Blood pressure behavior during mechanical thrombectomy and drugs used for conscious sedation or general anesthesia.

BACKGROUND: The optimal blood pressure (BP) during mechanical thrombectomy for acute ischemic stroke is currently unclear. OBJECTIVE: To investigate BP behavior during mechanical thrombectomy in patients with acute ischemic stroke and its relationship with drugs used for sedation or general anesthesia. Additionally, we investigated the association between BP oscillation during mechanical thrombectomy and recanalization status, and with functional outcome at discharge. METHODS: Consecutive patients treated with mechanical thrombectomy for acute ischemic stroke were evaluated in a tertiary hospital from December/2009 to December/2015. Maximum, minimum, and mean systolic and diastolic BP, and mean arterial pressures were collected during the procedure. Sedative drugs were also reviewed. RESULTS: Fifty-three patients with a mean age of 71.9 years (60.4% men) were treated with mechanical thrombectomy. The mean reduction in systolic BP and mean arterial pressure from hospital admission to mechanical thrombectomy were respectively 42 and 36 mmHg. During the procedure, oscillations were 50.4 mmHg for systolic, and 33.2 mmHg for diastolic BP. Patients treated with neuromuscular blocking drugs had more oscillation in systolic BP from hospital admission to procedure (51.1 versus 26.2 mmHg, P=0.06). The use of cisatracurium (43.9 versus 29.6 mmHg, P=0.02) and succinylcholine (44.7 versus 29.3 mmHg, P=0.01) were associated with a significant drop in BP during the procedure. CONCLUSIONS: Significant BP oscillation occurs during mechanical thrombectomy. Drugs used for conscious sedation or general anesthesia, specifically neuromuscular blocking agents, might have an influence upon BP levels.

Blood pressure behavior during mechanical thrombectomy and drugs used for conscious sedation or general anesthesia / Comportamento da pressão arterial durante trombectomia mecânica e drogas utilizadas para sedação consciente ou anestesia geral

ABSTRACT Background: The optimal blood pressure (BP) during mechanical thrombectomy for acute ischemic stroke is currently unclear. Objective: To investigate BP behavior during mechanical thrombectomy in patients with acute ischemic stroke and its relationship with drugs used for sedation or general anesthesia. Additionally, we investigated the association between BP oscillation during mechanical thrombectomy and recanalization status, and with functional outcome at discharge. Methods: Consecutive patients treated with mechanical thrombectomy for acute ischemic stroke were evaluated in a tertiary hospital from December/2009 to December/2015. Maximum, minimum, and mean systolic and diastolic BP, and mean arterial pressures were collected during the procedure. Sedative drugs were also reviewed. Results: Fifty-three patients with a mean age of 71.9 years (60.4% men) were treated with mechanical thrombectomy. The mean reduction in systolic BP and mean arterial pressure from hospital admission to mechanical thrombectomy were respectively 42 and 36 mmHg. During the procedure, oscillations were 50.4 mmHg for systolic, and 33.2 mmHg for diastolic BP. Patients treated with neuromuscular blocking drugs had more oscillation in systolic BP from hospital admission to procedure (51.1 versus 26.2 mmHg, P=0.06). The use of cisatracurium (43.9 versus 29.6 mmHg, P=0.02) and succinylcholine (44.7 versus 29.3 mmHg, P=0.01) were associated with a significant drop in BP during the procedure. Conclusions: Significant BP oscillation occurs during mechanical thrombectomy. Drugs used for conscious sedation or general anesthesia, specifically neuromuscular blocking agents, might have an influence upon BP levels.

RESUMO Antecedentes: Atualmente, a pressão arterial ideal durante a trombectomia mecânica em pacientes com acidente vascular cerebral isquêmico agudo não é clara. Objetivo: Investigar o comportamento da pressão arterial durante a trombectomia mecânica em pacientes com acidente vascular cerebral isquêmico agudo e sua relação com os medicamentos utilizados para sedação ou anestesia geral. Adicionalmente, investigar a associação entre a oscilação da pressão arterial durante a trombectomia mecânica e a capacidade de recanalização, além do status funcional no momento da alta hospitalar. Métodos: Avaliação de pacientes tratados com trombectomia mecânica por acidente vascular cerebral isquêmico agudo em um hospital terciário de dezembro/2009 a dezembro/2015. Valores máximos, mínimos e médios da pressão arterial sistólica, pressão diastólica e pressão arterial média foram coletados durante o procedimento. Drogas sedativas utilizadas também foram revisadas. Resultados: Um total de 53 pacientes com idade média de 71,9 anos (60,4% homens) foram tratados com trombectomia mecânica. A redução média da pressão arterial sistólica e da pressão arterial média desde a internação até a trombectomia mecânica foi respectivamente de 42 mmHg e 36 mmHg. Durante o procedimento, as oscilações da pressão arterial foram de 50,4 mmHg para pressão sistólica e 33,2 mmHg para pressão diastólica. Os pacientes tratados com bloqueadores neuromusculares apresentaram uma tendência a maior oscilação da pressão arterial sistólica desde a internação até o procedimento (51,1 mmHg versus 26,2 mmHg, P = 0,06). O uso de cisatracúrio (43,9 mmHg versus 29,6 mmHg, P = 0,02) e succinilcolina (44,7 mmHg versus 29,3 mmHg, P = 0,01) foram associados a uma queda significativa da pressão arterial durante o procedimento. Conclusões: Durante a trombectomia mecânica ocorre oscilação significativa da pressão arterial. Os medicamentos usados para sedação consciente ou anestesia geral, especificamente bloqueadores neuromusculares, podem ter influência nos níveis de pressão arterial.

