Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil.

Background: The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods: Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results: A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion: Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.

Disparities in Stroke Patient-Reported Outcomes Measurement Between Healthcare Systems in Brazil.

Introduction: Acute stroke interventions, such as stroke units and reperfusion therapy, have the potential to improve outcomes. However, there are many disparities in patient characteristics and access to the best stroke care. Thus, we aim to compare patient-reported outcome measures (PROMs) after stroke in two stroke centers representing the public and private healthcare systems in Brazil. Methods: PROMs through the International Consortium for Health Outcomes Measures (ICHOM) were assessed at 90 days after the stroke to compare two Brazilian hospitals in southern Brazil: a public university and a private stroke center, both with stroke protocols and stroke units. Results: When compared with the private setting (n = 165), patients from the public hospital (n = 175) were younger, had poorer control of risk factors, had more frequent previous strokes, and arrived with more severe strokes. Both hospitals had a similar percentage of IV thrombolysis treatment. Only 5 patients received mechanical thrombectomy (MT), all in the private hospital. Public hospital patients presented significantly worse outcomes at 3 months, including worse quality of life and functional dependence (60 vs. 48%, p = 0.03). Poor outcome, as measured by the mRS score, was significantly associated with older age, higher NIHSS score, and the presence of heart failure. However, the public practice was a strong predictor of any self-reported disability. Conclusion: Patients assisted at a good quality public stroke center with the same protocol used in the private hospital presented worse disability as measured by mRS and patient-reported outcome measures, with greater inability to communicate, dress, toilet, feed, and walk.

Home-Based Transcranial Direct Current Stimulation for the Treatment of Symptoms of Depression and Anxiety in Temporal Lobe Epilepsy: A Randomized, Double-Blind, Sham-Controlled Clinical Trial.

We conducted a double-blind randomized clinical trial in order to examine the effects and the safety of home-based transcranial direct current stimulation (tDCS) on depressive and anxious symptoms of patients with temporal lobe epilepsy (TLE). We evaluated 26 adults with TLE and depressive symptoms randomized into two different groups: active tDCS (tDCSa) and Sham (tDCSs). The patients were first submitted to 20 sessions of tDCS for 20 min daily, 5 days a week for 4 weeks and then received a maintenance tDCS application in the research laboratory once a week for 3 weeks. The intensity of the current was 2 mA, applied bilaterally over the dorsolateral prefrontal cortex, with the anode positioned on the left side and the cathode on the right side. Participants were evaluated on days 1, 15, 30, and 60 of the study using the Beck Depression Inventory II (BDI). A follow-up evaluation was performed 1 year after the end of treatment. They were also evaluated for quality of life and for anxious symptoms as secondary outcomes. The groups did not differ in clinical, socioeconomic or psychometric characteristics at the initial assessment. There was no statistically significant difference between groups regarding reported adverse effects, seizure frequency or dropouts. On average, between the 1st and 60th day, the BDI score decreased by 43.93% in the active group and by 44.67% in the Sham group (ΔBDIfinal - initial = -12.54 vs. -12.20, p = 0.68). The similar improvement in depressive symptoms observed in both groups was attributed to placebo effect and interaction between participants and research group and not to tDCS intervention per se. In our study, tDCS was safe and well tolerated, but it was not effective in reducing depressive or anxiety symptoms in patients with temporal lobe epilepsy. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT03871842].

Methylation of BDNF and SLC6A4 Gene Promoters in Brazilian Patients With Temporal Lobe Epilepsy Presenting or Not Psychiatric Comorbidities.

