RESUMO
BACKGROUND AND OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA). METHODS: We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective. CONCLUSIONS: We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient.
Assuntos
Isquemia Encefálica/prevenção & controle , Ataque Isquêmico Transitório/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Isquemia Encefálica/classificação , Isquemia Encefálica/etiologia , Medicina Baseada em Evidências , Humanos , Ataque Isquêmico Transitório/classificação , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral/classificação , Acidente Vascular Cerebral/etiologiaRESUMO
INTRODUCTION: Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies. DEVELOPMENT: Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible. CONCLUSION: Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated.
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Isquemia Encefálica/terapia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Isquemia Encefálica/etiologia , Humanos , Embolia Intracraniana/complicações , Embolia Intracraniana/terapia , Acidente Vascular Cerebral/etiologia , TrombectomiaRESUMO
INTRODUCTION: The Spanish Health System's stroke care strategy (EISNS) is a consensus statement that was drawn up by various government bodies and scientific societies with the aim of improving quality throughout the care process and ensuring equality among regions. Our objective is to analyse existing healthcare resources and establish whether they have met EISNS targets. MATERIAL AND METHODS: The survey on available resources was conducted by a committee of neurologists representing each of Spain's regions; the same committee also conducted the survey of 2008. The items included were the number of stroke units (SU), their resources (monitoring, neurologists on call 24h/7d, nurse ratio, protocols), SU bed ratio/100,000 inhabitants, diagnostic resources (cardiac and cerebral arterial ultrasound, advanced neuroimaging), performing iv thrombolysis, neurovascular interventional radiology (neuro VIR), surgery for malignant middle cerebral artery (MCA) infarctions and telemedicine availability. RESULTS: We included data from 136 hospitals and found 45 Stroke Units distributed unequally among regions. The ratio of SU beds to residents ranged from 1/74,000 to 1/1,037,000 inhabitants; only the regions of Cantabria and Navarre met the target. Neurologists performed 3,237 intravenous thrombolysis procedures in 83 hospitals; thrombolysis procedures compared to the total of ischaemic strokes yielded percentages ranging from 0.3 to 33.7%. Hospitals without SUs showed varying levels of available resources. Neuro VIR is performed in every region except La Rioja, and VIR is only available on a 24h/7 d basis in 17 cities. Surgery for malignant MCA infarction is performed in 46 hospitals, and 5 have telemedicine. CONCLUSION: Stroke care has improved in terms of numbers of participating hospitals, the increased use of intravenous thrombolysis and endovascular procedures, and surgery for malignant MCA infarction. Implementation of SUs and telemedicine remain insufficient. The availability of diagnostic resources is good in most SUs and irregular in other hospitals. Regional governments should strive to ensure better care and territorial equality, which would achieve the EISNS objectives.
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Recursos em Saúde/provisão & distribuição , Disparidades em Assistência à Saúde/organização & administração , Acidente Vascular Cerebral/terapia , Procedimentos Endovasculares/métodos , Hospitais , Humanos , Neurologia , Qualidade da Assistência à Saúde , Espanha , Inquéritos e Questionários , Terapia Trombolítica/métodos , Recursos HumanosRESUMO
INTRODUCTION: Patients with stroke associated with non-valvular atrial fibrillation (NVAF) are a specific group, and their disease has a considerable social and economic impact. The primary objective of the CONOCES study, the protocol of which is presented here, is to compare the costs of stroke in NVAF patients to those of patients without NVAF in Spanish stroke units from a societal perspective. MATERIALS AND METHODS: CONOCES is an epidemiological, observational, naturalistic, prospective, multicentre study of the cost of the illness in a sample of patients who have suffered a stroke and were admitted to a Spanish stroke unit. During a 12-month follow-up period, we record sociodemographic and clinical variables, score on the NIH stroke scale, level of disability, degree of functional dependency according to the modified Rankin scale, and use of healthcare resources (hospitalisation at the time of the first episode, readmissions, outpatient rehabilitation, orthotic and/or prosthetic material, medication for secondary prevention, medical check-ups, nursing care and formal social care services). Estimated monthly income, lost work productivity and health-related quality of life measured with the generic EQ-5D questionnaire are also recorded. We also administer a direct interview to the caregiver to determine loss of productivity, informal care, and caregiver burden. RESULTS AND CONCLUSIONS: The CONOCES study will provide more in-depth information about the economic and clinical impact of stroke according to whether or not it is associated with NVAF.
