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1.
J Stroke Cerebrovasc Dis ; 29(2): 104479, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31784379

RESUMO

OBJECTIVE: To examine the association of a comorbid seizure diagnosis with early hospital readmission rates following an index hospitalization for stroke in the United States. METHODS: Retrospective analysis of the 2014 National Readmission Database. The study population included adult patients (age >18 years old) with stroke, identified using the International Classification of Disease Ninth Revision, Clinical Modification (ICD-9-CM) codes 433.X1, 434.X1, and 436 for ischemic stroke as well as 430, 431, 432.0, 432.1, and 432.9 for hemorrhagic stroke. A subgroup of patients with a secondary discharge diagnosis of seizures was identified using the ICD-9-CM codes 780.39 and 345.X. We computed all-cause 30-day readmission rates for all strokes and by stroke type (ischemic versus hemorrhagic). Finally, we used a multivariable logistic regression model to examine the independent association between seizure and readmission by stroke type. RESULTS: Of 271,148 stroke patients, 6.3% (16,970) had a secondary discharge diagnosis of seizures including 5.0% (11,562) of patients with ischemic stroke and 13.4% (5,409) with hemorrhagic stroke. Overall readmission rate for stroke patients was 11.9% (hemorrhagic stroke: 14.2% versus ischemic strokes: 11.6%). Thirty-day readmission rate was higher in patients with seizures for all strokes (15.6% versus 11.7%, P value <.001), ischemic strokes (15.0% versus11.4%, P value <.001), and hemorrhagic strokes (16.7% versus 13.8%, P value <.001). After adjusting for several patient-specific and healthcare system-specific confounders, hospitalized stroke patients with comorbid seizure diagnosis were more likely than those without seizures to be readmitted within 30 days (OR: 1.20, 95% CI: 1.14-1.25). CONCLUSION: The presence of a comorbid diagnosis of seizure disorder in a hospitalized stroke patient significantly raises the occurrence of early hospital readmission in the United States.


Assuntos
Isquemia Encefálica/diagnóstico , Hemorragias Intracranianas/diagnóstico , Readmissão do Paciente , Convulsões/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/terapia , Comorbidade , Bases de Dados Factuais , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Convulsões/epidemiologia , Convulsões/terapia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
2.
Clín. investig. arterioscler. (Ed. impr.) ; 31(6): 282-288, nov.-dic. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-185155

RESUMO

Introducción: Tras un evento cerebrovascular isquémico el riesgo de recurrencias es elevado, por lo que se hace necesario el uso de terapia antitrombótica para disminuir nuevos eventos. Desarrollo: A pesar de su beneficio, estas terapias aumentan el riesgo de sangrado. Por tanto, determinar qué pacientes presentan mayor riesgo de hemorragia es fundamental. Existen diferentes modelos predictores de hemorragia y, en particular, de hemorragia intracraneal, asociados al uso de antiagregantes en pacientes con ictus isquémico o AIT, como las escalas CCSC, Intracranial-B2LEED3S score o la S2TOP-BLEED. No obstante, mientras que las principales guías internacionales recomiendan el uso de escalas, como HAS-BLED, para evaluar el riesgo de sangrado en pacientes anticoagulados, no existe una recomendación específica en el caso del uso de antiagregantes. Conclusiones: En esta revisión se presentan los principales modelos disponibles en la actualidad para la predicción de sangrado de la terapia antitrombótica en pacientes con ictus o AIT


Introduction: After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. Discussion: Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. Conclusions: In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Acidente Vascular Cerebral/tratamento farmacológico , Fatores de Risco , Hemorragias Intracranianas/epidemiologia , Fibrinolíticos/administração & dosagem , Hemorragias Intracranianas/prevenção & controle , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/metabolismo
3.
BMC Health Serv Res ; 19(1): 792, 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31684952

