Neurofibromatosis type 1, fibromuscular dysplasia, and ischemic stroke: an association lost in time? A case report.

Neurofibromatosis Type 1 (NF1) is a rare cause of ischemic stroke (IS) in the general population. We report a case of a young patient with NF1 in whom IS was caused by fibromuscular dysplasia. An angiographic study demonstrated occlusion in the right internal carotid artery (ICA), just after its origin, and the left ICA, just before the intracranial portion, and brain magnetic resonance imaging showed the limits of an area of brain infarction in the right frontoparietal region. Despite these concomitant neuroimaging findings, this association is rare, and it is difficult to establish the contribution to the outcome made by each of these diseases, which treatment is the best to implement, or what prognosis is.

A neurofibromatose tipo 1 (NF1) é uma causa rara de acidente vascular cerebral isquêmico (AVCi) na população geral. Neste estudo, relatamos o caso de um paciente jovem com AVCi, com diagnóstico de NF1 associada a displasia fibromuscular. O estudo angiográfico demonstrou oclusão da carótida interna direita, logo após sua origem, e esquerda, antes da porção intracraniana. A ressonância magnética do encéfalo mostrou delimitação de um infarto na região frontoparietal direita. Apesar desses achados concomitantes na neuroimagem, essa associação é rara, sendo difícil de estabelecer a contribuição de cada uma dessas doenças no desfecho, tampouco qual o melhor tratamento a ser implementado e qual o prognóstico.

Neurofibromatosis type 1, fibromuscular dysplasia, and ischemic stroke: an association lost in time? A case report / Neurofibromatose tipo 1, displasia fibromuscular e acidente vascular cerebral isquêmico: uma associação perdida no tempo? Um relato de caso

Abstract Neurofibromatosis Type 1 (NF1) is a rare cause of ischemic stroke (IS) in the general population. We report a case of a young patient with NF1 in whom IS was caused by fibromuscular dysplasia. An angiographic study demonstrated occlusion in the right internal carotid artery (ICA), just after its origin, and the left ICA, just before the intracranial portion, and brain magnetic resonance imaging showed the limits of an area of brain infarction in the right frontoparietal region. Despite these concomitant neuroimaging findings, this association is rare, and it is difficult to establish the contribution to the outcome made by each of these diseases, which treatment is the best to implement, or what prognosis is.

Resumo A neurofibromatose tipo 1 (NF1) é uma causa rara de acidente vascular cerebral isquêmico (AVCi) na população geral. Neste estudo, relatamos o caso de um paciente jovem com AVCi, com diagnóstico de NF1 associada a displasia fibromuscular. O estudo angiográfico demonstrou oclusão da carótida interna direita, logo após sua origem, e esquerda, antes da porção intracraniana. A ressonância magnética do encéfalo mostrou delimitação de um infarto na região frontoparietal direita. Apesar desses achados concomitantes na neuroimagem, essa associação é rara, sendo difícil de estabelecer a contribuição de cada uma dessas doenças no desfecho, tampouco qual o melhor tratamento a ser implementado e qual o prognóstico.

Can the choice reaction time be modified after COVID-19 diagnosis? A prospective cohort study / O tempo de reação de escolha pode ser modificado após o diagnóstico de COVID-19? Um estudo de coorte prospectiva

ABSTRACT Assessment of cognitive processing speed through choice reaction time (CRT) can be an objective tool to assess cognitive functions after COVID-19 infection. Objective: This study aimed to assess CRT in individuals after acute COVID-19 infection over 1 year. Methods: We prospectively analyzed 30 individuals (male: 9, female: 21) with mild-moderate functional status after COVID-19 and 30 individuals (male: 8, female: 22) without COVID-19. Cognitive and neuropsychiatric symptoms were evaluated using the Montreal Cognitive Assessment (MoCA) and Hospital Anxiety and Depression Scale (HADS), respectively. CRT (milliseconds) was evaluated by finding the difference between the photodiode signal and the electromyographic (EMG) onset latency of anterior deltoid, brachial biceps, and triceps during the task of reaching a luminous target. CRT was evaluated three times over 1 year after COVID-19: baseline assessment (>4 weeks of COVID-19 diagnosis), between 3 and 6 months, and between 6 and 12 months. Results: The multiple comparison analysis shows CRT reduction of the anterior deltoid in the COVID-19 group at 3-6 (p=0.001) and 6-12 months (p<0.001) compared to the control group. We also observed CRT reduction of the triceps at 6-12 months (p=0.002) and brachial biceps at 0-3 (p<0.001), 3-6 (p<0.001), and 6-12 months (p<0.001) in the COVID-19 compared to the control group. Moderate correlations were observed between MoCA and CRT of the anterior deltoid (r=-0.63; p=0.002) and brachial biceps (r=-0.67; p=0.001) at 6-12 months in the COVID-19 group. Conclusions: There was a reduction in CRT after acute COVID-19 over 1 year. A negative correlation was also observed between MoCA and CRT only from 6 to 12 months after COVID-19 infection.