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Fibrilação Atrial/complicações , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/etiologia , Efeitos Psicossociais da Doença , Humanos , Estudos Prospectivos , EspanhaRESUMO
Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognosis with higher rates of morbidity and mortality. Neurological deterioration is often observed during the first hours after onset and determines poor prognosis. Intracerebral haemorrhage, therefore, is a neurological emergency which must be diagnosed and treated properly as soon as possible. In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy, systematic diagnosis, acute treatment and secondary prevention for this condition.
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Hemorragia Cerebral/tratamento farmacológico , Hemorragia Cerebral/terapia , Hemorragia Cerebral/complicações , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/cirurgia , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Humanos , Neuroimagem , Procedimentos Neurocirúrgicos , Guias de Prática Clínica como Assunto , Prevenção Secundária , Acidente Vascular Cerebral/terapiaRESUMO
OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and transient ischaemic attack (TIA). METHODS: We reviewed available evidence on risk factors and means of modifying them to prevent ischaemic stroke and TIA. Levels of evidence and recommendation grades are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: This first section summarises the recommendations for action on the following factors: blood pressure, diabetes, lipids, tobacco and alcohol consumption, diet and physical activity, cardio-embolic diseases, asymptomatic carotid stenosis, hormone replacement therapy and contraceptives, hyperhomocysteinemia, prothrombotic states and sleep apnea syndrome. CONCLUSIONS: Changes in lifestyle and pharmacological treatment for hypertension, diabetes mellitus and dyslipidemia, according to criteria of primary and secondary prevention, are recommended for preventing ischemic stroke.
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Isquemia Encefálica/prevenção & controle , Ataque Isquêmico Transitório/prevenção & controle , Estilo de Vida , Acidente Vascular Cerebral/prevenção & controle , Isquemia Encefálica/epidemiologia , Medicina Baseada em Evidências , Humanos , Ataque Isquêmico Transitório/epidemiologia , Fatores de Risco , Espanha/epidemiologia , Acidente Vascular Cerebral/epidemiologiaRESUMO
INTRODUCTION: The increase in the ageing population in the last decades has led to an increased frequency of cancer-associated complications. Among these, neurological disorders stand out, as they appear in 10-30% of patients with systemic neoplasia. Neoplastic meningitis accounts for 4-15% of patients with solid tumours and it has a poor prognosis. The objective of this paper is to describe the clinical, imaging and prognostic characteristics as well as cerebrospinal fluid findings in a series of neoplastic meningitis. BACKGROUND AND DEVELOPMENT: We performed a retrospective review of all patients admitted to the Hospital Universitario of Gran Canaria Dr. Negrín with clinical suspicion of neoplastic meningitis between 1990 and 2008. We selected 37 patients with an average age ranging from 15 to 75 years old. A total of 81.8% of the cases in which a primary tumour was found were associated with solid tumours (24.2% were located in the breast, and 24.2% in the lung). The most frequent sign of cranial nerve dysfunction was dyplopia, which was observed in 32.4% of the cases. The average survival rate after diagnosis was 87.9 days (12.6 weeks). The cerebrospinal fluid cytology was positive in 46.4% of the cases. CONCLUSION: Neoplastic meningitis is a severe complication of both solid and haematological tumours. We stress the importance of maintaining a high level of suspicion to achieve early diagnosis, since the average survival probability for neoplastic meningitis patients is low.
