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1.
Neurosciences (Riyadh) ; 26(2): 158-162, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33814368

RESUMO

OBJECTIVES: To assess and quantify the impact COVID-19 has had thus far on ischemic stroke admission rate and severity (National Institutes of Health Stroke Scale (NIHSS) score) at a single tertiary center in Makkah, Saudi Arabia. METHODS: This is a retrospective analysis performed on admitted cases with definitive final diagnoses of transient ischemic attack (TIA) and ischemic stroke at King Abdullah Medical City in Makkah between January 1, 2020 and July 2020. RESULTS: Sixty-nine patients were included in our study, 41 of whom presented at our facility before the pandemic and 29 during the pandemic. No statistical significance was observed between rate of admission, stroke severity, and rate of thrombolysis before the COVID-19 pandemic and after the outbreak. We observed a reduction of mean arrival time after the pandemic began, as well as a reduction of hospital stay days. CONCLUSION: A 29% reduction of admission secondary to acute ischemic stroke was noted during the pandemic. However, COVID-19 did not affect acute stroke care at our institute. The study is limited because of its small sample size, as we assessed just one medical center.


Assuntos
Ataque Isquêmico Transitório/epidemiologia , /epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Ataque Isquêmico Transitório/terapia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Arábia Saudita/epidemiologia , Índice de Gravidade de Doença , Distribuição por Sexo , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Centros de Atenção Terciária , Terapia Trombolítica/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Adulto Jovem
2.
Angiol Sosud Khir ; 27(1): 164-168, 2021.
Artigo em Russo | MEDLINE | ID: mdl-33825744

RESUMO

This article describes a rare clinical and diagnostic case report regarding a female patient presenting with frequent transitory attacks in the basin of both middle cerebral arteries. Based on the findings of duplex scanning of the cervical arteries we revealed floating structures with the presence of pronounced slow turbulent blood flow. After excluding all known causes of cerebral artery microembolism, associated with heart pathology or with the presence of unstable atherosclerotic plaques, the leading hypothesis of transitory ischaemic attacks in the woman concerned was the formation of microthrombi in the zone of motility of the structures revealed. The results of bitemporal transcranial Doppler monitoring carried out during 30 minutes detected more than 10 microembolic signals in the middle cerebral artery, thus confirming the embolic nature of transitory ischaemic attacks.


Assuntos
Estenose das Carótidas , Ataque Isquêmico Transitório , Artérias Carótidas , Artérias Cerebrais , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Ultrassonografia Doppler Transcraniana
3.
J Rehabil Med ; 53(3): jrm00167, 2021 Mar 22.
Artigo em Inglês | MEDLINE | ID: mdl-33656562

RESUMO

BACKGROUND: The long-term impact of transient ischaemic attack is largely unknown. OBJECTIVES: To assess the long-term perceived impact of transient ischaemic attack and explore the influence of sex and age on these perceptions; and to evaluate the relationships between activities of daily living, participation and overall recovery, and the other domains of the Stroke Impact Scale 3.0 (SIS). METHODS: A retrospective study among adult community-dwelling individuals from 6 months up to 10 years after onset of transient ischaemic attack. A total of 299 survivors of transient ischaemic attack responded to the SIS. RESULTS: Most self-reported disabilities involved emotion, strength, and participation domains of SIS and remained stable until 10 years post-transient ischaemic attack. Women reported significantly more disabilities for emotion and hand function. Elderly subjects (age > 65 years) reported more disabilities for strength, mobility, hand function, activities of daily living/instrumental activities of daily living, and participation. The activities of daily living/instrumental activities of daily living, participation, and overall recovery demonstrated significant, although low-to-moderate, associations with other SIS domains after transient ischaemic attack. CONCLUSION: The broadly perceived disabilities were demonstrated consistently and played a significant meaningful role in everyday life and recovery among community-dwelling individuals up to 10 years after a transient ischaemic attack. These findings indicate the need for long-term multi-professional follow-up with holistic rehabilitation to improve overall recovery among survivors of transient ischaemic attack.


