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1.
Int J Stroke ; : 1747493018791030, 2018 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-30040047

RESUMO

Background Stroke is a leading cause of morbidity and mortality in Brazil, where there are significant imbalances in access to specialized stroke care. Telemedicine networks allow patients to receive neurological evaluation and intravenous thrombolysis in underserved areas, where performance measures are challenging. Aims To describe the impact caused by adequate stroke care training, using realistic simulation, in a developing country telestroke network. Methods Retrospective observational study comparing the number of all stroke diagnoses, thrombolysis rate, door-to-needle time and symptomatic intracranial hemorrhage after intravenous thrombolysis, during one year providing just algorithms and orientation in stroke care to spoke facilities (phase 1), with the results achieved along one year after the beginning of ongoing live training sessions (phase 2). Results The mean number of patients diagnosed with stroke increased from 7.5 to 16.58 per month ( P = 0.019) rising from 90 patients during phase 1 to 199 in phase 2. There was a reduction in the mean door-to-needle time from 137.1 to 95.5 min (-41.58; 95% CI -62.77 to -20.40). The thrombolysis and symptomatic intracranial hemorrhage rates had a non-significant decrease from 21.31% to 18.18% (OR 0.82; 95% CI 0.39 to 1.71) and 12.5% to 7.69% (OR 0.58; 95% CI 0.046 to 7.425), respectively. Conclusions Realistic simulation stroke care training provided by stroke centers to spoke facilities seems to significantly reduce door-to-needle time and enhance adherence in a telestroke network.

2.
Arq Neuropsiquiatr ; 75(1): 50-56, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28099563

RESUMO

These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/normas , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Brasil , Humanos
3.
Arq. neuropsiquiatr ; 75(1): 50-56, Jan. 2017. tab
Artigo em Inglês | LILACS-Express | ID: biblio-838851

RESUMO

ABSTRACT These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.


RESUMO Estas diretrizes são o resultado de um esforço conjunto de membros da Sociedade Brasileira de Doenças Cerebrovasculares (SBDCV), Departamento científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia (ABN), Rede Brasil AVC (RBAVC) e da Sociedade Brasileira de Neurorradiologia Diagnóstica e Terapêutica (SBNR). Membros destas 4 entidades participaram de fórum de discussões por internet de temas pré-definidos, seguidos de encontros de videoconferência para discussão de pontos controversos e das recomendações, em busca de um consenso final. Estas diretrizes tem seu foco sobre as implicações dos recentes ensaios clínicos de tratamento endovascular do acidente vascular cerebral (AVC) isquêmico agudo relacionado a oclusão de artérias proximais. O texto final foi elaborado para servir de orientação no manejo destes pacientes AVC isquêmico pelos diferentes profissionais de saúde, gestores de saúde pública e de saúde complementar no Brasil.

4.
Stroke ; 46(11): 3131-6, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26451022

RESUMO

BACKGROUND AND PURPOSE: The term metabolic syndrome describes the clustering of risk factors found in many individuals with obesity. Because of their pathophysiology, we hypothesized that 2 features of metabolic syndrome, central obesity and insulin resistance (IR), would be associated with cerebrovascular changes on magnetic resonance imaging, and specifically with incident lacunar disease and not white matter hyperintensity (WMH) progression. METHODS: Risk factors were defined at study baseline in 934 participants in the Atherosclerosis Risk in Communities (ARIC) study, who completed 2 brain magnetic resonance imagings≈10 years apart. WMH progression and incident lacunes between the 2 magnetic resonance imagings were determined. An IR score for each participant was created using principal component analysis of 11 risk factors, including (among others): insulin, homeostatic model assessment-IR, body mass index, and waist circumference. Metabolic syndrome (presence/absence), using standard clinical definitions, and IR score at the first magnetic resonance imaging, were independent variables, evaluated in multivariate logistic regression to determine odds of WMH progression (Q5 versus Q1-Q4) and incident lacunes. RESULTS: Metabolic syndrome (adjusted odds ratio, 1.98; 95% confidence interval, 1.28-3.05) and IR score (adjusted odds ratio per 1-SD increase, 1.33; 95% confidence interval, 1.05-1.68) were associated with incident lacunes but not with WMH progression. Insulin, homeostatic model assessment-IR, and body mass index were not associated with incident lacunes or WMH progression in separate models. CONCLUSIONS: The IR score and central obesity are associated with incident lacunar disease but not WMH progression in individuals. Central obesity and IR may be important risk factors to target to prevent lacunar disease.