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Leucemia , Carcinomatose Meníngea , Neoplasias , Adolescente , Adulto , Idoso , Líquido Cefalorraquidiano/citologia , Diagnóstico Diferencial , Feminino , Humanos , Leucemia/complicações , Leucemia/patologia , Leucemia/fisiopatologia , Masculino , Carcinomatose Meníngea/etiologia , Carcinomatose Meníngea/fisiopatologia , Carcinomatose Meníngea/secundário , Pessoa de Meia-Idade , Neoplasias/complicações , Neoplasias/patologia , Neoplasias/fisiopatologia , Prognóstico , Estudos Retrospectivos , Adulto JovemRESUMO
INTRODUCTION: Stroke is currently a major social health problem. For this reason, the Spanish Ministry of Health approved the Stroke National Strategy (SNS) in 2008 to improve the prevention, treatment and rehabilitation of stroke patients. This plan intends to guarantee 24-hour, 365-days neurological assistance in the whole country by the end of 2010. Our aim was to analyse the situation of stroke assistance in Spain in 2009. MATERIAL AND METHODS: A committee of neurologists practicing in the different autonomous communities (AC), and who had not participated in the preparation of the SNS, was created. A national survey was performed including the number of stroke units (SU) and their characteristics (monitoring, 24-h/7-day on-call neurology service, nursing staff ratio and the use of protocols), bed ratio of SU/100,000 people, availability of intravenous thrombolysis therapy, neurovascular intervention (NI) and telemedicine. RESULTS: We included data from 145 hospitals. There are 39 SU in Spain, unevenly distributed. The ratio between SU bed/number of people/AC varied from 1/75,000 to 1/1,037,000 inhabitants; Navarra and Cantabria met the goal. Intravenous thrombolysis therapy is used in 80 hospitals; the number of treatments per AC was between 7 and 536 in 2008. NI was performed in the 63% of the AC, with a total of 28 qualified hospitals (although only 1 hospital performed it 24h, 7 days a week in 2009). There were 3 hospitals offering clinical telemedicine services. CONCLUSIONS: Assistance for stroke patients has improved in Spain compared to previous years, but there are still some important differences between the AC that must be eliminated to achieve the objectives of the SNS.
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Transtornos Cerebrovasculares , Atenção à Saúde , Recursos em Saúde , Acidente Vascular Cerebral/terapia , Coleta de Dados , Fibrinolíticos/uso terapêutico , Hospitais , Humanos , Infusões Intravenosas , Neurologia , Sociedades , Espanha , Telemedicina , Terapia Trombolítica/métodos , Recursos HumanosRESUMO
INTRODUCTION AND OBJECTIVE: Imaging diagnosis is essential for treatment planning in stroke patients. However, use of these techniques varies due to uncertainty about their effectiveness. Our purpose was to describe the use of CT and MRI in stroke and transient ischaemic attack (TIA) over 5years in hospitals belonging to the Canary Islands Health Service and analyse interhospital variability based on routinely collected administrative data. PATIENTS AND METHOD: We gathered the minimum basic dataset (MBDS) from patients diagnosed with stroke or TIA between 2005 and 2010 in 4hospitals. Patients' age, sex, procedures, secondary diagnoses, and duration of hospital stay were also recorded. We conducted a descriptive analysis of patient characteristics and a bivariate analysis using the t test and the chi square test to detect differences between patients assessed and not assessed with MRI. Logistic regression was used to analyse unequal access to MRI. RESULTS AND CONCLUSIONS: Our study included 10,487 patients (8,571 with stroke and 1,916 with TIA). The percentage of stroke patients undergoing a CT scan increased from 89.47% in 2005 to 91.50% in 2010. In these patients, use of MRI also increased from 25.41% in 2005 to 36.02% in 2010. Among patients with TIA, use of CT increased from 84.64% to 88.04% and MRI from 32.53% to 39.13%. According to our results, female sex, younger age, and presence of comorbidities increase the likelihood of undergoing MRI.
