Risk of Early Bleeding with Dual Antiplatelet Therapy in Acute Stroke and Transient Ischemic Attack Regardless of NIHSS Admission.

BACKGROUND: Dual antiplatelet therapy (DAT) is a therapeutic option for patients with minor ischemic stroke (IS) or transient ischemic attack (TIA). No study has evaluated the incidence of early bleeding in patients with moderate to major ischemic stroke. The current study aimed to analyze both the frequency of early bleeding and hospital morbidity related to DAT for either acute IS or TIA regardless of admission National Institute of Health Stroke Scale (NIHSS) score. METHODS: This was a retrospective analysis based on data collected from a prospective data bank of a single center. We included patients who underwent DAT in the first 24 hours of symptom onset with a loading dose (aspirin 300 mg + clopidogrel 300 mg) on the first day, followed by a maintenance dose (aspirin 100 mg + clopidogrel 75 mg). We analyzed intracranial and/or extracranial hemorrhage that had occurred during the hospital admission, symptomatic bleeding, modified Rankin Scale (mRS) score at discharge, and death rates as outcomes. RESULTS: Of the 119 patients analyzed, 94 (79 %) had IS and 25 (21 %) had TIA. Hemorrhage occurred in 11 (9.2 %) and four (3.4 %) patients with TIA or NIHSS ≤ 3, respectively, although none were symptomatic. Patients with bleeding as a complication had higher admission NIHSS [4 (3-7) vs. 2 (1-4), p = 0.044] and had higher mRS at discharge (mRS 2 [1-5] vs. mRS 1 [0-2], p = 0.008). These findings did not indicate increased mortality, as one (9 %) patient died from bleeding and two (1.8 %) patients died without bleeding (p = 0.254). CONCLUSION: DAT seems to be a safe therapy in patients regardless of admission NIHSS if started within the first 24 h after symptom onset because only 1.6 % of patients had symptomatic bleeding.

Neurological complications of heart failure.

Heart failure (HF) is a major global cause of death with increasing absolute worldwide numbers of HF patients. HF results from the interaction between cardiovascular aging with specific risk factors, comorbidities, and disease modifiers. The failing heart and neuronal injury have a bidirectional interaction requiring specific management strategies. Decreased cardiac output has been associated with lower brain volumes. Cerebral blood flow (CBF) may normalize following heart transplantation among severe HF patients. Stroke and cognitive impairment remain the main neurologic conditions associated with HF. However, HF patients may also suffer from chronic cerebral hypoperfusion. It seems likely that HF-related ischemic strokes are primarily the result of cardiac embolism. Atrial fibrillation (AF) is present in half of stroke patient with HF. The increased risk of hemorrhagic strokes is less well characterized and likely multifactorial, but may in part reflect a higher use of long-term antithrombotic therapy. The steady improvement of neuroimaging techniques has demonstrated an increased prevalence of silent ischemic lesions among HF patients. The populations most likely to benefit from long-term anticoagulant therapy are HF patients with AF. Cognitive impairment in HF can have a variety of clinical manifestations from mild memory problems to dementia.

Current uses of intracranial vessel wall imaging for clinical practice: a high-resolution MR technique recently available.

Intracranial vessel wall imaging plays an increasing role in diagnosing intracranial vascular diseases. With the growing demand and subsequent increased use of this technique in clinical practice, radiologists and neurologists should be aware of the choices in imaging parameters and how they affect image quality, clinical indications, methods of assessment, and limitations in the interpretation of these images. Due to the improvement of the MRI techniques, the possibility of accurate and direct evaluation of the abnormalities in the arterial vascular wall (vessel wall imaging) has evolved, adding substantial data to diagnosis when compared to the indirect evaluation based on conventional flow analyses. Herein, the authors proposed a comprehensive approach of this technique reinforcing appropriated clinical settings to better use intracranial vessel wall imaging.

Current uses of intracranial vessel wall imaging for clinical practice: a high-resolution MR technique recently available / Usos atuais do estudo de parede vascular intracraniana na prática clínica: uma técnica de RM de alta resolução recentemente disponível

ABSTRACT Intracranial vessel wall imaging plays an increasing role in diagnosing intracranial vascular diseases. With the growing demand and subsequent increased use of this technique in clinical practice, radiologists and neurologists should be aware of the choices in imaging parameters and how they affect image quality, clinical indications, methods of assessment, and limitations in the interpretation of these images. Due to the improvement of the MRI techniques, the possibility of accurate and direct evaluation of the abnormalities in the arterial vascular wall (vessel wall imaging) has evolved, adding substantial data to diagnosis when compared to the indirect evaluation based on conventional flow analyses. Herein, the authors proposed a comprehensive approach of this technique reinforcing appropriated clinical settings to better use intracranial vessel wall imaging.

