Comparative global analysis of stroke rehabilitation recommendations across income levels.

OBJECTIVE: Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC). STUDY DESIGN AND SETTING: We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC. RESULTS: The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations. CONCLUSION: There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

Association of Mortality and Risk of Epilepsy With Type of Acute Symptomatic Seizure After Ischemic Stroke and an Updated Prognostic Model.

Importance: Acute symptomatic seizures occurring within 7 days after ischemic stroke may be associated with an increased mortality and risk of epilepsy. It is unknown whether the type of acute symptomatic seizure influences this risk. Objective: To compare mortality and risk of epilepsy following different types of acute symptomatic seizures. Design, Setting, and Participants: This cohort study analyzed data acquired from 2002 to 2019 from 9 tertiary referral centers. The derivation cohort included adults from 7 cohorts and 2 case-control studies with neuroimaging-confirmed ischemic stroke and without a history of seizures. Replication in 3 separate cohorts included adults with acute symptomatic status epilepticus after neuroimaging-confirmed ischemic stroke. The final data analysis was performed in July 2022. Exposures: Type of acute symptomatic seizure. Main Outcomes and Measures: All-cause mortality and epilepsy (at least 1 unprovoked seizure presenting >7 days after stroke). Results: A total of 4552 adults were included in the derivation cohort (2547 male participants [56%]; 2005 female [44%]; median age, 73 years [IQR, 62-81]). Acute symptomatic seizures occurred in 226 individuals (5%), of whom 8 (0.2%) presented with status epilepticus. In patients with acute symptomatic status epilepticus, 10-year mortality was 79% compared with 30% in those with short acute symptomatic seizures and 11% in those without seizures. The 10-year risk of epilepsy in stroke survivors with acute symptomatic status epilepticus was 81%, compared with 40% in survivors with short acute symptomatic seizures and 13% in survivors without seizures. In a replication cohort of 39 individuals with acute symptomatic status epilepticus after ischemic stroke (24 female; median age, 78 years), the 10-year risk of mortality and epilepsy was 76% and 88%, respectively. We updated a previously described prognostic model (SeLECT 2.0) with the type of acute symptomatic seizures as a covariate. SeLECT 2.0 successfully captured cases at high risk of poststroke epilepsy. Conclusions and Relevance: In this study, individuals with stroke and acute symptomatic seizures presenting as status epilepticus had a higher mortality and risk of epilepsy compared with those with short acute symptomatic seizures or no seizures. The SeLECT 2.0 prognostic model adequately reflected the risk of epilepsy in high-risk cases and may inform decisions on the continuation of antiseizure medication treatment and the methods and frequency of follow-up.

Tratamiento posterior a un ataque cerebrovascular con estatinas y metas de colesterol de baja densidad / Statin treatment and low density cholesterol targets in patients post stroke

RESUMEN INTRODUCCIÓN: El ACV es uno de los eventos cardiovasculares más prevalentes en el mundo, en Colombia es la segunda causa de muerte y la primera de discapacidad. Uno de los factores de riesgo más importantes para tener en cuenta es el control del colesterol, la reducción de los niveles de C-LDL, principalmente por medio del tratamiento con estatinas y otros fármacos hipolipemiantes. MATERIALES Y MÉTODOS: En esta revisión narrativa de la literatura se ha recogido la información más relevante sobre el uso y los beneficios de este tratamiento y algunas consideraciones adicionales. CONCLUSIÓN: Los hallazgos de esta revisión demuestran el efecto protector de esta terapia cuando se consiguen reducir los niveles de C-LDL y colesterol, además, las otras terapias como ezetimiba o inhibidores de PSCK9. Por otro lado, los estudios mencionan posibles efectos beneficiosos en el contexto de ACV pero se requieren más ensayos clínicos.

