Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era.

BACKGROUND AND PURPOSE: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, doctors and public authorities have demonstrated concern about the reduction in quality of care for other health conditions due to social restrictions and lack of resources. Using a population-based stroke registry, we investigated the impact of the onset of the COVID-19 pandemic in stroke admissions in Joinville, Brazil. METHODS: Patients admitted after the onset of COVID-19 restrictions in the city (defined as March 17, 2020) were compared with those admitted in 2019. We analyzed differences between stroke incidence, types, severity, reperfusion therapies, and time from stroke onset to admission. Statistical tests were also performed to compare the 30 days before and after COVID-19 to the same period in 2019. RESULTS: We observed a decrease in total stroke admissions from an average of 12.9/100 000 per month in 2019 to 8.3 after COVID-19 (P=0.0029). When compared with the same period in 2019, there was a 36.4% reduction in stroke admissions. There was no difference in admissions for severe stroke (National Institutes of Health Stroke Scale score >8), intraparenchymal hemorrhage, and subarachnoid hemorrhage. CONCLUSIONS: The onset of COVID-19 was correlated with a reduction in admissions for transient, mild, and moderate strokes. Given the need to prevent the worsening of symptoms and the occurrence of medical complications in these groups, a reorganization of the stroke-care networks is necessary to reduce collateral damage caused by COVID-19.

High five-year mortality rates of ischemic stroke subtypes: A prospective cohort study in Brazil.

BACKGROUND: Studies regarding long-term outcomes of ischemic stroke subtypes are scarce in low- and middle-income countries. We aimed to measure the five-year prognosis of ischemic stroke subtypes in Joinville, Brazil. METHODS: All first-ever ischemic strokes that occurred in Joinville in 2010 were followed-up for five years. RESULTS: We included 334 ischemic stroke patients. Over five years, 156 died, 51 had a recurrent stroke, and 128 were free of recurrent stroke. The overall cumulative risk of death was 17% (95% CI, 13% to 22%) at 30 days and 47% (95% CI, 41% to 52%) after five years. Undetermined with incomplete investigation ischemic stroke had a significantly worse survival probability (ß -4.91; 95% CI, -6.31 to -3.50; p < 0.001), followed by cardioembolic ischemic stroke (ß -3.07; 95% CI, -4.32 to -1.83; p < 0.001) and large artery disease ischemic stroke (ß -1.95; 95% CI, -3.30 to -0.60; p = 0.005). The survival probability of undetermined with negative investigation or cryptogenic ischemic stroke did not differ significantly from small artery disease ischemic stroke (ß -1.022; 95% CI, -3.37 to -1.43; p = 0.414). The five-year mortality for small artery disease ischemic stroke was 30% (95% CI, 22% to 39%) and 47% (95% CI, 35% to 60%) for large artery ischemic stroke. The risk of stroke recurrence was 2% in the first year and 5% in the second year. The proportion of disability among survivors in the first month ranged from 8% (95% CI, 3-15) for small artery disease ischemic stroke to 40% (95% CI, 30-52) for cardioembolic ischemic stroke patients. CONCLUSIONS: Cardioembolic and undetermined with incomplete investigation ischemic stroke sub-types have a poor long-term prognosis. An alarming finding was that our patients with both small and large artery ischemic stroke had higher five-year mortality rates compared with subjects from high-income countries.

Five-year survival, disability, and recurrence after first-ever stroke in a middle-income country: A population-based study in Joinvile, Brazil.

