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.

Higher arterial stiffness is associated with lower cognitive performance in patients with hypertension.

Cognitive impairment and elevated arterial stiffness have been described in patients with arterial hypertension, but their association has not been well studied. We evaluated the correlation of arterial stiffness and different cognitive domains in patients with hypertension compared with those with normotension. We evaluated 211 patients (69 with normotension and 142 with hypertension). Patients were age matched and distributed according to their blood pressure: normotension, hypertension stage 1, and hypertension stage 2. Cognitive function was assessed using the Mini-Mental State Examination, Montreal Cognitive Assessment, and a battery of neuropsychological evaluations that assessed six main cognitive domains. Pulse wave velocity was measured using a Complior device, and carotid properties were assessed by radiofrequency ultrasound. Central arterial pressure and augmentation index were obtained using applanation tonometry. The hypertension stage 2 group had higher arterial stiffness and worse performance either by Mini-Mental State Examination (26.8±2.1 vs 27.3±2.1 vs 28.0±2.0, P=.003) or the Montreal Cognitive Assessment test (23.4±3.5 vs 24.9±2.9 vs 25.6±3.0, P<.001). On multivariable regression analysis, augmentation index, intima-media thickness, and pulse wave velocity were the variables mainly associated with lower cognitive performance at different cognitive domains. Cognitive impairment in different domains was associated with higher arterial stiffness.

Hypertension Severity Is Associated With Impaired Cognitive Performance.

BACKGROUND: Most evidence of target-organ damage in hypertension (HTN) is related to the kidneys and heart. Cerebrovascular and cognitive impairment are less well studied. Therefore, this study analyzed changes in cognitive function in patients with different stages of hypertension compared to nonhypertensive controls. METHODS AND RESULTS: In a cross-sectional study, 221 (71 normotensive and 150 hypertensive) patients were compared. Patients with hypertension were divided into 2 stages according to blood pressure (BP) levels or medication use (HTN-1: BP, 140-159/90-99 or use of 1 or 2 antihypertensive drugs; HTN-2: BP, ≥160/100 or use of ≥3 drugs). Three groups were comparatively analyzed: normotension, HTN stage 1, and HTN stage 2. The Mini-Mental State Examination, Montreal Cognitive Assessment, and a validated comprehensive battery of neuropsychological tests that assessed 6 main cognitive domains were used to determine cognitive function. Compared to the normotension and HTN stage-1, the severe HTN group had worse cognitive performance based on Mini-Mental State Examination (26.8±2.1 vs 27.4±2.1 vs 28.0±2.0; P=0.004) or Montreal Cognitive Assessment (23.4±3.7 vs 24.9±2.8 vs 25.5±3.2; P<0.001). On the neuropsychological tests, patients with hypertension had worse performance in language, processing speed, visuospatial abilities, and memory. Age, hypertension stage, and educational level were the best predictors of cognitive impairment in patients with hypertension in different cognitive domains. CONCLUSIONS: Cognitive impairment was more frequent in patients with hypertension, and this was related to hypertension severity.

Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke.

These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.

Stroke Prevention in Atrial Fibrillation: Focus on Latin America.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention. The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events. The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region.

Stroke in Latin America.

Stroke is one of the leading causes of mortality in Latin America, with variable incidence and prevalence throughout the continent reflecting regional socioeconomic differences. In Latin America, uncontrolled hypertension is one of the major causes of stroke, but other modifiable risk factors also play a role, such as heavy alcohol consumption and smoking. Intracerebral hemorrhage and lacunar stroke are more frequent in Latin America than in North America and Europe. There are multiple causes of stroke that are endemic to Latin America, including neurocysticercosis, Chagas' disease, sickle cell anemia, malaria, hemorrhagic fever, and snake bites.

Clinical discriminators between acute brain hemorrhage and infarction: a practical score for early patient identification.

New treatments for acute stroke require a rapid triage system, which minimizes treatment delays and maximizes selection of eligible patients. Our aim was to create a score for assessing the probability of brain hemorrhage among patients with acute stroke based upon clinical information. Of 1805 patients in the Stroke Data Bank, 1273 had infarction (INF) and 237 had parenchymatous hemorrhage (HEM) verified by CT. INF and HEM discriminators were determined by logistic regression and used to create a score. ROC curve was used to choose the cut-point for predicting HEM (score

Neurologic complications after heart transplantation.

