IScore, a useful prognostic tool for patients with acute ischemic stroke treated with intravenous thrombolysis: a validation study.

BACKGROUND: Stroke is one of the major causes of disability and mortality worldwide. Up to 30% of individuals who experience stroke die within 30 days, and more than 50% of those who survive will have some degree of disability. There are some predetermining factors based on admission data that could be used to objectively assess the odds of poor outcomes, including the Ischemic Stroke Predictive Risk Score (IScore). OBJECTIVE: To analyze and validate the IScore in patients undergoing intravenous thrombolysis for stroke and compare the results of this predictor with actual death and disability outcomes. METHODS: In a retrospective study, data were collected from a database housed at the Stroke Unit of the Teaching Hospital of Universidade Federal do Paraná, Southern Brazil. The IScore was applied to admission data from 239 patients, and the results were compared with actual outcomes (death and disability) within 30 days and 1 year after the stroke event. Data analysis was performed using an analysis of the receiver operating characteristic (ROC) curve to determine the sensitivity and specificity of the IScore in the study population. RESULTS: The IScore demonstrated moderate sensitivity and high specificity in patients with stroke who underwent thrombolysis when evaluated after 30 days and 1 year of the event. CONCLUSIONS: The IScore can be applied to in stroke patients undergoing thrombolysis; therefore, it may be used as an objective prognostic tool to guide clinical decision-making. Understanding the prognosis of patients in the acute phase can assist clinicians in making the best therapeutic decisions and enable better end-of-life care.

ANTECEDENTES: O acidente vascular cerebral (AVC) é uma das principais causas de morte e incapacidade no mundo. Até 30% dos indivíduos evoluem a óbito nos primeiros 30 dias. Dos sobreviventes, mais da metade ficam com alguma sequela. Certas variáveis identificadas já na admissão podem sinalizar maior risco de desfecho desfavorável. Uma dessas ferramentas prognósticas é a Escala de Previsão de Riscos de AVC Isquêmico (Ischemic Stroke Predictive Risk Score, IScore, em inglês). OBJETIVO: Analisar e validar a aplicação do IScore em pacientes com AVC isquêmico submetidos a trombólise endovenosa e comparar os resultados obtidos com a aplicação da escala aos verdadeiros desfechos de morte e incapacidade funcional. MéTODOS: Trata-se de um estudo retrospectivo, cujos dados foram obtidos do banco de dados da Unidade de AVC do Hospital de Clínicas da Universidade Federal do Paraná. A IScore foi aplicada conforme os dados de admissão de 239 pacientes. Os pacientes foram acompanhados ambulatorialmente, e os resultados da escala foram comparados aos desfechos reais de mortalidade e incapacidade. Os resultados foram demonstrados por meio da curva característica de operação do receptor (receiver operating characteristic, ROC, em inglês) para determinar sensibilidade e especificidade da escala. RESULTADOS: Em pacientes com AVC submetidos a trombólise, a IScore demonstrou moderada sensibilidade e alta especificidade para predizer desfechos tanto de óbito quanto de incapacidade, nos intervalos de 30 dias e 1 ano após o evento. CONCLUSõES: A IScore pode ser aplicada em pacientes com AVC isquêmico, na população específica submetida a trombólise; portanto, pode ser usada como uma ferramenta prognóstica útil, que pode guiar decisões terapêuticas. Entender o prognóstico de paciente na fase aguda pode auxiliar os clínicos a fazer as melhores decisões terapêuticas e possibilitar melhores cuidados ao fim da vida.

Automated evaluation of ASPECTS from brain computerized tomography of patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Precise evaluation of brain computerized tomography (CT) is a crucial step in acute ischemic stroke evaluation. Electronic Alberta Stroke Program Early CT Score (E-ASPECTS) helps in the selection of patients who may be eligible for thrombolysis. This paper seeks to assess the performance of emergency physicians (EPs) in the evaluation of ASPECTS scores with and without the use of E-ASPECTS and to compare their results with neuroradiologists. METHODS: A total of 116 patients were selected. Initially, two EPs and two neuroradiologists evaluated the admission nonenhanced CT without E-ASPECTS. Then, after 30 days, they re-evaluated the images using E-ASPECTS. Sensitivity, specificity, Matthew's correlation coefficients (MCC), and receiver operating characteristic curves were generated for analysis before and after the software use. RESULTS: Eps' performances improved when they used E-ASPECTS, with their results closer to those obtained by neuroradiologists. In the initial evaluation, MCC values for the two EPs were -0.01 and 0.04, respectively. After the software assistance, they obtained 0.38 and 0.43, respectively, which was closer to the scores obtained by the neuroradiologists (0.53 and 0.39, respectively). DISCUSSION: This is the first study that has specifically compared neuroradiologists' and EPs' performances before and after using E-ASPECTS. E-ASPECTS assisted and improved the evaluation of the images of patients with acute ischemic stroke. CONCLUSION: Artificial intelligence in the emergency room may increase the number of patients treated with tissue-type plasminogen activators.

