Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience / Quien está en el servicio de emergencia importa al hablar de tiempo puerta-aguja: experiencia de un centro clínico

Abstract Background The efficacy of intravenous thrombolysis (IVT) is time-dependent. Objective To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. Methods Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. Results A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p < 0.003) remained significant. Conclusions Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.

Resumen Antecedentes La respuesta a la trombólisis intravenosa (TIV) es dependiente del tiempo. Objetivo Comparar los tiempo puerta-aguja (TPAs) de neurólogos vasculares (NVs) contra los de neurólogos no vasculares (NNVs) y médicos emergencistas (MEs), y determinar los elementos asociados a un PTA ≤ 20 minutos. Métodos Análisis observacional prospectivo de pacientes con TIV tratados en Clínica Alemana entre junio de 2016 y septiembre de 2021. Resultados En total, 301 pacientes con TIV fueron tratados. El TPA promedio fue de 43,3 ± 23,6 minutos. Un total de 173 (57,4%) pacientes fueron evaluados por NVs, 122 (40,5%), por NNVs, y 6 (2,1%), por MEs; los TPAs promedios fueron de 40,8 ± 23; 46 ± 24,7 y 58 ± 22,5 minutos, respectivamente. Los TPAs ≤ 20 minutos fueron más frecuentes en pacientes tratados por NVs versus NNVs y MEs: 15%, 4% y 0%, respectivamente (odds ratio [OR]: 4,3; intervalo de confianza del 95% [IC95%]: 1,66-11,5; p = 0,004). El análisis univariado demostró que TPA ≤ 20 minutos se asoció con: tratamiento por NVs (p = 0,002), periodo de la pandemia de enfermedad por coronavirus 2019 (COVID-19; p = 0,21), tiempo a urgencia (p = 0,21), diabetes (p = 0,142), hipercolesterolemia (p = 0,007), fibrilación auricular (p < 0,09), puntaje en la National Institutes of Health Stroke Scale [NIHSS] (p = 0,001), presión arterial sistólica (p = 0,143) y diastólica menores (p = 0,21), Alberta Stroke Program Early CT Score (ASPECTS ; p = 0,09), oclusión de vasos cerebrales (p =0,05), uso de tecneteplase (p = 0,18), trombectomía (p = 0,13) y años de experiencia del médico (p < 0,001). El análisis multivariado demostró que ser tratado por NVs (OR: 3,95; IC95%: 1,44-10,8; p = 0,007), el puntaje en la NIHSS (OR: 1,07; IC95%: 1,02-1,12; p < 0,002) y la presión arterial sistólica (OR: 0,98; IC95%: 0,96-0,99; p < 0,003) se asociaron a TPA ≤ 20 minutos. Conclusões El tratamiento por NVs resultó en un TPA menor y en una mayor probabilidad de tratamiento ≤ 20 minutos.

Diffusion-weighted imaging as predictor of acute ischemic stroke etiology / Imágenes por difusión cerebral como predictor de la etiología del accidente cerebrovascular isquémico agudo