RESUMO

BACKGROUND: There is little published data on brain imaging and intracranial haemorrhage after hospital inpatient falls. Imaging protocols for inpatient falls have been adopted from head injury guidelines developed from data in patients presenting to the Emergency Department. We sought to describe the use of brain computed tomography (CT) following inpatient falls, and determine the incidence and potential risk factors for intracranial haemorrhage. METHODS: We identified inpatient falls in acute medical wards at Monash Health, a large hospital network in the southeast region of Melbourne in Australia, from the incident reporting system during a 32 month period. We examined the post-fall medical assessment form, neurological observation chart and the diagnostic imaging system for details of the fall and brain CT findings. We used survival analysis to evaluate the timeliness of brain imaging and determined potential risk factors for intracranial haemorrhage by logistic regression. RESULTS: From 934 falls in 789 medical inpatients, 191 brain CT scans were performed. The median age of patients was 77 years. Only 55% of falls were from standing height and 24% experienced a head strike. Less than 10% of patients received an urgent scan within one hour, and timeliness of imaging was influenced by anticoagulation status rather than guideline determination of urgency. The overall incidence of intracranial haemorrhage was 0.9%. The factors associated with intracranial haemorrhage were head strike, anticoagulation, loss of consciousness or amnesia, drop in Glasgow Coma Scale and advanced chronic kidney disease. CONCLUSIONS: The incidence of intracranial haemorrhage was low as most inpatient falls were at low risk for head injury. Research is needed to determine if guidelines specific for hospital inpatients may reduce unnecessary scans without compromising case detection, and improve timeliness of urgent scans.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Unidades Hospitalares/estatística & dados numéricos , Hospitalização , Hemorragias Intracranianas/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Feminino , Humanos , Incidência , Hemorragias Intracranianas/epidemiologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X
4.
Neurology ; 93(21): e1955-e1963, 2019 11 19.
Artigo em Inglês | MEDLINE | ID: mdl-31645472

RESUMO

OBJECTIVE: To evaluate the safety and efficacy of induced hypertension in patients with acute ischemic stroke. METHODS: In this multicenter randomized clinical trial, patients with acute noncardioembolic ischemic stroke within 24 hours of onset who were ineligible for revascularization therapy and those with progressive stroke during hospitalization were randomly assigned (1:1) to the control and intervention groups. In the intervention group, phenylephrine was administered intravenously to increase systolic blood pressure (SBP) up to 200 mm Hg. The primary efficacy endpoint was early neurologic improvement (reduction in NIH Stroke Scale [NIHSS] score of ≥2 points during the first 7 days). The secondary efficacy endpoint was a modified Rankin Scale score of 0 to 2 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage/edema, myocardial infarction, and death. RESULTS: In the modified intention-to-treat analyses, 76 and 77 patients were included in the intervention and control groups, respectively. After adjustment for age and initial stroke severity, induced hypertension increased the occurrence of the primary (odds ratio 2.49, 95% confidence interval [CI] 1.25-4.96, p = 0.010) and secondary (odds ratio 2.97, 95% CI 1.32-6.68, p = 0.009) efficacy endpoints. Sixty-seven (88.2%) patients of the intervention group exhibited improvements in NIHSS scores of ≥2 points during induced hypertension (mean SBP 179·7 ± 19.1 mm Hg). Safety outcomes did not significantly differ between groups. CONCLUSION: Among patients with noncardioembolic stroke who were ineligible for revascularization therapy and those with progressive stroke, phenylephrine-induced hypertension was safe and resulted in early neurologic improvement and long-term functional independence. CLINICALTRIALSGOV IDENTIFIER: NCT01600235. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with acute ischemic stroke, therapeutic-induced hypertension increases the probability of early neurologic improvement.


Assuntos
Pressão Sanguínea , Encéfalo/irrigação sanguínea , Circulação Colateral , Hipertensão , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Encéfalo/diagnóstico por imagem , Edema Encefálico/epidemiologia , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio/epidemiologia , Planejamento de Assistência ao Paciente , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
5.
J Stroke Cerebrovasc Dis ; 28(11): 104363, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31501038