RESUMO A avaliação da velocidade de processamento cognitivo por meio do tempo de reação de escolha (TRE) pode ser uma ferramenta objetiva para acompanhar as alterações cognitivas após a COVID-19. Objetivo: Avaliar o TRE em pacientes após infecção aguda por COVID-19 ao longo de um ano. Métodos: Foram avaliados 30 indivíduos (sexo masculino: nove; feminino: 21) com estado funcional leve-moderado após infecção por COVID-19 e 30 (sexo masculino: oito; feminino: 22) sem COVID-19. A avaliação foi feita pelo Montreal Cognitive Assessment (MoCA) e pela Escala Hospitalar de Ansiedade e Depressão. O TRE (milissegundos) foi avaliado pela diferença entre o sinal luminoso e a latência de início da atividade muscular (EMG) do deltoide anterior (DA), do bíceps braquial (BB) e do tríceps durante uma tarefa de alcance. O TRE foi avaliado ao longo de um ano: avaliação inicial (>4 semanas após diagnóstico de COVID-19), em 3-6 meses e em 6-12 meses. Resultados: Houve redução do TRE do DA no grupo COVID-19 em 3-6 meses (p=0,001) e 6-12 meses (p<0,001) em comparação com o grupo de controle. Também foi observada redução na TRE do tríceps em 6-12 meses (p=0,002) e do BB em 0-3 meses (p<0,001), 3-6 meses (p<0,001) e 6-12 meses (p<0,001) no grupo COVID-19 em comparação com o grupo de controle. Correlações moderadas foram observadas entre MoCA e TRE do DA (r=-0,63; p=0,002) e BB (r=-0,67; p=0,001) aos 6-12 meses no grupo COVID-19. Conclusões: Houve redução do TRE após COVID-19 ao longo de um ano, além de correlação negativa entre MoCA e TRE no período de seis a 12 meses após COVID-19.

Needle Electromyography in the Acute Phase of Stroke: Correlation With Severity and Muscle Strength: Preliminary Findings.

Background: After the stroke, the development of the second motor neuron degeneration can reduce muscle strength and functional capacity. Objective: The aim of this study was to describe the electro-myographic findings in the acute phase of stroke and to correlate them with the severity and muscle strength. Material and Methods: Twenty patients were studied in the first 72 hours after stroke. The severity of the lesion was assessed using the National Institutes of Health Stroke Scale (NIHSS), and muscle strength was assessed using the Medical Research Council Scale (MRC). Sensory conduction and motor conduction were studied to exclude peripheral polyneuropathy, radiculopathies, or other neuro-muscular diseases, and electro-myography (EMG) was performed with co-axial needle electrodes in the deltoid, carpal radial extensor, vastus lateralis, and anterior tibialis at rest, slight effort and maximum effort. The associations between qualitative and quantitative variables were studied using the Chi-square test and Fisher's exact test. Results: Among the patients, 40% had abnormal EMG [positive sharp waves (PSWs), fibrillation, fasciculations, and abnormal patterns in maximum effort]. Positive correlations were found between NIHSS and PSW (p = 0.005; r = 0.65) and abnormal EMG (p = 0.017; r = 0.72), and negative correlations were found between MRC and PSW (p = 0.041; r = -0.83) and abnormal EMG (p = 0.027; r = -0.81). Conclusion: It was concluded that the main EMG findings in the acute phase of stroke were the presence of the denervation process and polyphasic motor unit potentials. These changes in EMG were correlated with stroke severity and lower muscle strength.

Brazilian practice guidelines for stroke rehabilitation: part II / Diretrizes brasileiras para reabilitação no acidente vascular cerebral: parte II

Abstract The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Resumo As Diretrizes Brasileiras de Reabilitação do Acidente Vascular Cerebral (AVC) - Parte II, desenvolvida pelo Departamento Científico de Reabilitação Neurológica da Academia Brasileira de Neurologia é voltada para intervenções específicas de técnicas de reabilitação de déficits neurológicos e incapacidades. Seguindo o mesmo modelo da Parte I, a Parte II também se baseia em estudos randomizados, revisões sistemáticas, metanálises e outras diretrizes sobre o mesmo tema. A segunda parte aborda os distúrbios da comunicação, disfagia, controle postural e equilíbrio, ataxias, espasticidade, reabilitação do membro superior, marcha, cognição, negligência espacial unilateral, déficits sensoriais, reabilitação domiciliar, aderênciaao usode medicamentos, cuidados paliativos,ofuturodareabilitação no AVC, e websites de orientação sobre AVC para pacientes e cuidadores. Nosso objetivo é fornecer aos profissionais envolvidos na reabilitação conhecimento atualizado e recomendações para um melhor cuidado no pós-AVC.

Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I / Diretrizes da Academia Brasileira de Neurologia para reabilitação do acidente vascular cerebral: parte I

ABSTRACT The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.