ABSTRACT INTRODUCTION: Stroke is one of the most prevalent cardiovascular events in the world, in Colombia it is the second cause of death and first in disability. One of the most important risk factors to consider is cholesterol control, the reduction of LDL-C and cholesterol levels, mainly through treatment with statins and other lipid-lowering drugs. MATERIALS AND METHODS: The most relevant information on the use and benefits of this treatment and some additional considerations have been collected in this narrative review of the literature. CONCLUSION: The results of this narrative review show the protective effect of this therapy when it is possible to reduce LDL-C and cholesterol levels, in addition to other therapies such as ezetimibe or PSCK9 inhibitors. On the other hand, studies mention possible beneficial effects in the context of stroke but more clinical trials are required.

Análisis de costos de la atención hospitalaria en un paciente con fibrilación auricular no valvular y accidente cerebrovascular a repetición / Cost analysis of in hospital attention in a non-valvular atrial fibrillation patient and recurrent stroke

RESUMEN INTRODUCCIÓN: Paciente de 71 años con diagnóstico de fibrilación auricular y ataques cerebrovasculares recurrentes, tratada con varios anticoagulantes. El costo del tratamiento del ictus en Colombia para el año 2008 fue de $450.000 millones de pesos colombianos. OBJETIVO: Estimar el costo hospitalario de la atención de un paciente con ictus a repetición secundario a fibrilación auricular. MÉTODOS: Estudio económico parcial de microcosteo de la atención intrahospitalaria para un caso de espectro severo recurrente, que no necesariamente refleja el caso promedio. El consumo de recursos se valoró mediante el uso de tarifas de referencia nacionales. Los resultados se presentan en precios actuales del 2019 (peso colombiano y dólar americano). RESULTADOS: Paciente con 3 eventos hospitalarios, que estuvo 31 días hospitalizada. Las hospitalizaciones tuvieron unos costos de: $53.883.490 (USD 16.141,1), $6.343.096 (USD 1.900,1) y $15.719.443 (USD 4.708,9) respectivamente, con un precio promedio por cada hospitalización de $25.315.343 (USD 7.583,4), costo total de $75.946.029 (USD 22.750,1) costo día de $2.449.872 (USD 729,5). El rubro que aumentó consistentemente los costos fueron los procedimientos (35,7 %). CONCLUSIONES: El ictus recurrente causado por fibrilación auricular no valvular se asocia con un incremento significativo de los costos directos, con un impacto de casi dos veces el PIB per cápita. Un diagnóstico oportuno y una selección adecuada pueden reducirlo.

ABSTRACT INTRODUCTION: A 71-year-old patient with a diagnosis of atrial fibrillation and recurrent strokes, treated with various anticoagulants, the stroke treatment in Colombia for 2008 was $ 450 billion Colombian pesos. OBJECTIVE: To estimate the hospital cost of caring for a patient with recurrent stroke secondary to atrial fibrillation. METHODS: Partial economic study of micro costing of in-hospital care for a case of recurrent severe spectrum stroke, which does not necessarily reflect the average case. Resource consumption was valued using national reference rates. The results are presented in current 2019 prices (Colombian pesos and US dollars). RESULTS: Patient with 3 hospital events, who was hospitalized for 31 days. Hospitalizations had costs of $ 53,883,490 (USD 16,141.1), $ 6,343,096 (USD 1,900.1) and $ 15,719,443 (USD 4,708.9) respectively, with an average price for each hospitalization of $ 25,315,343 (USD 7,583.4), total cost of $ 75,946,029 (USD 22,750.1) daily cost of $ 2,449,872 (USD 729.5). The item that consistently increased costs was procedures (35.7 %). CONCLUSIONS: Recurrent stroke caused by nonvalvular atrial fibrillation is associated with a significant increase in direct costs, with an impact of almost twice the GDP per capita. A timely diagnosis and proper selection can reduce it.

Ischemic stroke: A paradoxical manifestation of cancer.