Abstract Background: Topographic patterns may correlate with causes of ischemic stroke. Objective: To investigate the association between diffusion-weighted imaging (DWI) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Methods: We included 1019 ischemic stroke patients. DWI were classified as: i) negative; ii) DWI single lesion (cortico-subcortical, cortical, subcortical ≥20 mm, or subcortical <20 mm); iii) scattered lesions in one territory (small scattered lesions or confluent with additional lesions); and iv) multiple lesions (multiple unilateral anterior circulation [MAC], multiple posterior circulation [MPC], multiple bilateral anterior circulation [MBAC], and multiple anterior and posterior circulations [MAP]). Results: There was a relationship between DWI patterns and TOAST classification (p<0.001). Large artery atherosclerosis was associated with small, scattered lesions in one vascular territory (Odds Ratio [OR] 4.22, 95% confidence interval [95%CI] 2.61-6.8), MPC (OR 3.52; 95%CI 1.54-8.03), and subcortical lesions <20 mm (OR 3.47; 95%CI 1.76-6.85). Cardioembolic strokes correlated with MAP (OR 4.3; 95%CI 1.64-11.2), cortico-subcortical lesions (OR 3.24; 95%CI 1.9-5.5) and negative DWI (OR 2.46; 95%CI 1.1-5.49). Cryptogenic strokes correlated with negative DWI (OR 4.1; 95%CI 1,84-8.69), cortical strokes (OR 3.3; 95%CI 1.25-8.8), MAP (OR 3.33; 95%CI 1.25-8.81) and subcortical lesion ≥20 mm (OR 2.44; 95%CI 1,04-5.73). Lacunar strokes correlated with subcortical lesions diameter <20 mm (OR 42.9; 95%CI 22.7-81.1) and negative DWI (OR 8.87; 95%CI 4.03-19.5). Finally, MBAC (OR 9.25; 95%CI 1.12-76.2), MAP (OR 5.54; 95%CI 1.94-15.1), and MPC (OR 3.61; 95%CI 1.5-8.7) correlated with stroke of other etiologies. Conclusions: A relationship exists between DWI and stroke subtype.

RESUMEN Antecedentes: Los patrones topográficos pueden correlacionarse con las causas del accidente cerebrovascular isquémico. Objetivo: Investigar la asociación entre imágenes ponderadas por difusión por resonancia nuclear magnética (dRNM) y el ensayo de Org 10172 en la clasificación de tratamiento agudo de accidentes cerebrovasculares (TOAST). Métodos: Fueron incluidos 1.019 pacientes con accidente cerebrovascular isquémico. Las dRNM fueron clasificadas como: i) negativa; ii) dRNM lesión única (cortico-subcortical, cortical, subcortical ≥20 mm, o subcortical <20 mm); iii) lesiones disgregadas un territorio vascular (pequeñas lesiones dispersas o confluentes con lesiones adicionales); y iv) lesiones múltiples (unilaterales de circulación anterior [MAC], de circulación posterior [MPC], bilaterales de circulación anterior [MBAC] y de circulación anterior y posterior [MAP]). Resultados: Existió relación entre los patrones de dRNM y la clasificación TOAST (p<0,001). La aterosclerosis de las arterias grandes se asoció con lesiones pequeñas y disgregadas en un territorio vascular (Odds Ratio [OR] 4,22, intervalo de confianza del 95% [IC95%] 2,61-6,8), MPC (OR 3,52; IC95% 1,54-8,03), y lesiones subcorticales <20 mm (OR 3,47; IC95% 1,76-6,85). Cardioembolias se relacionaron con MAP (OR 4,3; IC95% 1,64-11,2), lesiones cortico-subcorticales (OR 3,24; IC95% 1,9-5,5) y dRNM negativas (OR 2,46; IC95% 1,1-5,49). Los accidentes cerebrovasculares criptogénicos se relacionaron con dRNM negativas (OR 4,1; IC95% 1,84-8,69), accidentes cerebrovasculares corticales (OR 3,3; IC95% 1,25-8,8), MAP (OR 3,33; IC95% 1,25-8,81) y lesiones subcorticales ≥20 mm (OR 2,44; IC95% 1,04-5,73). Los accidentes cerebrovasculares lacunares se correlacionaron con lesiones subcorticales de diámetro <20 mm (OR 42,9; IC95% 22,7-81,1) y dRNM negativas (OR 8,87; IC95% 4,03-19,5). Finalmente, MBAC (OR 9,25; IC95% 1,12-76,2), MAP (OR 5,54; IC95% 1,94-15,1) y MPC (OR 3,61; IC95% 1,5-8,7) se relacionaron con accidentes cerebrovasculares de otras etiologías. Conclusiones: Existe relación entre dRNM y subtipo de accidente cerebrovascular.

In-Hospital Acute Ischemic Stroke is Associated with Worse Outcome: Experience of a Single Center in Santiago Chile.