OBJECTIVE: Neurologic complications are known as important cause of morbidity and mortality in orthotopic heart transplantation. Our aim was to identify the frequency and outcome of neurologic complications after heart transplantation in a prospective observational study. METHOD: From September 93 to September 99, as part of our routine heart transplantation protocol all patients with end-stage cardiac failure were evaluated by the same neurologist before and at the time of any neurologic event (symptom or complaint) after transplantation. RESULTS: Out of 120 candidates evaluated, 62 were successfully transplanted (53 male; median age 45.5 years, median follow-up 26.8 months). Fifteen patients (24%) had ischemic, 22 (35%) idiopathic, 24 (39%) Chagas' disease and 1 (2%) had congenital cardiomyopathy. Neurologic complications occurred in 19 patients (31%): tremor, severe headache, transient encephalopathy and seizures related to drug toxicity or metabolic changes in 13; peripheral neuropathy in 4; and spinal cord compression in two (metastatic prostate cancer and epidural abscess). No symptomatic postoperative stroke was observed. CONCLUSIONS: Although frequent, neurologic complications were seldom related to persistent neurologic disability or death. Most of the complications resulted from immunosuppression, however, CNS infection was rare. The absence of symptomatic stroke in our series may be related to the lower frequency of ischemic cardiomyopathy.

Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke / Diretrizes brasileiras para o tratamento endovascular de pacientes com acidente vascular cerebral isquêmico agudo

ABSTRACT These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.

RESUMO Estas diretrizes são o resultado de um esforço conjunto de membros da Sociedade Brasileira de Doenças Cerebrovasculares (SBDCV), Departamento científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia (ABN), Rede Brasil AVC (RBAVC) e da Sociedade Brasileira de Neurorradiologia Diagnóstica e Terapêutica (SBNR). Membros destas 4 entidades participaram de fórum de discussões por internet de temas pré-definidos, seguidos de encontros de videoconferência para discussão de pontos controversos e das recomendações, em busca de um consenso final. Estas diretrizes tem seu foco sobre as implicações dos recentes ensaios clínicos de tratamento endovascular do acidente vascular cerebral (AVC) isquêmico agudo relacionado a oclusão de artérias proximais. O texto final foi elaborado para servir de orientação no manejo destes pacientes AVC isquêmico pelos diferentes profissionais de saúde, gestores de saúde pública e de saúde complementar no Brasil.

Stroke Prevention in Atrial Fibrillation: Focus on Latin America / Prevenção do Acidente Vascular Cerebral na Fibrilação Atrial: Foco na América Latina

Abstract Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention. The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events. The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region.

Resumo A fibrilação atrial (FA) é a arritmia cardíaca sustentada mais comum, com uma prevalência estimada de 1-2% na América do Norte e Europa. O aumento da prevalência da FA na América Latina está associado com o envelhecimento da população geral, juntamente com um mal controle dos principais fatores de risco, incluindo a hipertensão arterial. Como resultado, a prevalência do acidente vascular cerebral (AVC) e a mortalidade associada a ele aumentou dramaticamente na região. Há, portanto, uma clara necessidade de estratégias efetivas de anticoagulação na América Latina. O objetivo desta revisão é oferecer uma visão atual da anticoagulação na prevenção do AVC. O uso de antagonistas da vitamina K (AVKs, ex.: varfarina) e ácido acetilsalicílico (AAS) na prevenção do AVC em pacientes com FA na América Latina permanece frequente, apesar de cerca de um quinto de todos os pacientes com FA não receberem anticoagulação. O uso da varfarina é complicado pela falta de acesso a serviços de monitoramento eficazes, juntamente com um perfil farmacocinético imprevisível. A utilização excessiva do AAS está associada com riscos significativos de sangramento e eficácia reduzida na prevenção do AVC neste grupo de pacientes. Os novos anticoagulantes orais não AVK (NOACs) representam um meio potencial de superar muitas limitações associadas ao uso dos AVKs e do AAS, incluindo uma redução na necessidade de monitoramento e risco reduzido de eventos hemorrágicos. A decisão final sobre qual anticoagulante utilizar em pacientes com FA depende de diversos fatores. Pesquisas adicionais são necessárias para avaliar o impacto desses fatores na população latino-americana e, assim, reduzir o ônus do AVC associado à FA nesta região.

Aetiological diagnosis of ischaemic stroke in young adults.

Despite improvements in diagnosis and treatment, ischaemic stroke in young adults remains a catastrophic event from the patients' perspective. Stroke can cause death, disability, and hamper quality of life. For the neurologist treating a young adult with suspected ischaemic stroke, the diagnostic challenge is to identify its cause. Contemporary neuroimaging of the brain and its vessels, and a comprehensive cardiac assessment, will enable identification of the most frequent causes of stroke in this age group: cardioembolism and arterial dissection. Specific diagnostic tests for the many other rare causes of ischaemic stroke in young adults (angiography, CSF examination, screening for vasculitis and thrombophilia, genetic testing, and ophthalmological examination) should be guided by suspected clinical findings or by the high prevalence of diseases associated with stroke in some countries.