RESUMO

BACKGROUND AND AIM: Renal dysfunction (RD) is prevalent in patients with acute ischemic stroke requiring intravenous thrombolysis. The relationship between renal function and thrombolysis related intracranial hemorrhagic (ICH) complications is contradictory according to previous studies. The current study is to clarify whether RD could increase the risk of symptomatic intracranial hemorrhage (SICH) after recombinant tissue plasminogen activator (IV rtPA) in acute ischemic stroke patients. METHODS: In this observational study, acute ischemic stroke patients who received IV rtPA within 4.5 hours of symptom onset were retrospectively analyzed. Creatinine levels on admission served to calculate glomerular filtration rate (GFR) to estimate RD. SICH was defined with National Institute of Neurological Disorder and Stroke (NINDS, SICHNINDS) or European Cooperative Acute Stroke Study II (ECASS II, SICHECASSII) criteria. Association of RD with SICH was assessed using continuous GFR or binary GFR (RD defined as GFR < 90 ml/minute/1.73 m2). RESULTS: Of 312 patients included, the incidence of SICHNINDS was 7.69%, of SICHECASSII was 5.45%. Patients with RD had higher prevalence of SICHNINDS (12.80% versus 2.03%, P < .001) and SICHECASS II (9.15% versus 1.35%, P = .002). GFR as a continuous variable was associated with SICHNINDS (ORadjust = .97, P = .003), but not with SICHECASS II. GFR less than 90 ml/minute/1.73 m2 remained independently associated with SICHNINDS (ORadjust = 4.79, P = .016), and SICHECASS II (ORadjust = 2.99, P = .032) in multiple logistic regression analysis. CONCLUSIONS: Renal function is independently associated with SICH after IV rtPA thrombolysis. RD is an independent predictor for both SICHNINDS and SICHECASS II. RD should be considered when evaluating the risk of intravenous thrombolysis with IV rtPA.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/efeitos adversos , Taxa de Filtração Glomerular , Hemorragias Intracranianas/induzido quimicamente , Nefropatias/fisiopatologia , Rim/fisiopatologia , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/fisiopatologia , China/epidemiologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/epidemiologia , Nefropatias/diagnóstico , Nefropatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento
6.
Chin J Traumatol ; 22(5): 286-289, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31521457

RESUMO

PURPOSE: A head injury (HI) may cause a skull fracture, which may or may not be associated with injury to the brain. In essence, a skull base fracture (SBF) is a linear fracture at the base of the skull. Loss of consciousness and Glasgow coma score (GCS) may vary depending on an associated intracranial pathology. The pathomechanism is believed to be caused by high energy impact directly to the mastoid and supraorbital bone or indirectly from the cranial vault. Aim of this study is to define the correlation between SBF and intracranial hemorrhage (ICH) in patients with HI. METHODS: Analysis of data obtained from a retrospective review of medical records and from a systematized database pertaining to diagnostic criteria of SBF patients based only on clinical symptoms associated with ICH caused by HI treated in the Department of Neurosurgery at Dr. Hasan Sadikin Hospital, Bandung, Indonesia from January 1, 2012 to December 31, 2017. The exclusion criteria included age less than 15 years and no head computed tomography (CT) scan examination provided. RESULTS: A total of 9006 patients were included into this study in which they were divided into 3 groups: group 1, HI with no ICH; group 2, HI with single ICH and group 3, HI with multiple ICH. In all the SBF cases, SBF at anterior fossa accounted for 69.40% of them, which were mostly accompanied with mild HI (64.70%). Severity of HI and site of SBF correlated with the existence of traumatic brain lesions on CT scan, thus these factors were able to predict whether there were traumatic brain lesions or not. Most of the patients with epidural hemorrhage (EDH) has single traumatic lesion on CT scan, whereas most of the patients with cerebral contusion (CC) has multiple traumatic lesions on CT scan. On patients with both traumatic brain injury and SBF, most of the patients with anterior fossa SBF has EDH; whereas most of the patients with middle fossa SBF were accompanied with CC. Surgery was not required for most of the patients with SBF. CONCLUSION: SBFs were strongly correlated with traumatic ICH lesions patients with anterior fossa SBF were more likely to suffer EDH whereas with middle fossa SBF were more likely to suffer CC.