The relationship between epilepsy and psychiatric comorbidities has been recognized for centuries, but its pathophysiological mechanisms are still misunderstood. It is biologically plausible that genetic or epigenetic variations in genes that codify important neurotransmitters involved in epilepsy as well as in psychiatric disorders may influence the development of the latter in patients with epilepsy. However, this possibility remains poorly investigated. The aim of this study was to evaluate the methylation profile of the BDNF and SLC6A4, two genes importantly involved in neuroplasticity, in patients with temporal lobe epilepsy (TLE) regarding the development or not of psychiatric comorbidities. One hundred and thirty-nine patients with TLE, 90 females and 45 males, were included in the study. The mean age of patients was 44.0 (+12.0) years, and mean duration of epilepsy was 25.7 (+13.3) years. The Structured Clinical Interview for DSM-IV shows that 83 patients (59.7%) had neuropsychiatric disorders and 56 (40.3%) showed no psychiatric comorbidity. Mood disorders were the most common psychiatric disorder observed, being present in 64 (46.0%) of all 139 patients. Thirty-three (23.7%) patients showed anxiety disorders, 10 (7.2%) patients showed history of psychosis and 8 (5.8%) patients showed history of alcohol//drug abuse. Considering all 139 patients, 18 (12.9%) demonstrated methylation of the promoter region of both BDNF and SLC6A4 genes. A significant decreased methylation profile was observed only in TLE patients with mood disorders when compared with TLE patients without a history of mood disorders (O.R. = 3.45; 95% C.I. = 1.08-11.11; p = 0.04). A sub-analysis showed that TLE patients with major depressive disorder mostly account for this result (O.R. = 7.20; 95% C.I. = 1.01-56.16; p = 0.042). A logistic regression analysis showed that the independent factors associated with a history of depression in our TLE patients was female sex (O.R. = 2.30; 95% C.I. = 1.02-5.18; p = 0.044), not controlled seizures (O.R. = 2.51; 95% C.I. = 1.16-5.41; p = 0.019) and decreased methylation in BDNF and SLC6A4 genes (O.R. = 5.32; 95% C.I. = 1.14-25.00; p = 0.033). Our results suggest that BDNF or SLC6A4 genes profile methylation is independently associated with depressive disorders in patients with epilepsy. Further studies are necessary to clarify these matters.

Evaluating the Association of Calcified Neurocysticercosis and Mesial Temporal Lobe Epilepsy With Hippocampal Sclerosis in a Large Cohort of Patients With Epilepsy.

BACKGROUND: Neurocysticercosis (NCC) is a parasitic infection of the central nervous system that has been associated with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). However, this association has not been completely established. OBJECTIVE: To evaluate the prevalence of calcified NCC (cNCC), its characteristics and a possible association between cNCC and MTLE-HS in a cohort of 731 patients with epilepsy. METHODS: We review clinical, EEG and neuroimaging findings of 731 patients with epilepsy. From these, 659 had CT-scans and 441 patients had complete neuroimaging with CT-scans and MRI. In these patients, we review the prevalence and characteristic of epilepsy in cNCC and in MTLE-HS patients. RESULTS: Forty-two (6.4%) of the 659 patients studied with CT-scans had cNCC. cNCC lesions were more frequent in women than in men (n = 33-78.6% vs. n = 09-21.4%, respectively; OR = 3.64;(95%CI = 1.71-7.69); p < 0.001). cNCC was more often in patients who developed epilepsy later in life, in older patients, in patients who had a longer history of epilepsy, and in those with a lower educational level. MTLE-HS was observed in 93 (21.1%) of 441 patients that had complete neuroimaging, and 25 (26.9%) of these 93 patients also had cNCC. Calcified NCC was observed in only 17 (4.9%) of the remaining 348 patients that had other types of epilepsy rather than MTLE-HS. Thus, in our cohort, cNCC was more frequently associated with MTLE-HS than with other forms of epilepsy, O.R. = 11.90;(95%CI = 6.10-23.26); p < 0.0001). CONCLUSIONS: As expected, in some patients the epilepsy was directly related to cNCC lesional zone, although this was observed in a surprisingly lower number of patients. Also, cNCC lesions were observed in other forms of epilepsy, a finding that could occur only by chance, with epilepsy probably being not related to cNCC at all. In this cohort, cNCC was very commonly associated with MTLE-HS, an observation in agreement with the hypothesis that NCC can contribute to or directly cause MTLE-HS in many patients. Given the broad world prevalence of NCC and the relatively few studies in this field, our findings add more data suggesting a possible and intriguing frequent interplay between NCC and MTLE-HS, two of the most common causes of focal epilepsy worldwide.

Validation of a Smartphone Application in the Evaluation and Treatment of Acute Stroke in a Comprehensive Stroke Center.

