In-Hospital Aspirin Dose as a Risk Factor for Hemorrhagic Transformation in Patients Not Treated With Thrombolysis.

BACKGROUND: Aspirin is widely used as secondary prophylaxis for acute ischemic stroke. However, its influence on the risk of spontaneous hemorrhagic transformation (HT) is still unclear. Predictive scores of HT have been proposed. We hypothesized that an increased aspirin dose might be harmful in patients at a high risk of HT. This study aimed to analyze the relationship between in-hospital daily aspirin dose (IAD) and HT in patients with acute ischemic stroke. METHODS: We conducted a retrospective cohort study of patients admitted to our comprehensive stroke center between 2015 and 2017. The attending team defined IAD. All included patients underwent either computed tomography or magnetic resonance imaging within 7 days of admission. The risk of HT was assessed using the predictive score of HT in patients not undergoing reperfusion therapies. Regression models were used to evaluate the correlations between HT and IAD. RESULTS: A total of 986 patients were included in the final analysis. The prevalence of HT was 19.2%, and parenchymatous hematomas type-2 (PH-2) represented 10% (n=19) of these cases. IAD was not associated with HT ( P =0.09) or PH-2 ( P =0.06) among all patients. However, in patients at a higher risk for HT (patients not undergoing reperfusion therapies ≥3), IAD was associated with PH-2 (odds ratio 1.01,95% CI 1.001-1.023, P =0.03) in an adjusted analysis. Taking 200 versus 300 mg aspirin was protective against PH-2 (odds ratio 0.102, 95% CI 0.018-0.563, P =0.009). CONCLUSION: An increased in-hospital aspirin dose is associated with intracerebral hematoma in patients at a high risk of HT. Stratifying the risk of HT may lead to individualized daily aspirin dose choices. However, clinical trials on this topic are required.

Diagnostic approach in a patient with Creutzfeldt-Jakob disease.

Prion diseases are an important cause of rapidly progressive dementias. Among them, the most common is sporadic Creutzfeldt-Jakob disease (CJD). It is a rare and incurable disease, with rapid progression to death. Objective: To describe the diagnostic approach of a patient with Creutzfeldt-Jakob disease. Methods: The diagnosis is established through the clinical picture associated with characteristic changes in the brain magnetic resonance imaging, the electroencephalogram, and analysis of specific changes in the cerebrospinal fluid. Results: The present report describes the case of a 53-year-old patient in the city of Fortaleza-CE. The diagnosis was made based on the clinical condition and through diagnostic tests, including 14-3-3 protein and RT QUIC analysis. Differential diagnosis was performed with other rapidly progressive causes, such as infectious and immune-mediated diseases. Conclusions: The diagnosis of probable sporadic CJD was established.

As doenças priônicas são uma importante causa de demências rapidamente progressivas. Entre elas, a mais comum é a doença de Creutzfeldt-Jakob (DCJ) esporádica. É uma enfermidade rara e incurável, com rápida progressão para óbito. Objetivo: Descrever a abordagem diagnóstica de uma paciente com doença de Creutzfeldt-Jakob. Métodos: O diagnóstico é estabelecido pelo quadro clínico associado a alterações características na ressonância magnética cerebral, no eletroencefalograma e pela análise de alterações específicas no líquido cefalorraquidiano. Resultados: O presente relato descreve o caso de um paciente de 53 anos na cidade de Fortaleza (CE). O diagnóstico foi feito com base na condição clínica e por meio de testes diagnósticos, incluindo proteína 14-3-3 e análise Real-Time Quaking-Induced Conversion (RT QUIC). O diagnóstico diferencial foi realizado com outras causas rapidamente progressivas, como doenças infecciosas e imunomediadas. Conclusões: Por fim, foi estabelecido o diagnóstico de provável DCJ esporádica.

Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke in Brazil: Results from the RESILIENT trial.

