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1.
Emerg Med Clin North Am ; 39(1): 227-242, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33218660

RESUMO

The treatment of acute ischemic stroke is one of the most rapidly evolving areas in medicine. Like all ischemic vascular emergencies, the priority is reperfusion before irreversible infarction. The central nervous system is sensitive to brief periods of hypoperfusion, making stroke a golden hour diagnosis. Although the phrase "time is brain" is relevant today, emerging treatment strategies use more specific markers for consideration of reperfusion than time alone. Innovations in early stroke detection and individualized patient selection for reperfusion therapies have equipped the emergency medicine clinician with more opportunities to help stroke patients and minimize the impact of this disease.


Assuntos
Isquemia Encefálica/terapia , Ataque Isquêmico Transitório/terapia , Acidente Vascular Cerebral/terapia , Doença Aguda , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/cirurgia , Serviço Hospitalar de Emergência , Procedimentos Endovasculares , Humanos , Ataque Isquêmico Transitório/tratamento farmacológico , Fármacos Neuroprotetores/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/cirurgia , Terapia Trombolítica/métodos
4.
J Stroke Cerebrovasc Dis ; 29(11): 105228, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066882

RESUMO

BACKGROUND: This report aims to describe changes that centres providing transient ischaemic attack (TIA) pathway services have made to stay operational in response to the SARS-CoV-2 pandemic. METHODS: An international cross-sectional description of the adaptions of TIA pathways between 30th March and 6th May 2020. Experience was reported from 18 centres with rapid TIA pathways in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents. RESULTS: All pathways remained active (n = 18). Sixteen (89%) had TIA clinics. Six of these clinics (38%) continued to provide in-person assessment while the majority (63%) used telehealth exclusively. Of these, three reported PPE use and three did not. Five centres with clinics (31%) had adopted a different vascular imaging strategy. CONCLUSION: The COVID pandemic has led TIA clinics around the world to adapt and move to the use of telemedicine for outpatient clinic review and modified investigation pathways. Despite the pandemic, all have remained operational.


Assuntos
Infecções por Coronavirus/terapia , Procedimentos Clínicos/tendências , Prestação Integrada de Cuidados de Saúde/tendências , Equipe de Respostas Rápidas de Hospitais/tendências , Ataque Isquêmico Transitório/terapia , Pneumonia Viral/terapia , Padrões de Prática Médica/tendências , Telemedicina/tendências , Austrália , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/virologia , Estudos Transversais , Diagnóstico por Imagem/tendências , Europa (Continente) , Humanos , Ataque Isquêmico Transitório/diagnóstico , Nova Zelândia , América do Norte , Pandemias , Equipamento de Proteção Individual/tendências , Pneumonia Viral/diagnóstico , Pneumonia Viral/virologia , Fatores de Tempo
5.
Cerebrovasc Dis ; 49(5): 474-480, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32980849

RESUMO

INTRODUCTION: There are a limited number of studies investigating the relationship between the degree of liver fibrosis and the long-term prognosis, especially ischemic stroke (IS) recurrence, in first-ever IS or transient ischemic attack (TIA). OBJECTIVE: We investigated whether there are differences in the long-term all-cause and cardiovascular mortalities and IS recurrence based on the degree of liver fibrosis in first-ever IS or TIA. METHODS: This analysis included 2,504 patients with first-ever IS or TIA recruited from a prospective stroke cohort. Liver fibrosis was predicted using the fibrosis-4 (FIB-4) index, and advanced fibrosis was defined as an FIB-4 index of >3.25. Using Cox regression models, we compared the all-cause and cardiovascular mortalities and IS recurrence. As measures for the additive predictive value of the FIB-4 index for prediction of all-cause mortality, the integrated area under the receiver operating characteristic curve (iAUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used. RESULTS: There were 231 (9.2%) patients with advanced fibrosis. During a median follow-up of 1.2 years, the cumulative all-cause and cardiovascular mortalities were 6.4 and 1.9%, and IS recurrence was observed in 5.3%. The advanced fibrosis was associated with an increased risk of all-cause mortality (hazard ratio [HR] = 3.98, 95% confidence interval [CI] = 2.40-6.59), cardiovascular mortality (HR = 4.48, 95% CI = 1.59-12.65), and IS recurrence (HR = 1.95, 95% CI = 1.05-3.65). Adding the FIB-4 index to the model consisting of traditional cardiovascular risk factors improved the predictive accuracy for all-cause mortality as measured using the iAUC (from 0.7594 to 0.7729) and for all-cause mortality at 1 year as measured using the NRI (38.6%) and IDI (0.037). CONCLUSIONS: The burden of liver fibrosis is associated with unfavorable long-term prognosis, including recurrent IS, in first-ever IS or TIA.