RESUMO O estudo angiográfico intracraniano não invasivo está sendo amplamente utilizado no diagnóstico de doenças vasculares intracranianas. Com a crescente demanda e o aumento subsequente do uso dessa técnica na prática clínica, radiologistas e neurologistas devem estar cientes das opções nos parâmetros de imagem e como estes afetam a qualidade da imagem, as indicações clínicas, os métodos de avaliação e as limitações na interpretação dessas imagens. Devido ao aprimoramento das técnicas de imagem por RM, a possibilidade de avaliação precisa e direta das anormalidades na parede vascular arterial (vessel wall imaging) evoluiu, agregando dados substanciais ao diagnóstico quando comparados à avaliação indireta baseada em análises de fluxo convencionais. Neste artigo, os autores discorrem sobre a avaliação e interpretação dos achados de imagem desta nova técnica e suas aplicações clínicas.

Evaluation of cerebral autoregulation performance in patients with arterial hypertension on drug treatment.

Cerebral autoregulation (AR) keeps cerebral blood flow constant despite fluctuations in systemic arterial pressure. The final common AR pathway is made up of vasomotor adjustments of cerebrovascular resistance mediated by arterioles. Structural and functional changes in the arteriolar wall arise with age and systemic arterial hypertension. This study evaluated whether AR is impaired in hypertensive patients and whether this impairment differs with disease control. Three groups of patients were prospectively compared: hypertensive patients under treatment with systolic blood pressure (SBP) <140 and diastolic blood pressure (DBP) <90 mm Hg (n = 54), hypertensive patients under treatment with SBP > 140 or DBP > 90 mm Hg (n = 31), and normotensive volunteers (n = 30). Simultaneous measurements of cerebral blood flow velocity (CBFV) and BP were obtained by digital plethysmography and transcranial Doppler, and the AR index (ARI) was defined according to the step response to spontaneous fluctuations in BP. Compared to the uncontrolled hypertension, the normotensive individuals were younger (age 43.42 ± 11.14, P < .05) and had a lower resistance-area product (1.17 ± 0.24, P < .05), although age and greater arteriolar stiffness did not affect the CBFV mean of hypertensive patients, whether controlled or uncontrolled (62.85 × 58.49 × 58.30 cm/s, P = .29), most likely because their ARIs were not compromised (5.54 × 5.91 × 5.88, P = .6). Hypertensive patients under treatment, regardless of their BP control, have intact AR capacity.

Improving economic evaluations in stroke: A report from the ESO Health Economics Working Group.

INTRODUCTION: Approaches to economic evaluations of stroke therapies are varied and inconsistently described. An objective of the European Stroke Organisation (ESO) Health Economics Working Group is to standardise and improve the economic evaluations of interventions for stroke. METHODS: The ESO Health Economics Working Group and additional experts were contacted to develop a protocol and a guidance document for data collection for economic evaluations of stroke therapies. A modified Delphi approach, including a survey and consensus processes, was used to agree on content. We also asked the participants about resources that could be shared to improve economic evaluations of interventions for stroke. RESULTS: Of 28 experts invited, 16 (57%) completed the initial survey, with representation from universities, government, and industry. More than half of the survey respondents endorsed 13 specific items to include in a standard resource use questionnaire. Preferred functional/quality of life outcome measures to use for economic evaluations were the modified Rankin Scale (14 respondents, 88%) and the EQ-5D instrument (11 respondents, 69%). Of the 12 respondents who had access to data used in economic evaluations, 10 (83%) indicated a willingness to share data. A protocol template and a guidance document for data collection were developed and are presented in this article. CONCLUSION: The protocol template and guidance document for data collection will support a more standardised and transparent approach for economic evaluations of stroke care.

Stroke Care and Application of Thrombolysis in Ibero-America: Report From the SITS-SIECV Ibero-American Stroke Register