RESUMO As Diretrizes Brasileiras para Reabilitação do AVC são fruto de um esforço conjunto do Departamento Científico de Reabilitação Neurológica da Academia Brasileira de Neurologia com o objetivo de orientar os profissionais envolvidos no processo de reabilitação para a redução da incapacidade funcional e aumento da autonomia dos indivíduos. Membros do grupo acima participaram de fóruns de discussão na web com pré-temas, seguidos de reuniões por videoconferência em que as controvérsias foram discutidas, levando a um consenso. Essas diretrizes, divididas em duas partes, focam as implicações de recentes ensaios clínicos, revisões sistemáticas e metanálises sobre reabilitação do AVC. O objetivo principal é servir de orientação a médicos, fisioterapeutas, fonoaudiólogos, terapeutas ocupacionais, enfermeiros, nutricionistas e demais profissionais envolvidos no cuidado pós-AVC. As recomendações e níveis de evidência foram adaptados de acordo com a literatura disponível atualmente. Aqui é apresentada a Parte I sobre tópicos de reabilitação na fase aguda, prevenção e tratamento de doenças e comorbidades frequentes após o AVC.

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil.

Objectives: Cerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke. Materials and Methods: This retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments. Results: Patients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069-13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376-9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients. Conclusion: Altogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.

Semi-automated data collection from electronic health records in a stroke unit in Brazil / Coleta de dados semiautomáticos de registros eletrônicos de saúde na unidade de acidente vascular cerebral no Brasil

ABSTRACT Background: There is a high demand for stroke patient data in the public health systems of middle and low-income countries. Objective: To develop a stroke databank for integrating clinical or functional data and benchmarks from stroke patients. Methods: This was an observational, cross-sectional, prospective study. A tool was developed to collect all clinical data during hospitalizations due to stroke, using an electronic editor of structured forms that was integrated with electronic medical records. Validation of fields in the electronic editor was programmed using a structured query language (SQL). To store the results from SQL, a virtual table was created and programmed to update daily. To develop an interface between the data and user, the Embarcadero Delphi software and the DevExpress component were used to generate the information displayed on the screen. The data were extracted from the fields of the form and also from cross-referencing of other information from the computerized system, including patients who were admitted to the stroke unit. Results: The database was created and integrated with the hospital electronic system, thus allowing daily data collection. Quality indicators (benchmarks) were created in the database for the system to track and perform decision-making in conjunction with healthcare service managers, which resulted in improved processes and patient care after a stroke. An intelligent portal was created, in which the information referring to the patients was accessible. Conclusions: Based on semi-automated data collection, it was possible to create a dynamic and optimized Brazilian stroke databank.

RESUMO Antecedentes: Há alta demanda de dados de pacientes com acidente vascular cerebral (AVC) nos sistemas de saúde de países de baixa e média renda. Objetivo: Desenvolver um banco de dados de AVC para integrar dados clínicos ou funcionais e indicadores de qualidade de pacientes com AVC. Métodos: Estudo observacional, transversal e prospectivo. Foi desenvolvida uma ferramenta para coletar dados clínicos durante as internações por AVC por meio de um editor eletrônico de formulários estruturados integrado ao prontuário eletrônico. A validação dos campos no editor eletrônico foi programada em linguagem de consulta estruturada (SQL). Para armazenar os resultados da SQL, uma tabela virtual foi criada e programada para atualização diária. Para desenvolver interface entre os dados e o usuário, foram utilizados o software Embarcadero Delphi e o componente DevExpress para gerar informações apresentadas na tela. Os dados foram extraídos dos campos do formulário e também do cruzamento de outras informações do sistema informatizado, incluindo pacientes internados na unidade de AVC. Resultados: O banco de dados foi criado e integrado ao sistema eletrônico do hospital, permitindo coleta diária de dados. Indicadores de qualidade foram criados no banco de dados para que o sistema acompanhasse e realizasse a tomada de decisão com os gestores dos serviços de saúde, resultando em melhoria no processo e no atendimento ao paciente após AVC. Foi criado um portal inteligente, no qual eram registradas as informações referentes aos pacientes. Conclusões: Com a coleta de dados semiautomática, foi possível criar um banco de dados de AVC dinâmico e otimizado em unidade de AVC no Brasil.

Association of Proinflammatory Cytokine Levels with Stroke Severity, Infarct Size, and Muscle Strength in the Acute Phase of Stroke.

OBJECTIVE: Patterns of cytokine levels and their association with stroke severity, infarct size, and muscle strength are obscure. We aimed to analyze the immune mediators linked to T helper (Th)1, Th2, Th17, and regulatory T cell patterns and their association with stroke severity, infarct size, and muscle strength. MATERIALS AND METHODS: We included patients with acute stroke (n = 15) and healthy non-disabled individuals (n = 20) aged > 18 years. The dependent variables were stroke severity according to the National Institute of Health Stroke Scale (NIHSS), infarct size on computed tomography, handgrip strength by dynamometry, and global muscle strength according to the Medical Research Council (MRC) scale. The independent variables were the circulating cytokine levels. The cytokine levels were compared between the groups, and correlations between the clinical data were verified. RESULTS: The stroke group had higher interleukin (IL)-6 (p < 0.0001) and IL-10 (p < 0.0001) levels, but lower tumor necrosis factor (TNF)-α (p = 0.036) levels than the control group. IL-10 and soluble tumor necrosis factor receptor (sTNF-RII) levels were correlated with each other (r = 0.533; p = 0.042) and infarct size (r = 0.653; p = 0.033 and r = 0.689; p = 0.018, respectively). MRC scores were positively and negatively correlated with handgrip strength of the affected side (r = 0.78; p = 0.001) and NIHSS scores (r = -0.87; p < 0.0001), respectively. CONCLUSIONS: Plasma levels of some cytokines were associated with changes in the acute phase of stroke, and IL-10 and sTNF-RII levels are potential biomarkers of infarct size.