Assuntos
Ataque Isquêmico Transitório/complicações , Cirrose Hepática/complicações , Acidente Vascular Cerebral/complicações , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/mortalidade , Ataque Isquêmico Transitório/terapia , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Resultado do Tratamento
6.
J Stroke Cerebrovasc Dis ; 29(10): 105051, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912558

RESUMO

RATIONALE: Intracranial atherosclerotic disease (ICAD) is the most common cause of ischemic stroke with the highest rate of recurrence, despite aggressive medical management. Diverse mechanisms may be responsible for ICAD-related cerebral ischemia, with potential therapeutic implications. Here we present the rationale, design and methods of the Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) study. The aim of MyRIAD is to determine the mechanisms of stroke in ICAD through physiologic imaging biomarkers that evaluate impaired antegrade flow, poor distal perfusion, abnormal vasoreactivity, artery to artery embolism, and their interaction. METHODS AND DESIGN: This is a prospective observational study of patients with recently symptomatic (<21 days) ICAD with 50-99% stenosis treated medically and monitored for up to 1 year. An estimated 110 participants are recruited at 10 sites to identify the association between the presence of each mechanism of ischemia and recurrent stroke. The primary outcome is ischemic stroke in the territory of the symptomatic artery. Secondary outcomes include new cerebral infarction on MRI at 6-8 weeks and recurrent TIA in the territory of the symptomatic artery. DISCUSSION: MyRIAD is positioned to define the role of specific mechanisms of recurrent ischemia in patients with symptomatic ICAD. This knowledge will allow the development and implementation of effective and specific treatments for this condition.


Assuntos
Infarto Encefálico/etiologia , Circulação Cerebrovascular , Arteriosclerose Intracraniana/diagnóstico por imagem , Ataque Isquêmico Transitório/etiologia , Angiografia por Ressonância Magnética , Projetos de Pesquisa , Ultrassonografia Doppler Transcraniana , Adulto , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/fisiopatologia , Infarto Encefálico/terapia , Feminino , Humanos , Arteriosclerose Intracraniana/complicações , Arteriosclerose Intracraniana/fisiopatologia , Arteriosclerose Intracraniana/terapia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/fisiopatologia , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Recidiva , Fatores de Risco , Fatores de Tempo
7.
BMC Geriatr ; 20(1): 353, 2020 09 17.
Artigo em Inglês | MEDLINE | ID: mdl-32943015