Assuntos
Aterosclerose/diagnóstico , Resistência à Insulina , Imagem por Ressonância Magnética , Obesidade/diagnóstico , Características de Residência , Acidente Vascular Cerebral Lacunar/diagnóstico , Aterosclerose/epidemiologia , Feminino , Humanos , Incidência , Masculino , Síndrome Metabólica/diagnóstico , Síndrome Metabólica/epidemiologia , Microvasos/patologia , Pessoa de Meia-Idade , Obesidade/epidemiologia , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral Lacunar/epidemiologia
5.
Ann Intern Med ; 163(1): 22-31, 2015 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-26148278

RESUMO

BACKGROUND: Although cerebral lesions 3 mm or larger on imaging are associated with incident stroke, lesions smaller than 3 mm are typically ignored. OBJECTIVE: To examine stroke risks associated with subclinical brain lesions (<3 mm only, ≥3 mm only, and both sizes) and white matter hyperintensities (WMHs). DESIGN: Community cohort from the ARIC (Atherosclerosis Risk in Communities) Study. SETTING: Two ARIC sites with magnetic resonance imaging (MRI) data from 1993 to 1995. PARTICIPANTS: 1884 adults aged 50 to 73 years with MRI, no prior stroke, and average follow-up of 14.5 years. MEASUREMENTS: Lesions on MRI (by size), WMH score (scale of 0 to 9), incident stroke, all-cause mortality, and stroke-related mortality. Hazard ratios (HRs) were estimated with proportional hazards models. RESULTS: Compared with no lesions, stroke risk tripled with lesions smaller than 3 mm only (HR, 3.47 [95% CI, 1.86 to 6.49]), doubled with lesions 3 mm or larger only (HR, 1.94 [CI, 1.22 to 3.07]), was 8-fold higher with lesions of both sizes (HR, 8.59 [CI, 4.69 to 15.73]), and doubled with a WMH score of at least 3 (HR, 2.14 [CI, 1.45 to 3.16]). Risk for stroke-related death tripled with lesions smaller than 3 mm only (HR, 3.05 [CI, 1.04 to 8.94]) and was 7 times higher with lesions of both sizes (HR, 6.97 [CI, 2.03 to 23.93]). LIMITATION: Few strokes (especially hemorrhagic) and few participants with lesions smaller than 3 mm only or lesions of both sizes. CONCLUSION: Very small cerebrovascular lesions may be associated with increased risks for stroke and death; presence of lesions smaller than 3 mm and 3 mm or larger may result in a particularly striking risk increase. Larger studies are needed to confirm findings and provide more precise estimates. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.


Assuntos
Infarto Encefálico/patologia , Encéfalo/patologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Infarto Encefálico/complicações , Causas de Morte , Feminino , Humanos , Incidência , Estudos Longitudinais , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/mortalidade
6.
Atherosclerosis ; 237(1): 227-35, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25244507

RESUMO

OBJECTIVE: Carotid intima-media thickness (IMT) is a noninvasive measurement of early atherosclerosis. Most IMT studies have involved populations with low rates of racial blending. The aim of the present article is to describe IMT value distributions and analyze the influence of sex and race on IMT values in a large Brazilian sample, a setting with a high rate of racial admixture. METHODS: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a multicenter cohort of 15,105 adult (aged 35-74 years) civil servants in six Brazilian cities. Baseline assessment included IMT measurements in both common carotid arteries. Race was self-reported. We studied the association between sex and race with IMT values using multiple linear regression models. We conducted analyses in all and low-risk individuals, defined as those without classical cardiovascular risk factors. RESULTS: We analyzed complete IMT data from 10,405 ELSA-Brasil participants. We present nomograms by age for all and low-risk individuals, stratified by sex and race. We found that men had significantly higher maximal IMT values compared with women (ß = 0.058; P < 0.001). This association remained for low-risk individuals (ß = 0.027; P = 0.001). In addition, Brown and White individuals had lower maximal IMT values compared with Black individuals for all (ß = -0.034 and ß = -0.054, respectively; P < 0.001) and low-risk individuals (ß = -0.027; P = 0.013 and ß = -0.035; P < 0.001, respectively). CONCLUSION: We found significantly higher IMT values in men. We found significantly higher IMT values in Black individuals than White and Brown individuals. These results persisted when analyses were restricted to low-risk individuals.


