Stroke symptoms, risk factors awareness and personal decision making in Chile. A national survey.

BACKGROUND: Knowledge about stroke symptoms, correct decision in front of a stroke case and recognition of stroke risk factors are crucial to fight against stroke burden. We aimed to assess the stroke awareness among a sample of the Chilean population. METHODS: A closed-ended questions structured survey was applied in November 2019 using a computer-assisted telephone interviewing system. Probabilistic sample, random selection and stratification for region was used. Multivariate logistic regression model was used to estimate the association between participants' characteristics and responses. RESULTS: Of 706 participants, only 74.4% (95% CI 70.9-77.5) recognized at least one typical stroke symptom. Most (586, 82.4% 95% CI 75.2-89.7) chose to contact the emergency ambulance or directly go to the emergency department in case of a stroke symptom and recognized at least one risk factor (692, 97.9% CI 96.7-98.8). In multivariable analysis, sociodemographic characteristics associated to a worse recognition of at least one stroke symptom were being men (OR 0.67, 95% CI 0.47-0.96), being 55 years old or older (OR 0.59 95% CI 0.37-0.93) and from the lowest socioeconomic level (SES) (OR 0.33 95% CI 0.16-0.67). Female sex was associated with lower stroke risk factor knowledge (OR 0.64 95% IC 0.47-0.87). Participants who recognized at least one typical stroke symptom and would promptly seek care at an emergency department differed significantly between SES (p=0.001) and age groups (p=0.035). CONCLUSIONS: We found insufficient knowledge about stroke symptoms and best decisions making in the Chilean population. We describe gaps that can be targeted in future stroke awareness campaigns. There is a need to strengthen tailored stroke education particularly for underserved populations.

Stroke care and collaborative academic research in Latin America.

OBJECTIVE: A narrative overview of regional academic research collaborations to address the increasing burden and gaps in care for patients at risk of, and who suffer from, stroke in Latin America (LA). MATERIALS AND METHODS: A summary of experiences and knowledge of the local situation is presented. No systematic literature review was performed. RESULTS: The rapidly increasing burden of stroke poses immense challenges in LA, where prevention and manage-ment strategies are highly uneven and inadequate. Clinical research is increasing through various academic consortia and networks formed to overcome structural, funding and skill barriers. However, strengthening the ability to generate, analyze and interpret randomized evidence is central to further develop effective therapies and healthcare systems in LA. CONCLUSIONS: Regional networks foster the conduct of multicenter studies -particularly randomized controlled trials-, even in resource-poor regions. They also contribute to the external validity of international studies and strengthen systems of care, clinical skills, critical thinking, and international knowledge exchange.

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.

Diffusion-weighted imaging as predictor of acute ischemic stroke etiology.

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.

Risk Factors and Diet Components Determining Adherence to the Mediterranean Diet in Acute Ischemic Stroke Patients: A Cross-Sectional Analysis of a Prospective Hospital Register Study.

OBJECTIVES: Low adherence to a Mediterranean diet (MeDi) is associated with increased incidence, mortality, and severity of acute ischemic strokes (AIS). Nevertheless, the explanatory factors associated with such results are unclear. Our aim was to investigate stroke risk factors associated with adherence to a MeDi in a prospective cohort of AIS patients. MATERIALS AND METHODS: Patients admitted from February 2017 to February 2020 were included in this study. Adherence was measured using the 14-point Mediterranean Diet Adherence Screener (MEDAS). Demographic and clinical characteristics were compared with adherence with a univariate analysis. A binomial regression was used to investigate the independent association of premorbid factors and MeDi components with adherence. RESULTS: There were 413 patients. Mean age was 68.6 (17.4), 176 (42.6%) women. Median MEDAS score was 6 (IQR 4-7) points. 253 patients (61.2%) had a low adherence (MEDAS ≤ 6). In the univariate analysis, a low MEDAS was associated with lower education, diabetes, sedentary lifestyle, greater body mass index (BMI), lower alcohol consumption, and higher LDLc. In the regression analysis, younger age, lower education, functional disability, hypertension, sedentary lifestyle, and higher BMI were associated with lower MEDAS scores. Six MeDi components had particularly low patient adherence: seafood, legumes, olive oil, nuts, wine, and fruit. DISCUSSION: These data indicate low adherence to MeDi in younger patients who are less educated and have existing cardiovascular risk factors, in particular hypertension, sedentary lifestyle, and higher BMI. Some components of the diet had a particularly low adherence. CONCLUSIONS: Tailoring diet prevention interventions to these specific populations, focusing on components with known less adherence, could improve adherence to a MeDi and the opportunity for secondary stroke prevention.

Impact of COVID-19 Pandemic on Stroke Severity and Mortality in the South-East of Santiago, Chile.