Assuntos
Atividades Cotidianas/psicologia , Pessoas com Deficiência/estatística & dados numéricos , Ataque Isquêmico Transitório/complicações , Idoso , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Tempo
4.
Medicine (Baltimore) ; 100(9): e24698, 2021 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-33655934

RESUMO

RATIONALE: Capsular warning syndrome (CWS) is a term to describe stereotyped lacunar transient ischemic attacks (TIAs). Patients with CWS are at high risk of developing completed stroke. However, the exact pathophysiology of CWS is still unclear, and there is no conclusive clinical strategy for CWS patients. PATIENT SYMPTOMS: Two cases of middle-aged men with hypertension, hyperlipidemia, and diabetes mellitus presented with fluctuating right-sided weakness, numbness, and dysarthria. DIAGNOSES: These two patients were diagnosed with CWS. INTERVENTIONS: Recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis (0.9 mg/kg) was administered first and treated with aspirin (100 mg) and clopidogrel (75 mg) after 24 h of rt-PA for 21 days following by aspirin (100 mg) alone. OUTCOMES: Both cases got favorable clinical outcomes of somatic symptoms. In addition, diffusion-weighted imaging (DWI or DW-MRI) showed that ischemic injury disappeared in case 1 while maintained within a reasonable range in case 2. LESSONS: Early recognition and rt-PA/dual antiplatelet treatment may be an effective strategy for patients with CWS.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Fibrinolíticos/uso terapêutico , Ataque Isquêmico Transitório/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Imagem de Difusão por Ressonância Magnética , Terapia Antiplaquetária Dupla , Humanos , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Síndrome , Terapia Trombolítica , Resultado do Tratamento
6.
Medicine (Baltimore) ; 100(11): e25150, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33725999

RESUMO

BACKGROUND: The association between cytochrome P450 2C19 (CYP2C19) polymorphisms and neurological deterioration in stroke or transient ischemic attack (TIA) patients is not completely understood. Hence, we performed a systematic review and meta-analysis of prospective cohort studies to quantify this association. METHODS: PubMed, Cochrane Library, Excerpta Medica Database, China National Knowledge Infrastructure and WanFang databases were searched for studies published up to April 2019. Prospective cohort studies that reported an association between CYP2C19 polymorphisms and neurological deterioration in stroke/TIA patients were included. Data on risk ratio (RR) and 95% confidence intervals (CI) were extracted and pooled by the authors. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. RESULTS: Twelve eligible studies were included. Twelve studies reported CYP2C19∗2, ∗3 loss-of-function alleles and 5 studies reported CYP2C19∗17 gain-of-function allele. Compared to non-carriers, carriers of CYP2C19∗2, ∗3 loss-of-function alleles had a significantly higher risk of neurological deterioration (RR, 1.63; 95%CI, 1.32-2.02). Conversely, carriers of CYP2C19∗17 gain-of-function allele had a significantly lower risk of neurological deterioration (RR, 0.520; 95%CI, 0.393-0.689) compared to non-carriers. CONCLUSIONS: This meta-analysis demonstrated that the carriers of CYP2C19∗2, ∗3 loss-of-function alleles have an increased risk of neurological deterioration compared to non-carriers in stroke or TIA patients. Additionally, CYP2C19∗17 gain-of-function allele can reduce the risk of neurological deterioration.


Assuntos
Citocromo P-450 CYP2C19/genética , Ataque Isquêmico Transitório/patologia , Degeneração Neural/genética , Polimorfismo Genético/genética , Acidente Vascular Cerebral/patologia , Idoso , Feminino , Humanos , Ataque Isquêmico Transitório/genética , Mutação com Perda de Função/genética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Acidente Vascular Cerebral/genética
7.
J Stroke Cerebrovasc Dis ; 30(5): 105677, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33677312

RESUMO

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.