Background and Purpose- The increasing demand and shortage of experts to evaluate and treat acute stroke patients has led to the development of remote communication tools to aid stroke management. We aimed to evaluate the JOIN App smartphone system-a low-cost tool for rapid clinical and neuroimaging data sharing to expedite decision-making in stroke. Methods- Consecutive acute ischemic stroke patients treated at a University Hospital in Brazil from December 2014 to December 2015 were evaluated. The analysis included all patients presenting with acute ischemic stroke who underwent initial evaluation by neurology residents followed by JOIN teleconsultation with a stroke neurologist on call for management decisions. An expert panel of stroke neurologists and neuroradiologists revised all cases using a standard Picture Archiving and Communication System imaging workstation within 24 hours and analyzed the decision made with remote assistance during the emergency setting. Results- A total of 720 stroke codes were evaluated with 442 acute ischemic stroke qualifying. Seventy-eight (18%) patients were treated with intravenous thrombolysis. The main reasons for tPA (tissue-type plasminogen activator) exclusion were symptom onset >4.5 hours (n=295; 67%) and hypodense middle cerebral artery territory area >1/3 (n=31; 7%). The agreement rates between Picture Archiving and Communication System versus JOIN-based thrombolysis decisions were 100% for the stroke (unblinded) and 99.3% for the neuroradiologist (blinded) experts. The use of the application resulted in a significant reduction in the door-to-needle times across the pre- versus postimplementation periods (median, 90 [interquartile range, 75-106] versus 63 [interquartile range, 61-117] minutes; P=0.03). The rates of 90-day excellent outcomes (modified Rankin Scale, 0-1) were 51.3%; 90-day mortality, 2.6%; and symptomatic intracranial hemorrhage, 3.8%. Conclusions- The JOIN smartphone system allows rapid sharing of clinical and imaging data to facilitate decisions for stroke treatment. The remote application-based decisions seem to be as accurate as the physical presence of stroke experts and might lead to faster times to treatment. This system represents an easily implementable low-cost telemedicine solution for centers that cannot afford the full-time presence of stroke specialists.

What neuropsychological functions best discriminate performance in adults post-stroke?

This study aimed to develop a short version of an instrument to detect cognitive impairment in stroke patients, investigate which cognitive dimensions best discriminate between stroke patients and healthy adults and to graphically analyze the relationships among the neuropsychological variables and groups. This pilot study included 94 adults (49 post-stroke and 45 neurologically healthy) who answered the Brief Neuropsychological Assessment Battery NEUPSILIN for patients with expressive aphasia (NEUPSILIN-Af) to assess orientation, perception, memory, praxis, executive functions, oral language, and academic achievement (written language and arithmetic). The IRT Rasch model for dichotomous data indicated the exclusion of items that could not be used to discriminate performances. ROC curves indicated that only the orientation, oral language, academic achievement, and executive function dimensions could be used to differentiate between the clinical and healthy groups. Graphical analysis indicated that independently of the relation among variables, orientation and executive functions tasks are essentials in the neuropsychological assessments. This study contributes to the development of specific and sensitive neuropsychological instruments to assess stroke patients and to better understand the common deficits present in this clinical population.

Early Manipulation of Arterial Blood Pressure in Acute Ischemic Stroke (MAPAS): Results of a Randomized Controlled Trial.

INTRODUCTION: There is uncertainty over the optimal level of systolic blood pressure (SBP) in the setting of acute ischemic stroke (AIS). The aim of this study was to determine the efficacy of the early manipulation of SBP in non-thrombolised patients. The key hypothesis under investigation was that clinical outcomes vary across ranges of SBP in AIS. METHODS: 218 patients were randomized within 12 h of AIS to maintain the SBP during 24 h within three ranges: Group 1 140-160 mmHg, Group 2 161-180 mmHg or Group 3 181-200 mmHg. Vasoactive drugs and fluids were used to achieve these targets. Good outcome was defined as a modified Rankin score 0-2 at 90-days. RESULTS: The median SBP in the three groups in 24 h was: 153 mmHg, 163 mmHg, and 178 mmHg, respectively, P < 0.0001. Good clinical outcome did not differ among the different groups (51% vs 52% vs 39%, P = 0.27). Symptomatic intracranial hemorrhage (SICH) was more frequent in the higher SBP range (1% vs 2.7% vs 9.1%, P = 0.048) with similar mortality rates. No patient had acute neurological deterioration related to the SBP reduction in the first 24 h. In our logistic regression analysis, the odds of having good clinical outcome was higher in Group 2 (OR 2.83) after adjusting for important confounders. Regardless of the assigned group, the probability of good outcome was 47% in patients who were manipulated to increase the BP, 42% to decrease and 62% in non-manipulated (P = 0.1). Adverse effects were limited to Group 2 (4%) and Group 3 (7.6%) and were associated with the use of norepinephrine (P = 0.05). CONCLUSIONS: Good outcome in 90 days was not significantly different among the 3 blood pressure ranges. After logistic regression analysis, the odds of having good outcome was greater in Group 2 (SBP 161-180 mmHg). SICH occurred more frequently in Group 3 (181-200 mmHg).