Cognitive dysfunction and psychosis: expanding the phenotype of SPG7.

Spastic paraplegia type 7 (SPG7) is one of the most common forms of autosomal recessive hereditary spastic paraplegia, which can lead to a hybrid spastic-ataxic phenotype. Recently, novel complicated forms of SPG7, including cognitive and social impairment phenotypes, have been reported. We present a SPG7 case with two pathogenic variants in compound heterozygosity in the SPG7 gene, featuring a cerebellar cognitive affective syndrome with psychosis not yet described in the literature.

The cerebellar form of acquired hepatocerebral degeneration: The hepatic ataxia.

This article reports a patient with acquired hepatocerebral degeneration that presented with progressive cerebellar ataxia, cerebellar atrophy, and middle cerebellar peduncle lesions. He had a marked improvement after liver transplantation. We reinforce that hepatic failure should be investigated in patients with pure cerebellar syndrome, resembling neurodegenerative diseases.

Movement Disorders in Prionopathies: A Systematic Review.

Background: Movement disorders are frequent features of prionopathies. However, their prevalence and onset remain poorly described. Methods: We performed a systematic review of case reports and case series of pathologically- and genetically confirmed prionopathies. Timing of symptom and movement disorder onset were documented. Continuous variables were compared between two groups using the Wilcoxon rank sum test and between multiple groups using Kruskal-Wallis test. Categorical variables were compared using Fisher's exact test. Results: A total of 324 cases were included in this analysis. Movement disorders were a common feature at the onset of symptoms in most prionopathies. Gait ataxia was present in more than half of cases in all types of prionopathies. The prevalence of limb ataxia (20%) and myoclonus (24%) was lower in Gerstmann-Sträussler-Scheinker disease compared to other prionopathies (p ≤ 0.004). Myoclonus was common but often a later feature in sporadic Creutzfeldt-Jakob disease (2 months before death). Chorea was uncommon but disproportionately prevalent in variant Creutzfeldt-Jakob disease (30% of cases; p < 0.001). In genetic Creutzfeldt-Jakob disease, E200K PRNP carriers exhibited gait and limb ataxia more often when compared to other mutation carriers. Discussion: Movement disorders are differentially present in the course of the various prionopathies. The movement phenomenology and appearance are associated with the type of prion disease and the PRNP genotype and likely reflect the underlying pattern of neurodegeneration. Reliance on myoclonus as a diagnostic feature of sporadic Creutzfeldt-Jakob disease may delay its recognition given its relatively late appearance in the disease course.

Get With The Guidelines®-Stroke performance indicators in patients with transient ischemic attack.

OBJECTIVE: Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. METHODS: This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. RESULTS: A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. CONCLUSIONS: The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

Get With The Guidelines®-Stroke performance indicators in patients with transient ischemic attack / Indicadores de desempenho do programa "Get With The Guidelines®-Stroke" em pacientes com ataque isquêmico transitório

ABSTRACT Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. Objective: The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. Methods: This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. Results: A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. Conclusions: The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