IScore, a useful prognostic tool for patients with acute ischemic stroke treated with intravenous thrombolysis: a validation study / IScore, uma ferramenta prognóstica útil para pacientes com AVC isquêmico submetidos a trombólise: estudo de validação

Abstract Background Stroke is one of the major causes of disability and mortality worldwide. Up to 30% of individuals who experience stroke die within 30 days, and more than 50% of those who survive will have some degree of disability. There are some predetermining factors based on admission data that could be used to objectively assess the odds of poor outcomes, including the Ischemic Stroke Predictive Risk Score (IScore). Objective To analyze and validate the IScore in patients undergoing intravenous thrombolysis for stroke and compare the results of this predictor with actual death and disability outcomes. Methods In a retrospective study, data were collected from a database housed at the Stroke Unit of the Teaching Hospital of Universidade Federal do Paraná, Southern Brazil. The IScore was applied to admission data from 239 patients, and the results were compared with actual outcomes (death and disability) within 30 days and 1 year after the stroke event. Data analysis was performed using an analysis of the receiver operating characteristic (ROC) curve to determine the sensitivity and specificity of the IScore in the study population. Results The IScore demonstrated moderate sensitivity and high specificity in patients with stroke who underwent thrombolysis when evaluated after 30 days and 1 year of the event. Conclusions The IScore can be applied to in stroke patients undergoing thrombolysis; therefore, it may be used as an objective prognostic tool to guide clinical decision-making. Understanding the prognosis of patients in the acute phase can assist clinicians in making the best therapeutic decisions and enable better end-of-life care.

Resumo Antecedentes O acidente vascular cerebral (AVC) é uma das principais causas de morte e incapacidade no mundo. Até 30% dos indivíduos evoluem a óbito nos primeiros 30 dias. Dos sobreviventes, mais da metade ficam com alguma sequela. Certas variáveis identificadas já na admissão podem sinalizar maior risco de desfecho desfavorável. Uma dessas ferramentas prognósticas é a Escala de Previsão de Riscos de AVC Isquêmico (Ischemic Stroke Predictive Risk Score, IScore, em inglês). Objetivo Analisar e validar a aplicação do IScore em pacientes com AVC isquêmico submetidos a trombólise endovenosa e comparar os resultados obtidos com a aplicação da escala aos verdadeiros desfechos de morte e incapacidade funcional. Métodos Trata-se de um estudo retrospectivo, cujos dados foram obtidos do banco de dados da Unidade de AVC do Hospital de Clínicas da Universidade Federal do Paraná. A IScore foi aplicada conforme os dados de admissão de 239 pacientes. Os pacientes foram acompanhados ambulatorialmente, e os resultados da escala foram comparados aos desfechos reais de mortalidade e incapacidade. Os resultados foram demonstrados por meio da curva característica de operação do receptor (receiver operating characteristic, ROC, em inglês) para determinar sensibilidade e especificidade da escala. Resultados Em pacientes com AVC submetidos a trombólise, a IScore demonstrou moderada sensibilidade e alta especificidade para predizer desfechos tanto de óbito quanto de incapacidade, nos intervalos de 30 dias e 1 ano após o evento. Conclusões A IScore pode ser aplicada em pacientes com AVC isquêmico, na população específica submetida a trombólise; portanto, pode ser usada como uma ferramenta prognóstica útil, que pode guiar decisões terapêuticas. Entender o prognóstico de paciente na fase aguda pode auxiliar os clínicos a fazer as melhores decisões terapêuticas e possibilitar melhores cuidados ao fim da vida.

Stroke-related mortality analysis in Paraná, Brazil, over 10 years.

BACKGROUND: Stroke is the second leading cause of death and disability around the world. OBJECTIVE: The purpose of this study is to evaluate the age- and sex-specific mortality rates related to stroke in the state of Paraná, Brazil, between 2007 and 2016. METHODS: In this cross-sectional study, residents in the state of Paraná were selected by death certificates (from 2007-2016); the basic cause of death was stroke. A descriptive analysis was performed, and mortality rates were calculated with a 95% confidence interval (95% CI) for each year. RESULTS: From 2007 to 2016, there were 62,607 deaths in the state of Paraná due to stroke. Most individuals had medical assistance before death (85.7% in 2007 versus 83.9% in 2016), and most of these deaths occurred in hospitals (73.6% in 2007 versus 74.8% in 2016). Death rates due to stroke increased from 138 (95% CI 135-142) to 163 (95% CI 159-166) per 100,000 inhabitants. This raise occurred mainly in those over 79 years old. For the ages groups of 34 to 44 and 44 to 54 years, mortality rate decreased. CONCLUSIONS: In the past 15 years, despite the advances in the diagnosis and treatment of stroke, there has been an increase in mortality due to stroke in the state of Paraná. This fact is possibly associated with the aging of the population because there was a more pronounced increase in the group over 79 years old. Thus, new health strategies are necessary to improve the survival and quality of life of poststroke individuals.

ANTECEDENTES: O acidente vascular cerebral (AVC) é a segunda principal causa de morte e invalidez em todo o mundo. OBJETIVO: O objetivo desse estudo é avaliar as taxas de mortalidade específicas por idade e sexo relacionadas ao AVC no estado do Paraná, Brasil, entre 2007 e 2016. MéTODOS: Neste estudo transversal, foram selecionados residentes no estado do Paraná por certidões de óbito (de 2007­2016); a causa básica da morte foi AVC. Uma análise descritiva foi realizada e as taxas de mortalidade calculadas com intervalo de confiança de 95% (IC 95%) para cada ano. RESULTADOS: De 2007 a 2016, ocorreram 62.607 óbitos no estado do Paraná por AVC. A maioria dos indivíduos teve assistência médica antes do óbito (85,7% em 2007 contra 83,9% em 2016), e a maioria desses óbitos ocorreu em hospitais (73,6% em 2007 contra 74,8% em 2016). As taxas de mortalidade por AVC aumentaram de 138 (IC 95% 135­142) para 163 (IC 95% 159­166) por 100.000 habitantes. Esse aumento ocorreu principalmente em maiores de 79 anos. Para as faixas etárias de 34 a 44 e 44 a 54 anos, a taxa de mortalidade diminuiu. CONCLUSõES: Nos últimos 15 anos, apesar dos avanços no diagnóstico e tratamento do AVC, houve aumento da mortalidade no estado do Paraná. Este fato está possivelmente associado ao envelhecimento da população, pois houve um aumento mais acentuado no grupo acima de 79 anos. Assim, novas estratégias de saúde são necessárias para melhorar a sobrevida e a qualidade de vida dos indivíduos pós-AVC.