RESUMO

BACKGROUND: Cognitive impairment and dementia following cerebrovascular disease are increasingly common in the UK. One potential strategy to prevent post-stroke cognitive decline is multimodal vascular risk factor management. However, its efficacy remains uncertain and its application in vulnerable patients with incident cerebrovascular disease and early cognitive impairment has not been assessed. The primary aim of this study was to assess the feasibility of recruitment and retention of patients with early cognitive impairment post-stroke or transient ischaemic attack (TIA) to a trial of enhanced vascular risk factor management combining primary and secondary care. METHODS: In this single centre, open label trial adults with a recent stroke or TIA and mild cognitive impairment (MCI) were randomised 1:1 to a three-monthly multimodal vascular risk factor intervention jointly delivered by the trial team and General Practitioner (GP), or control (defined as usual care from the GP). Chosen risk factors were blood pressure (BP), total cholesterol, blood glucose (HbA1C) in those with diabetes, and heart rate and adequacy of anticoagulation in those with atrial fibrillation (AF). Similar patients with normal cognition were enrolled in an embedded observational cohort and also received usual care from the GP. Repeat cognitive screening was undertaken in all participants after 12 months. RESULTS: Seventy three participants were recruited to the randomised trial and 94 to the observational cohort (21.8% of those screened). From the randomised trial 35/73 (47.9%) dropped out before final follow-up. In all groups guideline based rates of risk factor control were mostly poor at baseline and did not significantly improve during follow-up. The observational cohort demonstrated greater decline in cognitive test scores at 12 months, with no difference between the randomised groups. CONCLUSIONS: Recruitment to such a study was feasible, but retention of participants was difficult and generally poor rates of risk factor control suggested insufficient application of the intervention. Consequently, successful scaling up of the trial would require protocol changes with less reliance on primary care services. Any future trial should include participants with normal cognition post-stroke as they may be at greatest risk of cognitive decline. TRIAL REGISTRATION: ISRCTN, ISRCTN42688361 . Registered 16 April 2015.


Assuntos
Disfunção Cognitiva/prevenção & controle , Medicina Geral , Ataque Isquêmico Transitório/complicações , Acidente Vascular Cerebral/complicações , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Estudos de Viabilidade , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/terapia , Masculino , Fatores de Risco
8.
J Stroke Cerebrovasc Dis ; 29(11): 105229, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32828638

RESUMO

BACKGROUND AND AIMS: Concerns have arisen regarding patient access and delivery of acute stroke care during the COVID-19 pandemic. We investigated key population level events on activity of the three hyperacute stroke units (HASUs) within Greater Manchester and East Cheshire (GM & EC), whilst adjusting for environmental factors. METHODS: Weekly stroke admission & discharge counts in the three HASUs were collected locally from Emergency Department (ED) data and Sentinel Stroke National Audit Programme core dataset prior to, and during the emergence of the COVID-19 pandemic (Jan 2020 to May 2020). Whilst adjusting for local traffic-related air pollution and ambient measurement, an interrupted time-series analysis using a segmented generalised linear model investigated key population level events on the rate of stroke team ED assessments, admissions for stroke, referrals for transient ischaemic attack (TIA), and stroke discharges. RESULTS: The median total number of ED stroke assessments, admissions, TIA referrals, and discharges across the three HASU sites prior to the first UK COVID-19 death were 150, 114, 69, and 76 per week. The stable weekly trend in ED assessments and stroke admissions decreased by approximately 16% (and 21% for TIAs) between first UK hospital COVID-19 death (5th March) and the implementation of the Act-FAST campaign (6th April) where a modest 4% and 5% increase per week was observed. TIA referrals increased post Government intervention (23rd March), without fully returning to the numbers observed in January and February. Trends in discharges from stroke units appeared unaffected within the study period reported here. CONCLUSION: Despite adjustment for environmental factors stroke activity was temporarily modified by the COVID-19 pandemic. Underlying motivations within the population are still not clear. This raises concerns that patients may have avoided urgent health care risking poorer short and long-term health outcomes.


Assuntos
Infecções por Coronavirus/terapia , Prestação Integrada de Cuidados de Saúde/tendências , Meio Ambiente , Ataque Isquêmico Transitório/terapia , Aceitação pelo Paciente de Cuidados de Saúde , Pneumonia Viral/terapia , Acidente Vascular Cerebral/terapia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Inglaterra/epidemiologia , Humanos , Análise de Séries Temporais Interrompida , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Pandemias , Admissão do Paciente/tendências , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Encaminhamento e Consulta/tendências , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo
9.
Stroke ; 51(9): 2705-2714, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32811373