INTRODUCTION: Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality among cancer patients, leading to increased disability and healthcare costs. OBJECTIVE: To provide elements to guide physicians for when to suspect and evaluate for cancer in stroke patients. DEVELOPMENT: We performed a narrative review, portrayed in a question-answer format, to report relevant aspects of cancer stroke patients in the clinical practice and provide a guide based on the state-of-the-art literature. Conventional stroke mechanisms are only found in a fraction of patients with cancer. Although cardiovascular risk factors play an important role in both cancer and stroke pathogenesis, the recognition of more specific cancer-associated risk factors raises clinical suspicion for occult malignancy. We also expose the main type location and histology of tumors that are most commonly associated with stroke as well as potential blood biomarkers and current treatment considerations in the scenario of cancer associated stroke. CONCLUSION: Subjects with active cancer are a patient population at increased risk for developing an ischemic stroke. Cryptogenic stroke patients have a higher risk of cancer diagnosis in the following 6-12 months. We recommend a multidisciplinary approach considering the high probability of a hidden malignancy and running a comprehensive evaluation including neurologic imaging, serological biomarkers and tight follow up.

Trombólisis endovenosa como tratamiento del ACV isquémico agudo en Colombia: una revisión sistemática de la literatura

INTRODUCCIÓN: En Colombia el ataque cerebrovascular isquémico es la primera causa de discapacidad y la tercera causa de muerte, el uso oportuno de rt-PA puede mejorar su pronóstico. OBJETIVOS: Conocer la experiencia de centros acerca del uso de trombolíticos para el ACV en Colombia, a fin de establecer brechas de atención y oportunidades de mejoría. MÉTODOS: Se hizo revisión sistemática utilizando Google, Google Académico, PubMed, Scielo, así como otras fuentes de literatura gris para las publicaciones sobre trombólisis en Colombia, con un análisis de la calidad de los estudios, así como un registro de tiempos de atención, escalas utilizadas y medidas de desenlace. RESULTADOS: Al final se obtuvieron seis estudios, con 179 sujetos que recibieron trombólisis. Todos los estudios cumplieron con los requisitos mínimos de calidad de publicación, con un número total de pacientes por año de 7,5 a 12. El periodo de estudio más corto fue de dos años y el más largo de ocho años. Entre cuatro ciudades encontradas se estableció que un total de 30 pacientes por año recibió el tratamiento. Tan solo en dos estudios se pudo establecer el porcentaje de pacientes trombolizados en su población, porcentaje que oscilaba entre 9,5 y 17,5 %. El tiempo puerta aguja promedio de los estudios fue de 124,8 min (DE ± 64,1). A los 90 días se obtuvo un promedio de 58,3 % de escala de Rankin modificada entre 0 y 2 puntos. CONCLUSIÓN: En Colombia existe un subregistro de trombólisis. Es necesario tener un registro nacional de ACV que permita contar con la información para la toma de decisiones en políticas en salud.

SUMMARY INTRODUCTION: Ischemic stroke is the leading cause of disability and the third cause of death, timely use of rt-PA can improve prognosis. OBJECTIVES: To know the experience of centers about the use of thrombolytic therapy for stroke in Colombia. To establish attention gaps and opportunities for improvement. METHODS: A systematic review was made using Google, Google Scholar, Pubmed, Scielo, as well as other sources of gray literature for publications on thrombolysis in Colombia. With an analysis of the quality of the studies, as well as a record of attention times, scales used and outcome measures. RESULTS: Six studies were obtained at the end, with 179 subjects who received thrombolysis. All the studies met the minimum quality requirements for publication. A total number of patients per year between 7.5 to 12. The shortest study period was 2 years and the longest was 8 years. Among 4 cities found, it was established that a total of 30 patients / year received the treatment. In only two studies was possible to establish the percentage of thrombolysis patients in their population that ranged from 9.5 to 17.5 %. The average Door to Needle Time for the studies was 124.8 minutes (SD ± 64.1). After 90 days, an average of 58.3 % of modified Rankin scale was obtained between 0-2 points. CONCLUSION: There is an underreporting of thrombolysis in Colombia. It is necessary to have a national registry of stroke that allows us having the information for decision making in health policies.