Additional acute effects of virtual reality head-mounted displays on balance outcomes in non-disabled individuals: a proof-of-concept study

Abstract Aim: This study aims to evaluate the additional acute effect of virtual reality (VR) head-mounted displays (HMD) when associated with balance exercises in balance outcomes in non-disabled individuals. Methods: Thirty individuals were randomized into two groups: balance exercise group (GBE; n = 15); and virtual reality + balance exercise group (GVR + BE; n = 15). The individuals were evaluated by static and dynamic balance using the tandem test (TT), single-leg stance (SLS), and Fukuda stepping test (FST). Both groups performed 30 min of balance exercises. The GVR + BE performed 8 additional minutes of virtual reality prior to balance exercises. A roller coaster application was used for the HMD. The Mann-Whitney test was used for intra-group and differences of inter-group analysis, considering a significance level of p < 0.05. Results: In the GBE group analysis, there was observed an increase of time in TT with closed eyes (p = 0.025) and SLS with closed eyes (p = 0.003). In the same way, the GVR + BE group increase TT with closed eyes (p = 0.003) and SLS with closed eyes (p = 0.002) after the intervention. In the intergroup analysis, the increase in the SLS with closed eyes was superior in the GVR + BE group when compared with GBE (p = 0.006; d = 1.67). Conclusion: The use of HMD in combination with balance exercise has an acute effect on increasing static balance in non-disabled individuals.

Evaluation of subjective vertical perception among stroke patients: a systematic review / Avaliação da percepção vertical subjetiva em pacientes com acidente vascular cerebral: uma revisão sistemática

Abstract Background: Verticality misperception is relatively common among patients after stroke, and it may be evaluated in terms of (a) subjective visual vertical (SVV), (b) subjective haptic vertical (SHV) and (c) subjective postural vertical (SPV). To better understand these assessment methods, we conducted a systematic review of the methodological characteristics of different protocols for evaluating SVV, SHV and SPV among individuals after stroke. Objective: To standardize the methodological characteristics of protocols for evaluating verticality perception after stroke. Methods: We searched the following databases: PUBMED, regional BVS portal (MEDLINE, LILACS, IBECS, CUBMED, Psychology Index and LIS), CINAHL, SCOPUS, Web of Science, Science Direct, Cochrane Library and PEDro. Two review authors independently used the QUADAS method (Quality Assessment of Diagnostic Accuracy Studies) and extracted data. Results: We included 21 studies in the review: most (80.9%) used SVV, eight (38.1%) used SPV and four (19.0%) used SHV. We observed high variability in assessments of verticality perception, due to patient positions, devices used, numbers of repetitions and angle of inclination for starting the tests. Conclusion: This systematic review was one of the first to explore all the methods of assessing verticality perception after stroke, and it provides crucial information on how to perform the tests, in order to guide future researchers/clinicians.

Resumo Antecedentes: A percepção errônea da verticalidade é relativamente comum em pacientes após Acidente Vascular Cerebral (AVC) e pode ser avaliada pelas: (a) vertical visual subjetiva (SVV), (b) vertical háptica subjetiva (SVH) e (c) vertical postural subjetiva (SPV). Para melhor compreender esses métodos de avaliação, realizamos uma revisão sistemática das características metodológicas de diferentes protocolos para avaliações de SVV, SHV e SVP em indivíduos após AVC. Objetivo: Padronizar as características metodológicas de protocolos de avaliação da verticalidade após AVC. Métodos: Foi realizada busca nas bases de dados PUBMED, Portal Regional da BVS (MEDLINE, LILACS, IBECS, CUBMED, Psychology Index, LIS), CINAHL, SCOPUS, Web of Science, Science Direct, Biblioteca Cochrane e PEDro. Dois revisores avaliaram independentemente o QUADAS (Avaliação da Qualidade dos Estudos de Precisão de Diagnóstico) e extraíram os resultados. Resultados: Foram incluídos 21 estudos: a maioria (80,9%) utilizando a SVV, oito (38,1%) a SPV e quatro (19,0%) a SHV. Observou-se grande variabilidade na avaliação da verticalidade, devido às posições dos pacientes, dispositivos utilizados, número de repetições e ângulo de inclinação para iniciar os testes. Conclusão: Esta revisão sistemática é uma das primeiras a explorar todos os métodos de avaliação da verticalidade após o AVC e fornece informações cruciais sobre como realizar os testes para orientar os futuros pesquisadores e clínicos.