OBJECTIVES: In-hospital acute ischemic stroke (HIS) accounts for 2-17% of all acute ischemic strokes (AIS) seen in hospital and they have worse prognosis. In this study we aimed to identify the frequency of HIS and their characteristics in our center. MATERIALS AND METHODS: Retrospective analysis of a prospective register of patients with AIS seen at Clínica Alemana de Santiago, between January 2017 and January 2019. HIS and community onset ischemic strokes patients (CIS) were compared, univariate analysis was performed, covariates with p < 0.25 were selected for multivariate analysis. Differences between, proportion of strokes treated with thrombolytic therapy, door to needle time were compared between HIS and CIS patients, as also mortality rates at 90 days. RESULTS: During the study period 369 patients with AIS were seen; of these 20 (5.4%, 95 CI%, 3.5-8.2) corresponded to HIS. In univariate analysis, HIS compared to patients arriving form the community to the emergency room, suffered more frequently from, heart failure (p = 0.04), and active malignancies (p < 0.001). HIS patients had longer times from symptom onset to non-contrast brain tomography (540 ±150 minutes); they were also less frequently treated with intravenous thrombolysis compared to community AIS: 15% versus 30% respectively (p = 0.08). Mortality rates at 90 days were higher in HIS: 30 versus 5% (p = 0.001). CONCLUSIONS: In this cohort, HIS patients suffered delays in their neuroimaging studies and received less intravenous thrombolysis; this underscores the need for a standardized approach to the recognition and management of inhospital acute ischemic stroke.

Smoking influences outcome in patients who had thrombolysed ischaemic stroke: the ENCHANTED study.

BACKGROUND AND PURPOSE: As studies vary in defining the prognostic significance of smoking in acute ischaemic stroke (AIS), we aimed to determine the relation of smoking and key outcomes in patient participants who had thrombolysed AIS of the international quasi-factorial randomised Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). METHODS: Post-hoc analyses of ENCHANTED, an international quasi-factorial randomised evaluation of intravenous alteplase-dose comparison and levels of blood pressure control in patients who had thrombolysed AIS. Multivariable logistic regression models with inverse probability of treatment weighting (IPTW) propensity scores were used to determine associations of self-reported smoking status and clinical outcomes, according to 90-day modified Rankin Scale (mRS) scores and symptomatic intracerebral haemorrhage (sICH). RESULTS: Of 4540 patients who had an AIS, there were 1008 (22.2%) current smokers who were younger and predominantly male, with more comorbidities of hypertension, coronary artery disease, atrial fibrillation and diabetes mellitus, and greater baseline neurological impairment, compared with non-smokers. In univariate analysis, current smokers had a higher likelihood of a favourable shift in mRS scores (OR 0.88, 95% CI 0.77 to 0.99; p=0.038) but this association reversed in a fully adjusted model with IPTW (adjusted OR 1.15, 95% CI 1.04 to 1.28; p=0.009). A similar trend was also apparent for dichotomised poor outcome (mRS scores 2-6: OR 1.18, 95% CI 1.05 to 1.33; p=0.007), but not with the risk of sICH across standard criteria. CONCLUSION: Smoking predicts poor functional recovery in patients who had thrombolysed AIS. TRIAL REGISTRATION NUMBER: NCT01422616.

Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience.

BACKGROUND: Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. OBJECTIVE: We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. METHODS: Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. RESULTS: 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient's age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37‒14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98‒32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81‒357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37‒14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10‒0.40) remained independently associated. CONCLUSIONS: Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.

Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience / Dosis reducida de alteplase en el accidente cerebrovascular isquémico después del estudio Enchanted y sus determinantes, una experiencia de un solo centro

Abstract Background: Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. Objective: We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. Methods: Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. Results: 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient's age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37‒14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98‒32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81‒357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37‒14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10‒0.40) remained independently associated. Conclusions: Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.