Risk Factors for Epilepsy After Thrombolysis for Ischemic Stroke: A Cohort Study.

The effects of thrombolysis in seizure and epilepsy after acute ischemic stroke have been poorly explored. In this study, we examine risk factors and consequences of intravenous rt-PA for treatment of acute ischemic stroke. In a retrospective cohort study we evaluate risk factors for seizure and epilepsy after stroke thrombolysis, as well as the impact of seizures and epilepsy in outcome of stroke patients. In our cohort, mean age of patients was 67.2 years old (SD = 13.1) and 79 of them (51.6%) were male and. Initial NIHSS mean score were 10.95 (SD = 6.25). Three months NIHSS mean score was 2.09 (SD = 3.55). Eighty seven (56.9%) patients were mRS of 0-1 after thrombolysis. Hemorrhagic transformation was observed in 22 (14.4%) patients. Twenty-one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation (OR = 3.26; 95% CI = 1.08-9.78; p = 0.035) and with mRS ≥ 2 at 3 months after stroke (OR = 3.51; 95% CI = 1.20-10.32; p = 0.022). Hemorrhagic transformation (OR = 3.55; 95% CI = 1.11-11.34; p = 0.033) and mRS ≥ 2 at 3 months (OR = 5.82; 95% CI = 1.45-23.42; p = 0.013) were variables independently associated with post-stroke epilepsy. In our study, independent risks factors for poor outcome in stroke thrombolysis were age (OR = 1.03; 95% CI = 1.01-1.06; p = 0.011), higher NIHSS (OR = 1.08; 95% CI = 1.03-1.14; p = 0.001), hemorrhagic transformation (OR = 2.33; 95% CI = 1.11-4.76; p = 0.024), seizures (OR = 3.07; 95% CI = 1.22-7.75; p = 0.018) and large cortical area (ASPECTS ≤ 7) (OR = 2.04; 95% CI = 1.04-3.84; p = 0.036). Concluding, in this retrospective cohort study, the neurological impairment after thrombolysis (but not before) and hemorrhagic transformation remained independent risk factors for seizures or post-stroke epilepsy after thrombolysis. Moreover, we observed that seizures emerged as an independent risk factor for poor outcome after thrombolysis therapy in stroke patients (OR = 3.07; 95% CI = 1.22-7.75; p = 0.018).

High Risk of Seizures and Epilepsy after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke
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BACKGROUND: Decompressive hemicraniectomy (DHC) is a life-saving procedure for treatment of large malignant middle cerebral artery (MCA) strokes. Post-stroke epilepsy is an additional burden for these patients, but its incidence and the risk factors for its development have been poorly investigated. OBJECTIVE: To report the prevalence and risk factors for post-stroke seizures and post-stroke epilepsy after DHC for treatment of large malignant MCA strokes in a cohort of 36 patients. METHODS: In a retrospective cohort study of 36 patients we report the timing and incidence of post-stroke epilepsy. We analyzed if age, sex, vascular risk factors, side of ischemia, reperfusion therapy, stroke etiology, extension of stroke, hemorrhagic transformation, ECASS scores, National Institutes of Health Stroke Scale (NIHSS) scores, or modified Rankin scores were risk factors for seizure or epilepsy after DHC for treatment of large MCA strokes. RESULTS: The mean patient follow-up time was 1,086 days (SD = 1,172). Out of 36 patients, 9 (25.0%) died before being discharged. After 1 year, a total of 11 patients (30.6%) had died, but 22 (61.1%) of them had a modified Rankin score ≤4. Thirteen patients (36.1%) developed seizures within the first week after stroke. Seizures occurred in 22 (61.1%) of 36 patients (95% CI = 45.17-77.03%). Out of 34 patients who survived the acute period, 19 (55.9%) developed epilepsy after MCA infarcts and DHC (95% CI = 39.21-72.59%). In this study, no significant differences were observed between the patients who developed seizures or epilepsy and those who remained free of seizures or epilepsy regarding age, sex, side of stroke, presence of the clinical risk factors studied, hemorrhagic transformation, time of craniectomy, and Rankin score after 1 year of stroke. CONCLUSION: The incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC might be very high. Seizure might occur precociously in patients who are not submitted to anticonvulsant prophylaxis. The large stroke volume and the large cortical ischemic area seem to be the main risk factors for seizure or epilepsy development in this subtype of stroke.
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Early mobilization in ischemic stroke: a pilot randomized trial of safety and feasibility in a public hospital in Brazil.