BACKGROUND: The RESILIENT trial demonstrated the clinical benefit of mechanical thrombectomy in patients presenting acute ischemic stroke secondary to anterior circulation large vessel occlusion in Brazil. AIMS: This economic evaluation aims to assess the cost-utility of mechanical thrombectomy in the RESILIENT trial from a public healthcare perspective. METHODS: A cost-utility analysis was applied to compare mechanical thrombectomy plus standard medical care (n = 78) vs. standard medical care alone (n = 73), from a subset sample of the RESILIENT trial (151 of 221 patients). Real-world direct costs were considered, and utilities were imputed according to the Utility-Weighted modified Rankin Score. A Markov model was structured, and probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of results. RESULTS: The incremental costs and quality-adjusted life years gained with mechanical thrombectomy plus standard medical care were estimated at Int$ 7440 and 1.04, respectively, compared to standard medical care alone, yielding an incremental cost-effectiveness ratio of Int$ 7153 per quality-adjusted life year. The deterministic sensitivity analysis demonstrated that mRS-6 costs of the first year most affected the incremental cost-effectiveness ratio. After 1000 simulations, most of results were below the cost-effective threshold. CONCLUSIONS: The intervention's clear long-term benefits offset the initially higher costs of mechanical thrombectomy in the Brazilian public healthcare system. Such therapy is likely to be cost-effective and these results were crucial to incorporate mechanical thrombectomy in the Brazilian public stroke centers.

Fighting Against Stroke in Latin America: A Joint Effort of Medical Professional Societies and Governments.

Introduction: Stroke is one of the leading causes of death in Latin America, a region with countless gaps to be addressed to decrease its burden. In 2018, at the first Latin American Stroke Ministerial Meeting, stroke physician and healthcare manager representatives from 13 countries signed the Declaration of Gramado with the priorities to improve the region, with the commitment to implement all evidence-based strategies for stroke care. The second meeting in March 2020 reviewed the achievements in 2 years and discussed new objectives. This paper will review the 2-year advances and future plans of the Latin American alliance for stroke. Method: In March 2020, a survey based on the Declaration of Gramado items was sent to the neurologists participants of the Stroke Ministerial Meetings. The results were confirmed with representatives of the Ministries of Health and leaders from the countries at the second Latin American Stroke Ministerial Meeting. Results: In 2 years, public stroke awareness initiatives increased from 25 to 75% of countries. All countries have started programs to encourage physical activity, and there has been an increase in the number of countries that implement, at least partially, strategies to identify and treat hypertension, diabetes, and lifestyle risk factors. Programs to identify and treat dyslipidemia and atrial fibrillation still remained poor. The number of stroke centers increased from 322 to 448, all of them providing intravenous thrombolysis, with an increase in countries with stroke units. All countries have mechanical thrombectomy, but mostly restricted to a few private hospitals. Pre-hospital organization remains limited. The utilization of telemedicine has increased but is restricted to a few hospitals and is not widely available throughout the country. Patients have late, if any, access to rehabilitation after hospital discharge. Conclusion: The initiative to collaborate, exchange experiences, and unite societies and governments to improve stroke care in Latin America has yielded good results. Important advances have been made in the region in terms of increasing the number of acute stroke care services, implementing reperfusion treatments and creating programs for the detection and treatment of risk factors. We hope that this approach can reduce inequalities in stroke care in Latin America and serves as a model for other under-resourced environments.

The Role of Hemorrhagic Transformation in Acute Ischemic Stroke Upon Clinical Complications and Outcomes.