Background Information about long-term outcomes after stroke in developing countries provided by population-based methodologies is scarce. Aim This study aimed to know outcomes five years after a first-ever stroke in Joinville, Brazil. Methods Data were extracted from the Joinville Stroke Registry about all patients who had strokes in Joinville in 2010 and were followed up to 2015. Stroke recurrence, Kaplan-Meier survival probabilities, functional outcomes, and causes of death were ascertained at 30 days, six months, one and five years. Results A total of 399 strokes were studied. The mean age was 64 (standard deviation 16) years. After five years, 52% (95% confidence interval: 47-57%) survived and 20% (95% confidence interval: 15-26%) of the survivors had modified Rankin scale scores >2. More than half of these patients were institutionalized in nursing or home care settings. The average risk of death per year was ≈7%. Survival rates were significantly lower for subarachnoid hemorrhage and primary intracerebral hemorrhage than for ischemic stroke. The five-year recurrence rate was 12% (95% confidence interval: 9-15%). The index stroke was the cause of death in three quarters of the patients. Conclusions The results showed that 68% of the patients with stroke were either dead or disabled five years after first-ever stroke. This percentage is similar to proportions of other recent cohorts from developed countries, despite the lower age of the patients in this study.

Joinville stroke biobank: study protocol and first year's results.

Aiming to contribute to studies that use detailed clinical and genomic information of biobanks, we present the initial results of the first Latin American Stroke Biobank. METHODS: Blood samples were collected from patients included in the Joinville Stroke Registry and four Brazilian cities. Demographic socio-economic data, cardiovascular risk factors, Causative Classification System for Ischemic Stroke, Trial of Org 10172 in Acute Stroke Treatment and National Institutes of Health scores, functional stroke status (modified Rankin) and brain images were recorded. Additionally, controls from both geographic regions were recruited. High-molecular-weight genomic DNA was obtained from all participants. RESULTS: A total of 2,688 patients and 3,282 controls were included. Among the patients, 76% had ischemic stroke, 12% transient ischemic attacks, 9% hemorrhagic stroke and 3% subarachnoid hemorrhage. Patients with undetermined ischemic stroke were most common according the Trial of Org 10172 in Acute Stroke Treatment (40%) and Causative Classification System for Ischemic Stroke (47%) criteria. A quarter of the patients were under 55 years of age at the first-ever episode. CONCLUSIONS: We established the Joinville Stroke Biobank and discuss its potential for contributing to the understanding of the risk factors leading to stroke.

Joinville stroke biobank: study protocol and first year's results / Biobanco de acidente cerebrovascular de Joinville: protocolo de estudos e resultados dos primeiros anos

ABSTRACT Aiming to contribute to studies that use detailed clinical and genomic information of biobanks, we present the initial results of the first Latin American Stroke Biobank. Methods: Blood samples were collected from patients included in the Joinville Stroke Registry and four Brazilian cities. Demographic socio-economic data, cardiovascular risk factors, Causative Classification System for Ischemic Stroke, Trial of Org 10172 in Acute Stroke Treatment and National Institutes of Health scores, functional stroke status (modified Rankin) and brain images were recorded. Additionally, controls from both geographic regions were recruited. High-molecular-weight genomic DNA was obtained from all participants. Results: A total of 2,688 patients and 3,282 controls were included. Among the patients, 76% had ischemic stroke, 12% transient ischemic attacks, 9% hemorrhagic stroke and 3% subarachnoid hemorrhage. Patients with undetermined ischemic stroke were most common according the Trial of Org 10172 in Acute Stroke Treatment (40%) and Causative Classification System for Ischemic Stroke (47%) criteria. A quarter of the patients were under 55 years of age at the first-ever episode. Conclusions: We established the Joinville Stroke Biobank and discuss its potential for contributing to the understanding of the risk factors leading to stroke.