BACKGROUND: The effect of early mobilization after acute stroke is still unclear, although some studies have suggested improvement in outcomes. We conducted a randomized, single-blind, controlled trial seeking to evaluate the feasibility, safety, and benefit of early mobilization for patients with acute ischemic stroke treated in a public teaching hospital in Southern Brazil. This report presents the feasibility and safety findings for the pilot phase of this trial. METHODS: The primary outcomes were time to first mobilization, total duration of mobilization, complications during early mobilization, falls within 3 months, mortality within 3 months, and medical complications of immobility. We included adult patients with CT- or MRI-confirmed ischemic stroke within 48 h of symptom onset who were admitted from March to November 2012 to the acute vascular unit or general emergency unit of a large urban emergency department (ED) at the Hospital de Clínicas de Porto Alegre. The severity of the neurological deficit on admission was assessed by the National Institutes of Health Stroke Scale (NIHSS). The NIHSS and modified Rankin Scale (mRS, functional outcome) scores were assessed on day 14 or at discharge as well as at 3 months. Activities of daily living (ADL) were measured with the modified Barthel Index (mBI) at 3 months. RESULTS: Thirty-seven patients (mean age 65 years, mean NIHSS score 11) were randomly allocated to an intervention group (IG) or a control group (CG). The IG received earlier (p = 0.001) and more frequent (p < 0.0001) mobilization than the CG. Of the 19 patients in the CG, only 5 (26%) underwent a physical therapy program during hospitalization. No complications (symptomatic hypotension or worsening of neurological symptoms) were observed in association with early mobilization. The rates of complications of immobility (pneumonia, pulmonary embolism, and deep vein thrombosis) and mortality were similar in the two groups. No statistically significant differences in functional independence, disability, or ADL (mBI ≥85) were observed between the groups at the 3-month follow-up. CONCLUSIONS: This pilot trial conducted at a public hospital in Brazil suggests that early mobilization after acute ischemic stroke is safe and feasible. Despite some challenges and limitations, early mobilization was successfully implemented, even in the setting of a large, complex ED, and without complications. Patients from the IG were mobilized much earlier than controls receiving the standard care provided in most Brazilian hospitals.

Implementation of a dedicated cardiovascular and stroke unit in a crowded emergency department of a tertiary public hospital in Brazil: effect on mortality rates.

BACKGROUND: Emergency department (ED) care for acute vascular diseases faces the challenge of overcrowding. A vascular unit is a specialized, protocol-oriented unit in the ED with a team trained to manage acute vascular disorders, including stroke, coronary syndromes, pulmonary embolism (PE), and aortic diseases. OBJECTIVES: The objective was to compare case fatality rates for selected cardiovascular conditions before and after the implementation of a vascular unit. METHODS: Patients with the selected diagnoses admitted to the ED in two different time periods, 2002 through 2005 (before unit opening) and 2007 to 2010 (after vascular unit opening), were identified by ICD-10 codes, and their electronic records were reviewed. Case fatality rates were calculated and compared for both time periods. RESULTS: The period prior to unit implementation (2002 through 2005) included 4,164 patients, and the vascular unit period (2007 to 2010) included 6,280 patients. Overall, the case fatality rate for acute vascular conditions decreased from 9% to 7.3% with vascular unit implementation (p = 0.002). The in-hospital mortality rates for acute coronary syndrome (ACS) dropped from 6% to 3.8% (p = 0.003), and for acute PE dropped from 32.1% to 10.8% (p < 0.001). The stroke case-fatality rate did not decrease despite improvements in the quality of stroke health care indicators. CONCLUSIONS: The vascular unit strategy has the potential to reduce overall mortality for most acute vascular conditions.