BACKGROUND AND PURPOSE: Hemorrhagic transformation (HT) is a common neurological complication after ischemic stroke. The influence of symptomatic HT upon clinical outcomes post-stroke is well established, however, the role of asymptomatic HT upon prognosis is still unclear. We aimed to analyze the relationship between HT, clinical complications and outcomes in patients not submitted to reperfusion therapies (RT). METHODS: We included 448 randomly selected patients admitted with acute ischemic stroke to a tertiary hospital stroke unit from 2015 to 2017. Patients submitted to RT were excluded. All patients were evaluated with computed tomography (CT) at admission and within 7 days from the initial CT. Patients with HT were divided into two groups: symptomatic and asymptomatic cases based on the ECASS II definition. A good clinical outcome was defined as a modified Rankin Scale (mRS) 0-2 at discharge. RESULTS: A total of 95 patients (21.2%) had HT (51 asymptomatic and 44 symptomatic). Age, NIHSS at admission and symptomatic HT were associated with a higher risk of developing pneumonia and seizures during hospitalization. Symptomatic HT was also associated with a prolonged length of hospitalization and death and inversely associated with good clinical outcomes at discharge (OR 0.96, 95% CI 0.94-0.98, p<0.001). In an adjusted analysis, even asymptomatic HT was independently associated with worse clinical outcomes at discharge (mRS 4-6) (OR 5.99, 95% CI 1.83-19.58, p = 0.003). CONCLUSIONS: Symptomatic HT is associated with a higher risk of clinical complications, prolonged hospitalization, death and worse clinical outcome at discharge. Furthermore, even patients with asymptomatic HT had a higher chance of worse clinical outcomes at discharge.

Influence of myofascial pain on the pressure pain threshold of masticatory muscles in women with migraine.

OBJECTIVE: To evaluate the influence of myofascial pain on the Pressure Pain Threshold (PPT) of masticatory muscles in women with migraine. METHODS: The sample comprised 101 women, ages ranging from 18 to 60 years, with an episodic migraine diagnosis previously confirmed by a neurologist. All patients were evaluated using Research Diagnostic Criteria for Temporomandibular Disorders to determine the presence of myofascial pain and were divided into 2 groups: group I (n=56), comprising women with a migraine, and group II (n=45), comprising women with a migraine and myofascial pain. Two more groups (49 asymptomatic women and 50 women with myofascial pain), matched for sex and race, obtained from a previous study, were added to this study. The PPT values of masseter and temporalis (anterior, middle, and posterior regions) muscles were recorded bilaterally using a pressure algometer. One-way analysis of variance and the Tukey test for pairwise comparisons were used in statistical analysis with a 5% significance level. RESULTS: We found that all groups had significantly lower PPT values compared with asymptomatic women, with lower values seen in group II (women with migraine and myofascial pain). Women with a migraine and myofascial pain showed significantly lower PPT values compared with women with a migraine only, and also when compared with women with myofascial pain only. DISCUSSION: Migraine, especially when accompanied by myofascial pain, reduces the PPT of masticatory muscles, suggesting the importance of masticatory muscle palpation during examination of patients with migraine.

Stroke epidemiology, patterns of management, and outcomes in Fortaleza, Brazil: a hospital-based multicenter prospective study.

BACKGROUND AND PURPOSE: Little information exists on the epidemiology and patterns of treatment of patients admitted to Brazilian hospitals with stroke. Our objective was to describe the frequency of risk factors, patterns of management, and outcome of patients admitted with stroke in Fortaleza, the fifth largest city in Brazil. METHODS: Data were prospectively collected from consecutive patients admitted to 19 hospitals in Fortaleza with a diagnosis of stroke or transient ischemic attack from June 2009 to October 2010. RESULTS: We evaluated 2407 consecutive patients (mean age, 67.7±14.4 years; 51.8% females). Ischemic stroke was the most frequent subtype (72.9%) followed by intraparenchymal hemorrhage (15.2%), subarachnoid hemorrhage (6.0%), transient ischemic attack (3%), and undetermined stroke (2.9%). The median time from symptoms onset to hospital admission was 12.9 (3.8-32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2-26.5) hours. In-hospital mortality was 20.9% and the frequency of modified Rankin Scale score≤2 at discharge was less than 30%. Older age, prestroke disability, and having a depressed level of consciousness at admission were independent predictors of poor outcome; conversely, male gender was a predictor of good outcome. CONCLUSIONS: The prevalence of stroke risk factors and clinical presentation in our cohort were similar to previous series. Treatment with thrombolysis and functional independency after a stroke admission were infrequent. We also found long delays in hospital admission and in evaluation with neuroimaging and high in-hospital mortality.