RESUMO Com o objetivo de contribuir para estudos que utilizam informações clínicas e genômicas de biobancos, apresentamos os resultados iniciais do primeiro Biobanco Latinoamericano em Acidente Vascular Cerebral (AVC). Métodos: Foram coletadas amostras de sangue de pacientes recrutados pelo Registro de AVC de Joinville e posteriormente de quatro cidades brasileiras. Foram registrados dados socioeconômicos demográficos, fatores de risco cardiovasculares, Causative Classification System (CCS), Trial of Org 10172 in Acute Stroke Treatment, National Institutes of Health, estado funcional (Rankin modificado) e imagens cerebrais. Adicionalmente, foram recrutados controles das regiões geográficas correspondentes. Obteve-se DNA genômico de todos participantes. Resultados: Foram incluídos 2688 pacientes e 3282 controles. Entre os pacientes, 76% tiveram AVC isquêmico, 12% ataques isquêmicos transitórios, 9% AVC hemorrágico e 3% hemorragia subaracnóidea. Os casos indeterminados foram os mais frequentes e classificados de acordo com TOAST (40%) e CCS (47%). Um quarto dos pacientes tinham menos de 55 anos no primeiro evento. Conclusões: Estabelecemos o Joinville Stroke Biobank, e discutimos aqui seu potencial na compreensão dos fatores de risco do AVC.

Incidence and functional outcome of atrial fibrillation and non-atrial fibrillation- related cardioembolic stroke in Joinville, Brazil: a population-based study.

Among ischemic strokes, cardioembolic (CE) stroke has the worst outcome. We measured the incidence of atrial fibrillation (AF) and non-AF related CE strokes, previous anticoagulant use, and the 90-day functional outcome. Using multiple overlapping sources, we included all CE strokes that occurred in 2015 in Joinville, Brazil. Of the 374 ischemic strokes, 23% (84) were CE. The CE age-adjusted incidence, per 1,000 person-years, was 0.14 (0.11-0.17). Of the 26 patients with known prior AF, 73% (19) were not anticoagulated, 77% (20) had a CHA2DS2VASc score ≥ 3 and 81% (21) had a HAS-BLED score < 3. After three months, approximately one third of those 26 patients died or became disabled. The incidence of CE stroke in our sample was lower than in other population-based studies. The opportunity for anticoagulation was missed in one third of cases.

Incidence and functional outcome of atrial fibrillation and non-atrial fibrillation- related cardioembolic stroke in Joinville, Brazil: a population-based study / Incidência e desfecho funcional de AVC cardioembólico com e sem fibrilação atrial em Joinville, Brazil: estudo de base populacional

ABSTRACT Among ischemic strokes, cardioembolic (CE) stroke has the worst outcome. We measured the incidence of atrial fibrillation (AF) and non-AF related CE strokes, previous anticoagulant use, and the 90-day functional outcome. Using multiple overlapping sources, we included all CE strokes that occurred in 2015 in Joinville, Brazil. Of the 374 ischemic strokes, 23% (84) were CE. The CE age-adjusted incidence, per 1,000 person-years, was 0.14 (0.11–0.17). Of the 26 patients with known prior AF, 73% (19) were not anticoagulated, 77% (20) had a CHA2DS2VASc score ≥ 3 and 81% (21) had a HAS-BLED score < 3. After three months, approximately one third of those 26 patients died or became disabled. The incidence of CE stroke in our sample was lower than in other population-based studies. The opportunity for anticoagulation was missed in one third of cases.

RESUMO Entre todos os subtipos de AVC isquêmico, os eventos cardioembólicos (CE) apresentam os piores prognósticos. Determinamos a incidência de AVC isquêmico CE, associada ou não à fibrilação atrial (FA), o uso prévio de anticoagulantes e os desfechos funcionais em Joinville, Brasil. Utilizando múltiplas e sobrepostas fontes de informação, registramos todos os primeiros eventos CE ocorridos em 2015. Entre 374 eventos isquêmicos, 23% (84) foram CE. A incidência ajustada, para qualquer fonte cardioembólica, foi 0.14 (0.11–0.17) por 1000 pessoas-ano. Entre 26 pacientes com FA previamente conhecida, 73% (19) não estavam anticoagulados, 77% (20) tinham ≥ 3 pontos na escala CHA2DS2VASc e 81 % (21) < 3 pontos na escala HAS-BLED. Após 3 meses, um terço destes 26 pacientes morreram ou ficaram dependentes. A incidência de AVC I CE em Joinville é menor do que em outros estudos de base populacional. Um terço dos casos de AVC I CE com FA previamente conhecida perderam a oportunidade de anticoagulação.