Assuntos
Aspirina/efeitos adversos , Clopidogrel/efeitos adversos , Avaliação da Deficiência , Terapia Antiplaquetária Dupla/efeitos adversos , Hemorragias Intracranianas/induzido quimicamente , Ataque Isquêmico Transitório/tratamento farmacológico , Admissão do Paciente , Inibidores da Agregação de Plaquetas/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Tempo para o Tratamento , Idoso , Aspirina/administração & dosagem , Brasil/epidemiologia , Clopidogrel/administração & dosagem , Bases de Dados Factuais , Esquema de Medicação , Terapia Antiplaquetária Dupla/mortalidade , Feminino , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/mortalidade , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/mortalidade , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
8.
Lancet Neurol ; 20(4): 294-303, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33743239

RESUMO

BACKGROUND: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING: British Heart Foundation and Stroke Association.


Assuntos
Fibrinolíticos/uso terapêutico , Hemorragias Intracranianas/etiologia , /tratamento farmacológico , Adulto , Idoso , Feminino , Humanos , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/tratamento farmacológico , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Recidiva , Risco
9.
Khirurgiia (Mosk) ; (3): 50-56, 2021.
Artigo em Russo | MEDLINE | ID: mdl-33710826

RESUMO

OBJECTIVE: To determine the most optimal period of surgical treatment after previous stroke. MATERIAL AND METHODS: There were 186 patients with significant ICA stenosis and previous unilateral stroke for the period 2008-2014 at the Pletnev Hospital (Moscow). Surgical approach was used in 136 (73.1%) patients (group I), conservative treatment at the neurological department - in 50 (26.9%) patients (group II). We analyzed neurological and cognitive status in both groups, regression of symptoms depending on the period after stroke, early and long-term postoperative outcomes. RESULTS: In early postoperative period, 7 (5.1%) cerebral ischemic events (transient ischemic attack (TIA) and stroke) occurred in the 1st group. No correlation of neurological complications and type of intervention was revealed. In long-term period, stroke occurred in 3.6% in the first group and in 14% in the second group over the same period. Surgical treatment was followed by more complete recovery of neurological functions (NIHSS score 6.2±0.5 versus 7.0±0.8; modified Rankin score 1.5±0.2 versus 2.1±0.5, p<0.05) and cognitive mechanisms (MoCA score 22.04±1.48 versus 20.04±1.48, p<0.05). CONCLUSION: Carotid endarterectomy and carotid artery stenting are effective for prevention of recurrent stroke. Carotid artery repair accelerates recovery of cognitive functions and regression of neurological symptoms in these patients.


Assuntos
Implante de Prótese Vascular , Estenose das Carótidas , Endarterectomia das Carótidas , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/cirurgia , Tratamento Conservador , Endarterectomia das Carótidas/efeitos adversos , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Fatores de Risco , Stents , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
10.
Int Heart J ; 62(2): 312-319, 2021 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-33678799

RESUMO

This study aims to evaluate the incidence of ischemic stroke or transient ischemic attack (TIA) based on CHA2DS2-VASc scores in non-AF Chinese patients with sinus rhythm.We used health check-up data of 101,510 participants from the Kailuan Cohort Study. Participants' risk levels were defined by their CHA2DS2-VASc scores (range 0-3): Men with scores of 0, 1, or ≥ 2 and women with scores of 1, 2, or ≥ 3 were considered at low, intermediate, or high risk, respectively. Cox proportional hazards model was used to assess the association between the CHA2DS2-VASc-determined risk and the incidence of ischemic stroke/TIA.The mean 7.5 year follow-up examination revealed 2968 ischemic strokes/TIA events. The incidence rates for ischemic stroke/TIA events in men and women were 3.8% and 1.5%, respectively. The incidence of ischemic stroke/TIA increased with elevated predicted risks based on CHA2DS2-VASc scores in men: 2.2% for low-risk, 4.1% for intermediate-risk, and 7.8% for high-risk groups (P < 0.001 for trend). The incidences of ischemic stroke/TIA also increased with elevated predicted risks in women: 0.8% for low-risk, 2.1% for intermediate-risk, and 5.0% for high-risk groups (P < 0.001 for trend). Compared with low-risk group, the crude hazard ratio (95% confidence interval) of ischemic stroke/TIA for men in moderate- and high-risk groups were 1.96 (1.79-2.14; P < 0.001) and 4.18 (3.81-4.57; P < 0.001). Similar findings were observed in women.Risks of ischemic stroke/TIA events was high, particularly among those with high CHA2DS2-VASc scores.