Stroke-related mortality analysis in Paraná, Brazil, over 10 years / Análise da mortalidade relacionada ao acidente vascular cerebral no estado do Paraná, Brasil, ao longo de 10 anos

Abstract Background Stroke is the second leading cause of death and disability around the world. Objective The purpose of this study is to evaluate the age- and sex-specific mortality rates related to stroke in the state of Paraná, Brazil, between 2007 and 2016. Methods In this cross-sectional study, residents in the state of Paraná were selected by death certificates (from 2007-2016); the basic cause of death was stroke. A descriptive analysis was performed, and mortality rates were calculated with a 95% confidence interval (95% CI) for each year. Results From 2007 to 2016, there were 62,607 deaths in the state of Paraná due to stroke. Most individuals had medical assistance before death (85.7% in 2007 versus 83.9% in 2016), and most of these deaths occurred in hospitals (73.6% in 2007 versus 74.8% in 2016). Death rates due to stroke increased from 138 (95% CI 135-142) to 163 (95% CI 159-166) per 100,000 inhabitants. This raise occurred mainly in those over 79 years old. For the ages groups of 34 to 44 and 44 to 54 years, mortality rate decreased. Conclusions In the past 15 years, despite the advances in the diagnosis and treatment of stroke, there has been an increase in mortality due to stroke in the state of Paraná. This fact is possibly associated with the aging of the population because there was a more pronounced increase in the group over 79 years old. Thus, new health strategies are necessary to improve the survival and quality of life of poststroke individuals.

Resumo Antecedentes O acidente vascular cerebral (AVC) é a segunda principal causa de morte e invalidez em todo o mundo. Objetivo O objetivo desse estudo é avaliar as taxas de mortalidade específicas por idade e sexo relacionadas ao AVC no estado do Paraná, Brasil, entre 2007 e 2016. Métodos Neste estudo transversal, foram selecionados residentes no estado do Paraná por certidões de óbito (de 2007-2016); a causa básica da morte foi AVC. Uma análise descritiva foi realizada e as taxas de mortalidade calculadas com intervalo de confiança de 95% (IC 95%) para cada ano. Resultados De 2007 a 2016, ocorreram 62.607 óbitos no estado do Paraná por AVC. A maioria dos indivíduos teve assistência médica antes do óbito (85,7% em 2007 contra 83,9% em 2016), e a maioria desses óbitos ocorreu em hospitais (73,6% em 2007 contra 74,8% em 2016). As taxas de mortalidade por AVC aumentaram de 138 (IC 95% 135-142) para 163 (IC 95% 159-166) por 100.000 habitantes. Esse aumento ocorreu principalmente em maiores de 79 anos. Para as faixas etárias de 34 a 44 e 44 a 54 anos, a taxa de mortalidade diminuiu. Conclusões Nos últimos 15 anos, apesar dos avanços no diagnóstico e tratamento do AVC, houve aumento da mortalidade no estado do Paraná. Este fato está possivelmente associado ao envelhecimento da população, pois houve um aumento mais acentuado no grupo acima de 79 anos. Assim, novas estratégias de saúde são necessárias para melhorar a sobrevida e a qualidade de vida dos indivíduos pós-AVC.

Store-and-forward teleneurology results in a large Brazilian city.

BACKGROUND: Neurology is a high-demand specialty with long waiting lines. Some pathologies require rapid decision-making. Through technology, telemedicine can allow neurological patients to have faster access to specialized assessment. In store-and-forward telemedicine, the specialist physician evaluates data collected by a general practitioner and optimizes screening. OBJECTIVE: The aim of the present study is to evaluate the effectiveness of asynchronous telemedicine, used to refer patients from primary care to neurology, in the city of Curitiba, in southern Brazil. METHODS: A retrospective analysis of all patients referred from primary care to neurology between September 2019 and February 2020. After a request is made by a general medical doctor for a specialist's opinion, 5 neurologists with complete access to patients' records are tasked with the decision-making. The main variables analyzed were clinical reasons for telemedicine request, neurologist decision, final diagnosis, indication for diagnostic procedures, and subsequent follow-up. RESULTS: Between September 2019 and February 2020, 1,035 asynchronous telemedicine consultations were performed. Headache (30.43%), epilepsy (19.03%), and dementia (15.85%) accounted for almost two-thirds of the primary care requests; one-third of the cases (33.62%) required a complementary diagnostic procedure. More than 70% of the cases did not require face-to-face assessment by a neurologist. CONCLUSIONS: In this study, store-and-forward teleneurology successfully reduced the need for in-visit consultation in 70% of cases. Further studies should identify the best opportunities for teleneurology in the city of Curitiba to facilitate better integrated care between primary care providers and neurologists.