RESUMEN Introducción: Dosis reducidas de trombolitico (LrtPA) podrían no ser inferiores en muerte/discapacidad. Objetivo: Evaluar el porcentaje de pacientes tratados con LrtPA en nuestro centro después del ensayo ENCHANTED, y los factores asociados con el uso de esta dosis. Métodos: Estudio prospectivo de pacientes consecutivos con infarto cerebral ingresados ​entre junio de 2016 y noviembre de 2018. Resultados: 160 pacientes fueron tratados con trombólisis intravenosa, 50% mujeres; edad media 65,4±18,5 años. 48 casos (30%) recibieron LrtPA. En el análisis univariado, LrtPA se asoció con la edad del paciente (p=0,000), escala de Rankin modificadas (mRS) (p<0,000), hipertensión arterial (p=0,076), diabetes mellitus (p=0,021), hipercolesterolemia (p=0,19), tabaquismo (p=0,06), fibrilación auricular (p=0,10), antecedentes de enfermedad coronaria (p=0,06), tratamiento previo con antiplaquetarios (p<0,000), International Normalized Ratio-INR (p=0,18), recuento de plaquetario (p=0,045), leucoaraiosis en neuroimagen (p<0,003), contraindicaciones para el tratamiento trombolítico (p=0,000) y tratamiento endovascular (p=0,027). Las hemorragias previas relevantes fueron determinantes para el tratamiento con LrtPA. El diagnóstico al alta de imitador de accidente cerebrovascular fue significativo (p=0,02) para el tratamiento con dosis estándar. El análisis multivariado demostró que mRS (OR: 2,21; IC95% 1,37‒14,19), tratamiento antiplaquetario previo (OR: 11,41; IC95% 3,98‒32,7), contraindicaciones para trombólisis (OR: 56,1; IC95% 8,81‒357,8), leucoaraiosis (OR: 4,41; IC95% 1,37‒14,1) y un diagnóstico de imitador de accidente cerebrovascular (OR: 0,22; IC95% 0,1‒0,40) fueron asociados con la dosis recibida. Conclusiones: LrtPA está restringido al 30% de nuestros pacientes. Los criterios para tomar esta decisión se basan en variables que podrían aumentar el riesgo de hemorragia cerebral/sistémica o excluir al paciente del tratamiento con fármacos líticos.

Determinantes del tiempo puerta-aguja en trombolisis endovenosa en el infarto cerebral, experiencia de un centro

Background: Intravenous thrombolysis (IT) in acute ischemic stroke (AIS) is time dependent. The time elapsed from hospital admission to the thrombolytic bolus is named door to needle time (DNT) and is recommend to be of less than 60 min. Aim: To describe the DNT in our center and determine those factors associated with a DNT longer than 60 min. Material and Methods: Prospective analysis of patients treated with IT at a private hospital between June 2016 and June 2019. The percentage of patients with DNT exceeding 60 min, and the causes for this delay were evaluated. Results: IT was used in 205 patients. DNT was 43.6 ± 23.8 min. Forty patients (19.5% (95% CI, 14.4-25.7), had a DNT longer than 60 min. Uni-varied analysis demonstrated that AIS with infratentorial symptomatology (ITS), was significantly associated with DNTs exceeding 60 min. A history of hypertension, a higher NIH Stroke Scale score, the presence of an hyperdense sign in brain tomography (p = 0.001) and the need for endovascular therapy (p = 0.019), were associated with DNT shorter than 60 min. Multivariate analysis ratified the relationship between ITS and DNT longer than 60 min (Odds ratio: 3.19, 95% confidence intervals 1.26-8). Conclusions: The individual elements that correlated with a DNT longer than 60 min were the failure to detect the AIS during triage and doubts about its diagnosis.

Dysphagia screening and risks of pneumonia and adverse outcomes after acute stroke: An international multicenter study.