Assuntos
Fibrilação Atrial/complicações , Isquemia Encefálica/epidemiologia , Frequência Cardíaca/fisiologia , Ataque Isquêmico Transitório/epidemiologia , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , China/epidemiologia , Feminino , Humanos , Incidência , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
11.
JAMA ; 325(11): 1088-1098, 2021 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-33724327

RESUMO

Importance: Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually. Observations: Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]). Conclusions and Relevance: Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.


Assuntos
Ataque Isquêmico Transitório/terapia , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombectomia , Terapia Trombolítica , Anticoagulantes/uso terapêutico , Terapia Combinada , Quimioterapia Combinada , Humanos , Ataque Isquêmico Transitório/diagnóstico , Trombectomia/métodos , Terapia Trombolítica/métodos
12.
Vnitr Lek ; 67(1): 7-14, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33752385

RESUMO

Stroke is frequent disease especially in older age. It is complex multidisciplinary issue and the internist plays very important role in the care of the stroke patients. Recurrent stroke is often disabling. Therefor the early and proper implementation of the effective secondary prevention is essential. This review presents basic information about the aetiology, diagnostic assessment and the secondary prevention of the ischemic stroke.


Assuntos
Isquemia Encefálica , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Idoso , Isquemia Encefálica/etiologia , Humanos , Fatores de Risco , Prevenção Secundária , Acidente Vascular Cerebral/etiologia
13.
J Stroke Cerebrovasc Dis ; 30(4): 105613, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33529924

RESUMO

INTRODUCTION: Experimental models have clearly demonstrated sex differences in the pathophysiology of stroke and prognosis, however clinical evidence remains elusive. In this study, we examined sex differences as a post hoc analysis of RELAXED (Recurrent Embolism Lessened by rivaroxaban, an anti-X agent, of Early Dosing for acute IS and TIA with atrial fibrillation) Study. METHODS: We stratified study participants by sex and compared baseline and clinical characteristics as well as clinical outcomes. The primary outcome measure was a good outcome defined as a modified Rankin Scale score of 0-2 at 90 days after stroke. Secondary outcomes were mortality at 90 days, intracranial hemorrhage within 90 days, and recurrence of stroke or transient ischemic attack within 90 days. We constructed a logistic regression model to estimate the adjusted odds ratio of female patients compared with male patients for the primary and secondary outcomes. RESULTS: Of 1303 patients, most were male (57.7%) with a mean age of 74.5 years. Female patients were older with a mean age of 80.6 ± 8.9 years and had significantly less frequent anticoagulation therapy before onset of stroke and more severe NIHSS scores. Good outcome was observed in 51.2% and 63.3% of the females and males (p < 0.0001). The adjusted odds ratio of a good outcome in females was 1.12 (95% confidence interval, 0.44-2.87) (p = 0.81). There were no sex differences in secondary outcomes. CONCLUSION: Adjusted regression analysis found no sex difference in the treatment outcomes at 90 days after stroke with non-valvular atrial fibrillation.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Ataque Isquêmico Transitório/prevenção & controle , Rivaroxabana/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Avaliação da Deficiência , /etiologia , Feminino , Humanos , Hemorragias Intracranianas/induzido quimicamente , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/mortalidade , Japão , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
14.
JAMA Netw Open ; 4(2): e2036227, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33587132

RESUMO

Importance: Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. Objective: To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). Design, Setting, and Participants: This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. Interventions: Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. Main Outcomes and Measures: The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. Results: Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. Conclusions and Relevance: This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT01763203.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , Hipertensão/tratamento farmacológico , Ataque Isquêmico Transitório/terapia , Adesão à Medicação , Autogestão , Afro-Americanos , Idoso , Americanos Asiáticos , Proteína C-Reativa/metabolismo , Agentes Comunitários de Saúde , Grupo com Ancestrais do Continente Europeu , Exercício Físico , Feminino , Hispano-Americanos , Humanos , Hipertensão/metabolismo , Ataque Isquêmico Transitório/metabolismo , Masculino , Pessoa de Meia-Idade , Profissionais de Enfermagem , Equipe de Assistência ao Paciente , Assistentes Médicos , Médicos , Comportamento de Redução do Risco , Provedores de Redes de Segurança , Prevenção Secundária , Autorrelato , Cloreto de Sódio na Dieta , Acidente Vascular Cerebral/metabolismo , Acidente Vascular Cerebral/terapia
16.
Herz ; 46(2): 195-204, 2021 Mar.
Artigo em Alemão | MEDLINE | ID: mdl-33598821