ANTECEDENTES: Neurologia é uma especialidade de alta demanda com grandes filas de espera. Algumas doenças necessitam de rapidez na tomada de decisões. A telemedicina permite que pacientes neurológicos tenham acesso mais rápido à avaliação especializada. Na telerregulação, um ramo da telemedicina, o especialista avalia os dados coletados pelo generalista e otimiza a triagem. OBJETIVO: Avaliar a eficácia da telerregulação assíncrona, usada para referenciar pacientes da atenção primária à neurologia, na cidade de Curitiba, no sul do Brasil. MéTODOS: Análise retrospectiva de todos os pacientes referenciados da atenção primária para a especialidade de neurologia, no período entre setembro de 2019 e fevereiro de 2020, em Curitiba, Brasil. Para cada pedido de avaliação do médico generalista, 5 neurologistas experientes tiveram acesso completo ao prontuário para a tomada de decisão. As variáveis analisadas foram: razões para o referenciamento, decisão do especialista, diagnóstico final, indicação de exame complementar e necessidade de acompanhamento com a especialidade. RESULTADOS: Durante o período de estudo, 1.035 telerregulações foram realizadas. Cefaleia (30.43%), epilepsia (19.03%) e demência (15.85%) compreenderam aproximadamente dois terços de todos os pedidos de consulta; para um terço dos casos, o especialista indicou exame complementar. Mais de 70% dos pacientes não necessitaram de consulta presencial com neurologista. CONCLUSõES: A telerregulação assíncrona diminuiu de forma importante a necessidade de avaliação presencial pelo neurologista em 70% dos casos. Através da tecnologia, é possível conseguir melhor integração entre atenção primária e serviços especializados. Ainda são necessários mais estudos para explorar as janelas de oportunidade para a teleneurologia no Brasil.

Store-and-forward teleneurology results in a large Brazilian city / Telerregulação em neurologia e seus resultados em uma grande cidade brasileira

Abstract Background Neurology is a high-demand specialty with long waiting lines. Some pathologies require rapid decision-making. Through technology, telemedicine can allow neurological patients to have faster access to specialized assessment. In store-and-forward telemedicine, the specialist physician evaluates data collected by a general practitioner and optimizes screening. Objective The aim of the present study is to evaluate the effectiveness of asynchronous telemedicine, used to refer patients from primary care to neurology, in the city of Curitiba, in southern Brazil. Methods A retrospective analysis of all patients referred from primary care to neurology between September 2019 and February 2020. After a request is made by a general medical doctor for a specialist's opinion, 5 neurologists with complete access to patients' records are tasked with the decision-making. The main variables analyzed were clinical reasons for telemedicine request, neurologist decision, final diagnosis, indication for diagnostic procedures, and subsequent follow-up. Results Between September 2019 and February 2020, 1,035 asynchronous telemedicine consultations were performed. Headache (30.43%), epilepsy (19.03%), and dementia (15.85%) accounted for almost two-thirds of the primary care requests; one-third of the cases (33.62%) required a complementary diagnostic procedure. More than 70% of the cases did not require face-to-face assessment by a neurologist. Conclusions In this study, store-and-forward teleneurology successfully reduced the need for in-visit consultation in 70% of cases. Further studies should identify the best opportunities for teleneurology in the city of Curitiba to facilitate better integrated care between primary care providers and neurologists.

Resumo Antecedentes Neurologia é uma especialidade de alta demanda com grandes filas de espera. Algumas doenças necessitam de rapidez na tomada de decisões. A telemedicina permite que pacientes neurológicos tenham acesso mais rápido à avaliação especializada. Na telerregulação, um ramo da telemedicina, o especialista avalia os dados coletados pelo generalista e otimiza a triagem. Objetivo Avaliar a eficácia da telerregulação assíncrona, usada para referenciar pacientes da atenção primária à neurologia, na cidade de Curitiba, no sul do Brasil. Métodos Análise retrospectiva de todos os pacientes referenciados da atenção primária para a especialidade de neurologia, no período entre setembro de 2019 e fevereiro de 2020, em Curitiba, Brasil. Para cada pedido de avaliação do médico generalista, 5 neurologistas experientes tiveram acesso completo ao prontuário para a tomada de decisão. As variáveis analisadas foram: razões para o referenciamento, decisão do especialista, diagnóstico final, indicação de exame complementar e necessidade de acompanhamento com a especialidade. Resultados Durante o período de estudo, 1.035 telerregulações foram realizadas. Cefaleia (30.43%), epilepsia (19.03%) e demência (15.85%) compreenderam aproximadamente dois terços de todos os pedidos de consulta; para um terço dos casos, o especialista indicou exame complementar. Mais de 70% dos pacientes não necessitaram de consulta presencial com neurologista. Conclusões A telerregulação assíncrona diminuiu de forma importante a necessidade de avaliação presencial pelo neurologista em 70% dos casos. Através da tecnologia, é possível conseguir melhor integração entre atenção primária e serviços especializados. Ainda são necessários mais estudos para explorar as janelas de oportunidade para a teleneurologia no Brasil.

Comparison of right-to-left shunt characteristics in cryptogenic embolic ischemic stroke and non-cardioembolic ischemic stroke.

BACKGROUND: Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. OBJECTIVE: The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. METHODS: A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. RESULTS: Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). CONCLUSIONS: The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.