Effects of rehabilitation programs on heart rate variability after stroke: a systematic review / Efeitos dos programas de reabilitação na variabilidade da frequência cardíaca após acidente vascular cerebral: uma revisão sistemática

ABSTRACT Background: It has been shown that the autonomic nervous system can be modulated by physical exercise after stroke, but there is a lack of evidence showing rehabilitation can be effective in increasing heart rate variability (HRV). Objective: To investigate the effectiveness and safety of rehabilitation programs in modulating HRV after stroke. Methods: The search strategy was based in the PICOT (patients: stroke; interventions: rehabilitation; comparisons: any control group; outcomes: HRV; time: acute, subacute and chronic phases of stroke). We searched MEDLINE, CENTRAL, CINAHL, LILACS, and SCIELO databases without language restrictions, and included randomized controlled trials (RCTs), quasi-randomized controlled trials (quasi-RCTs), and non-randomized controlled trials (non-RCTs). Two authors independently assessed the risk of bias and we used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the certainty of the evidence for each included study. Results: Four studies (two RCTs with low certainty of the evidence and two non-RCTs with very low certainty of the evidence) were included. Three of them showed significant cardiac autonomic modulation during and after stroke rehabilitation: LF/HF ratio (low frequency/high frequency) is higher during early mobilization; better cardiac autonomic balance was observed after body-mind interaction in stroke patients; and resting SDNN (standard deviation of normal R-R intervals) was significantly lower among stroke patients indicating less adaptive cardiac autonomic control during different activities. Conclusions: There are no definitive conclusions about the main cardiac autonomic repercussions observed in post-stroke patients undergoing rehabilitation, although all interventions are safe for patients after stroke.

RESUMO Antecedentes: O sistema nervoso autônomo pode ser modulado pelo exercício físico após o acidente vascular cerebral (AVC), mas faltam evidências que demonstrem que a reabilitação pode ser eficaz no aumento da variabilidade da frequência cardíaca (VFC). Objetivo: Investigar a eficácia e segurança dos programas de reabilitação na modulação da VFC após o AVC. Métodos: A estratégia de busca foi baseada na estratégia PICOT (pacientes: AVC; intervenções: reabilitação; comparações: qualquer grupo de controle; desfechos: VFC; tempo: fase aguda, subaguda e crônica). Foi realizada busca nas bases MEDLINE, CENTRAL, CINAHL, LILACS e SCIELO sem restrições de idioma, sendo incluídos ensaios clínicos randomizados (ECRs), ensaios clínicos quasi-randomizados (quasi-ECRs) e ensaios clínicos não-randomizados (não-ECRs). Dois autores avaliaram independentemente o risco de viés e a metodologia GRADE para classificar a certeza das evidências para cada estudo incluído. Resultados: Quatro estudos (dois ECRs com baixa certeza de evidência e dois não-ECRs com muito baixa certeza de evidência) foram incluídos. Três deles apresentaram modulação autonômica cardíaca durante e após a reabilitação: a razão LF/HF (low frequency/high frequency) foi maior durante a mobilização precoce; maior equilíbrio autonômico foi observado após prática de interação corpo-mente após AVC; e SDNN (desvio padrão dos intervalos R-R normais) foi significativamente menor em pacientes com AVC indicando menor adaptação autonômica cardíaca durante diferentes atividades. Conclusões: Não há conclusão definitivas sobre as principais repercussões cardíaca autonômica nos pacientes com AVC na reabilitação, embora todas as intervenções foram seguras para os pacientes após AVC.

Translation, cross-cultural adaptation and validation of the Cincinnati prehospital stroke scale in Brazil / Tradução, adaptação transcultural e validação da escala de Cincinnati no Brasil

ABSTRACT Background: Use of internationally standardized instruments to assist healthcare professionals in accurately recognizing stroke early is recommended. The process of translation and cross-cultural adaptation is important for ensuring that scales are interpreted in the same way in different languages, thus ensuring applicability in several countries. Objective: To translate into Brazilian Portuguese, cross-culturally adapt and validate the Cincinnati Prehospital Stroke Scale, using a representative sample of the Brazilian population. Method: The present study included patients with suspected stroke who were treated at a Brazilian emergency medical service and referred to a stroke center. A systematic process of translation and cross-cultural adaptation of the original scale and application of the final instrument was performed. Statistical analysis was used to assess the sensitivity, specificity and accuracy of the scale. Cohen's kappa coefficient was used to assess inter-rater reliability. Results: After translation and cross-cultural adaptation, the scale was applied to 64 patients. It showed 93.0% accuracy and 92.4% sensitivity in relation to the final "gold standard" diagnosis. Cohen's kappa coefficient was calculated using data from 26 patients (40.6%) and showed excellent inter-rater reliability between items on the scale (0.8385 to 1.0000). Conclusion: The scale demonstrated excellent accuracy, sensitivity and inter-rater reliability. It was a useful tool for assisting healthcare professionals during initial assessments on patients with suspected stroke and significantly contributed to early recognition of stroke in a simple and quick manner.