RESUMO

BACKGROUND AND PURPOSE: Early neurological deterioration (END) after stroke onset may predict severe outcomes. Estimated rates of END after intravenous thrombolysis among small patient samples have been reported up to 29.8%. We studied the incidence and factors associated with END among patients following intravenous thrombolysis. METHODS: We analyzed SITS-International Stroke Thrombolysis registry patients with known outcomes enrolled in 2010 to 2017. END was defined as an increase in National Institutes of Health Stroke Scale score ≥4 or death within 24 hours from baseline National Institutes of Health Stroke Scale. We determined the incidence of END and used logistic regression models to inspect its associated factors. We adjusted for variables found significant in univariate analyses (P<0.05). Main outcomes were incidence of END, associated predictors of END, ordinal day-90 mRS, and day-90 mortality. RESULTS: We excluded 53 539 patients and included 50 726 patients. The incidence of END was 3415/50 726 (6.7% [95% CI, 6.5%-7.0%]). Factors independently associated with END on multivariate analysis were intracerebral hemorrhage (OR, 3.23 [95% CI, 2.96-3.54], P<0.001), large vessel disease (LVD) with carotid stenosis (OR, 2.97 [95% CI, 2.45-3.61], P<0.001), other LVD (OR, 2.41 [95% CI, 2.03-2.88], P<0.001), and ischemic stroke versus transient ischemic attack (TIA)/stroke mimics (OR, 16.14 [95% CI, 3.99-65.3], P<0.001). END was associated with worse outcome on ordinal mRS: adjusted OR 2.48 (95% CI, 2.39-2.57, P<0.001) by day-90 compared with no END. The adjusted OR for day-90 mortality was 9.70 (95% CI, 8.36-11.26, P<0.001). CONCLUSIONS: The routinely observed rate of END reflected by real-world data is low, but END greatly increases risk of disability and mortality. Readily identifiable factors predict END and may help with understanding causal mechanisms to assist prevention of END.


Assuntos
Doenças do Sistema Nervoso/etiologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/complicações , Isquemia Encefálica/terapia , Avaliação da Deficiência , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Incidência , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/mortalidade , Valor Preditivo dos Testes , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
10.
J Stroke Cerebrovasc Dis ; 29(8): 104871, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689591

RESUMO

BACKGROUND: Prior studies demonstrated that young adults with stroke present later to medical attention, have lower initial NIHSS, and are frequently misdiagnosed as compared to older adults. We sought to assess potential differences in temporal and clinical characteristics of stroke symptoms between young (age 18-50 years) and older adults (age > 50). METHODS: This retrospective cohort study included patients age ≥ 18 years hospitalized at a comprehensive stroke center with acute ischemic stroke (AIS), transient ischemic attack (TIA), or intracerebral hemorrhage (ICH). Outcomes included progression of neurologic deficits over the first 24 h, fluctuation in neurologic deficits, and characterization of the triage chief complaint as typical or atypical (less specific) for stroke. Univariate analyses for baseline covariates were performed with Chi-square and Mann-Whitney U tests. Associations with the three outcomes were assessed with multivariable logistic regression. RESULTS: 432 adults (73 young adults, 359 older adults) were included in the analysis. Overall, 28% demonstrated progression of neurologic deficits, 14% had fluctuating deficits, and 26% presented with symptoms considered atypical for stroke. After adjustment for demographics, stroke subtype, diabetes, admission blood pressure, and acute revascularization treatments, increased age was inversely associated with progression of deficits (OR 0.97 per year of age, 95% CI 0.95-0.98) and fluctuation in deficits (OR 0.98 per year of age, 95% CI 0.96-0.99). Hemorrhagic stroke subtype was inversely associated with fluctuation in neurologic deficits (OR 0.050, CI 0.0028-0.24). CONCLUSION: Young adults are more likely to have progression or fluctuation of neurologic deficits in acute stroke. Patients with ischemic stroke are more likely to have fluctuation in neurologic deficits.