Embolic Stroke of Undetermined Source (ESUS) and Stroke in Atrial Fibrillation Patients: not so Different after all?

Abstract Background: Stroke related to atrial fibrillation (AF) is associated with high recurrence and mortality rates. Embolic Stroke of Undetermined Source (ESUS) is associated with fewer vascular risk factors, less disability, and a high recurrence rate. Objective: To compare risk factors, functional outcomes and the occurrence of primary endpoint (a composite of recurrent stroke, cardiovascular death, and myocardial infarction) between AF stroke and ESUS patients. Method: A retrospective analysis was conducted including all consecutive patients with first-ever ischemic stroke admitted to the Hospital de Clinicas (Clinical Hospital) of the Federal University of Paraná from October 2012 to January 2017 (n=554). There were 61 patients with stroke due to AF and 43 due to ESUS. Both groups were compared for demographic characteristics and vascular risk factors. Logistic regression models were performed to assess the impact of each variable on the primary endpoint in a 12-month follow-up. Statistical significance was considered for p-values < 0.05. Results: ESUS patients, as compared to AF patients, were younger and more likely to be smokers. ESUS patients presented a mean CHADS2VASc score of 4, while the AF group presented a score of 5 (p <0.001). The primary endpoint was observed in 9 (20.9%) ESUS and 11 (18.0%) AF patients over a 12-month period (p=0.802). Higher glucose levels upon hospital admission (p=0.020) and a higher modified Rankin Scale upon hospital discharge (p=0.020) were predictors of the primary endpoint occurrence. Conclusion: AF and ESUS stroke patients presented very similar independence rates upon hospital discharge and outcomes after 12 months, despite some baseline differences, including stroke recurrence, vascular death, and myocardial infarction.

Comparison of right-to-left shunt characteristics in cryptogenic embolic ischemic stroke and non-cardioembolic ischemic stroke / Comparação das características do shunt direita-esquerda em pacientes com AVC isquêmico criptogênio e AVC não cardioembólico

Abstract Background: Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. Objective: The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. Methods: A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. Results: Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). Conclusions: The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.

RESUMO Antecedentes: Uma das potenciais fontes embólicas no acidente vascular cerebral (AVC) de origem indeterminada é o forame oval patente (FOP). Objetivo: O objetivo do presente estudo foi identificar as características do shunt direita-esquerda em paciente com AVC de etiologia indeterminada, presumidamente embólica, e comparar tais características com pacientes apresentando AVC por outras causas não embólicas. Métodos: Trata-se de um estudo retrospectivo com 168 pacientes com AVC e forame oval patente, separados em dois grupos: AVC embólico de etiologia indeterminada e AVC por outras causas não embólicas. Todos os pacientes foram submetidos a Doppler transcraniano, para avaliar a presença de shunt direita-esquerda por meio do teste de embolia paradoxal. Além da quantificação de microbolhas, também foi avaliada a presença de shunt em repouso e sob manobra de Valsalva. Resultado: Do total, 96 pacientes foram incluídos no primeiro grupo (AVC indeterminado) e 72, no segundo grupo (AVC não embólico). No primeiro grupo, 65 pacientes exibiram shunt com passagem de mais de 10 microbolhas (67,5%), enquanto no segundo grupo isso aconteceu em 51,4% (p=0,038) dos casos. Além disso, 75 pacientes (78,1%) do primeiro grupo tiveram teste positivo ao repouso, comparados com 42 pacientes (58,3%) no segundo grupo (p=0,007). Conclusão: O presente estudo demonstrou que até 70% dos pacientes com AVC de etiologia indeterminada e forame oval apresentaram shunts maiores; em mais de 75%, houve passagem de microbolhas ao repouso. Esses achados sugerem que as características do shunt, como quantidade de microbolhas e passagem ao repouso, devem ser levadas em consideração na avaliação do FOP como possível mecanismo subjacente ao AVC.

Small vessel occlusion and syphilis in patients with first-ever ischemic stroke.

BACKGROUND: Syphilis is an endemic disease, particularly in low- and middle-income countries, with vascular involvement in large vessels (aortitis), but no clear relationship with stroke patients, except for those who presented with meningovascular neurosyphilis. OBJECTIVE: To investigate the relationship between a positive history of syphilis determined by serological testing and ischemic stroke etiology, particularly small vessel disease (SVD). METHODS: In total, 269 first-ever ischemic stroke patients admitted to the stroke unit were tested for syphilis. Patients with neurosyphilis were excluded. All patients were classified according to the ASCOD phenotyping as SVD - when SVD was the potential causal mechanism (S1) - or non-SVD - when SVD was uncertain (S2), unlike (S3), or not detected (S0). RESULTS: Syphilis was positive in 32 (12%) patients. When comparing patients with positive and negative serology, the only significant difference was SVD as the causal mechanism (S1) in patients with positive results: 9 (28%) vs. 22 (9%), p<0.01. CONCLUSION: The current study showed that the frequency of positive syphilis serological test was higher in patients with first-ever ischemic stroke and SVD as the potential causal mechanism. This finding could be related to the endothelial dysfunction occurring in syphilis.