BACKGROUND: Dysphagia is associated with aspiration pneumonia after stroke. Data are limited on the influences of dysphagia screen and assessment in clinical practice. AIMS: To determine associations between a "brief" screen and "detailed" assessment of dysphagia on clinical outcomes in acute stroke patients. METHODS: A prospective cohort study analyzed retrospectively using data from a multicenter, cluster cross-over, randomized controlled trial (Head Positioning in Acute Stroke Trial [HeadPoST]) from 114 hospitals in nine countries. HeadPoST included 11,093 acute stroke patients randomized to lying-flat or sitting-up head positioning. Herein, we report predefined secondary analyses of the association of dysphagia screening and assessment and clinical outcomes of pneumonia and death or disability (modified Rankin scale 3-6) at 90 days. RESULTS: Overall, 8784 (79.2%) and 3917 (35.3%) patients were screened and assessed for dysphagia, respectively, but the frequency and timing for each varied widely across regions. Neither use of a screen nor an assessment for dysphagia was associated with the outcomes, but their results were compared to "screen-pass" patients, those who failed had higher risks of pneumonia (adjusted odds ratio [aOR] = 3.00, 95% confidence interval [CI] = 2.18-4.10) and death or disability (aOR = 1.66, 95% CI = 1.41-1.95). Similar results were evidence for the results of an assessment for dysphagia. Subsequent feeding restrictions were related to higher risk of pneumonia in patients failed dysphagia screen or assessment (aOR = 4.06, 95% CI = 1.72-9.54). CONCLUSIONS: Failing a dysphagia screen is associated with increased risks of pneumonia and poor clinical outcome after acute stroke. Further studies concentrate on determining the effective subsequent feeding actions are needed to improve patient outcomes.

Prevention of stroke: a global perspective.

Along with the rising global burden of disability attributed to stroke, costs of stroke care are rising, providing the impetus to direct our research focus towards effective measures of stroke prevention. In this Series paper, we discuss strategies for reducing the risk of the emergence of disease (primordial prevention), preventing the onset of disease (primary prevention), and preventing the recurrence of disease (secondary prevention). Our focus includes global strategies and campaigns, and measurements of the effectiveness of worldwide preventive interventions, with an emphasis on low-income and middle-income countries. Our findings reveal that effective tobacco control, adequate nutrition, and development of healthy cities are important strategies for primordial prevention, whereas polypill strategies, use of mobile technology (mHealth), along with salt reduction and other dietary interventions, are effective in the primary prevention of stroke. An effective collaboration between various health-care sectors, government policies, and campaigns can successfully implement secondary prevention strategies, through surveillance and registries, such as the WHO's non-communicable diseases programmes, across high-income and low-income countries.

Characterization of Patients with Embolic Strokes of Undetermined Source in the NAVIGATE ESUS Randomized Trial.

BACKGROUND: The New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial vs. ASA to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS) trial is a randomized phase-III trial comparing rivaroxaban versus aspirin in patients with recent ESUS. AIMS: We aimed to describe the baseline characteristics of this large ESUS cohort to explore relationships among key subgroups. METHODS: We enrolled 7213 patients at 459 sites in 31 countries. Prespecified subgroups for primary safety and efficacy analyses included age, sex, race, global region, stroke or transient ischemic attack prior to qualifying event, time to randomization, hypertension, and diabetes mellitus. RESULTS: Mean age was 66.9 ± 9.8 years; 24% were under 60 years. Older patients had more hypertension, coronary disease, and cancer. Strokes in older subjects were more frequently cortical and accompanied by radiographic evidence of prior infarction. Women comprised 38% of participants and were older than men. Patients from East Asia were oldest whereas those from Latin America were youngest. Patients in the Americas more frequently were on aspirin prior to the qualifying stroke. Acute cortical infarction was more common in the United States, Canada, and Western Europe, whereas prior radiographic infarctions were most common in East Asia. Approximately forty-five percent of subjects were enrolled within 30 days of the qualifying stroke, with earliest enrollments in Asia and Eastern Europe. CONCLUSIONS: NAVIGATE-ESUS is the largest randomized trial comparing antithrombotic strategies for secondary stroke prevention in patients with ESUS. The study population encompasses a broad array of patients across multiple continents and these subgroups provide ample opportunities for future research.