Background and Purpose: Standardized registries may provide valuable data to further improve stroke care. Our aim was to obtain updated information about characteristics of stroke patients and management of stroke across the Ibero-American countries, using a common in-hospital registry (Safe Implementation of Treatments in Stroke­Sociedad Iberoamericana de Enfermedades Cerebrovasculares) as a basis for further quality improvement. Methods: Data for this study were entered into the Safe Implementation of Treatments in Stroke registry from September 2009 to December 2013 by 58 centers in 14 countries. Data included demographics, risk factors, onset-to-door time, National Institutes of Health Stroke Scale score, stroke subtype, ischemic stroke etiology, treatments, 3-month mortality, and modified Rankin Scale score. Time to treatment was also recorded for patients treated with thrombolysis. Results: Five thousand four hundred one patients were registered; median age, 65 years; 46% women; 3915 (72.5%) ischemic strokes; 686 (13.7%) hemorrhagic strokes; 213 (4.3%) subarachnoid hemorrhages; 414 (8.3%) transient ischemic attacks; and 31 (0.6%) cerebral vein thrombosis. The most prevalent risk factors were hypertension (71.3%), dyslipidemia (35.2%), and diabetes mellitus (23.6%). Atrial fibrillation was present in 15.1%. Three hundred one ischemic strokes were treated with intravenous thrombolysis (IVT; 7.7%). Patients undergoing IVT were more severely affected (median baseline National Institutes of Health Stroke Scale score, 11 versus 6). The rate of symptomatic intracerebral hemorrhages after IVT was 5.7%. At 3 months, 60.3% of IVT-treated patients and 59.1% of untreated patients were independent (modified Rankin Scale score, 0­2). Mortality was 11.4% in treated and 12.8% in untreated patients. Conclusions: Safe Implementation of Treatments in Stroke­Sociedad Iberoamericana de Enfermedades Cerebrovasculares is the largest registry of a general stroke population and the first study to evaluate the level of IVT use in Ibero-America. It provides valuable information that may help to improve the quality of stroke care in the Ibero-American region.

Latin American Consensus Statement for the Use of Contrast-Enhanced Transcranial Ultrasound as a Diagnostic Test for Detection of Right-to-Left Shunt.

BACKGROUND: The role of patent foramen ovale is a field of debate and current publications have increasing controversies about the patients' management in young undetermined stroke. Work up with echocardiography and transcranial Doppler (TCD) can aid the decision with better anatomical and functional characterization of right-to-left shunt (RLS). Medical and interventional strategy may benefit from this information. SUMMARY: a group of experts from the Latin American participants of the Neurosonology Research Group (NSRG) of World Federation of Neurology created a task force to review literature and describe the better methodology of contrast TCD (c-TCD). All signatories of the present consensus statement have published at least one study on TCD as an author or co-author in an indexed journal. Two meetings were held while the consensus statement was being drafted, during which controversial issues were discussed and voted on by the statement signatories. The statement paper was reviewed and approved by the Executive Committee of the NSRG of the World Federation of Neurology. The main objective of this consensus statement is to establish a standardization of the c-TCD technique and its interpretation, in order to improve the informative quality of the method, resulting in expanding the application of TCD in the clinical setting. These recommendations optimize the comparison of different diagnostic methods and encourage the use of c-TCD for RLS screening and complementary diagnosis in multicenter studies.

Otimizando a reperfusão na fase aguda do AVCI: um convite aos cardiologistas / Optimizing reperfusion in the acute phase of stroke: an invitation to cardiologists

Trombólise IV é o tratamento de escolha para pacientes com AVCI agudo. O NNT para evitar incapacidade funcional varia de 3 a 14, dependendo do tempo entre o início dos sintomas e a infusão do trombolítico. Entretanto, a janela de oportunidade para tratamento é de apenas 4 horas e 30 minutos. Nosso objetivo é apresentar a estratégia adotada em um centro cardiológico terciário que levou à otimização da reperfusao cerebral com trombolítico IV realizada por cardiologistas. A ação principal tomada foi o desenvolvimento do protocolo de sequência rápida da reperfusao cerebral. Os pontos chaves do protocolo foram: triagem imediata e encaminhamento direto para tomografia com infusão do trombolítico com o paciente na mesa de exame, treinamentos no manejo da fase aguda e na interpretação rápida da tomografia, suporte neurológico à distância nos casos com dúvidas na interpretação da imagem ou contraindicações, ampliação do horário da tomografia para 24x7 e disponibilização do trombolítico na farmácia satélite do pronto socorro. Com essas ações o número de pacientes trombolisados saltou de 4 em 2017 para 15 em 2018, um aumento de 375%. A taxa de trombólise foi de 3,2% em 2017 e 16,3% em 2018 (aumento de 5 vezes) Dos pacientes trombolisados, 60% apresentavam melhora clínica com base no critério "respondedor". A união de forças entre cardiologistas e neurologistas, na fase aguda do AVCI ampliou o percentual de pacientes beneficiados com tratamento trombolítico em nosso hospital. Essa experiência pode ser replicada através das Sociedades de Cardiologia. (AU)