Management of acute stroke and urgent neurointerventional procedures during COVID-19 pandemic: recommendations on the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, Brazilian Society of Cerebrovascular Diseases and Brazilian Society of Neuroradiology / Tratamento do acidente vascular cerebral agudo e realização de procedimentos de neurointervenção urgentes durante a pandemia de COVID-19: recomendações do Departamento Científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia, Sociedade Brasileira de Doenças Cerebrovasculares e Sociedade Brasileira de Neurorradiologia

ABSTRACT Introduction: Although the 2019 severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2, COVID-19) pandemic poses new challenges to the healthcare system to provide support for thousands of patients, there is special concern about common medical emergencies, such as stroke, that will continue to occur and will require adequate treatment. The allocation of both material and human resources to fight the pandemic cannot overshadow the care for acute stroke, a time-sensitive emergency that with an inefficient treatment will further increase mortality and long-term disability. Objective: This paper summarizes the recommendations from the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Society of Cerebrovascular Diseases and the Brazilian Society of Neuroradiology for management of acute stroke and urgent neuro-interventional procedures during the COVID-19 pandemic, including proper use of screening tools, personal protective equipment (for patients and health professionals), and patient allocation.

RESUMO Introdução: A pandemia causada pelo novo coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2, COVID-19) apresenta novos e importantes desafios à gestão de saúde no Brasil. Além da difícil missão de prestar atendimento aos milhares de pacientes infectados pelo COVID-19, os sistemas de saúde têm que manter a assistência às emergências médicas comuns em períodos sem pandemia, tais como o acidente vascular cerebral (AVC), que continuam ocorrendo e requerem tratamento com presteza e eficiência. A alocação de recursos materiais e humanos para o enfrentamento à pandemia não pode comprometer o atendimento ao AVC agudo, uma emergência cujo tratamento é tempo-dependente e se não realizado implica em importante impacto na mortalidade e incapacitação a longo prazo. Objetivo: Este trabalho resume as recomendações do Departamento Científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia, da Sociedade Brasileira de Doenças Cerebrovasculares e da Sociedade Brasileira de Neurorradiologia para o tratamento do AVC agudo e para a realização de procedimentos de neurointervenção urgentes durante a pandemia de COVID-19, incluindo o uso adequado de ferramentas de triagem e equipamentos de proteção pessoal (para pacientes e profissionais de saúde), além da alocação apropriada de pacientes.

Is the Mini-Mental State Examination the best cognitive screening test for less educated people?

OBJECTIVE: Mini-Mental State Examination (MMSE) results are strongly influenced by educational level. The Brief Cognitive Screening Battery (BCSB) is an alternative assessment tool that provides more accurate results in individuals with less education. Our aim was to compare the MMSE and BCSB as screening tests. METHODS: The MMSE and BCSB were assessed in 112 participants by two evaluators blind to the other test's result. Participants were classified according to their level of education. The influence of education level was analyzed using the Kruskal-Wallis and multiple comparison tests. RESULTS: Scores of the MMSE (p < 0.0001) and the clock-drawing test (p < 0.0001) were influenced by education level but the delayed recall test score was not (p = 0.0804). The verbal fluency test (p = 0.00035) was influenced only by higher educational levels. It took three minutes less to apply the MMSE than to apply the BCSB (p < 0.0001). CONCLUSIONS: These findings suggest that the delayed recall test and the verbal fluency test of the BCSB are better than the MMSE and clock-drawing test as tools for evaluating cognition in people with limited education.

Is the Mini-Mental State Examination the best cognitive screening test for less educated people? / O mini-exame de estado mental é o melhor teste de rastreamento cognitivo para indivíduos com menor escolaridade?

ABSTRACT Mini-Mental State Examination (MMSE) results are strongly influenced by educational level. The Brief Cognitive Screening Battery (BCSB) is an alternative assessment tool that provides more accurate results in individuals with less education. Objective: Our aim was to compare the MMSE and BCSB as screening tests. Methods: The MMSE and BCSB were assessed in 112 participants by two evaluators blind to the other test's result. Participants were classified according to their level of education. The influence of education level was analyzed using the Kruskal-Wallis and multiple comparison tests. Results: Scores of the MMSE (p < 0.0001) and the clock-drawing test (p < 0.0001) were influenced by education level but the delayed recall test score was not (p = 0.0804). The verbal fluency test (p = 0.00035) was influenced only by higher educational levels. It took three minutes less to apply the MMSE than to apply the BCSB (p < 0.0001). Conclusions: These findings suggest that the delayed recall test and the verbal fluency test of the BCSB are better than the MMSE and clock-drawing test as tools for evaluating cognition in people with limited education.

Resumo Os resultados do Mini-Exame de Estado Mental (MEEM) são consideravelmente influenciados pelo nível de escolaridade. A Bateria Breve de Rastreio Cognitivo (BBRC) é uma ferramenta de rastreamento cognitivo alternativa que fornece resultados mais acurados em indivíduos com menor nível de escolaridade. Objetivo: Comparar o MEEM e a BBRC como testes de rastreamento cognitivo. Métodos: 112 participantes foram submetidos ao MEEM e a BBRC por 2 avaliadores cegos para o resultados do outro teste. Os participantes foram classificados de acordo o nível de escolaridade. A influência do nível de escolaridade foi analisada utilizando o teste de Kruskal-Wallis e o teste de comparações múltiplas. Resultados: As pontuações do MEEM (p < 0,0001) e do teste do desenho do relógio (p < 0,0001) foram influenciadas pelo nível de escolaridade, porém o teste de memória tardia não sofreu influência do nível de escolaridade (p = 0,0804). O teste de fluência verbal (p = 0,00035) foi influenciado apenas pelos níveis educacionais mais altos. A aplicação do MEEM levou 3 minutos a menos que a da BBRC (p < 0,0001). Conclusão: Os achados desse estudo sugerem que o teste de memória tardia e o teste de fluência verbal da BBRC são mais adequados que o MEEM e o teste do desenho do relógio como ferramentas para avaliação cognitiva em populações com menor nível educacional.