Fatal reversible cerebral vasoconstriction syndrome: A systematic review of case series and case reports.

OBJECTIVE: To describe patient characteristics, radiological findings and the clinical course of adults with fatal reversible cerebral vasoconstriction syndrome (RCVS). METHODS: A systematic literature search from January 1, 2000, until December 31, 2018, was performed using PubMed, EMBASE, Scopus, Cochrane reviews, LILACS and Scielo. Studies reporting RCVS in adult patients with fatal outcomes were included. RESULTS: 430 studies were initially identified, 179 full-text articles were reviewed, and 9 publications describing 12 subjects were included. The vast majority of the reports were from the U.S. Most of the female cases occurred during postpartum. All patients had a headache on initial presentation, although only 42% had thunderclap headache. A CT scan was performed on 67% of the patients. Imaging results were diverse, with a tendency toward cerebral hemorrhage followed by mixed cases. The main course of treatment included steroids (58% of the patients), with only 42% receiving nimodipine. The time to death ranged from 4 to 14 days, with a median of 9.2 days (SD ±â€¯3.2). CONCLUSION: We found that the majority of fatal cases reported in the literature are most likely related to postpartum angiopathy. We established a tendency in the onset of brain hemorrhage and the combination of infarction and brain hemorrhage. We described various markers for poor prognosis, including focal signs, the presence of hemorrhage and infarct in the first diagnostic image obtained and the need for invasive interventions. The majority of fatal cases in our report occurred in women, with over half of those cases during the puerperium period.

Factores relacionados con desenlace adverso para ataque cerebrovascular en un hospital de Bogotá. Estudio de casos y controles / Factors related to an adverse outcome for stroke in a Bogota hospital. Case-control study

RESUMEN OBJETIVOS: Determinar los factores de riesgo para resultado adverso entre los pacientes con ataque cerebrovascular (ACV) isquémico agudo. MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo de casos y controles. Se analizaron pacientes con un desenlace adverso al egreso con una escala de Rankin modificada mayor o igual a 3, contra los pacientes con un desenlace calificado como favorable por una escala menor o igual a 2. Se compararon los 2 grupos para determinar los factores que podrían estar relacionados con un desenlace adverso. Como desenlace secundario se analizaron los factores de riesgo asociados con mortalidad intrahospitalaria. En cuanto a las técnicas estadísticas, se realizó un análisis univariado y otro multivariado por regresión logística, con ajuste por variables como la edad y la severidad, medidas por la escala de NIHSS, conocidos previamente como factores de riesgo para desenlace adverso. RESULTADOS: Los factores de riesgo relacionados con un desenlace adverso entre los pacientes con ACV isquémico agudo fueron los antecedentes de hipertensión arterial, fibrilación auricular, la etiología cardioembólica y el hecho de ser candidato a trombolisis. Como factor protector se encontró la rápida mejoría. CONCLUSIONES: Los factores de riesgo encontrados en el estudio para desenlace adverso en ACV isquémico agudo son similares a los descritos previamente, aunque estos se han relacionado con desenlace en general, no solo para la entidad analizada.

SUMMARY OBJECTIVES: Determining risk factors for adverse outcome among acute ischemic stroke patients. METHODS: Retrospective case-control study. We compared two groups of patients: the first one with bad outcome after ischemic stroke (Modified Ranking Scale >3) and the second one with good outcome (Modified Ranking Scale <2) to find the risk factors that contributed to the complications. The secondary outcome observed was the in-hospital mortality risk factors. Statistics: univariate and multivariate analysis was made adjusted to age and severity using NIHSS and logistic regression. RESULTS: High blood pressure, atrial fibrillation, cardioembolic etiology and thrombolysis were identified as risk factors for bad outcome. The rapidly improving stroke proved to be a protective factor. CONCLUSION: Risk factors were similar to the ones known in the general group of stroke, proving they are similar in the group with acute stroke.