Intravenous rtPA versus mechanical thrombectomy in acute ischemic stroke: A historical cohort in Joinville, Brazil.

Groundbreaking results concerning ischemic stroke (IS) hyperacute treatment worldwide were published in 2014 and 2015. We aimed to compare functional status after 3 months in patients treated with intra-arterial thrombectomy (IAT) and those treated with intravenous thrombolysis (IVT) alone in Joinville, Brazil. From the Joinville Stroke Registry, we extracted and compared all consecutive IVT patients treated with r-tPA within 4.5 h in the period 2009-2011 versus all consecutive IAT treated within 6 h with the Solitaire FR device plus IVT in the period 2012-2014. We registered 82 patients in the IVT group and 31 patients in the IAT group. At hospital admission, patients in the IAT group were significantly younger (p < 0.001), had a higher educational level (p = 0.001), had a slightly higher prevalence of atrial fibrillation (p = 0.057) and had more severe strokes measured by the NIH stroke scale (p = 0.011). After 90 days, 45% of patients in the IAT group and 27% in the IVT group were independent (0-1 points) according to the modified Rankin scale (adjusted odds ratio: 4.53; 95% CI: 1.22 to 16.75). Symptomatic hemorrhage was diagnosed in 10% of patients in both groups (p = 1.0). The 90-day case-fatality was 39% (32/82) in the IVT group and 26% (8/31) in the IAT group (p = 0.27). In this small cohort, a greater rate of functional independence was achieved in patients treated with IAT plus IVT, compared with patients treated with IVT lysis alone. Our "real-world" findings are consistent with results of controlled, randomized clinical trials.

Three-year survival and recurrence after first-ever stroke: the Joinville stroke registry.

BACKGROUND: Data estimating the recurrence and risk of death are lacking in low and middle income countries, where two thirds of the stroke burden occurs. Previously we had shown that the incidence and mortality have been decreasing over the last 18 years in Joinville, Southern Brazil. In this study, we aim to determine the recurrence rates, survival rates and the cause of death in 3 years after their first-ever incident in a urban population-based setting. METHODS: From the Joinville Stroke Registry, we identified all the cases of first-ever stroke that occurred from October 2009 to September 2010. Multiple overlapping sources of information were used to ensure the completeness of case identification. Patients were followed up prospectively at regular intervals from 30-days to 3 years after the index event. Kaplan-Meir and Cox proportional hazards were used to assess the cumulative risk of death and recurrence. RESULTS: We registered 407 first-ever stroke patients. After 3 years, 136 (33%) had died. In the first year of stroke the risk of death was 28% (95% CI, 25 to 32). Beyond the first year, approximately 3 to 5% of survivors died each year. The cumulative risk of death in ischemic stroke (IS) subtypes was 3.6 higher for cardioembolic (CE) IS (hazard ratio 3.6, 95% CI, 2.1 to 6.4; p = 0.001) and 3.3 times higher for undetermined IS (HR 3.3, 95% CI 1.9 to 5.8; p = 0.001) compared to small artery occlusion IS. Over 3 years, the overall stroke recurrence risk was 9% (35/407). We found no difference in stroke recurrence risk between IS subtypes. Cardiovascular disease was the main cause of death all follow up time. CONCLUSIONS: Compared to other cohort studies conducted between 10 and 20 years ago in high-income countries, our recurrence rates and 3-year risk of death were similar. Among IS subtypes, we confirmed that CE has highest risk of death. The most common cause of death after a first-ever stroke is cardiovascular disease. This has implications for the uptake of current secondary preventive strategies and the development of new strategies.