Assuntos
Hemorragia Cerebral/diagnóstico , Avaliação de Sintomas , Adolescente , Adulto , Fatores Etários , Hemorragia Cerebral/complicações , Hemorragia Cerebral/terapia , Progressão da Doença , Feminino , Humanos , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Adulto Jovem
11.
J Stroke Cerebrovasc Dis ; 29(8): 104915, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689625

RESUMO

INTRODUCTION: Transient ischemic attack (TIA) is a temporary event of neurological dysfunction. Patients with TIA may be discharged from the Emergency Department or following an observational admission since their symptoms have resolved. Some portion of these patients, however, return to the hospital due to various reasons. The aim of our study is to find the trend of TIA readmissions in the United States. MATERIALS AND METHODS: Using the Healthcare Cost and Utilization Project (HCUP) database, we analyzed TIA discharges and TIA readmissions between 2009-2014 using the statistical z-test. RESULTS AND STATISTICAL ANALYSIS: We recorded a total of 985,851 hospitalizations of patients discharged with TIA with a significant decrease from 2009 to 2014 (p<0.001). Patients had a mean age of 70.4 years and were mainly women (58.43%, P<0.01). HCUP reported 34,503 discharges due to TIA readmissions within 7 days (3.73%) and 91,261 discharges due to readmissions within 30 days (9.83%); both values showed a significant decrease during the study period. Summation of the TIA readmissions found that acute cerebrovascular disease was the leading cause of readmission, followed by another TIA in both seven and thirty days. CONCLUSION: Between 2009-2014 the rate of TIA and TIA readmissions has significantly decreased in the United States, especially in the female gender. Acute cerebrovascular disease and another TIA have been the leading cause of hospital readmissions. With a better understanding of the risk factors associated with hospital readmissions, it is possible to reduce the impending burden of these patients on the healthcare system.


Assuntos
Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/terapia , Readmissão do Paciente/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Lactente , Ataque Isquêmico Transitório/diagnóstico , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
13.
Stroke ; 51(8): 2315-2321, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32530738

RESUMO

BACKGROUND AND PURPOSE: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, doctors and public authorities have demonstrated concern about the reduction in quality of care for other health conditions due to social restrictions and lack of resources. Using a population-based stroke registry, we investigated the impact of the onset of the COVID-19 pandemic in stroke admissions in Joinville, Brazil. METHODS: Patients admitted after the onset of COVID-19 restrictions in the city (defined as March 17, 2020) were compared with those admitted in 2019. We analyzed differences between stroke incidence, types, severity, reperfusion therapies, and time from stroke onset to admission. Statistical tests were also performed to compare the 30 days before and after COVID-19 to the same period in 2019. RESULTS: We observed a decrease in total stroke admissions from an average of 12.9/100 000 per month in 2019 to 8.3 after COVID-19 (P=0.0029). When compared with the same period in 2019, there was a 36.4% reduction in stroke admissions. There was no difference in admissions for severe stroke (National Institutes of Health Stroke Scale score >8), intraparenchymal hemorrhage, and subarachnoid hemorrhage. CONCLUSIONS: The onset of COVID-19 was correlated with a reduction in admissions for transient, mild, and moderate strokes. Given the need to prevent the worsening of symptoms and the occurrence of medical complications in these groups, a reorganization of the stroke-care networks is necessary to reduce collateral damage caused by COVID-19.


Assuntos
Infecções por Coronavirus/epidemiologia , Ataque Isquêmico Transitório/epidemiologia , Pandemias , Admissão do Paciente/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Feminino , Humanos , Incidência , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/terapia , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde , Reperfusão , Acidente Vascular Cerebral/terapia , Hemorragia Subaracnóidea/epidemiologia , Hemorragia Subaracnóidea/terapia
14.
Neurologia ; 35(6): 363-371, 2020.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32563566

RESUMO

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.