RESUMO

In cases of stroke a distinction is made between a transient ischemic attack (TIA), a manifest ischemic infarction and cerebral hemorrhage. Cerebral ischemia can be caused by large vessel disease, small vessel disease, embolic causes, rare causes or stroke of unknown etiology. Acute diagnostic tests include a neurological examination, computed tomography (CT) and/or magnetic resonance imaging (MRI) with angiography, electrocardiography (ECG), and laboratory tests. The basic treatment of patients with TIA or acute ischemic infarction is performed in the stroke unit and includes monitoring of respiratory function, cardiac function, treatment of potential heart failure, detection of swallowing disorders, prophylaxis of thromboembolism, control of blood pressure and elevated blood sugar levels, and lowering of elevated body temperature. In patients with cardioembolic infarction, oral anticoagulation is initiated depending on the severity of the stroke and the size of the stroke on imaging.


Assuntos
Isquemia Encefálica , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Hemorragia Cerebral , Humanos , Imagem por Ressonância Magnética , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia
17.
Lancet Neurol ; 20(3): 193-202, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33609477

RESUMO

BACKGROUND: There is uncertainty around which patients with asymptomatic carotid stenosis should be offered surgical intervention. Although stroke rates were unrelated to the degree of stenosis in the medical-treatment-only groups in previous randomised trials, this could simply reflect recruitment bias and there has been no systematic analysis of a stenosis-risk association in cohort studies. We aimed to establish whether there is any association between the degree of asymptomatic stenosis and ipsilateral stroke risk in patients on contemporary medical treatment. METHODS: We did a prospective population-based study (Oxford Vascular Study; OxVasc), and a systematic review and meta-analysis. All patients in OxVasc with a recent suspected transient ischaemic attack or stroke, between April 1, 2002, and April 1, 2017, who had asymptomatic carotid stenosis were included in these analyses. We commenced contemporary medical treatment and determined ipsilateral stroke risk in this cohort by face-to-face follow-up (to Oct 1, 2020). We also did a systematic review and meta-analysis of all published studies (from Jan 1, 1980, to Oct 1, 2020) reporting ipsilateral stroke risk in patients with asymptomatic carotid stenosis. We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials, and included both observational cohort studies and medical treatment groups of randomised controlled trials if the number of patients exceeded 30, ipsilateral stroke rates (or the raw data to calculate these) were provided, and were published in English. FINDINGS: Between April 1, 2002, and April 1, 2017, 2354 patients were consecutively enrolled in OxVasc and 2178 patients underwent carotid imaging, of whom 207 had 50-99% asymptomatic stenosis of at least one carotid bifurcation (mean age at imaging: 77·5 years [SD 10·3]; 88 [43%] women). The 5-year ipsilateral stroke risk increased with the degree of stenosis; patients with 70-99% stenosis had a significantly greater 5-year ipsilateral stroke risk than did those with 50-69% stenosis (six [14·6%; 95% CI 3·5-25·7] of 53 patients vs none of 154; p<0·0001); and patients with 80-99% stenosis had a significantly greater 5-year ipsilateral stroke risk than did those with 50-79% stenosis (five [18·3%; 7·7-29·9] of 34 patients vs one [1·0%; 0·0-2·9] of 173; p<0·0001). Of the 56 studies identified in the systematic review (comprising 13 717 patients), 23 provided data on ipsilateral stroke risk fully stratified by degree of asymptomatic stenosis (in 8419 patients). Stroke risk was linearly associated with degree of ipsilateral stenosis (p<0·0001); there was a higher risk in patients with 70-99% stenosis than in those with 50-69% stenosis (386 of 3778 patients vs 181 of 3806 patients; odds ratio [OR] 2·1 [95% CI 1·7-2·5], p<0·0001; 15 cohort studies, three trials) and a higher risk in patients with 80-99% stenosis than in those with 50-79% stenosis (77 of 727 patients vs 167 of 3272 patients; OR 2·5 [1·8-3·5], p<0·0001; 11 cohort studies). Heterogeneity in stroke risk between studies for patients with severe versus moderate stenosis (phet<0·0001) was accounted for by highly discrepant results (pdiff<0·0001) in the randomised controlled trials of endarterectomy compared with cohort studies (trials: pooled OR 0·8 [95% CI 0·6-1·2], phet=0·89; cohorts: 2·9 [2·3-3·7], phet=0·54). INTERPRETATION: Contrary to the assumptions of current guidelines and the findings of subgroup analyses of previous randomised controlled trials, the stroke risk reported in cohort studies was highly dependent on the degree of asymptomatic carotid stenosis, suggesting that the benefit of endarterectomy might be underestimated in patients with severe stenosis. Conversely, the 5-year stroke risk was low for patients with moderate stenosis on contemporary medical treatment, calling into question any benefit from revascularisation. FUNDING: NIHR Oxford Biomedical Research Centre, Wellcome Trust, Wolfson Foundation, and the British Heart Foundation.