Stroke recurrence in the different subtypes of ischemic stroke. The importance of the intracranial disease.

The aim of the study was to analyze the long-term recurrence rate in patients with a first-ever ischemic stroke secondary to intracranial large artery atherosclerosis (LAA) in a Brazilian population. METHODS: All stroke patients admitted to the hospital between October 2012 and September 2015 were evaluated. The stroke mechanism subtypes were classified as cardioembolism, LAA, small-vessel occlusion, other determined etiologies, and stroke of undetermined etiology. RESULTS: The 359 first-ever ischemic stroke patients were followed up for a mean time of 21.6 ± 15.1 months. The LAA intracranial (38.9%) and extracranial (24.6%) stroke patients presented with a higher stroke recurrence. Intracranial LAA [HR, 10.2 (3.6-29.1); p < 0.001] and extracranial LAA [HR, 5.05 (1.79-14.2); p = 0.002] were the only conditions to show positive correlation with the recurrence rate, after adjusting for risk factors, thrombolysis, and National Institutes of Health Stroke Scale score at admission. CONCLUSION: Intracranial LAA presents a higher incidence of recurrence of ischemic stroke when compared with other etiologies in a Southern Brazilian population.

Stroke recurrence in the different subtypes of ischemic stroke. The importance of the intracranial disease / Recorrência nos diferentes subtipos de acidente vascular cerebral isquêmico. A importância da doença intracraniana

ABSTRACT The aim of the study was to analyze the long-term recurrence rate in patients with a first-ever ischemic stroke secondary to intracranial large artery atherosclerosis (LAA) in a Brazilian population. Methods: All stroke patients admitted to the hospital between October 2012 and September 2015 were evaluated. The stroke mechanism subtypes were classified as cardioembolism, LAA, small-vessel occlusion, other determined etiologies, and stroke of undetermined etiology. Results: The 359 first-ever ischemic stroke patients were followed up for a mean time of 21.6 ± 15.1 months. The LAA intracranial (38.9%) and extracranial (24.6%) stroke patients presented with a higher stroke recurrence. Intracranial LAA [HR, 10.2 (3.6-29.1); p < 0.001] and extracranial LAA [HR, 5.05 (1.79-14.2); p = 0.002] were the only conditions to show positive correlation with the recurrence rate, after adjusting for risk factors, thrombolysis, and National Institutes of Health Stroke Scale score at admission. Conclusion: Intracranial LAA presents a higher incidence of recurrence of ischemic stroke when compared with other etiologies in a Southern Brazilian population.

RESUMO O objetivo do presente estudo é analisar a taxa de recorrência a longo prazo em pacientes com o primeiro AVCi secundário à aterosclerose de grande artéria intracraniana em uma amostra brasileira. Métodos: Pacientes admitidos entre outubro de 2012 e setembro de 2015 foram analisados. Os subtipos do mecanismo de AVC foram classificados como cardioembolismo, aterosclerose de grandes artérias, oclusão de pequenos vasos, outras etiologias determinadas e AVCi de causa indeterminada. Resultados: Foram avaliados 359 pacientes com primeiro AVCi. O tempo médio de seguimento foi de 21,6 ± 15,1 meses. A aterosclerose de grande artéria, intracraniana (38,9%) e extracraniana (24,6%), apresentou a maior taxa de recorrência. A aterosclerose de grande artéria intracraniana [HR, 10,2 (3,6-29,1); p < 0,001] e extracraniana [HR, 5,05 (1,79-14,2); p = 0,002] demonstraram correlação positiva com a taxa de recorrência, após o ajuste para fatores de risco, trombólise e gravidade dos sintomas na admissão. Conclusão: A aterosclerose de grande artéria, tanto intracraniana como extracraniana, apresenta maior recorrência comparado aos outros mecanismos de AVCi em uma amostra do Sul do Brasil.

Predictors of dependence after MCA ischemic stroke submitted to thrombolysis.

OBJECTIVES: Stroke is one of the most common causes of disability-adjusted life years worldwide. The aim of this study is to identify variables associated with dependence at 3 months and also after the first 3 months after the first-ever ischemic stroke (IS) in middle cerebral artery (MCA) territory submitted to intravenous thrombolysis (IVT). METHODS: A single-center cohort study of patients with first-ever MCA IS treated with IVT at the Hospital de Clínicas, Universidade Federal do Paraná, was followed over 5 years. Logistic regression was performed to determine predictors of early and late dependence. RESULTS: A total of 144 patients were included; 48.6% women, and 47.2% were dependent at 3 months after stroke. NIHSS at admission (OR = 1.3, 95%CI = 1.16-1.45, p < 0.001), large artery atherosclerosis (LAA) stroke (OR = 4.11, 95%CI = 1.31-12.85, p = 0.014) and pneumonia during hospitalization (OR = 9.17, 95%CI = 1.42-59.07, p = 0.019) were predictors for early dependence. For the late dependence analyses, 99 patients were included; 49.5% women and 39.4% were dependent after 3 months of stroke. NIHSS at admission (OR = 1.33, 95%CI = 1.15-1.54, p < 0.001), pneumonia during hospitalization (OR = 11.08, 95%CI = 1.45-84.73, p = 0.019) and seizure after discharge (OR = 5.82, 95%CI = 1.06-32.01, p = 0.040) were predictors for late dependence. DISCUSSION: .Dependence is an important indicator of the efficacy of stroke care. Besides it was not possible to evaluate rehabilitation, this is the first study on predictors of post-stroke dependence that focus exclusively on patients with first-ever MCA IS submitted to IVT. NIHSS, LAA stroke, in-hospital pneumonia and seizures after discharge were associated with dependence after first-ever MCA IS submitted to IVT.

