Predicting hemorrhagic transformation in patients not submitted to reperfusion therapies.

BACKGROUND: Well studied in patients with ischemic stroke after reperfusion therapies (RT), hemorrhagic transformation (HT) is also common in patients not treated with RT and can lead to disability even in initially asymptomatic cases. The best predictors of HT in patients not treated with RT are not well established. Therefore, we aimed to identify predictors of HT in patients not submitted to RT and create a user-friendly predictive score (PROpHET). MATERIAL AND METHODS: Patients admitted to a Comprehensive Stroke Center from 2015 to 2017 were prospectively evaluated and randomly selected to the derivation cohort. A multivariable logistic regression modeling was built to produce a predictive grading score for HT. The external validation was assessed using datasets from 7 Comprehensive Stroke Centers using the area under the receiver operating characteristic curve (AUROC). RESULTS: In the derivation group, 448 patients were included in the final analysis. The validation group included 2,683 patients. The score derived from significant predictors of HT in the multivariate logistic regression analysis was male sex (1 point), ASPECTS ≤ 7 (2 points), presence of leukoaraiosis (1 point), hyperdense cerebral middle artery sign (1 point), glycemia at admission ≥180 mg/dL (1 point), cardioembolism (1 point) and lacunar syndrome (-3 points) as a protective factor. The grading score ranges from -3 to 7. A Score ≥3 had 78.2% sensitivity and 75% specificity, and AUROC of 0.82 for all cases of HT. In the validation cohort, our score had an AUROC of 0.83. CONCLUSIONS: The PROpHET is a simple, quick, cost-free, and easy-to-perform tool that allows risk stratification of HT in patients not submitted to RT. A cost-free computerized version of our score is available online with a user-friendly interface.

Blood pressure behavior during mechanical thrombectomy and drugs used for conscious sedation or general anesthesia.

BACKGROUND: The optimal blood pressure (BP) during mechanical thrombectomy for acute ischemic stroke is currently unclear. OBJECTIVE: To investigate BP behavior during mechanical thrombectomy in patients with acute ischemic stroke and its relationship with drugs used for sedation or general anesthesia. Additionally, we investigated the association between BP oscillation during mechanical thrombectomy and recanalization status, and with functional outcome at discharge. METHODS: Consecutive patients treated with mechanical thrombectomy for acute ischemic stroke were evaluated in a tertiary hospital from December/2009 to December/2015. Maximum, minimum, and mean systolic and diastolic BP, and mean arterial pressures were collected during the procedure. Sedative drugs were also reviewed. RESULTS: Fifty-three patients with a mean age of 71.9 years (60.4% men) were treated with mechanical thrombectomy. The mean reduction in systolic BP and mean arterial pressure from hospital admission to mechanical thrombectomy were respectively 42 and 36 mmHg. During the procedure, oscillations were 50.4 mmHg for systolic, and 33.2 mmHg for diastolic BP. Patients treated with neuromuscular blocking drugs had more oscillation in systolic BP from hospital admission to procedure (51.1 versus 26.2 mmHg, P=0.06). The use of cisatracurium (43.9 versus 29.6 mmHg, P=0.02) and succinylcholine (44.7 versus 29.3 mmHg, P=0.01) were associated with a significant drop in BP during the procedure. CONCLUSIONS: Significant BP oscillation occurs during mechanical thrombectomy. Drugs used for conscious sedation or general anesthesia, specifically neuromuscular blocking agents, might have an influence upon BP levels.

Get With The Guidelines®-Stroke performance indicators in patients with transient ischemic attack.

OBJECTIVE: Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. METHODS: This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. RESULTS: A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. CONCLUSIONS: The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

Blood pressure behavior during mechanical thrombectomy and drugs used for conscious sedation or general anesthesia / Comportamento da pressão arterial durante trombectomia mecânica e drogas utilizadas para sedação consciente ou anestesia geral

ABSTRACT Background: The optimal blood pressure (BP) during mechanical thrombectomy for acute ischemic stroke is currently unclear. Objective: To investigate BP behavior during mechanical thrombectomy in patients with acute ischemic stroke and its relationship with drugs used for sedation or general anesthesia. Additionally, we investigated the association between BP oscillation during mechanical thrombectomy and recanalization status, and with functional outcome at discharge. Methods: Consecutive patients treated with mechanical thrombectomy for acute ischemic stroke were evaluated in a tertiary hospital from December/2009 to December/2015. Maximum, minimum, and mean systolic and diastolic BP, and mean arterial pressures were collected during the procedure. Sedative drugs were also reviewed. Results: Fifty-three patients with a mean age of 71.9 years (60.4% men) were treated with mechanical thrombectomy. The mean reduction in systolic BP and mean arterial pressure from hospital admission to mechanical thrombectomy were respectively 42 and 36 mmHg. During the procedure, oscillations were 50.4 mmHg for systolic, and 33.2 mmHg for diastolic BP. Patients treated with neuromuscular blocking drugs had more oscillation in systolic BP from hospital admission to procedure (51.1 versus 26.2 mmHg, P=0.06). The use of cisatracurium (43.9 versus 29.6 mmHg, P=0.02) and succinylcholine (44.7 versus 29.3 mmHg, P=0.01) were associated with a significant drop in BP during the procedure. Conclusions: Significant BP oscillation occurs during mechanical thrombectomy. Drugs used for conscious sedation or general anesthesia, specifically neuromuscular blocking agents, might have an influence upon BP levels.

