods: We reviewed clinical records of patients with diagnosis of cerebral infarction hospitalized at the Instituto Nacional de Ciencias Neurologicas, January 2008 to December 2010. We describe the demographic and clinical variables. In addition, the logistic regression model was used to determine the factors associated with mortality in these patients. Results: We reviewed clinical records of 461 patients with brain infarction. The median age was 67 years and 56% were men. We calculated a ratio of 7.6% dead, 95% IC (5.3-10.4); the factors significantly associated are the sensitive deficit OR = 2.7, headache OR = 2.75, consciousness disorder OR = 12, NIHSS scale OR = 1.25 and anterior vascular territory OR = 2.65. Conclusions: in this exploratory study factors associated with mortality by cerebral infarction were the presence of sensitive deficit, headache, loss of consciousness, severe neurological deficit and vascular territory of the anterior circulation.