Mulher jovem com IAM: é tempo de pensarmos além dos fatores de risco cardiovascular convencionais / Young woman with AMI: time to think beyond conventional cardiovascular risk factors

Estudos recentes consideram a depressão como um fator de risco cardiovascular modificável independente para IAM. Nosso objetivo é relatar o caso de uma paciente jovem com IAM que apresentava depressão e ansiedade moderadas até então pouco valorizadas. Paciente do sexo feminino, 44 anos com HAS leve admitida com IAM com supra de ST no território da coronária direita. Recebeu terapia trombolítica, 2 horas após início da dor torácica, evoluindo com critérios de reperfusão miocárdica. Na investigação complementar apresentou CATE normal e ressonância cardíaca com infarto transmural. Medicada com antiagregante plaquetário, estatina e anti-hipertensivo. Durante as orientações de alta o neurologista levantou a hipótese de ansiedade e depressão como fatores de risco adicionais. Para confirmar essa hipótese foi solicitada avaliação psicológica. Na anamnese psíquica a paciente referiu situação familiar instável com marido esquizofrênico e filho usuário de drogas. Durante o exame psíquico pôde-se evidenciar tristeza e impotência frente à situação familiar prévia ao IAM. Aplicada Escala de Hamilton que foi compatível com ansiedade e depressão moderadas. A avaliação com os critérios de estresse crônico e depressão validados no estudo INTERHEART evidenciou aspectos depressivos relacionados com perda de interesse e prazer nas atividades, dificuldade de concentração, desmotivação e falta de energia. Recebeu alta com desvenlafaxina 50 mg e acompanhamento psicológico. Nas avaliações psicológicas de 30 e 60 dias apresentou sinais de melhora emocional. Depressão foi um dos 10 fatores de risco cardiovascular modificáveis mais importantes para IAM no estudo INTERHEART. Uma subanálise desse estudo sugeriu que fatores estressantes no lar foram 2.12 vezes mais comuns em pacientes com IAM, quando comparados ao grupo controle. Entretanto, a maioria dos pacientes com IAM não possuem avaliação psicológica durante a internação e médicos, geralmente, não são treinados para a investigação e manejo dos aspectos emocionais nos pacientes com doenças cardiovasculares. Nosso relato de caso visa despertar a importância do trabalho conjunto de médicos e psicólogos no atendimento dos pacientes com urgências e emergências cardiovasculares. (AU)

Impact of Low Ankle-Brachial Index on the Risk of Recurrent Vascular Events.

Background and Purpose- Low ankle-brachial index (ABI) identifies a stroke subgroup with high risk of recurrent stroke, cardiovascular events, and death. However, limited data exist on the relationship between low ABI and stroke in low and middle-income countries. Therefore, we evaluated the prevalence of ABI ≤0.90 (which is diagnostic of peripheral artery disease) in nonembolic stroke patients or transient ischemic attack and assessed the correlation of low ABI with stroke risk, factors, and recurrent vascular events and death. Methods- Patients ≥45 years with acute transient ischemic attack or minor ischemic strokes were recruited consecutively from over 17 low-income and middle-income countries (Latin America [1543 patients], Middle East [1041 patients], North Africa [834 patients], and South Africa [217 patients]). The ABI measurement was performed at a single visit. Stroke recurrence and risk of new vascular events were assessed after 24 months of follow-up. Results- Among 3487 enrolled patients, abnormal ABI (<0.9) was present in 22.3 %. Patients with an ABI of ≤0.9 were more likely ( P<0.05) to be male, older, and have a history of peripheral artery disease, hypertension, and diabetes mellitus. During 2-year follow-up, the rate of major cardiovascular event was higher in patients with ABI <0.9 than those with ABI ≥0.9 (Kaplan-Meier estimates, 22.5%; 95% CI, 19.6-25.8 versus 13.7%; 21.4-15.1; P<0.001), and when ABI was categorized into 4 groups (≤0.6; 95% CI, 0.6-0.9; 0.9-1; 1-1.4), the rate of major cardiovascular event was higher in those with ABI ≤0.6 than the other groups (Kaplan-Meier estimates, 32.6%; 95% CI, 21.0-48.3 for ABI≤0.6 versus 21.7%; 95% CI, 18.8-25.0 for ABI 0.6-0.9 versus 14.3%; 95% CI, 12.4-16.6 for ABI 0.9-1 versus 13.3%; 95% CI, 11.6-15.2 for ABI 1-1.4; P<0.001). Conclusions- Among patients with nonembolic ischemic stroke or transient ischemic attack, those with low ABI had a higher rate of vascular events and death in this population. Screening for ABI in stroke patients may help identify patients at high risk of future events.