Assuntos
Lesões Encefálicas Traumáticas/etiologia , Traumatismos Craniocerebrais/complicações , Hemorragias Intracranianas/etiologia , Base do Crânio/lesões , Fraturas Cranianas/etiologia , Adulto , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Traumatismos Craniocerebrais/diagnóstico por imagem , Feminino , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/epidemiologia , Masculino , Estudos Retrospectivos , Base do Crânio/diagnóstico por imagem , Fraturas Cranianas/diagnóstico por imagem
7.
J Stroke Cerebrovasc Dis ; 28(11): 104342, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31521517

RESUMO

GOAL: Cerebral amyloid angiopathy (CAA) is the second-most common cause of nontraumatic intracerebral hemorrhages (ICH), surpassed only by uncontrolled hypertension. We characterized the percentage, risk factors, and comorbidities of patients suffering from CAA-related ICH in relation to long-term outcomes. MATERIAL AND METHODS: We performed retrospective analyses and clinical follow-ups of individuals suffering from ICH who were directly admitted to neurosurgery between 2002 and 2016. FINDINGS: Seventy-four of 174 (42%) spontaneous nontraumatic lobar ICH cases leastwise satisfied the modified Boston criteria definition for at least "possible CAA." Females suffered a higher risk of CAA-caused ICH (42 of 74, 56.8%, P= .035). Atrial fibrillation as a major comorbidity was observed in 19 patients (25.7%). Recovery (decrease of modified Rankin scale [mRS]) was highest during hospitalization in the acute clinic. One-year mortality was as follows: 14 of 25 patients (56%) with probable CAA without supporting pathology, 6 of 18, and 8 of 31 patients with supporting pathology and possible CAA, respectively. Only 10 of 74 (13.6%) had favorable long-term outcomes (mRS ≤2). Increasing numbers of lobar hemorrhages, low initial Glasgow Coma Scale, and subarachnoid hemorrhage were significantly associated with poor survivability, whereas statins, antithrombotic agents, an intraventricular hemorrhage, and midline shift played seemingly minor roles. CONCLUSIONS: Symptomatic ICH is a serious stage in CAA progression with high mortality. The high incidence of concurrent atrial fibrillation in these patients may support data on more widespread vascular pathology in CAA.


Assuntos
Fibrilação Atrial/epidemiologia , Angiopatia Amiloide Cerebral/epidemiologia , Hemorragias Intracranianas/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/terapia , Angiopatia Amiloide Cerebral/diagnóstico por imagem , Angiopatia Amiloide Cerebral/mortalidade , Angiopatia Amiloide Cerebral/terapia , Comorbidade , Progressão da Doença , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
8.
Int J Med Sci ; 16(8): 1050-1056, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31523166

RESUMO

This study sought to evaluate associations between nephrolithiasis and hemorrhagic and ischemic stroke using a national sample cohort from Korea. Data from 2002 to 2013 were collected for individuals ≥ 20 years of age in the Korean National Health Insurance Service (NHIS)-National Sample Cohort. We extracted nephrolithiasis patients (n = 22,636) and 1:4 matched controls (n = 90,544) and analyzed the occurrence of stroke. Matching was performed based on age, sex, income, region of residence, hypertension, diabetes mellitus, and dyslipidemia history. Crude and adjusted hazard ratios (HRs) were calculated using Cox proportional hazard models, and 95% confidence intervals (CIs) were determined. We performed subgroup analyses according to age, sex, and follow-up period. The adjusted HR of ischemic stroke was 1.13 (95% CI = 1.06-1.21) in the nephrolithiasis group (P < 0.001). The relationship between nephrolithiasis and ischemic stroke remained present for the young women and middle-aged men as well as during a follow-up period of ≤ 1 year. The HR for hemorrhagic stroke did not reach statistical significance. The risk of ischemic stroke was higher in the nephrolithiasis patients.