Características de pacientes do ambulatório de doenças cerebrovasculares de hospital público universitário do Rio Grande do Sul / Profile of patients attending a cerebrovascular disease clinic in a public school hospital in South Brazil

Introdução: As doenças cerebrovasculares ainda são as principais causas de mortalidade no Brasil. Este estudo objetiva apresentar as características epidemiológicas e demográficas e os principais fatores de risco para acidente vascular cerebral (AVC) em pacientes atendidos no ambulatório de doenças cerebrovasculares de um hospital público universitário de Porto Alegre, durante os anos de 2008 e 2009. Métodos: Foram analisados 446 formulários de casos de pacientes pós-AVC realizando-se análises descritivas e inferenciais das características dos pacientes. Resultados: 56,4% eram procedentes da Capital e a média de idade foi de 60 anos. A distribuição por tipo de AVC foi de 66% para AVC isquêmico, 12% para AVC hemorrágico e somente 4% para ataque isquêmico transitório (AIT). Hipertensão arterial, diabetes melito, fumo e dislipidemia foram os fatores de risco mais presentes; porém, apenas 51% dos pacientes faziam uso de anti-hipertensivo. Conclusão: Os resultados sugerem que o AVC ainda é uma doença negligenciada, fazendo-se necessária a reorganização da rede assistencial no Estado e a elaboração de estratégias de prevenção primária e secundária e de tratamento.

Introduction: Cerebrovascular diseases are still the leading cause of death in Brazil. This study aims to present the epidemiological and demographic characteristics and major risk factors for stroke in patients attending a cerebrovascular diseases clinic in a public school hospital in Porto Alegre from 2008 to 2009. Methods: We analyzed the medical records of 446 post-stroke patients by performing descriptive and inferential analysis of patient data. Results: 56.4% of the patients were from Porto Alegre and their mean age was 60 years. Distribution by type of stroke was 66% for ischemic stroke, 12% for hemorrhagic stroke, and only 4% for transient ischemic attack (TIA). Hypertension, diabetes mellitus, smoking, and dyslipidemia were the most common risk factors; however, only 51% of the patients used antihypertensive medication. Conclusion: The results suggest that stroke is still a neglected disease, thus showing the need for a reorganization of the state’s healthcare system and development of strategies for primary and secondary prevention and treatment.

Thrombolytic therapy for acute stroke in the elderly: an emergent condition in developing countries.

Elderly patients may represent an important group when considering new stroke treatments, particularly in developing countries. The aim of this study was to analyze the use of recombinant tissue plasminogen activator (rtPA) in elderly Brazilian patients with acute ischemic stroke. Clinical and neuroimaging parameters at admission, frequency of symptomatic intracranial hemorrhage, and outcome were compared between elderly (≥80 years) and nonelderly (<80 years) stroke patients treated with rtPA in the Porto Alegre Stroke Network. We evaluated 183 nonelderly patients (mean age, 63 ± 12 years) and 55 elderly patients (mean age, 84 ± 3 years). Female sex, hypertension, congestive heart failure, atrial fibrillation, and previous history of stroke or transient ischemic attack were more frequent in the elderly patients. Elderly patients also presented with higher mean systolic blood pressure (P = .03) and National Institutes of Health Stroke Scale (NIHSS) score (P < .0001), whereas the nonelderly patients had a higher serum glucose level (P = .03). The rate of symptomatic intracranial hemorrhage was 10.9% in the elderly patients and 6.6% in the nonelderly patients (P = .28), and a substantial proportion of the elderly patients achieved a favorable outcome (modified Rankin Scale score ≤1) at 90 days, although this proportion was lower than that in the nonelderly patients (42% vs 58%; P = .04). Poorer outcomes were generally seen in elderly patients with an anterior circulation stroke, a higher NIHSS score, hypoattenuation in ≥1/3 lf the middle cerebral artery territory, and an Alberta Stroke Program Early CT score of ≤7 on an initial computed tomography scan. Our results support the administration of intravenous rtPA in selected elderly stroke patients presenting early to the hospital in developing countries.

Levels of vascular cell adhesion molecule-1 and endothelin-1 in ischemic stroke: a longitudinal prospective study.

OBJECTIVES: To determine levels of vascular cellular adhesion molecule (VCAM)-1 and endothelin (ET)-1 in patients with stroke. DESIGN AND METHODS: Thirty-four patients were prospectively studied. Plasma levels of VCAM-1 and ET-1 were measured by ELISA within 72 h of the event, at 7 and 90 days. RESULTS: Levels of VCAM-1 increased overtime, whereas ET-1 values were initially and persistently elevated. CONCLUSIONS: Increased circulating levels of VCAM-1 and ET-1 are present during stroke.