Higher arterial stiffness is associated with lower cognitive performance in patients with hypertension.

Cognitive impairment and elevated arterial stiffness have been described in patients with arterial hypertension, but their association has not been well studied. We evaluated the correlation of arterial stiffness and different cognitive domains in patients with hypertension compared with those with normotension. We evaluated 211 patients (69 with normotension and 142 with hypertension). Patients were age matched and distributed according to their blood pressure: normotension, hypertension stage 1, and hypertension stage 2. Cognitive function was assessed using the Mini-Mental State Examination, Montreal Cognitive Assessment, and a battery of neuropsychological evaluations that assessed six main cognitive domains. Pulse wave velocity was measured using a Complior device, and carotid properties were assessed by radiofrequency ultrasound. Central arterial pressure and augmentation index were obtained using applanation tonometry. The hypertension stage 2 group had higher arterial stiffness and worse performance either by Mini-Mental State Examination (26.8±2.1 vs 27.3±2.1 vs 28.0±2.0, P=.003) or the Montreal Cognitive Assessment test (23.4±3.5 vs 24.9±2.9 vs 25.6±3.0, P<.001). On multivariable regression analysis, augmentation index, intima-media thickness, and pulse wave velocity were the variables mainly associated with lower cognitive performance at different cognitive domains. Cognitive impairment in different domains was associated with higher arterial stiffness.

Impact of hypertension severity on arterial stiffness, cerebral vasoreactivity, and cognitive performance / Impacto da gravidade da hipertensão na rigidez arterial, vasorreatividade cerebral e desempenho cognitivo

ABSTRACT. Aging, hypertension (HTN), and other cardiovascular risk factors contribute to structural and functional changes of the arterial wall. Objective: To evaluate whether arterial stiffness (AS) is related to cerebral blood flow changes and its association with cognitive function in patients with hypertension. Methods: 211 patients (69 normotensive and 142 hypertensive) were included. Patients with hypertension were divided into 2 stages: HTN stage-1 and HTN stage-2. The mini-mental state examination (MMSE), Montreal Cognitive Assessment (MoCA) and a battery of neuropsychological (NPE) tests were used to determine cognitive function. Pulse wave velocity was measured using the Complior®. Carotid properties were assessed by radiofrequency ultrasound. Central arterial pressure and augmentation index were obtained using applanation tonometry. Middle cerebral artery flow velocity was measured by transcranial Doppler ultrasonography. Results: Both arterial stiffness parameters and cerebral vasoreactivity worsened in line with HTN severity. There was a negative correlation between breath holding index (BHI) and arterial stiffness parameters. Cognitive performance worsened in line with HTN severity, with statistical difference occurring mainly between the HTN-2 and normotension groups on both the MMSE and MoCA. The same tendency was observed on the NPE tests. Conclusion: Hypertension severity was associated with higher AS, worse BHI, and lower cognitive performance.

RESUMO. A idade, hipertensão arterial (HA), e outros fatores de risco cardiovascular contribuem para as alterações estruturais e funcionais da parede arterial. Objetivo: Avaliar o quanto a rigidez arterial está relacionada com as alterações do fluxo sanguíneo cerebral e sua associação com a função cognitiva em pacientes com hipertensão. Métodos: Foram incluídos 211 pacientes (69 normotensos e 142 hipertensos). Os pacientes com hipertensão foram divididos em dois estágios: HA-1 e HA-2. O mini exame do estado mental (MEEM), Montreal Cognitive Assessment (MoCA) e uma bateria de testes neuropsicológicos foram usados para avaliar a função cognitiva. A velocidade da onda de pulso foi medida usando o Complior®. As propriedades da artéria carótida foram avaliadas usando o ultrassom de radiofrequência. A pressão arterial central e o índice de incremento foram obtidos usando a tonometria de aplanação. A velocidade de fluxo sanguíneo da arterial cerebral média foi medida pelo ultrassom com Doppler Transcraniano. Resultados: Tanto os parâmetros da rigidez arterial quanto a vasorreatividade cerebral foram piores com a gravidade da hipertensão. Houve uma correlação negativa entre o índice de apnéia e os parâmetros da rigidez arterial. O desempenho cognitivo foi pior com a gravidade de hipertensão arterial com diferença estatística ocorrendo principalmente entre os grupos HA-2 e normotensão tanto no MEEM quanto no MoCA. A mesma tendência foi observada em relação aos testes neuropsicológicos. Conclusão: A gravidade de hipertensão arterial foi associada com maior rigidez arterial, pior índice de apneia, e menor desempenho cognitivo.