Determinants of emergency medical services use in a Brazilian population with acute ischemic stroke.

Emergency medical services (EMS) plays a key role in the recognition and treatment of stroke. This study evaluates the determinants of EMS use in a Brazilian population with acute ischemic stroke. We performed a post hoc analysis of prospectively collected data of consecutive patients admitted to a Brazilian tertiary hospital with acute ischemic stroke. Groups were compared according to their mode of arrival to the hospital: those brought by EMS and those arriving at the hospital by their own means. Among 165 patients evaluated between January and December 2009, 17.6% arrived by EMS and 82.4% arrived by their own means. After multivariate adjustment, individuals with higher National Institutes of Health Stroke Scale score at presentation (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06-1.23 for each point on the National Institutes of Health Stroke Scale score) were more likely to use EMS, as were those with atrial fibrillation (OR, 5.8; 95% CI, 1.41-24.07) and with lower blood pressure at hospital admission (OR, 0.72; 95% CI, 0.56-0.93 for each mm Hg). Patients brought by EMS had trends toward a lower door-to-neuroimaging time and a higher frequency of thrombolysis therapy (13% in EMS users vs 5% in patients arriving by their own means; P = .10). Our data demonstrate that in a Brazilian population with acute ischemic stroke, the patients with more severe stroke, those with atrial fibrillation, and those with lower blood pressure at hospital presentation were more likely to use EMS. EMS use was associated with trends toward a lower door-to-neuroimaging time and a higher frequency of thrombolysis therapy.

Get with the guidelines stroke performance indicators in a brazilian tertiary hospital.

BACKGROUND: Stroke is the fourth leading killer in the US, the first in Brazil and a leading cause of adult long-term disability in both countries. In spite of widespread recommendation, clinical practice guidelines have had limited effect on changing physician behavior. Recognizing that both knowledge and acceptance of guidelines do not necessarily imply guideline adherence, the American Heart Association/American Stroke Association (AHA/ASA) developed a national stroke quality improvement program, the 'Get With The Guidelines (GWTG) stroke'. Even though GWTG has produced remarkable results in the US, other countries have not adopted the program. METHODS: We compared the stroke treatment quality indicators from a private Brazilian tertiary hospital to those published by the GWTG stroke program. Seven predefined performance measures selected by the GWTG stroke program as targets for stroke quality improvement were evaluated: (1) tissue plasminogen activator use in patients who arrived <2 h from symptom onset; (2) antithrombotic medication use within 48 h of admission; (3) deep vein thrombosis prophylaxis within 48 h of admission for nonambulatory patients; (4) discharge use of antithrombotics; (5) discharge use of anticoagulation for atrial fibrillation; (6) dosing of LDL and treatment for LDL >100 mg/dl in patients meeting the National Cholesterol Education Program Adult Treatment Panel (NCEP) III guidelines, and (7) counseling for smoking cessation. RESULTS: A total of 343 consecutive patients with acute ischemic stroke (70.8%) or transient ischemic attack (29.2%) were evaluated from August 2008 to December 2010. Antithrombotic medication within 48 h was used in 98.5% of the eligible patients and deep vein thrombosis prophylaxis in 100%. A total of 123 patients arrived within 2 h from symptoms onset, 23 were eligible for intravenous thrombolysis and 16 were treated (69.5%). All eligible patients were discharged using antithrombotic medication, and 86.9% of the eligible patients who had atrial fibrillation received anticoagulation. Only 56.1% of the eligible patients were treated according to the NCEP III guidelines. Counseling for smoking cessation was done in 63.6% of the eligible patients. CONCLUSIONS: Our study is the first in Brazil and the second outside the US to analyze compliance with the GWTG recommendations. Close attention to a better implementation of these measures may produce an improvement in such results similar to what happened after the full implementation of the program in the US. Whether or not a US disease-based registry such as GWTG can be adopted with success beyond the US is still a matter of debate.

The challenge of managing fusiform basilar artery aneurysms: from acute ischemic stroke to a massive subarachnoid hemorrhage.

We present the case of a patient with acute brain stem ischemic stroke who was found to have a fusiform basilar aneurysm with a thrombus within the dilated vessel. Three days after the ischemic stroke, the patient had a massive subarachnoid hemorrhage and died. This case illustrates the difficulties in the acute management of ischemic events in patients with basilar fusiform aneurysms, because the natural history of this disease encompasses both bleeding and thrombosis.