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Ataque Isquêmico Transitório/diagnóstico por imagem , Imageamento por Ressonância Magnética , Neuroimagem , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Tomografia Computadorizada por Raios X , Fatores Etários , Idoso , Feminino , Humanos , Ataque Isquêmico Transitório/terapia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , EspanhaRESUMO
INTRODUCTION: Cerebral venous sinus thrombosis (CVSTs) constitutes an infrequent location of the venous thrombotic disease. It is caused by diverse factors, although up to 35% of the CVSTs can remain without aetiologic diagnosis. Coagulation disorders have been involved in up to 75% of the CVSTs. AIM. To describe the prevalence of coagulation disorders in a consecutive series of CVSTs. PATIENTS AND METHODS: We performed a retrospective revision of the clinical history of all patients with CVST admitted in our service between January, 1st 1995 and December, 31st 2005. The thrombophilic study was carried out a posteriori in whatever individual who lacked it. RESULTS: We studied twenty-one cases (7 men and 14 women), within an age range of 16-69 years old (corresponding to an average of 35,4 +/- 14,4 years old). The thrombophilic study was carried out in eighteen patients. Five (27,7%) presented some hereditary coagulation disorder; in four of them, a hormonal cause coexisted. CONCLUSION: Recent advances in the diagnostic procedures for the detection of thrombophilias and hereditary prothrombotic mutations have enabled the specialists to be more precise in the aetiologic diagnosis of suspected CVST. Even so, the apparent cause for a high percentage of patients with CVST has not been found yet.
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Trombose dos Seios Intracranianos/epidemiologia , Trombofilia/epidemiologia , Resistência à Proteína C Ativada/epidemiologia , Resistência à Proteína C Ativada/genética , Adolescente , Adulto , Idoso , Ilhas Atlânticas/epidemiologia , Comorbidade , Anticoncepcionais Orais Hormonais/efeitos adversos , Fator V/genética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Protrombina/genética , Transtornos Puerperais/sangue , Transtornos Puerperais/epidemiologia , Estudos Retrospectivos , Espanha/epidemiologia , Trombofilia/induzido quimicamente , Trombofilia/genéticaRESUMO
OBJECTIVE: To study acute cerebrovascular ischemia in young persons in our environment. PATIENTS AND METHODS: A retrospective study was made of 68 patients, aged between 15 and 45, with transient ischemic accidents (TIA) or cerebral infarcts. Etiological factors, clinical features, diagnostic groups according to the TOAST classification and prognosis were analyzed. RESULTS: In our series there was a ratio of 1.26 in favor of the women. TIAs made up 29.4% of the cases. The most commonly affected territory was that of the carotid artery. In persons over the age of 30 there was greater prevalence of this pathology and of the risk factors diabetes, arterial hypertension and dyslipaemia. There was a significant association with migraine in those aged under 30. The biggest diagnostic group was that of infarct of unknown origin (39.7%), probably because of the specificity of the classification. The functional condition on follow-up was good: only 4.4% of the patients had a score greater than 3 on the Rankin scale. There were no deaths either during the acute phase or subsequently. Recurrences were seen in 10.2% of the patients. CONCLUSIONS: The results obtained in our series are similar to those published in the literature. In acute cerebrovascular ischaemia in young persons, full diagnostic investigations should be carried out in order to give suitable treatment.
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Isquemia Encefálica/epidemiologia , Doença Aguda , Adolescente , Adulto , Fatores Etários , Infarto Cerebral/epidemiologia , Feminino , Humanos , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/complicações , Prognóstico , Recidiva , Fatores de Risco , Espanha/epidemiologiaAssuntos
Isquemia Encefálica/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/prevenção & controle , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Complicações do Diabetes/tratamento farmacológico , Complicações do Diabetes/epidemiologia , Uso de Medicamentos/estatística & dados numéricos , Dislipidemias/tratamento farmacológico , Dislipidemias/epidemiologia , Fidelidade a Diretrizes , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Ataque Isquêmico Transitório/tratamento farmacológico , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/prevenção & controle , Admissão do Paciente , Estudos Retrospectivos , Prevenção SecundáriaRESUMO
INTRODUCTION: Idiopathic intracranial hypertension (IICH) is characterized by a rising in intracranial hypertension without evidence of intracranial expansive disease. Diagnostic criteria of headache related to IICH are described in the International Classification of Headache Disorders. In clinical practice, however, headache related to IICH may be heterogeneous. PATIENTS AND METHODS: Clinical charts of patients with IICH admitted to the Hospital Universitario de Gran Canaria Dr. Negrin between 1990 and 2007 were retrospectively reviewed. RESULTS: Fifty-five patients were included, with a ratio female/male of 8.1:1. Headache was present in 85.4%. The headache was continuous in 63.8% of patients, and diffuse in 51%. CONCLUSION: Headache related to IICH is heterogeneous, and may mimic primary headache, so a high level of suspicion is needed to avoid diagnostic delay.