Assuntos
Betacoronavirus , Infecções por Coronavirus , Procedimentos Clínicos/organização & administração , Assistência à Saúde/organização & administração , Pandemias , Pneumonia Viral , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/terapia , Doença Aguda , Assistência Ambulatorial/organização & administração , Agendamento de Consultas , Conversão de Leitos , Infecções por Coronavirus/diagnóstico , Assistência à Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Pesquisas sobre Serviços de Saúde , Acesso aos Serviços de Saúde/estatística & dados numéricos , Número de Leitos em Hospital , Departamentos Hospitalares/organização & administração , Hospitais Urbanos/organização & administração , Hospitais Urbanos/estatística & dados numéricos , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/terapia , Trombólise Mecânica/estatística & dados numéricos , Neurologia/organização & administração , Admissão do Paciente/estatística & dados numéricos , Pneumonia Viral/diagnóstico , Espanha/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Reabilitação do Acidente Vascular Cerebral/estatística & dados numéricos , Telemedicina , Terapia Trombolítica/estatística & dados numéricos
16.
Stroke ; 51(6): 1820-1824, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32397929

RESUMO

Background and Purpose- Multiple studies have shown the 90-day risk of stroke following an emergency department (ED) diagnosis of transient ischemic attack (TIA) or minor stroke is significant, with the greatest risk of recurrence being within the first 24 to 48 hours following initial symptom onset. This study explored regional differences in ED disposition, neuroimaging, and subsequent 90-day stroke risk of patients diagnosed with TIA or minor stroke in Alberta. Methods- We used administrative databases to identify ED visits, neuroimaging, and 90-day return visits for TIA or minor stroke in Alberta from April 2011 to March 2016 among adults ≥20 years of age and stratified them based on regions of presentation (Edmonton, Calgary, or nonmajor urban). Results- During the 5-year study period, 22 421 patients had index ED visits for TIA or minor stroke. All 3 regions had a similar number of ED visits for TIA/minor stroke; however, on index ED visit, Calgary had a higher proportion of computed tomographic angiography imaging (48.8%; P<0.0001) compared with Edmonton (6.7%) and nonmajor urban region (5.7%) and higher proportion of discharged patients (83%; P<0.0001) compared with Edmonton (77.7%) and nonmajor urban region (73.5%). The risk of admission for stroke within 90 days of discharge after index ED visit for TIA/minor stroke in Calgary (3.4%) was lower than Edmonton (4.5%) and the nonmajor urban region (4.6%; P=0.002). Conclusions- This study demonstrates regional variation in computed tomographic angiography for neurovascular imaging of patients presenting to the ED for TIA/minor stroke and a possible association with frequency of index visit admission and 90-day readmission for the same problem.


Assuntos
Angiografia por Tomografia Computadorizada , Assistência à Saúde , Serviço Hospitalar de Emergência , Hospitalização , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Adulto , Idoso , Alberta , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia
17.
Stroke ; 51(7): 2228-2231, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32432998

RESUMO

BACKGROUND AND PURPOSE: The current coronavirus disease 2019 (COVID-19) pandemic represents a global public health crisis, disrupting emergency healthcare services. We determined whether COVID-19 has resulted in delays in stroke presentation and affected the delivery of acute stroke services in a comprehensive stroke center in Hong Kong. METHODS: We retrospectively reviewed all patients with transient ischemic attack and stroke admitted via the acute stroke pathway of Queen Mary Hospital, Hong Kong, during the first 60 days since the first diagnosed COVID-19 case in Hong Kong (COVID-19: January 23, 2020-March 24, 2020). We compared the stroke onset to hospital arrival (onset-to-door) time and timings of inpatient stroke pathways with patients admitted during the same period in 2019 (pre-COVID-19: January 23, 2019-March 24, 2019). RESULTS: Seventy-three patients in COVID-19 were compared with 89 patients in pre-COVID-19. There were no significant differences in age, sex, vascular risk factors, nor stroke severity between the 2 groups (P>0.05). The median stroke onset-to-door time was ≈1-hour longer in COVID-19 compared with pre-COVID-19 (154 versus 95 minutes, P=0.12), and the proportion of individuals with onset-to-door time within 4.5 hours was significantly lower (55% versus 72%, P=0.024). Significantly fewer cases of transient ischemic attack presented to the hospital during COVID-19 (4% versus 16%, P=0.016), despite no increase in referrals to the transient ischemic attack clinic. Inpatient stroke pathways and treatment time metrics nevertheless did not differ between the 2 groups (P>0.05 for all comparisons). CONCLUSIONS: During the early containment phase of COVID-19, we noted a prolongation in stroke onset to hospital arrival time and a significant reduction in individuals arriving at the hospital within 4.5 hours and presenting with transient ischemic attack. Public education about stroke should continue to be reinforced during the COVID-19 pandemic.