RESUMO Introdução: O uso de instrumentos padronizados internacionalmente para auxiliar os profissionais de saúde a reconhecer precocemente o AVC é recomendado. O processo de tradução e adaptação transcultural tem sido importante para garantir que a escala seja interpretada da mesma maneira em diferentes idiomas, assegurando sua aplicabilidade em vários países. Objetivo: Traduzir para o idioma português do Brasil, adaptar transculturalmente e validar a Cincinnati Prehospital Stroke Scale na população brasileira. Método: O estudo incluiu pacientes com suspeita de acidente vascular cerebral (AVC) atendidos por um Serviço de Atendimento Móvel Urgência (SAMU) 192 e encaminhados para uma Unidade de Cuidado Integral ao AVC. Foram realizados um processo sistemático de tradução e adaptação transcultural da escala original e a aplicação do instrumento final, que possibilitou a realização dos testes de sensibilidade, especificidade e acurácia, de acordo com o estudo original, além do índice de Cohen de Kappa, para avaliar a confiabilidade interobservador. Resultados: Após a tradução e a adaptação transcultural, a escala foi aplicada em 64 pacientes, apresentando acurácia de 93,0% e sensibilidade de 92,4% em relação ao diagnóstico final, considerado padrão-ouro. Em 26 pacientes (40,6%) foi possível calcular o índice de Cohen de Kappa, evidenciando excelente confiabilidade interobservador entre os itens da escala (0,8385 a 1,0000). Conclusão: A escala apresenta ótima acurácia, sensibilidade e concordância interobservador. Trata-se de um instrumento útil para auxiliar os profissionais da saúde durante a avaliação inicial do paciente com suspeita de AVC, uma vez que contribui significativamente para o reconhecimento precoce da doença de uma maneira simples e rápida.

Safety of the effective radiation dose received during stroke hospitalization.

BACKGROUND: Neuroimaging is widely used for diagnosis and treatment of stroke. However, little is known about whether the radiation doses received by patients comply with international safety guidelines. OBJECTIVES: The aim of this study was to evaluate the effective radiation dose received while in hospital for stroke and analyze its safety according to current guidelines. METHODS: This cross-sectional study included 109 patients who were hospitalized and diagnosed with ischemic stroke. The National Institutes of Health Stroke Scale was used to evaluate stroke severity, the Bamford clinical classification was used for topography, and the TOAST classification was used for etiology. The computed tomography dose index and size-specific dose estimates were used to calculate the effective radiation dose (ERD) received while in hospital. A Mann-Whitney test was used to compare the ERD received by thrombolysed and non-thrombolysed patients. Non-parametric statistics were used to analyze the data with a 95% confidence interval. RESULTS: During the study period, the median ERD received was 10.9 mSv. Length of stay was not associated with radiation exposure. No differences were demonstrated in ERD according to stroke etiology or Bamford clinical classification. Patients who had CT perfusion (only or in addition to CT or angiotomography) received the highest ERD (46.5 mSv) and the difference compared to those who did not (10.8 mSv) was statistically significant (p<0.001). No differences were found in the ERD between thrombolysed and non-thrombolysed patients. There was no correlation between ERD while in hospital and stroke severity. CONCLUSIONS: According to the current national guidelines, the protocol for examining images at our stroke unit is safe in terms of the ERD received by the patient while in hospital. There was no difference in the ERD received by patients stratified by thrombolytic treatment or stroke severity.

CONTEXTO: A neuroimagem é amplamente utilizada para o diagnóstico e tratamento do acidente vascular cerebral (AVC). No entanto, pouco se sabe se a dose de radiação recebida nesses exames está de acordo com as diretrizes internacionais de segurança. OBJETIVOS: O objetivo deste estudo foi avaliar a dose de radiação efetiva (DRE) durante a hospitalização por AVC. MÉTODOS: Trata-se de estudo transversal com 109 pacientes hospitalizados com diagnóstico de AVC isquêmico. A gravidade do AVC foi avaliada pela National Institutes of Health Stroke Scale, a topografia pela classificação clínica de Bamford e a etiologia pelo Trial of ORG 10172 in Acute Stroke Treatment (TOAST). O índice de dose recebida no exame de tomografia computadorizada (TC) e as estimativas de dose específicas foram usados ​​para calcular a DRE recebida durante a hospitalização. O teste de Mann-Whitney foi utilizado para comparar a DRE recebida por pacientes trombolisados ​​e não trombolisados. Estatísticas não paramétricas foram utilizadas para analisar os dados. RESULTADOS: Durante o período do estudo, a DRE foi de 10,9 mSv. O tempo de internação não foi associado à exposição à radiação. Nenhuma diferença foi demonstrada na DRE de acordo com a etiologia e classificação clínica de Bamford. Os pacientes que fizeram perfusão (isolada, associada à TC ou angiotomografia) receberam a maior DRE (46,5 mSv) em comparação aos que não fizeram (10,8 mSv), sendo estatisticamente significativo (p <0,001). Não foram encontradas diferenças na DRE entre pacientes trombolisados e não trombolisados. Não houve correlação entre a DRE durante a hospitalização com a gravidade do AVC. CONCLUSÕES: De acordo com as atuais diretrizes nacionais, o protocolo de exame de imagens na unidade de AVC é seguro em relação à DRE recebido pelo paciente durante a internação. Não houve diferença na DRE dos pacientes de acordo com o tratamento trombolítico e a gravidade do AVC.