Practice Patterns for Neurosurgical Utilization and Outcome in Acute Intracerebral Hemorrhage: Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials 1 and 2 Studies.

BACKGROUND: The prognosis in acute spontaneous intracerebral hemorrhage (ICH) is related to hematoma volume, where >30 mL is commonly used to define large ICH as a threshold for neurosurgical decompression but without clear supporting evidence. OBJECTIVES: To determine the factors associated with large ICH and neurosurgical intervention among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT). METHODS: We performed pooled analysis of the pilot INTERACT1 (n = 404) and main INTERACT2 (n = 2839) studies of ICH patients (<6 h of onset) with elevated systolic blood pressure (SBP, 150-220 mm Hg) who were randomized to intensive (target SBP < 140 mm Hg) or contemporaneous guideline-recommended (target SBP < 180 mm Hg) management. Neurosurgical intervention data were collected at 7 d postrandomization. Multivariable logistic regression was used to determine associations. RESULTS: There were 372 (13%) patients with large ICH volume (>30 mL), which was associated with nonresiding in China, nondiabetic status, severe neurological deficit (National Institutes of Health stroke scale [NIHSS] score ≥ 15), lobar location, intraventricular hemorrhage extension, raised leucocyte count, and hyponatremia. Significant predictors of those patients who underwent surgery (226 of 3233 patients overall; 83 of 372 patients with large ICH) were younger age, severe neurological deficit (lower Glasgow coma scale score, and NIHSS score ≥ 15), baseline ICH volume > 30 mL, and intraventricular hemorrhage. CONCLUSIONS: Early identification of severe ICH, based on age and clinical and imaging parameters, may facilitate neurosurgery and intensive monitoring of patients.

Intensive Care Unit Admission for Patients in the INTERACT2 ICH Blood Pressure Treatment Trial: Characteristics, Predictors, and Outcomes.

BACKGROUND: Wide variation exists in criteria for accessing intensive care unit (ICU) facilities for managing patients with critical illnesses such as acute intracerebral hemorrhage (ICH). We aimed to determine the predictors of admission, length of stay, and outcome for ICU among participants of the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). METHODS: INTERACT2 was an international, open, blinded endpoint, randomized controlled trial of 2839 ICH patients (<6 h) and elevated systolic blood pressure (SBP) allocated to receive intensive (target SBP <140 mmHg within 1 h) or guideline-recommended (target SBP <180 mmHg) BP-lowering treatment. The primary outcome was death or major disability, defined by modified Rankin scale scores 3-6 at 90 days. Logistic regression and propensity score analyses were used to determine independent associations. MAIN RESULTS: Predictors of ICU admission included younger age, recruitment in China, prior ischemic/undetermined stroke, high SBP, severe stroke [National Institute of Health stroke scale (NIHSS) score ≥15], large ICH volume (≥15 mL), intraventricular hemorrhage (IVH) extension, early neurological deterioration, intubation and surgery. Determinants of prolonged ICU stay (≥5 days) were prior antihypertensive use, NIHSS ≥15, large ICH volume, lobar ICH location, IVH, early neurological deterioration, intubation and surgery. ICU admission was associated with higher-risk major disability at 90-day assessment compared to those without ICU admission. CONCLUSIONS: This study presents prognostic variables for ICU management and outcome of ICH patients included in a large international cohort. These data may assist in the selection and counseling of patients and families concerning ICU admission.