Assuntos
Artéria Carótida Primitiva/patologia , Espessura Intima-Media Carotídea , Adulto , Grupo com Ancestrais do Continente Africano , Fatores Etários , Idoso , Brasil , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etnologia , Grupos Étnicos , Grupo com Ancestrais do Continente Europeu , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Fatores Sexuais
7.
Neuroradiology ; 54(2): 139-46, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21484321

RESUMO

INTRODUCTION: Currently, there is no reliable method to differentiate acute from chronic carotid occlusion. We propose a novel CTA-based method to differentiate acute from chronic carotid occlusions that could potentially aid clinical management of patients. METHODS: We examined 72 patients with 89 spontaneously occluded extracranial internal carotids with CT angiography (CTA). All occlusions were confirmed by another imaging modality and classified as acute (imaging <1 week of presumed occlusion) orchronic (imaging >4 weeks), based on circumstantial clinical and radiological evidence. A neuroradiologist and a neurologist blinded to clinical information determined the site of occlusion on axial sections of CTA. They also looked for (a) hypodensity in the carotid artery (thrombus), (b) contrast within the carotid wall (vasa vasorum), (c) the site of the occluded carotid, and (d) the "carotid ring sign" (defined as presence of a and/or b). RESULTS: Of 89 occluded carotids, 24 were excluded because of insufficient circumstantial evidence to determine timing of occlusion, 4 because of insufficient image quality, and 3 because of subacute timing of occlusion. Among the remaining 45 acute and 13 chronic occlusions, inter-rater agreement (kappa) for the site of proximal occlusion was 0.88, 0.45 for distal occlusion, 0.78 for luminal hypodensity, 0.82 for wall contrast, and 0.90 for carotid ring sign. The carotid ring sign had 88.9% sensitivity, 69.2% specificity, and 84.5% accuracy to diagnose acute occlusion. CONCLUSION: The carotid ring sign helps to differentiate acute from chronic carotid occlusion. If further confirmed, this information may be helpful in studying ischemic symptoms and selecting treatment strategies in patients with carotid occlusions.


Assuntos
Angiografia/métodos , Estenose das Carótidas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Doença Aguda , Idoso , Artérias Carótidas/diagnóstico por imagem , Doença Crônica , Meios de Contraste , Feminino , Humanos , Iohexol , Masculino , Valor Preditivo dos Testes , Sensibilidade e Especificidade
8.
Pacing Clin Electrophysiol ; 34(11): 1492-7, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21797898

RESUMO

OBJECTIVE: To determine the prevalence and the prognostic value of exercise-induced ventricular arrhythmia (EIVA) in chronic Chagas' heart disease. STUDY DESIGN AND SETTING: An open prospective cohort of 130 clinically stable patients at a University Hospital outpatient unit in Rio de Janeiro, Brazil, was followed up at scheduled clinical visits from 1990 through 2007. The endpoint was total cardiovascular mortality. Survival curves (Kaplan-Meier) and a multivariate Cox proportional hazard model were adjusted to determine the association between EIVA and mortality. RESULTS: The median duration of follow-up was 9.9 years (range, 132 days to 17 years). EIVA prevalence was 43.1% (95% CI: 34.5-51.7). Thirty-three cardiovascular deaths (25.4%) occurred. The hazard ratio of EIVA for cardiovascular death, after adjustment for age, was 1.84 (P = 0.09). An interaction was found between EIVA and cardiomegaly on x-ray. In the group with cardiomegaly, the hazard of dying was four times greater in the presence of EIVA (P for interaction = 0.05). CONCLUSION: In clinically stable chagasic subjects with cardiomegaly, EIVA is a clinically significant marker of total cardiovascular mortality and may be a useful risk stratification tool in this population.


Assuntos
Doença de Chagas/diagnóstico , Doença de Chagas/mortalidade , Eletrocardiografia/estatística & dados numéricos , Teste de Esforço/estatística & dados numéricos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Cardiomiopatias , Comorbidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Sensibilidade e Especificidade , Análise de Sobrevida , Taxa de Sobrevida
9.
Cerebrovasc Dis ; 20 Suppl 2: 109-18, 2005.
Artigo em Inglês | MEDLINE | ID: mdl-16327260

RESUMO

Antiplatelet drugs have an established efficacy in the secondary prevention of ischemic stroke. The recent results of the CAPRIE, CURE, and CREDO studies formed the rationale for the MATCH, designed to test whether the association of clopidogrel and aspirin was better than clopidogrel alone for the prevention of vascular events among high-risk ischemic cerebrovascular patients. Although the benefits were outweighed for a higher bleeding risk in the combination group, this study will provide important insight for upcoming trials in other to determine what populations might mostly benefit from these drugs for the secondary prevention of stroke in the future.