RESUMO O "Get With The Guidelines®-Stroke (GWTG-S)" é um programa hospitalar criado para melhorar os cuidados em pacientes com AVC ao promover a adesão às diretrizes. Dez a quinze porcento dos pacientes com ataque isquêmico transitório terão um AVC em 3 meses, sendo que muitos não recebem intervenções de prevenção secundária recomendadas. Objetivo: Avaliar a adesão aos indicadores de qualidade do programa GWTG em pacientes com ataque isquêmico transitório. Métodos: Este estudo retrospectivo observacional avaliou pacientes consecutivos admitidos em um centro de AVC com suspeita de ataque isquêmico transitório ou AVC isquêmico agudo de agosto/2008 a dezembro/2013. Seis indicadores de qualidade aplicáveis tanto ao ataque isquêmico transitório quanto ao AVC isquêmico agudo foram analisados e comparados entre os grupos. Resultados: Um total de 357 pacientes com ataque isquêmico transitório e 787 pacientes com AVC isquêmico agudo foram avaliados. O uso de antiagregante dentro das primeiras 48 horas da admissão, liberação na alta com anticoagulante para fibrilação atrial e aconselhamento para cessação do tabagismo foram similares entre os grupos. No grupo com ataque isquêmico transitório, o uso de antiagregante na alta hospitalar, o tratamento com estatina e a educação sobre o AVC foram observados menos frequentemente quando comparados ao grupo de pacientes com AVC isquêmico agudo. Conclusões: A adesão a alguns dos indicadores de qualidade do programa GWTG-S foi mais baixa em pacientes com ataque isquêmico transitório quando compara a pacientes com AVC isquêmico agudo. Medidas devem ser tomadas para reforçar a importância dessas intervenções em pacientes admitidos com ataque isquêmico transitório.

Arm Levitation as Initial Manifestation of Creutzfeldt-Jakob Disease: Case Report and Review of the Literature.

Background: Arm levitation is an involuntary elevation of the upper limb, a manifestation of the alien-limb phenomenon. It has rarely been reported in Creutzfeldt-Jakob disease (CJD), less so as an initial manifestation. Case Report: We report a 56-year-old right-handed man with rapidly progressive gait ataxia and involuntary elevation of the left upper limb. During the next few weeks, the patient developed cognitive impairment, apraxia, visual hallucinations, and myoclonus. He met diagnostic criteria for CJD. We evaluated additional published cases of early-appearance of alien-limb phenomenon in the context of CJD; there were 22 such cases and alien-limb phenomenon was the first and exclusive manifestation in only five of them. Discussion: Arm levitation may be a distinct presentation of CJD, appearing earlier than other clinical features.

A Avaliação Global da Pessoa Idosa como Instrumento de Educação Médica: Relato de Experiência / Overall Assessment of the Elderly as a Tool for Medical Education: Case Report

RESUMO O programa de Educação pelo Trabalho para a Saúde (PET-Saúde) fomentou a integração ensino-serviço por meio da inserção de alunos de graduação nos cenários de prática, permitindo o desenvolvimento de competências no mundo do trabalho. Este relato analisa a experiência de estudantes de Medicina no “Projeto de Avaliação da Pessoa Idosa”, desenvolvido ao longo do PET-Saúde em dois semestres do curso de Medicina da Universidade Federal de Ouro Preto. A análise situacional de saúde revelou a necessidade de um acompanhamento individualizado ao idoso. Estudantes do segundo e terceiro ano de Medicina foram capacitados a desenvolver a avaliação global de idosos, realizando avaliações domiciliárias de saúde que alcançaram 20% dos idosos da comunidade. As alterações mais prevalentes na população idosa foram avaliadas e analisadas por estatística descritiva, e as conclusões foram encaminhadas à equipe de saúde. O projeto foi relevante para os idosos, com a identificação de fatores de risco de perda de capacidade funcional, para os médicos das equipes de Saúde da Família, devido à identificação de problemas não relatados nas consultas, para os agentes comunitários de saúde, que estreitaram o relacionamento com a população idosa, e para os estudantes, que ampliaram os conhecimentos, entendendo o trabalho em equipe e desenvolvendo competências na área de saúde do idoso.

ABSTRACT The “Education through Work in Health Program” (PET-Saúde) has promoted integration between teaching and service by inserting undergraduate students in practical scenarios, allowing the development of skills in the workplace. This report analyzes medical students’ experience in the “Elderly Evaluation Project”, developed throughout the PET-Saúde in two semesters at the Federal University of Ouro Preto medical school. Situational analysis revealed the need for individualized monitoring of the elderly. Second and third-year students were able to develop an overall evaluation of the elderly, performing home health assessments that reached 20% of the community’s elderly population. The most prevalent changes were evaluated and subjected to descriptive statistical analysis, and the conclusions were fed back to the health care team. The project was important for the elderly, helping to assess and diagnose risk factors for the loss of functional capacity. The family health teams physicians stressed the importance of reporting health problems not commonly referred to in consultations. For the community health agents, it helped to strengthen their relationship with the elderly population. Finally, for the students, the project was an opportunity to increase knowledge, and develop teamwork and other skills in the area of senior health.