Assuntos
Isquemia Encefálica/etiologia , Hemorragias Intracranianas/etiologia , Cálculos Renais/complicações , Acidente Vascular Cerebral/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Seguimentos , Humanos , Hemorragias Intracranianas/epidemiologia , Cálculos Renais/epidemiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , República da Coreia/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto Jovem
9.
J Stroke Cerebrovasc Dis ; 28(11): 104395, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31540781

RESUMO

BACKGROUND AND PURPOSE: We investigated the associations between alcohol-related emergency department visits and hospitalizations and vascular events including acute ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage. METHODS: The New York State Inpatient and Emergency Department Databases were examined (2006-2013). Validated International Classification of Diseases 9th edition definitions identified index vascular hospitalizations and alcohol abuse encounters. We used case cross-over analysis with conditional logistic regression to estimate odds ratios (OR) for the association between alcohol-related encounters during 6 case periods (7, 14, 30, 60, 90, and 120 days before index event) compared to control periods (1 year before). Multivariate logistic regression was used to examine the association between an alcohol-related encounter within 6 months before index admission and 30-day readmission after discharge. RESULTS: An alcohol encounter before index admission was associated with acute ischemic stroke (OR = 1.765 within 60 days, 1.418 within 90 days, and 1.287 within 120 days) and subarachnoid hemorrhage (OR = 2.375 within 90 days), but not ICH. Alcohol-related encounters within 6 months before index vascular events increased the likelihood of 30-day readmission after index admission. CONCLUSION: We found that a recent alcohol-related counter was associated with occurrence of vascular events, but not ICH, as well as worse outcomes after index admission.


Assuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Alcoolismo/epidemiologia , Serviço Hospitalar de Emergência , Hemorragias Intracranianas/epidemiologia , Trombose Intracraniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Tromboembolia Venosa/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Consumo de Bebidas Alcoólicas/epidemiologia , Alcoolismo/diagnóstico , Bases de Dados Factuais , Feminino , Hospitalização , Humanos , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/terapia , Trombose Intracraniana/diagnóstico , Trombose Intracraniana/terapia , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Prognóstico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/terapia
10.
World Neurosurg ; 131: e495-e502, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31382073

RESUMO

OBJECTIVE: We investigated the efficacy of a combined approach with stent retriever-assisted aspiration catheter for distal intracranial vessel occlusion (distal combined technique [DCT]). METHODS: We evaluated consecutive patients with acute ischemic stroke with distal occlusion in anterior circulation, including occlusions of the M2/M3 or A2/A3 segments, who received endovascular therapy (EVT) in a single center. Modified Thrombolysis in Cerebral Infraction (mTICI) score including TICI 2C category, processing time from puncture to reperfusion, proportion of a favorable clinical outcome at discharge (modified Rankin Scale [mRS] score ≤2), and incidence of symptomatic intracranial hemorrhage (sICH) were compared between the DCT and single device approach technique (non-DCT) groups. RESULTS: Of 65 patients, 28 were treated with EVT using the DCT and 37 were treated with EVT with a single device approach (non-DCT). In the DCT group, a higher reperfusion rate at the first pass (mTICI score ≥2B, 92% vs. 54%; P = 0.0008; mTICI score ≥2C, 71% vs. 16%; P < 0.0001; mTICI score 3, 57% vs. 14%; P = 0.0004) and shorter time from puncture to successful reperfusion (median, 31 vs. 43 minutes; P = 0.0006) were achieved, respectively. The final successful reperfusion rate was also higher in the DCT group than in the non-DCT group (mTICI score ≥2C, 85% vs. 51%; P = 0.004; mTICI score 3, 75% vs. 43%; P = 0.012), respectively. sICH occurred in 2 patients in the non-DCT group. Patients with mRS score ≤2 at discharge were more prevalent in the DCT than in the non-DCT group (57% vs. 27%, respectively; P = 0.021). CONCLUSIONS: This retrospective analysis indicated that the DCT is a useful and safe strategy for patients with distal anterior intracranial vessel occlusion.


Assuntos
Trombose Intracraniana/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Trombose Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Trombectomia/instrumentação , Resultado do Tratamento , Dispositivos de Acesso Vascular
11.
J Stroke Cerebrovasc Dis ; 28(11): 104322, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31427188