Assuntos
Aspirina/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Ticlopidina/análogos & derivados , Fatores Etários , Idoso , Aspirina/efeitos adversos , Transtornos Cerebrovasculares/complicações , Clopidogrel , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Humanos , Ataque Isquêmico Transitório/complicações , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Fatores de Risco , Prevenção Secundária , Acidente Vascular Cerebral/epidemiologia , Ticlopidina/efeitos adversos , Ticlopidina/uso terapêutico , Resultado do Tratamento
11.
Arch Neurol ; 62(8): 1217-20, 2005 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-16087761

RESUMO

BACKGROUND: Aspirin, or acetylsalicylic acid, is widely used to prevent ischemic vascular disease. Clinical and experimental data suggest that a rebound effect occurs 4 or fewer weeks after interruption of aspirin therapy. OBJECTIVE: To study the discontinuation of aspirin therapy as a risk factor for ischemic stroke (IS). DESIGN: Case-control study. SETTING: Stroke unit. PARTICIPANTS: Three hundred nine patients with IS or transient ischemic attack undergoing long-term aspirin treatment before their index event and 309 age-, sex-, and antiplatelet therapy-matched controls who had not had an IS in the previous 6 months. METHODS: We compared the frequency of aspirin therapy discontinuation during the 4 weeks before an ischemic cerebral event in patients and the 4 weeks before interview in controls. RESULTS: The 2 groups had a similar frequency of risk factors, except for coronary heart disease, which was more frequent in patients (36% vs 18%; P < .001). Aspirin use had been discontinued in 13 patients and 4 controls. Aspirin interruption yielded an odds ratio for IS/transient ischemic attack of 3.4 (95% confidence interval, 1.08-10.63; P < .005) after adjustment in a multivariable model. CONCLUSIONS: These results highlight the importance of aspirin therapy compliance and give an estimate of the risk associated with the discontinuation of aspirin therapy in patients at risk for IS, particularly those with coronary heart disease.


Assuntos
Aspirina/efeitos adversos , Isquemia Encefálica/induzido quimicamente , Acidente Vascular Cerebral/induzido quimicamente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/fisiopatologia , Estudos de Casos e Controles , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/tratamento farmacológico , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia
12.
Arch Neurol ; 62(6): 938-41, 2005 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15956164

RESUMO

BACKGROUND: While it is known that posterior cerebral artery (PCA) infarction may simulate middle cerebral artery (MCA) infarction, the frequency and localization of this occurrence are unknown. OBJECTIVE: To determine the frequency of PCA infarction mimicking MCA infarction and the territory of the PCA most commonly involved in this simulation. DESIGN: We studied 202 patients with isolated infarction in the PCA admitted to our stroke center to determine the frequency of PCA infarction simulating MCA infarction, the involved PCA territory, and the patterns of clinical presentation. RESULTS: We found 36 patients (17.8%) with PCA ischemic stroke who had clinical features suggesting MCA stroke. The PCA territory most commonly involved was the superficial PCA territory (66.7%), followed by the proximal PCA territory (16.7%) and both the proximal and the superficial PCA territories (16.7%). The principal stroke mechanism was cardioembolic (54.1%) in the superficial PCA territory, lacunar (46.2%) in the proximal PCA territory, and undetermined (40.2%) in both the proximal and the superficial territories. Among the 36 patients, the most common clinical associations were aphasia (13 patients), visuospatial neglect (13 patients), and severe hemiparesis (7 patients). CONCLUSIONS: Posterior cerebral artery infarction simulating MCA infarction is more common than previously thought. Early recognition of the different stroke subtypes in these 2 arteries may allow specific management.


Assuntos
Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Posterior/complicações , Infarto da Artéria Cerebral Posterior/diagnóstico , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
13.
Future Cardiol ; 1(5): 579-90, 2005 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-19804096

RESUMO

Clopidogrel (Plavix) is a potent platelet inhibitor that has been demonstrated to be significantly more effective than aspirin for the prevention of atherothrombotic events in patients with established atherosclerotic disease in the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) study. Furthermore, the benefit of clopidogrel compared with placebo in patients with acute coronary syndromes, as well as those undergoing percutaneous coronary intervention receiving a standard therapy including aspirin, has been largely demonstrated by the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE), Clopidogrel for the Reduction of Events During Observation (CREDO), CLopidogrel as Adjunctive ReperfusIon TherapY-Thrombolysis In Myocardial Infarction (CLARITY-TIMI)28, and Clopidogrel and Metoprolol in Myocardial Infarction Trial/Secon Chinese Cardiac Study (COMMIT/CCS-2) trials. However, in the Management of Atherothrombosis with Clopidogrel in High-risk patients with recent transient ischemic attack or ischemic stroke (MATCH) trial, there was no clinical benefit of adding aspirin versus placebo to a standard therapy of clopidogrel in patients with cerebrovascular disease. The implications of these findings, as well as future perspectives from upcoming trials, shall be discussed herein.

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