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

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

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

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

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

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

Hipertensão arterial e acidente vascular encéfalico / Stroke and hypertension

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

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

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

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

Neurologic complications after heart transplantation

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

Is the number of microembolic signals related to neurologic outcome in coronary bypass surgery?

Coronary artery bypass surgery (CABG) without cardiopulmonary bypass (CPB) may potentially reduce the number of microembolic signals (MES) associated with aortic manipulation or generated by the pump circuit, resulting in a better neurologic outcome after surgery. Our aim was to compare the frequency of MES and neurologic complications in CABG with and without CPB. Twenty patients eligible to routine CABG without CPB were randomized to surgery with CPB and without CPB and continuously monitored by transcranial Doppler. Neurologic examination was performed in all patients before and after surgery. The two groups were similar with respect to demographics, risk factors, grade of aortic atheromatous disease and number of grafts. The frequency of MES in the nonCPB group was considerably lower than in CPB patients, however, we did not observe any change in the neurologic examination during the early postoperative period. Neurologic complications after CABG may be related to the size and composition of MES rather than to their absolute numbers. A large prospective multicentric randomized trial may help to elucidate this complex issue