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Cefaleia/etiologia , Pseudotumor Cerebral/complicações , Adolescente , Adulto , Feminino , Cefaleia/diagnóstico , Cefaleia/fisiopatologia , Humanos , Masculino , Pseudotumor Cerebral/diagnóstico , Pseudotumor Cerebral/fisiopatologia , Estudos Retrospectivos , Adulto JovemRESUMO
INTRODUCTION: The stroke network considers the presence of hospitals with stroke teams (STH), stroke units (SUH) and Comprehensive Stroke Centers (CSC). The aim of the current study is to identify, according to specialized vascular neurologists, the main components needed in different kind of stroke centers. METHODS: A survey was carried out between February and March 2008 to know the opinion of 36 vascular neurologists. Questions were about the components needed in each hospital level treating stroke patients. RESULTS: Neurologists considered that STH must have as indispensable requirements the following components: emergency department, laboratory and computerized tomography scan facilities with full time availability (24 hours a day/7 days a week), multidisciplinary team including physiotherapists, action plans and pre-established referral circuits to SUH and CSC. Experts considered indispensable for SUH the aforementioned components and specific beds with multiparametric vitals monitoring, expert vascular neurologists, specialized nursery, neurologist on call, intravenous thrombolysis (full time), intensive care unit (ICU), neurorehabilitation specialists, diagnosis neuroradiologists, social workers, echocardiography, full time available neurosurgery, stroke register and educational programmes for patients and relatives. CSC must have the same components as STH-SUH and neurosurgeons specialized in stroke surgery, vascular surgeons specialized in carotid surgery and doctors specialized in endovascular intervention with full time availability. CONCLUSIONS: The results show the components or requirements that are considered necessary by specialized vascular neurologists, evaluated on the basis of different hospital levels treating stroke patients.
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Unidades Hospitalares/normas , Hospitais/normas , Acidente Vascular Cerebral , Coleta de Dados , Serviço Hospitalar de Emergência , Humanos , Neurologia , Equipe de Assistência ao Paciente , Guias de Prática Clínica como Assunto , Espanha , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Inquéritos e Questionários , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: The objective of this work is to describe the clinical, etiological and prognostic differences in diabetic and non-diabetic patients presenting ischemic stroke. MATERIALS AND METHODS: We performed a retrospective review of all patients with ischemic stroke requiring admission to the Neurology Service at the University Hospital of Gran Canaria Dr. Negrín (Spain) during our study period (1 Jan, 2004 -31 Dec, 2006). We collected demographic, clinical and prognostic variables. RESULTS: A total of 633 patients were included, 256 (40.4%) were diabetic and 377 (59.6%) were non-diabetic. The group of diabetic patients presented a mean age of 69.2 < or = 9.3 years (65.4 < or = 13.9 years in non-diabetic). Mean made up 63.7% of the diabetic patients and women 36.3% (62.2% men and 37.8% women in non-diabetics). A total of 85.9% of diabetic patients presented arterial hypertension (62.9% in non-diabetics); 49.2% had previous hyperlipidemia (31% in non-diabetics); 22% had ischemic heart disease (12.7% in nondiabetics); and 8.6% had peripheral arteriopathy (4.8% in non-diabetics). In the group of diabetic patients, 25% presented atherothrombotic stroke (16.4% in non-diabetics); 20.3% were cardioembolic (24.4% in non-diabetics); 26.1% were lacunar (22% in non-diabetics); and 25.7% had undetermined origin (27.2% in non-diabetics). The modified Rankin Scale at discharge was +/- in 65.3% of diabetic patients and 62.5% in non-diabetics. CONCLUSIONS: In our series, diabetic patients frequently present other conventional vascular risk factors and show a tendency to more atherothrombotic strokes. We have found no significant differences in relation to prognosis.