Background and purpose; Chile has been one of the most affected countries by the COVID-19 pandemic, with one of the highest case rates per population. This has affected the epidemiological behaviour of various pathologies. We analyze the impact of the pandemic on the number of admissions due to stroke, its severity and mortality in Santiago, Chile. METHODS: a multicenter observational study based on the records of the 3 hospitals of the South East health service in Santiago, Chile. We recorded the number of patients admitted for ischemic stroke between 01 January 2020 and 30 June 2020. We grouped the cases into two periods, pre-pandemic and pandemic, according to the setting of the state of emergency in Chile. RESULTS: 431 patients were admitted with ischemic stroke during the study period. There was a non-significant decrease in weekly admissions (17 vs 15 patients per week). No differences were observed in the proportion of patients with medical treatment (p = 0.810), IVT (p = 0.638), EVT (p = 0.503) or IVT + EVT (p = 0.501). There was a statistically significant increase in the NIHSS on admission (7.23 vs 8.78, p = 0.009) and mortality (5.2% vs 12.4%, p = 0.012). In a multivariate analysis the NIHSS on admission was associated with the increased mortality (RR 1.11, CI 1.04-1.19, p = 0.003). CONCLUSION: We found an increase in the severity of ischemic stroke on admission and in-hospital mortality during the pandemic period. The main factor to increase in-hospital mortality was the NIHSS on admission.

COVID-19 Lockdown Effects on Acute Stroke Care in Latin America.

OBJECTIVES: COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially during peak periods. We assessed the impact of the pandemic and lockdowns in stroke admissions and care in Latin America. MATERIALS AND METHODS: A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March-June 2020). Comparisons were made with the same period in 2019. Numbers of cases, stroke etiology and severity, acute care and hospitalization outcomes were assessed. RESULTS: Most countries reported mild decreases in stroke admissions compared to the same period of 2019 (1187 vs. 1166, p = 0.03). Among stroke subtypes, there was a reduction in ischemic strokes (IS) admissions (78.3% vs. 73.9%, p = 0.01) compared with 2019, especially in IS with NIHSS 0-5 (50.1% vs. 44.9%, p = 0.03). A substantial increase in the proportion of stroke admissions beyond 48 h from symptoms onset was observed (13.8% vs. 20.5%, p < 0.001). Nevertheless, no differences in total reperfusion treatment rates were observed, with similar door-to-needle, door-to-CT, and door-to-groin times in both periods. Other stroke outcomes, as all-type mortality during hospitalization (4.9% vs. 9.7%, p < 0.001), length of stay (IQR 1-5 days vs. 0-9 days, p < 0.001), and likelihood to be discharged home (91.6% vs. 83.0%, p < 0.001), were compromised during COVID-19 lockdown period. CONCLUSIONS: In this Latin America survey, there was a mild decrease in admissions of IS during the COVID-19 lockdown period, with a significant delay in time to consultations and worse hospitalization outcomes.

[Thrombolysis with Tenecteplase in a stroke with a long time window after onset of symptoms. Report of one case]. / Trombolisis endovenosa con tenecteplase en ventana extendida tras selección por CT y AngioCT: Caso clínico.

We report a 78-year-old man with a basal Rankin score of 2 points, last seen 10 hours before in good conditions, who arrived at the emergency department with left hemiparesis, hypoesthesia, and spacial neglect. Neuroimaging was compatible with stroke in the territory of the right middle cerebral artery. Due to the evolution time of the stroke, usual thrombolysis was contraindicated. Therefore, a thrombolysis with Tenecteplase was used with reversal of symptoms without symptomatic bleeding and with recovery of baseline functionality.

Trombolisis endovenosa con tenecteplase en ventana extendida tras selección por CT y AngioCT: Caso clínico

We report a 78-year-old man with a basal Rankin score of 2 points, last seen 10 hours before in good conditions, who arrived at the emergency department with left hemiparesis, hypoesthesia, and spacial neglect. Neuroimaging was compatible with stroke in the territory of the right middle cerebral artery. Due to the evolution time of the stroke, usual thrombolysis was contraindicated. Therefore, a thrombolysis with Tenecteplase was used with reversal of symptoms without symptomatic bleeding and with recovery of baseline functionality.

Transcranial Doppler as a Predictor of Ischemic Events in Vertebral Artery Dissection.

BACKGROUND AND PURPOSE: Transcranial Doppler (TCD) helps identify patients with carotid dissections at risk of ischemic events (IEs). There is paucity of data identifying independent predictors of IE in vertebral arterial dissection (VAD). We sought to investigate the clinical and ultrasound predictors of IE. METHODS: Patients with VAD admitted between June 2017 and February 2020 were evaluated clinically and with TCD; sonographic curves, microembolic signals (MES), and the breath-holding index (BHI) test were applied. Covariates found on univariate screen (P < .25) were included in a multivariable linear regression to identify independent predictors of IEs. RESULTS: Of 88 patients with 100 VAD, 75 (85.2%) were females with a mean age 37.9 ± 7.5 years. All patients received antiplatelet treatment. TCD monitoring lasted an average of 21 ± 2.1 minutes. TCD was abnormal in 23 cases (26.1%); 21 patients had abnormal sonographic curves in the vertebral/basilar arteries, while in 4 cases, MES were present and in 5 (4.5%), BHI was abnormal. None of the patients with a normal TCD had an IE. Six strokes occurred during follow up. On univariate analysis, male sex, diabetes, dyslipidemia, a previous myocardial infarct, migraine, time of consultation to the ER, bilateral VAD, MES, BHI abnormalities, post stenotic flow in the basilar artery (PFB), and basilar/vertebral velocities were significantly associated with the risk of IEs. In the multivariate analysis, only the presence of PFB was a significant predictor of IE (OR: 68.6, 95% CI 5-937, <.001). CONCLUSIONS: TCD in VAD predicts patients at high risk of IE.