Trombolisis intravenosa en cuadros imitadores de isquemia cerebral: experiencia de un centro / Thrombolysis in stroke mimics: experience in 10 cases

Background: The effectiveness of intravenous thrombolysis (IVT) in cerebral ischemia is time dependent. Stroke mimics (SM) are frequent in emergency rooms. The effort to reduce door to needle time, can lead to administer thrombolytics to SM. Aim: To describe the frequency and prognosis of SM treated with IVT. Material and Methods: Prospective analysis of all patients evaluated in a Chilean private clinic between December 2004 and July 2015 with a suspected acute ischemic stroke (AIS). We calculated the number of SM that were treated with IVT. In these patients, we analyzed the presence of symptomatic cerebral hemorrhage defined as the presence of a neurological deterioration of four points or more on the National Institute of Health Stroke Scale, the presence of extracranial bleeding according to Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries criteria and the patient’s functional status at three months by modified Rankin scale (MRS). Results: We evaluated 1,417 patients with suspected AIS, of which 240 (16.9%) were finally diagnosed as SM. A total of 197 patients were treated with IVT, of these 10 (5%) corresponded to SM. All SM patients treated with thrombolytic drugs were functionally independent at 3 months and showed no bleeding complications. Conclusions: Occasionally SM patients were treated with IVT. This treatment was not associated with bleeding complications and the prognosis of these patients at three months was favorable.

Significance of intraventricular hemorrhage in acute intracerebral hemorrhage: intensive blood pressure reduction in acute cerebral hemorrhage trial results.

BACKGROUND AND PURPOSE: Intraventricular hemorrhage (IVH) with spontaneous intracerebral hemorrhage indicates a poor prognosis but uncertainty exists over the pattern of association. We aimed to elucidate risk associations of IVH and outcome in the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) data set. METHODS: INTERACT2 was an international prospective, open-blinded end point, randomized controlled trial in 2839 patients with intracerebral hemorrhage (<6 hours) with elevated systolic blood pressure randomly assigned to intensive (target systolic blood pressure <140 mm Hg) or guideline-based (systolic blood pressure <180 mm Hg) blood pressure management. Associations of baseline IVH in 740 of 2613 (28%) patients and poor outcomes (death and major disability defined on the modified Rankin Scale) at 90 days were determined in linear and logistic regression models. RESULTS: Patients with IVH were significantly older and with greater neurological impairment, history of ischemic stroke, and larger hematomas more often deep hemisphere located at presentation, after adjustment for other baseline variables. Death or major disability occurred in 66% with IVH versus 49% in intracerebral hemorrhage-alone patients (adjusted odds ratio, 1.68; 95% confidence interval, 1.38-2.06; P<0.01). Associations of IVH volume and clinical outcomes were strong and near continuous. Adjusted analyses by thirds of IVH volume indicate thresholds of ≈5 and 10 mL for significantly increased odds of death and death or major disability, respectively. CONCLUSIONS: A strong association exists between the amount of IVH and poor outcome in intracerebral hemorrhage. An IVH volume of 5 to 10 mL emerges as a significant threshold for decision making on prognosis in these patients. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00716079.

Sonotrombolisis en el ataque cerebrovascular isquémico: once años de experiencia en Clínica Alemana de Santiago / Sonothrombolysis for acute ischemic stroke

Background: Sonothrombolysis (ST) is an emerging modality for the treatment of stroke. Aim: To assess the feasibility to perform ST in a Chilean hospital. Material and Methods: Patients attended at a private clinic with an acute ischemic stroke, between September 2002 and May 2013 and eligible for endovenous thrombolysis, were studied with a transcranial Doppler (Spencer PMD 100 or 150®). Those with an adequate sonographic window and a demonstrated arterial occlusion were monitored continuously with transcranial Doppler at the site of worst residual flow following the CLOTBUST study protocol. Results: One thousand twenty six patients were studied, of whom 136 received intravenous thrombolysis (rt-PA) and 61, aged 66 ± 18 years (59% males), were subjected to ST (7% of total). Their median National Institutes of Health Stroke Scale score was 14, the lapse from symptom onset to rt-PA was 127 minutes (43-223). Middle cerebral artery (MCA) occlusion was found in 88.5% of patients. Complete recanalization was achieved in 44.3% of patients. Sixty percent had Modified Rankin Scale of 0 to 2 at 3 months (95% confidence intervals (CI) 48.1 to 72). Case fatality was 9.8% and asymptomatic intracranial hemorrhage occurred in 9.8% (95% CI: 4.3 to 20.2). Conclusions: ST can be carried out in a complex medical center and is safe.