Assuntos
Estenose das Carótidas/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Estudos de Coortes , Endarterectomia das Carótidas , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Fumar/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
18.
Lakartidningen ; 1182021 02 05.
Artigo em Sueco | MEDLINE | ID: mdl-33567096

RESUMO

Spinal cord infarction (SCI) causes acute spinal cord dysfunction with high morbidity. Without an inciting event such as a surgical procedure, a definitive diagnosis may be challenging. Thus, patients with a spontaneous (i e, non-traumatic, non-surgical) SCI are often misdiagnosed and the radiological distinction between SCI and other conditions with similar symptoms is more difficult than in cerebral infarction. Compared to cerebral infarction, SCI is rare and only accounts for approximately 1.2% of all strokes. SCI is usually localized to the anterior spinal artery area, causing the anterior spinal artery syndrome. Misdiagnosis may lead to unnecessary and possibly deleterious treatments as well as missed secondary stroke prevention. In this review, a typical case, an overview of the disease and newly proposed diagnostic criteria are presented.


Assuntos
Ataque Isquêmico Transitório , Doenças da Medula Espinal , Isquemia do Cordão Espinal , Humanos , Infarto/diagnóstico por imagem , Doenças da Medula Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia
19.
Expert Rev Cardiovasc Ther ; 19(3): 211-220, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33605829

RESUMO

Introduction: A patent foramen ovale (PFO) is highly prevalent among the adult population. It allows shunting of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, platypnea-orthodeoxia syndrome, decompression sickness (e.g. deep-water divers), and migraines.Areas Covered: In this manuscript, we will review the anatomy of PFO with particular emphasis on the factors associated with increased risk of paradoxical embolization, as well as the different modalities for the diagnosis of PFO. We will discuss medical, surgical, and transcatheter therapy for secondary prevention in patients with PFO and cryptogenic stroke, and summarize the data from observational studies, randomized controlled trials (RCTs), and meta-analysis of RCTs that have established the beneficial effect of transcatheter PFO closure in this patient population. Finally, we will provide a brief overview of the role of transcatheter PFO closure in patients with migraine.Expert Opinion: Transcatheter closure is the preferred treatment option in young (<60 years) patients with PFO and cryptogenic stroke. A multi-disciplinary approach with input from clinical cardiologist, neurologist, hematologist, cardiac surgeon, and interventional cardiologist provides the best therapeutic plan for each patient taking into account the available data, but also medical, social, and occupational considerations.


Assuntos
Cateterismo Cardíaco/métodos , Forame Oval Patente/terapia , /prevenção & controle , Septo Interatrial/patologia , Humanos , Ataque Isquêmico Transitório/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária , Dispositivo para Oclusão Septal , Resultado do Tratamento
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