RESUMO Antecedentes: Atualmente, a pressão arterial ideal durante a trombectomia mecânica em pacientes com acidente vascular cerebral isquêmico agudo não é clara. Objetivo: Investigar o comportamento da pressão arterial durante a trombectomia mecânica em pacientes com acidente vascular cerebral isquêmico agudo e sua relação com os medicamentos utilizados para sedação ou anestesia geral. Adicionalmente, investigar a associação entre a oscilação da pressão arterial durante a trombectomia mecânica e a capacidade de recanalização, além do status funcional no momento da alta hospitalar. Métodos: Avaliação de pacientes tratados com trombectomia mecânica por acidente vascular cerebral isquêmico agudo em um hospital terciário de dezembro/2009 a dezembro/2015. Valores máximos, mínimos e médios da pressão arterial sistólica, pressão diastólica e pressão arterial média foram coletados durante o procedimento. Drogas sedativas utilizadas também foram revisadas. Resultados: Um total de 53 pacientes com idade média de 71,9 anos (60,4% homens) foram tratados com trombectomia mecânica. A redução média da pressão arterial sistólica e da pressão arterial média desde a internação até a trombectomia mecânica foi respectivamente de 42 mmHg e 36 mmHg. Durante o procedimento, as oscilações da pressão arterial foram de 50,4 mmHg para pressão sistólica e 33,2 mmHg para pressão diastólica. Os pacientes tratados com bloqueadores neuromusculares apresentaram uma tendência a maior oscilação da pressão arterial sistólica desde a internação até o procedimento (51,1 mmHg versus 26,2 mmHg, P = 0,06). O uso de cisatracúrio (43,9 mmHg versus 29,6 mmHg, P = 0,02) e succinilcolina (44,7 mmHg versus 29,3 mmHg, P = 0,01) foram associados a uma queda significativa da pressão arterial durante o procedimento. Conclusões: Durante a trombectomia mecânica ocorre oscilação significativa da pressão arterial. Os medicamentos usados para sedação consciente ou anestesia geral, especificamente bloqueadores neuromusculares, podem ter influência nos níveis de pressão arterial.

Get With The Guidelines®-Stroke performance indicators in patients with transient ischemic attack / Indicadores de desempenho do programa "Get With The Guidelines®-Stroke" em pacientes com ataque isquêmico transitório

ABSTRACT Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. Objective: The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. Methods: This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. Results: A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. Conclusions: The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

RESUMO O "Get With The Guidelines®-Stroke (GWTG-S)" é um programa hospitalar criado para melhorar os cuidados em pacientes com AVC ao promover a adesão às diretrizes. Dez a quinze porcento dos pacientes com ataque isquêmico transitório terão um AVC em 3 meses, sendo que muitos não recebem intervenções de prevenção secundária recomendadas. Objetivo: Avaliar a adesão aos indicadores de qualidade do programa GWTG em pacientes com ataque isquêmico transitório. Métodos: Este estudo retrospectivo observacional avaliou pacientes consecutivos admitidos em um centro de AVC com suspeita de ataque isquêmico transitório ou AVC isquêmico agudo de agosto/2008 a dezembro/2013. Seis indicadores de qualidade aplicáveis tanto ao ataque isquêmico transitório quanto ao AVC isquêmico agudo foram analisados e comparados entre os grupos. Resultados: Um total de 357 pacientes com ataque isquêmico transitório e 787 pacientes com AVC isquêmico agudo foram avaliados. O uso de antiagregante dentro das primeiras 48 horas da admissão, liberação na alta com anticoagulante para fibrilação atrial e aconselhamento para cessação do tabagismo foram similares entre os grupos. No grupo com ataque isquêmico transitório, o uso de antiagregante na alta hospitalar, o tratamento com estatina e a educação sobre o AVC foram observados menos frequentemente quando comparados ao grupo de pacientes com AVC isquêmico agudo. Conclusões: A adesão a alguns dos indicadores de qualidade do programa GWTG-S foi mais baixa em pacientes com ataque isquêmico transitório quando compara a pacientes com AVC isquêmico agudo. Medidas devem ser tomadas para reforçar a importância dessas intervenções em pacientes admitidos com ataque isquêmico transitório.