Observational study of thrombolytic treatment for acute stroke in patients older and younger than 80 years: experience from one hospital in Bogotá, Colombia, 2007-2014 / Estudio observacional sobre tratamiento trombolítico del infarto cerebral agudo en pacientes mayores y menores de 80 años: experiencia de un hospital en Bogotá, Colombia, 2007-2014

Abstract Background: We depict the experience with the use of thrombolysis for acute ischemic stroke in a tertiary center in South America. Objective: To describe the main outcomes in our population of patients aged less and older than 80 years treated with recombinant tissue plasminogen activator. Materials and Methods: Retrospective observational study. We described the main variables and the difference in outcome accounting for age. Results: 70 patients were included. 51.4% of the patients were women, 22.8% were older than 80 years. The average window time was 70 minutes and the average door-to-needle time was 90 minutes. Hypertension, dyslipidemia and previous stroke were the most common risk factors. Favorable outcome Modified Rankin Scale ≤2 was present in 25% of the patients older than 80 years and 53.7% in the population younger than 80 years (p=0.009). Mortality was present in 31.2% of the patients older than 80 years and in 5.5% of the patients younger than 80 years (p=0.005). Symptomatic intra-cerebral hemorrhage was found in 6.25% of the patients older than 80 years (p=0.65), compared to 3.7% in the younger than 80 years. Conclusions: We found that intravenous thrombolysis still had benefit in people older than 80 years. Significant differences in symptomatic intra-cerebral hemorrhage were not found, however, a greater mortality in patients older than 80 years was. These findings of our experience of recombinant tissue plasminogen activator use in real life are consistent with other latinamerican publications. MÉD.UIS. 2017;30(3):21-30.

Resumen Introducción: Describimos la experiencia con el uso de trombólisis para el infarto cerebral isquémico agudo en un centro terciario en América del Sur. Objetivos: Describir los principales resultados en nuestra población de pacientes menores y mayores de 80 años tratados con activador recombinante de plasminógeno tisular. Materiales y Métodos: Estudio observacional retrospectivo. Se describieron las principales variables y se determinaron los resultados según la edad. Resultados: Se incluyeron 70 pacientes. Se encontró que 51,4% eran mujeres y 22,8% eran mayores de 80 años. El tiempo de ventana promedio estuvo en 70 minutos, así como el de puerta-aguja de 90 minutos. La hipertensión, dislipidemia y accidente cerebrovascular previo fueron los factores de riesgo más comunes. En el 25% de los pacientes mayores de 80 años y el 53,7% de los menores de 80 años, tuvieron un resultado favorable en la Escala Modificada de Rankin ≤ 2 (p = 0,009). La mortalidad estuvo presente en el 31,2% de los pacientes mayores de 80 años y en el 5,5% de los pacientes menores de 80 años (p = 0,005). La hemorragia intracerebral sintomática fue de 6,25% en los pacientes mayores de 80 años, frente a los menores de 80 años 3,7% (p = 0,65). Conclusiones: Se encontró que la trombólisis todavía presenta beneficio en personas mayores de 80 años. No se encontraron diferencias en cuanto a la hemorragia intra-cerebral sintomática, pero se presentó una mayor mortalidad en los mayores de 80 años. En esta experiencia el uso de rt-PA en la vida real es consistente con otras publicaciones latinoamericanas. MÉD.UIS. 2017;30(3):21-30.

Prevalencia de infarto criptogénico en pacientes con diagnóstico de infarto cerebral / Prevalence of cryptogenic stroke in patients with a diagnosis of cerebral infarction