Hipertensão arterial e acidente vascular encéfalico / Stroke and hypertension

O Acidente Vascular Encefàlico (AVE) é um dos principais problemas de saúde pública na atualidade sendo a hipertensão arterial o mais importante fator de risco modificável, tanto para o AVE isquêmico quanto hemorrágico, devido a seu risco relativo e, principalmente, pela sua elevada prevalência na população mundial. O benefício do tratamento com anti-hipertensivos é observado em todas as faixas etárias e é maior dependendo da redução da pressão arterial, e pode continuar mesmo após serem atingidos os níveis basais pré-estabelecidos. A escolha do anti-hipertensivo ideal para cada paciente deve levar em consideração as propriedades farmacológicas, mecanismos de ação e as características individuais de cada paciente. A elevação da pressão arterial observada na fase aguda do AVE isquêmico é frequente e transitória, mesmo em pacientes previamente normotensos. Nos pacientes com AVE isquêmico agudo candidatos à terapia trombolítica intravenosa, a pressão arterial não controlada contribui para aumentar o risco de hemorragia sintomática após a recanalização arterial. Níveis elevados de pressão arterial estão associados a um prognóstico desfavorável nos pacientes com hematoma intraparenquimatoso cerebral. A expansão do hematoma é, frequentemente, demonstrada na fase precoce e pode estar relacionada ao aumento da pressão arterial e ao prognóstico desfavorável. O AVE e os eventos isquêmicos transitórios são apenas parte do espectro das doenças cerebro-vasculares presentes em indivíduos hipertensos. Este espectro inclui as doenças vasculares assintomáticas ou oligosintomáticas resultantes da hipertensão arterial, onde apresentam uma evolução clínica progressiva e crônica.

Stroke is a major public health condition today and hypertension is the most important modifiable risk factor for ischemic and hemorrhagic stroke due to the relative risk and especially for its high prevalence in the population. the treatment benefit using antihypertensive drugs in observed in all age groups and is greater depending on the blood pressure reduction and may continue even after reaching basal blood pressure levels. The choice of the antihypertensive medication must take into consideration the pharmacological properties, mechanisms of action and individual features of each patient. Increasing blood pressure levels is observed during the acute phase of the ischemic stroke and often is transient even in previously normotensive patients. In those patients with acute ischemic stroke and candidates to IV thrombolytic therapy, uncontrolled blood pressure contributes to increasing the risk of symptomatic hemorrhage after arterial recanalization. Elevated blood pressure levels are associated with poor prognosis in stroke patients with cerebral hematoma. The Hematoma expansion in aften demonstrated in the early stage and may be related to increased blood pressure and unfavorable outcome. Stroke and transient ischemic attacks are just part of the spectrum of cerebrovascular diseases related to hypertension. This spectrum may include asymptomatic and oligosymptomatic strokes resulting from hypertension which show a progressive and chronic clinical course.

Clinical discriminators between acute brain hemorrhage and infarction: a practical score for early patient identification

New treatments for acute stroke require a rapid triage system, which minimizes treatment delays and maximizes selection of eligible patients. Our aim was to create a score for assessing the probability of brain hemorrhage among patients with acute stroke based upon clinical information. Of 1805 patients in the Stroke Data Bank, 1273 had infarction (INF) and 237 had parenchymatous hemorrhage (HEM) verified by CT. INF and HEM discriminators were determined by logistic regression and used to create a score. ROC curve was used to choose the cut-point for predicting HEM (score <= 2), with sensitivity of 76 percent and specificity of 83 percent. External validation was done using the NOMASS cohort. Although the use of a practical score by emergency personnel cannot replace the gold-standard brain image differentiation of HEM from INF for thrombolytic therapy, this score can help to select patients for stroke trials and pre-hospital treatments, alert CT scan technicians, and warn stroke teams of incoming patients to reduce treatment delays

Neurologic complications after heart transplantation

OBJECTIVE: Neurologic complications are known as important cause of morbidity and mortality in orthotopic heart transplantation. Our aim was to identify the frequency and outcome of neurologic complications after heart transplantation in a prospective observational study. METHOD: From September 93 to September 99, as part of our routine heart transplantation protocol all patients with end-stage cardiac failure were evaluated by the same neurologist before and at the time of any neurologic event (symptom or complaint) after transplantation. RESULTS: Out of 120 candidates evaluated, 62 were successfully transplanted (53 male; median age 45.5 years, median follow-up 26.8 months). Fifteen patients (24 percent) had ischemic, 22 (35 percent) idiopathic, 24 (39 percent) Chagas' disease and 1 (2 percent) had congenital cardiomyopathy. Neurologic complications occurred in 19 patients (31 percent): tremor, severe headache, transient encephalopathy and seizures related to drug toxicity or metabolic changes in 13; peripheral neuropathy in 4; and spinal cord compression in two (metastatic prostate cancer and epidural abscess). No symptomatic postoperative stroke was observed. CONCLUSIONS: Although frequent, neurologic complications were seldom related to persistent neurologic disability or death. Most of the complications resulted from immunosuppression, however, CNS infection was rare. The absence of symptomatic stroke in our series may be related to the lower frequency of ischemic cardiomyopathy