Validez del Doppler transcraneal en el diagnóstico de muerte encefálica / Validation of transcranial Doppler in the diagnosis of brain death

Background: The clinical diagnosis of brain death is complex. Aim: To evaluate the diagnostic accuracy of transcranial Doppler (TCD) for brain death. Patients and Methods: Patients seen on the intensive care unit of a private hospital between January 2004 to December 2008, were included if they were in structural coma, had no craniectomy and had a blind evaluation by a neurologist and TCD done in less than three hours. The diagnosis of brain death was based on a clinical evaluation that considered the absence of sedative drugs, median blood pressure >60 mmHg, body temperature over 35º Celsius and complete absence of brainstem refexes. An expert neurosonologist, with a TCD-PMD-100, 2 Mhz transducer, used an institutional protocol that considers the examination as positive for brain circulatory arrest when there is presence of reverberating, small systolic peaks or the disappearance of a previous signal present on both middle cerebral arteries and intracranial vertebral arteries. Results: Fifty three patients were evaluated, 25 with clinical brain death. On 45 cases (84.9 percent), the interval between both evaluations was less than one hour. The sensitivity, specifcity, positive and negative predictive values for the diagnosis of brain death with TCD were 100, 96, 96.1 and 100 percent respectively. Positive and negative likelihood ratios for brain death were 28 and 0, respectively. Conclusions: TCD is a valid and useful technique for the diagnosis of brain death and can be used on complicated cases.

Unidades de tratamiento del ataque cerebrovascular (UTAC) en Chile / Stroke units in Chile

Stroke is a major public health problem in Chile, with an incidence similar to that of many industrialized nations, it accounts for 10% of all deaths and ranks 5th in number of healthy years of life lost to a disease. Organized inpatient care for stroke patients has been shown in systematic reviews of randomized clinical trials to be effective in preventing death, disability and institutional care, without increasing length of stay compared to usual care. Organized stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward (stroke ward) of which there are various possible models; acute stroke units which accept patients acutely but discharge early (usually within 7 days). This could include an "intensive" model of care with continuous monitoring and high nurse staffing levels; comprehensive (i.e. combined acute and rehabilitation) stroke units which accept patients acutely but also provide rehabilitation for at least several weeks if necessary. The way in which stroke units affect outcome is through reduction of complications of immobility and probably non specific neuroprotection. Stroke units should deliver high quality evidence based interventions to all eligible patients and should maintain high standards of care through staff training, guidelines and protocols, audit and quality assurance. Given that stroke is one of the fifty six health priorities in the health reform, inpatient stroke care should be delivered through stroke units organized in hospitals throughout Chile.

Cáncer de ovario: comunicación preliminar / Ovarian cancer: preliminary communication

Se analizan los antecedentes clínicos de 51 pacientes con cáncer de ovario, estudiadas y tratadas en el Servicio de Obstetricia y Ginecología del Hospital del Salvador, entre diciembre de 1980 y diciembre de 1986. El diagnóstico se efectuó en etapas avanzadas en 68,2% de los casos, siendo los tumores de origen epitelial la variedad predominante, en el 78,3%. Se desarrolló un protocolo operatorio preestablecido en forma completa en el 82,3%, y se analizan las principales complicaciones postoperatorias. La terapia complementaria predominante fue quimioterapia, que se efectuó en 23 de 27 casos. La tasa de mortalidad en el tiempo de seguimiento alcanza al 8,3% en etapa I; 25% en etapa II; 35% en etapa III, y 70% en etapa IV. En 12 pacientes se ha efectuado revisión de "segundo vistazo", evidenciándose ausencia de enfermedad en sólo la mitad de los casos