Assuntos
Betacoronavirus , Infecções por Coronavirus , Ataque Isquêmico Transitório/epidemiologia , Pandemias , Pneumonia Viral , Acidente Vascular Cerebral/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Assistência à Saúde/estatística & dados numéricos , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hong Kong/epidemiologia , Hospitais Especializados/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/terapia , Trombectomia/estatística & dados numéricos , Terapia Trombolítica/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/uso terapêutico
18.
J Stroke Cerebrovasc Dis ; 29(7): 104821, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32312632

RESUMO

BACKGROUND: Development of acute ischemic stroke in hospitalized patients represents a significant proportion of all cerebral ischemia. Several prehospital stroke scales were developed to screen for acute ischemic stroke in the community. Despite the advent of inpatient stroke alert systems, there is a lack of validated screening tools for the inpatient population. This study aims to assess the validity of BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) as a screening tool for acute ischemic stroke among inpatients. METHODS: We retrospectively analyzed all stroke alert activations at a single academic medical center between 2012 and 2016. We classified the triggering symptom as: focal neurologic deficit, aphasia, dysarthria, ataxia/vertigo/dizziness, alteration of consciousness, acute confusion, or headache. BE-FAST was applied retrospectively, and patients were classified as BE-FAST positive or negative. The final diagnosis was classified as acute ischemic stroke, transient ischemic attack , intracranial hemorrhage or noncerebrovascular diagnosis. RESULTS: Of 1965 stroke alerts, 489 were among inpatients. The mean age was 63 ± 16.1 years; 57% of patients were women (n = 1121). Acute ischemic stroke was diagnosed in 29% of all the activations (n = 567), transient ischemic attack in 12% (n = 232), intracranial hemorrhage in 8 % (n = 160) and noncerebrovascular in 51% (n = 1006). When comparing inpatient with community-onset stroke alerts, the sensitivity of BE-FAST for diagnosing acute ischemic stroke was 85% versus 94% (P = .005), with a specificity of 43% versus 23% (P < .001), respectively. However, when evaluating in-patients with an intact level of consciousness separately, BE-FAST sensitivity for diagnosing acute ischemic stroke was 92% compared to 94% in the community (P = .579). Among in-patients with acute ischemic stroke who were (1) candidates for reperfusion therapy and (2) diagnosed with acute large vessel occlusion, the sensitivity of BE-FAST was 83% and 94%, respectively. CONCLUSIONS: This is the first study to analyze the performance of BE-FAST among hospitalized patients evaluated through the inpatient stroke alert system. We found BE-FAST to be a very sensitive tool for screening for all in-hospital acute ischemic strokes, including inpatients that were candidates for acute reperfusion therapy.


Assuntos
Isquemia Encefálica/diagnóstico , Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência , Pacientes Internados , Hemorragias Intracranianas/diagnóstico , Ataque Isquêmico Transitório/diagnóstico , Exame Neurológico , Acidente Vascular Cerebral/diagnóstico , Idoso , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/psicologia , Isquemia Encefálica/terapia , Tomada de Decisão Clínica , Feminino , Humanos , Hemorragias Intracranianas/fisiopatologia , Hemorragias Intracranianas/psicologia , Hemorragias Intracranianas/terapia , Ataque Isquêmico Transitório/fisiopatologia , Ataque Isquêmico Transitório/psicologia , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/psicologia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica
19.
Stroke ; 51(5): 1555-1562, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32279618