What are the barriers to participation in a neuromodulation pilot trial for aphasia after stroke? / Quais são as barreiras para a participação em estudo piloto de neuromodulação para afasia após acidente vascular cerebral?

ABSTRACT Purpose Aphasia is a common and debilitating manifestation of stroke. Transcranial electrical stimulation uses low-intensity electric currents to induce changes in neuronal activity. Recent evidence suggests that noninvasive techniques can be a valuable rehabilitation tool for patients with aphasia. However, it is difficult to recruit patients with aphasia for trials, and the reasons for this are not well understood. This study aimed to elucidate the main difficulties involved in patient's recruitment and inclusion in a randomized clinical study of neuromodulation in aphasia. Methods We evaluated the reasons for the exclusion of patients in a pilot, randomized, double-blinded clinical trial in which patients diagnosed with motor aphasia after stroke were recruited from March to November 2018. A descriptive statistical analysis was performed. Results Only 12.9% (4) of patients with ischemic stroke were included in the clinical trial. A total of 87.1% (27) of the 31 recruited patients were excluded for various reasons including: sensory aphasia (32.2%), dysarthria (25.8%), spontaneous clinical recovery (16.1%), previous stroke (6.4%), and death or mutism (3.2%). Conclusion The presence of other types of aphasia, dysarthria, spontaneous recovery, deaths, and mutism were barriers to recruiting patients evidenced in this neuromodulation study.

RESUMO Objetivo A afasia é uma manifestação comum e debilitante do acidente vascular cerebral (AVC). A estimulação elétrica transcraniana por corrente contínua oferece uma corrente elétrica de baixa intensidade que induz alterações na atividade neuronal e evidências recentes sugerem que técnicas não invasivas podem servir como uma ferramenta benéfica para a reabilitação de pacientes afásicos. No entanto, é muito difícil recrutar esses pacientes para estudos clínicos e as razões não são claras. O objetivo do estudo foi identificar as principais dificuldades envolvidas no recrutamento e inclusão de pacientes em ensaio clínico piloto randomizado sobre neuromodulação em pacientes com afasia. Método Foram avaliadas as razões para a exclusão e não inclusão de pacientes em um ensaio clínico piloto, randomizado, duplo-cego no qual foram incluídos pacientes diagnosticados com afasia motora após AVC no período de março a novembro de 2018. Análise estatística descritiva foi realizada. Resultados Apenas 12,9% (4) dos pacientes com AVC isquêmico foram incluídos no estudo. Um total de 87,1% (27) dos 31 pacientes recrutados foram excluídos por apresentarem afasia sensorial (32,2%), disartria (25,8%), recuperação clínica espontânea (16,1%), AVC prévio (6,4%) e óbito ou mutismo (3,2%). Conclusão A presença de outros tipos de afasia, disartria, recuperação espontânea, óbitos e mutismo foram as principais barreiras ao recrutamento de pacientes evidenciadas nesse estudo de neuromodulação.

Single session of action observation in choice reaction time in healthy children

Abstract Aim: Learning by action observation (AO) is a fundamental cognitive ability existing from birth either in live or in the video. However, the specific AO training, in live or in the video, can influence decision making and motor planning in healthy children? This study aimed to evaluate if a single session of both practices (live and video) modifies the choice reaction time during reaching tasks in healthy children. Methods: This is a cross-sectional and randomized study with 22 children aged 6 to 8 years. We measured the choice reaction time (CRT) by electromyography at baseline and after both practices. Data were analyzed using Friedman and posthoc Dunn non-parametric tests for each age group individually as well as all ages combined. Kurtosis analysis was performed to assess data variability. Results: Significant decrease in CRT was observed after action observation in the video in 8-year-olds. Also, we observed choice reaction time variability reduction in 8-year-olds after both practices compared to that at baseline. Conclusion: A decrease in CRT was observed after the single session of action observation in the video in 8-year-olds. Additionally, there was a reduced variability in CRT after performing both practices in the same age group.

Safety of the effective radiation dose received during stroke hospitalization / Segurança da dose de radiação efetiva recebida durante internação por acidente vascular cerebral