Physicians are not well informed about the new guidelines for the treatment of acute stroke.

OBJECTIVE: Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data has added challenges to the treatment of ischemic stroke in the acute phase. OBJECTIVE: To evaluate the knowledge of physicians about the treatment of ischemic stroke in the acute phase. METHODS: An online questionnaire was submitted to all physicians enrolled in the Regional Council of Medicine in Brazil. RESULTS: 456 physicians from different specialties answered the questions. Most of them did not know that mechanical endovascular thrombectomy is often considered as the gold standard treatment in cases of ischemic stroke in the acute phase; and 85% of them did not realize that thrombectomy together with intravenous thrombolysis was possible. The maximum time to act in an acute event also presented many divergences, even with regard to the infusion of rtPA. The lack of structure, medication and absence of a neurologist were considered the main barriers to treatment. CONCLUSION: Physicians are not well informed about the new guidelines for the treatment of acute stroke. Most physicians incorrectly answered most of the questions on the questionnaire.

Physicians are not well informed about the new guidelines for the treatment of acute stroke / Os médicos não estão bem informados sobre as novas diretrizes para o tratamento de AVC agudo

ABSTRACT Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data has added challenges to the treatment of ischemic stroke in the acute phase. Objective: To evaluate the knowledge of physicians about the treatment of ischemic stroke in the acute phase. Methods: An online questionnaire was submitted to all physicians enrolled in the Regional Council of Medicine in Brazil. Results: 456 physicians from different specialties answered the questions. Most of them did not know that mechanical endovascular thrombectomy is often considered as the gold standard treatment in cases of ischemic stroke in the acute phase; and 85% of them did not realize that thrombectomy together with intravenous thrombolysis was possible. The maximum time to act in an acute event also presented many divergences, even with regard to the infusion of rtPA. The lack of structure, medication and absence of a neurologist were considered the main barriers to treatment. Conclusion: Physicians are not well informed about the new guidelines for the treatment of acute stroke. Most physicians incorrectly answered most of the questions on the questionnaire.

RESUMO O tratamento da doença cerebrovascular tem avançado rapidamente nas últimas duas décadas. Dados recentes acrescentaram desafios ao tratamento do AVC isquêmico na fase aguda (AIFA). Objetivo: Avaliar o conhecimento médico sobre o tratamento do AIFA. Métodos: Um questionário on-line foi submetido a todos os médicos inscritos no Conselho Regional de Medicina. Resultados: 456 médicos de diferentes especialidades responderam às perguntas. A maioria deles não sabia que a trombectomia endovascular mecânica é freqüentemente considerada como tratamento padrão-ouro nos casos de AIFA. 85% não realizariam trombectomia junto com a trombólise intravenosa. O tempo máximo para atuar no evento agudo também apresentou muitas divergências, mesmo em relação à infusão de rtPA. A falta de estrutura, medicação e neurologista foram consideradas as principais barreiras ao tratamento. Conclusão: Os médicos não estão bem informados sobre as novas diretrizes para o tratamento do AIFA. A maioria dos médicos errou a maioria das perguntas desse questionário.

Factors Related to Cardioembolism as Major Predictors of Poor Survival after First-Ever Middle Cerebral Artery Stroke Treated with Thrombolysis.

BACKGROUND AND PURPOSE: Prognostic factors related to mortality rates after stroke have been reported; however, most studies included different treatments and did not focus solely on ischemic stroke. The study aimed to report the short- and long-term survival and predictors of death in patients with first-ever ischemic stroke in the middle cerebral artery (MCA) territory, submitted to intravenous thrombolysis (IVT). METHODS: A prospective observational cohort study of patients with first-ever ischemic stroke in the MCA territory treated with IVT from March 2010 to February 2015 was conducted, and patients were followed up until May 2015. The Kaplan-Meier method was used to estimate the cumulative case fatality rates. The potential prognostic factors were identified using Cox proportional hazards regression analysis. RESULTS: A total of 169 patients, 51% women of mean age of 64.1 ± 12.9 years were followed up for a median time of 23.6 (8.1-36.2) months. At the end of the study, 53 (31.4%) patients had died. The estimated cumulative case fatality rate was 41.8% for 5 years. Chronic heart failure (hazards ratio [HR] 2.89, 95% CI 1.43-5.84, p = 0.003), atrial fibrillation (HR 3.88, 95% CI 1.30-11.57, p = 0.015), and symptomatic intracerebral hemorrhage (SICH; HR 7.83, 95% CI 3.43-17.92, p < 0.001) were significant unfavorable independent outcome predictors. The most frequent cause of death was infection (46%). CONCLUSIONS: Stroke in the MCA territory has a high mortality rate, even in patients treated with IVT. SICH, atrial fibrillation, and chronic heart failure are modifiable factors related to cardioembolism that need to be aggressively targeted for improved outcomes after stroke.