Resumen Objetivo: Definir la prevalencia del infarto de origen criptogénico en pacientes con diagnóstico de infarto cerebral isquémico entre los años 2007 a 2014. Métodos: Se realizó un estudio de tipo corte transversal. Se incluyeron todos los pacientes mayores de 18 años con ataque cerebrovascular isquémico agudo. Se evaluó cada caso mediante una lista de chequeo para la etiología y los estudios de cardiología. Se hizo una descripción de la población y de los factores de riesgo con análisis univariado. La asociación de los criptogénicos y no criptogénicos con las diferentes exposiciones se evaluó con el uso de Chi2 o T de Student de acuerdo con el tipo de variable. Se calcularon las razones de disparidad para los factores de riesgo. Se hizo un análisis multivariado para las variables independientes con p < 0,1. Resultados: en 340 pacientes se encontró una prevalencia de evento cerebrovascular Criptogénico del 19,71% (n = 67). Al dicotomizar la edad se observó que la prevalencia de ataque cerebrovascular criptogénico fue mayor en el grupo de <45 años 42,31% vs. 17,83% ≥45 años (p = 0,003), con una razón de prevalencias de 2,37. Solo la enfermedad coronaria (p = 0,04) y la fibrilación auricular (p < 0,0001), se relacionaron con los casos no criptogénicos en el modelo multivariado. Conclusiones: se halló una prevalencia de infarto criptogénico ligeramente inferior a la encontrada en la literatura reciente, que pudiera explicarse por un estudio más profundo en nuestra población o un subregistro de la enfermedad.

Abstract Objective: To define the prevalence of cryptogenic stroke in patients with a diagnosis of ischemic cerebral infarction between 2007 and 2014. Methods: A cross-sectional study was performed that included all patients over the age of 18 who had suffered an acute ischemic stroke. Each case was evaluated using a checklist for aetiology and cardiology studies. A description was made of the population and the risk factors with univariate analysis. The association with different exposures of cryptogenic and non-cryptogenic stroke was evaluated using the Chi2 or Student's t-test according to the type of variable. The disparity ratios were calculated for the risk factors. A multivariate analysis was undertaken for the independent variables with p < 0.1. Results: a prevalence of 19.71% (n = 67) of cryptogenic stroke was found in 340 patients. When dichotomising age it was observed that the prevalence of cryptogenic stroke was greater in the <45 age group, 42.31% vs 17.83% in the ≥45 age group (p = 0.003), with a prevalence ratio of 2.37. Only coronary heart disease (p = 0.04) and atrial fibrillation (p < 0.0001), were associated with the non-cryptogenic cases in the multivariate model. Conclusions: a slightly lower prevalence of cryptogenic stroke was found than that described in the recent literature. This could be explained by a more in-depth study in our population or under-reporting of the disease.

Infarto de la arteria cerebral posterior secundario a oclusión aguda de la arteria carótida interna / Posterior Cerebral Artery Stroke Secondary to Acute Occlusion of the Internal Carotid Artery

Bases: los principales síntomas del compromiso de la arteria carótida interna son la amaurosis fugax y aquellos que se deben a un compromiso de las arterias cerebral media y anterior. Métodos: se trata de un hombre de 79 años diabético e hipertenso que se presentó con un cuadro que sugería un compromiso de la arteria cerebral media izquierda. Se documentó una obstrucción aguda de la arteria carótida interna izquierda, con infartos del territorio de la arteria coroidea anterior y la cerebral posterior del mismo lado; en el estudio se halló una fuente cardioembólica. Conclusión: si bien la obstrucción aguda de la arteria carótida interna se asocia sobre todo a síntomas visuales y de compromiso de la circulación anterior, se puede relacionar también con infartos de la arteria cerebral posterior.

Background: the main symptoms of a compromise to the internal carotid artery are monocular blindness and those which are secondary to the lesion of the medial cerebral and anterior cerebral arteries. Methods: a 79 year old male patient, with past medical history of diabetes and high blood pressure and clinical symptoms of compromise to the left medial cerebral artery. The patient shows an acute occlusion of the left internal carotid artery with arterial infarcts in the choroidal anterior and cerebral posterior territories in the same side of the carotid lesion. The cardioembolic source of the infarct was documented. Conclusion: Although acute obstruction of the internal carotid artery is mostly associated with visual symptoms and engagement of the anterior circulation, it may also be associated with infarcts of the posterior cerebral artery.