Abstract Background Neuroimaging is widely used for diagnosis and treatment of stroke. However, little is known about whether the radiation doses received by patients comply with international safety guidelines. Objectives The aim of this study was to evaluate the effective radiation dose received while in hospital for stroke and analyze its safety according to current guidelines. Methods This cross-sectional study included 109 patients who were hospitalized and diagnosed with ischemic stroke. The National Institutes of Health Stroke Scale was used to evaluate stroke severity, the Bamford clinical classification was used for topography, and the TOAST classification was used for etiology. The computed tomography dose index and size-specific dose estimates were used to calculate the effective radiation dose (ERD) received while in hospital. A Mann-Whitney test was used to compare the ERD received by thrombolysed and non-thrombolysed patients. Non-parametric statistics were used to analyze the data with a 95% confidence interval. Results During the study period, the median ERD received was 10.9 mSv. Length of stay was not associated with radiation exposure. No differences were demonstrated in ERD according to stroke etiology or Bamford clinical classification. Patients who had CT perfusion (only or in addition to CT or angiotomography) received the highest ERD (46.5 mSv) and the difference compared to those who did not (10.8 mSv) was statistically significant (p<0.001). No differences were found in the ERD between thrombolysed and non-thrombolysed patients. There was no correlation between ERD while in hospital and stroke severity. Conclusions According to the current national guidelines, the protocol for examining images at our stroke unit is safe in terms of the ERD received by the patient while in hospital. There was no difference in the ERD received by patients stratified by thrombolytic treatment or stroke severity.

Resumo Contexto A neuroimagem é amplamente utilizada para o diagnóstico e tratamento do acidente vascular cerebral (AVC). No entanto, pouco se sabe se a dose de radiação recebida nesses exames está de acordo com as diretrizes internacionais de segurança. Objetivos O objetivo deste estudo foi avaliar a dose de radiação efetiva (DRE) durante a hospitalização por AVC. Métodos Trata-se de estudo transversal com 109 pacientes hospitalizados com diagnóstico de AVC isquêmico. A gravidade do AVC foi avaliada pela National Institutes of Health Stroke Scale, a topografia pela classificação clínica de Bamford e a etiologia pelo Trial of ORG 10172 in Acute Stroke Treatment (TOAST). O índice de dose recebida no exame de tomografia computadorizada (TC) e as estimativas de dose específicas foram usados ​​para calcular a DRE recebida durante a hospitalização. O teste de Mann-Whitney foi utilizado para comparar a DRE recebida por pacientes trombolisados ​​e não trombolisados. Estatísticas não paramétricas foram utilizadas para analisar os dados. Resultados Durante o período do estudo, a DRE foi de 10,9 mSv. O tempo de internação não foi associado à exposição à radiação. Nenhuma diferença foi demonstrada na DRE de acordo com a etiologia e classificação clínica de Bamford. Os pacientes que fizeram perfusão (isolada, associada à TC ou angiotomografia) receberam a maior DRE (46,5 mSv) em comparação aos que não fizeram (10,8 mSv), sendo estatisticamente significativo (p <0,001). Não foram encontradas diferenças na DRE entre pacientes trombolisados e não trombolisados. Não houve correlação entre a DRE durante a hospitalização com a gravidade do AVC. Conclusões De acordo com as atuais diretrizes nacionais, o protocolo de exame de imagens na unidade de AVC é seguro em relação à DRE recebido pelo paciente durante a internação. Não houve diferença na DRE dos pacientes de acordo com o tratamento trombolítico e a gravidade do AVC.

Presentation of cerebral and cervical arterial dissections in Botucatu, Brazil: case series / Apresentação de dissecções arteriais cerebrais e cervicais em Botucatu, Brasil: uma série de casos

Abstract Spontaneous dissection of the cervical and cerebral arteries is an important cause of stroke and disability in young patients. In this report, the authors present a case series of patients with spontaneous carotid, vertebral, or cerebral artery dissection who underwent digital angiography. A review of the published literature on this subject is also presented.

Resumo A dissecção espontânea das artérias cervicais e cerebrais é uma causa importante de acidente vascular cerebral e incapacidade em pacientes jovens. Neste relato, é apresentada uma série de casos de pacientes com dissecção espontânea da artéria carótida, vertebral ou cerebral submetidos à angiografia digital. Além disso, é fornecida uma revisão da literatura sobre esse assunto.

Abnormal findings on digital vectoelectronystagmography in patients with temporomandibular disorders

ABSTRACT Purpose: this study aimed to verify the occurrence of abnormal vectoelectronystagmography findings in patients with temporomandibular disorders (TMDs). Methods: in this cross-sectional study, patients diagnosed with TMDs underwent an otorhinolaryngological examination, audiological evaluation, and balance and vestibular function examinations, using vectoelectronystagmography. The tests performed were 1) spontaneous nystagmus, 2) saccadic movements, 3) pendular tracking, 4) optokinetic nystagmus gain and velocity, 5) rotational chair testing, and 6) post-caloric vertigo and the direction and velocity of the slow component of nystagmus. Results: thirty patients were selected (22 females and 8 males) with mean age of 30.8(14.9 years. Sensorineural hearing loss was seen in four patients (13.3%); the other patients (86.7%) had results within the normal range at all frequencies. Five patients (16.7%) showed abnormalities on the Romberg test and seven (23.3%) on the Tandem test. Abnormalities on the caloric test were seen in 40.0% of patients. More prevalence of headache (p<0.0001) and tinnitus (p<0.0001) was observed in patients with unilateral hyperreflexia, and dizziness, depression, anxiety, gait imbalance and falls in patients with bilateral hyperreflexia. Conclusion: patients with TMDs may present vectoelectronystagmography abnormalities characterized by unilateral or bilateral hyperreflexia and unilateral hyporeflexia of post-caloric nystagmus.