RESUMO

Background and Purpose- Immigrants to high-income countries have a lower incidence of stroke compared with long-term residents; however, little is known about the care and outcomes of stroke in immigrants. Methods- We used linked clinical and administrative data to conduct a retrospective cohort study of adults seen in the emergency department or hospitalized with ischemic stroke or transient ischemic attack between July 1, 2003, and April 1, 2013, and included in the provincial stroke registry. We ascertained immigration status using immigration records and compared processes of stroke care delivery between immigrants (defined as those immigrating after 1985) and long-term residents. In the subgroup with ischemic stroke, we calculated inverse probability treatment weight (IPTW)-adjusted risk ratios for disability on discharge (modified Rankin Scale score of 3 to 5), accounting for demographic characteristics and comorbid conditions to compare outcomes between immigrants and long-term residents. Results- We included 34 987 patients with ischemic stroke or transient ischemic attack, of whom 2649 (7.6%) were immigrants. Immigrants were younger than long-term residents at the time of stroke/transient ischemic attack (median age 67 years versus 76 years; P<0.001). In the subgroup with ischemic stroke, there were no differences in stroke care delivery, except that a higher proportion of immigrants received thrombolysis than long-term residents (21.2% versus 15.5%; P<0.001). Immigrants with ischemic stroke had a higher adjusted risk of being disabled on discharge (adjusted risk ratio, 1.18; 95% CI, 1.13-1.22) compared to long-term residents. Conclusions- Stroke care is similar in Canadian immigrants and long-term residents. Future research is needed to confirm the observed association between immigration status and disability after stroke and to identify factors underlying the association.


Assuntos
Emigrantes e Imigrantes/estatística & dados numéricos , Ataque Isquêmico Transitório/terapia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Artérias Carótidas/diagnóstico por imagem , Estudos de Coortes , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Transtornos de Deglutição/diagnóstico , Diabetes Mellitus/epidemiologia , Ecocardiografia/estatística & dados numéricos , Eletrocardiografia Ambulatorial/estatística & dados numéricos , Emigração e Imigração , Feminino , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Hipertensão/epidemiologia , Hipolipemiantes/uso terapêutico , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Inibidores da Agregação de Plaquetas/uso terapêutico , Estudos Retrospectivos , Índice de Gravidade de Doença , Fumar/epidemiologia
20.
Curr Cardiol Rep ; 22(5): 27, 2020 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-32193624

RESUMO

PURPOSE OF THE REVIEW: The burden of ischemic stroke is disproportionally distributed between ethnic and racial subgroups in the USA, minority populations with lower socioeconomic status being at higher risk. These discrepancies are mirrored in susceptibility, primary care, and post-discharge procedures. Post-discharge strategies are of particular importance as their primary goal is to prevent recurrent stroke, which makes up about 25% of stroke cases per year in US. As disadvantaged minorities have faster growing populations, recurrent stroke poses a significant challenge not only for caretakers but also for the health care system as the whole. A number of educational strategies were employed to inform the general public of major symptoms, risk factors, and preventive measures for recurrent stroke. However, over affected subgroups did not prove responsive to such measures as these did not conform to their cultural and sociological specificities. RECENT FINDINGS: The Discharge Educational Strategies for Reduction of Vascular Events Intervention (DESERVE) is a randomized control trial with a one year follow up, set out to investigate the possibility that culturally tailored, community-centered post-discharge strategies would improve compliance to therapy and prevention against secondary stroke. The trial targeted African Americans, Hispanic, and non-Hispanic whites, adapting discharge strategies for each individual group. DESERVE accomplished a significant reduction in blood pressure in the Hispanic intervention group by 9.9 mm Hg compared with usual care. The remaining two groups were not susceptible to these measures. DESERVE holds promise for culturally tailored interventions in the future in a battle against stroke and other chronic diseases.


Assuntos
Assistência ao Convalescente/métodos , Ataque Isquêmico Transitório/terapia , Alta do Paciente/estatística & dados numéricos , Educação de Pacientes como Assunto/métodos , Prevenção Secundária/métodos , Acidente Vascular Cerebral/terapia , Humanos , Ataque Isquêmico Transitório/fisiopatologia , Ataque Isquêmico Transitório/reabilitação , Fatores de Risco , Comportamento de Redução do Risco , Acidente Vascular Cerebral/fisiopatologia , Reabilitação do Acidente Vascular Cerebral , Resultado do Tratamento
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