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.

[Determinants of door to needle time for intravenous thrombolysis in acute ischemic stroke]. / 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.

[Intravenous thrombolysis after reversion of acenocoumarol anticoagulation. Report of one case]. / Trombolisis endovenosa post reversión de acenocumarol con complejo de protrombina. Caso clínico.

We report an 89-year-old male under oral anticoagulant therapy with a therapeutic international normalized ratio, presenting at the emergency room with right side hemiparesis and aphasia. Neuroimaging was compatible with an acute middle cerebral artery ischemic stroke. Anticoagulation was reverted with the use of four factor prothrombin complex, followed by thrombolysis with alteplase, with a favorable evolution, returning to his basal functional status.

Trombolisis endovenosa post reversión de acenocumarol con complejo de protrombina: caso clínico / Intravenous thrombolysis after reversion of acenocoumarol anticoagulation: report of one case

We report an 89-year-old male under oral anticoagulant therapy with a therapeutic international normalized ratio, presenting at the emergency room with right side hemiparesis and aphasia. Neuroimaging was compatible with an acute middle cerebral artery ischemic stroke. Anticoagulation was reverted with the use of four factor prothrombin complex, followed by thrombolysis with alteplase, with a favorable evolution, returning to his basal functional status.

Comportamiento de la infección meníngea, Hospital Infantil Consejo de Medellín, 1994 - 1998 / Meningeal infection behaviour, Infantile Hospital Concejo de Medellín, 1994 - 1998

La incidencia de meningitis ha aumentado en varios países del mundo. En las últimas décadas se han registrado epidemias especialmente por meningococo en Egipto, Finlandia, Brasil, Chile y cuba. En Colombia, en los últimos años se han encontrado la mayoría de los casos en Antioquia, siendo de los de mayor incidencia las meningitis por meningococo. En Medellín, en su área Metropolitana su mayor incidencia se ha venido presentando en la zona nororiental. En el transcurso de los 24 años de funcionamiento del Hospital Infantil Consejo de Medellín (H.I.C.M.), se ha venido encontrando una alta incidencia en la presentación de la infección meníngea, la cual ha ido aumentando progresivamente.

Ablación de úterosacros por videolaparoscopia, una alternativa en dismenorrea primaria incapacitante / Ablation of uterosacral ligaments by video laparoscopy. A resource in primary, incapacitating dysmenorrhea

En la dismenorrea incapacitante se han utilizado múltiples tratamientos médicos y quirúrgicos, de ellos la ablación de ligamentos úterosacros es la que ha tenido una mejor respuesta. El objetivo del estudio es demostrar la utilidad de la ablación de los ligamentos úterosacros como tratamiento en la dismenorrea primaria incapacitante. Se efectúo un estudio prospectivo, longitudinal, de una cohorte, en el cual las pacientes fueron sus propios controles. La muestra de trabajo de tipo no probabilístico se integró por 15 pacientes del servicio de ginecología, que se encontraban en estudio por dismenorrea primaria incapacitante y que habían recibido tratamiento médico mínimo de tres meses, sin respuesta favorable al mismo, habiéndose descartado patología pélvica. Se les realizó videolaparoscopia diagnóstica, se utilizó como medio de distensión CO2, para revisión pélvica, lente de 10 mm, gran angular, marca Storz y corriente monopolar para ablación de úterosacros cuando no existió otra patología asociada. Su seguimiento fue de 6 a 16 meses, calificándose la respuesta al dolor dismenorreico en ausente, leve, moderado y severo; considerándose éxito cuando el dolor permitió la actividad diaria al pasar de severo a leve, etc. Se utilizó X2 a un nivel de significancia de p 0.05. En relación al dolor se observó que uno (7 por ciento) permaneció asintomática, nueve (50 por ciento) se transformó en leve, tres (20 por ciento) en mdoerada y dos (13 por ciento) permaneció sin cambio. Al comparar las diferencias pre y post tratamiento fueron estadísticamente significativas a una P 0.0025 a favor de la mejoría de la dismenorrea. Concluimos que no obstante que se trata de una muestra pequeña, los resultados son alentadores ya que cualquier grado de mejoría observado beneficia a nuestras pacientes para la realización de su actividad diaria normal

Introducción al tratamiento de datos estadísticos

1. Introducción 2. Probabilidad 3. Estadística 4. Teoría de errores 5. Tablas 6. Gráficos 7. Ecuaciones 8. Correlación 9. Ajuste analítico 10. Análisis armónico