RESUMO

BACKGROUND: To determine if the nephrotic syndrome (NS) is an independent risk factor of ischemic stroke. METHODS: This is a retrospective nationwide cohort study through an analysis of the National Health Insurance Research Database in Taiwan. To evaluate the risk of stroke, the corresponding controls were selected at a 4:1 ratio in the number of subjects, and they were matched with the study group in age, gender, Charlson comorbidity index (CCI), and index date. RESULTS: From a total of 16,245 surveyed subjects, ischemic stroke occurred in 1235 (7.6%) and hemorrhagic stroke in 129 (.74%) of them. The incidence of ischemic stroke was significantly higher in patients with NS (n = 3496) compared to control patients without NS (n = 13,984) (9.92 versus 7.10, per 1000 person-year, P < .001). In the multivariate analysis, the overall adjusted hazard ratio (aHR) of stroke in NS patients was 1.37 (95% CI, 1.21-1.54, P < .001). The risk factors of ischemic stroke were NS (aHR, 1.38 [95% confidence interval {CI}, 1.21-1.57]; P < .001), age greater than 45 years (aHR, 7.98 [95% CI, 6.47-9.48]; P < .001), male gender (aHR, 1.23 [95% CI, 1.10-1.38]; P < .001), CCI greater than or equal to 1 (aHR ≥ 1.25 in different CCI score groups, all at P ≤ .003), ischemic heart disease (aHR, 1.95 [95% CI, 1.67-2.29]; P < .001), heart failure (HR, 1.77 [95% CI, 1.30-2.42]; P < .001). Risk factors of hemorrhagic stroke were those aged greater than 45 years, or with systemic lupus erythematosus, but not NS. CONCLUSIONS: We provided the first evidence that patients with NS had an increased risk of ischemic stroke.


Assuntos
Isquemia Encefálica/epidemiologia , Hemorragias Intracranianas/epidemiologia , Síndrome Nefrótica/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adolescente , Adulto , Fatores Etários , Isquemia Encefálica/diagnóstico , Comorbidade , Bases de Dados Factuais , Feminino , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico , Masculino , Pessoa de Meia-Idade , Síndrome Nefrótica/diagnóstico , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/diagnóstico , Taiwan/epidemiologia , Adulto Jovem
12.
J Stroke Cerebrovasc Dis ; 28(9): 2363-2375, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31281110

RESUMO

The prevalence of atrial fibrillation (AF), the most common cardiac arrhythmia, increases with age, predisposing elderly patients to an increased risk of embolic stroke. With an increasingly aged population the number of people who experience a stroke every year, overall global burden of stroke, and numbers of stroke survivors and related deaths continue to increase. Anticoagulation with vitamin K antagonists (VKAs) reduces the risk of ischemic stroke in patients with AF; however, increased bleeding risk is well documented, particularly in the elderly. Consequently, VKAs have been underused in the elderly. Alternative anticoagulants may offer a safer choice, particularly in patients who have experienced previous stroke. The aim of this narrative review is to examine available evidence for the effective treatment of patients with AF and previous cerebral vascular events with non-VKA oral anticoagulants, including the most appropriate time to start or reinitiate treatment after a stroke, systemic embolism, or clinically relevant bleed. For patients with AF treated with oral anticoagulants it is important to balance increased protection against future stroke/systemic embolism and reduced risk of major bleeding events. For patients with AF who have previously experienced a cerebrovascular event, the use of oral anticoagulants alone also appears more effective than low-molecular weight heparin (LMWH) alone or LMWH followed by oral anticoagulants. Available data suggest that significant reduction in stroke, symptomatic cerebral bleeding, and major extracranial bleeding within 90 days from acute stroke can be achieved if oral anticoagulation is initiated at 4-14 days from stroke onset.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Esquema de Medicação , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Recidiva , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento
13.
J Clin Neurosci ; 69: 224-229, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31327589

RESUMO

BACKGROUND: Atrial fibrillation (AF)-related stroke causes severe disability and poor prognosis. Adjunctive statin therapy has been recommended for atherosclerotic-related stroke but not AF-related stroke. This study investigated the effects of statin in AF patients who experienced acute ischemic stroke. METHODS: Data from patients with AF experiencing first-ever ischemic stroke between 2001 and 2010 were collected from the Taiwan National Health Insurance Research Database and categorized into non-statin and statin groups. The statin group was further divided into pre-stroke statin (those who began statin therapy before stroke) and post-stroke statin (those who began statin therapy after stroke) groups. The risks for recurrent ischemic stroke, coronary artery disease (CAD), intracranial hemorrhage (ICH), and 1-year mortality were compared among the groups. RESULTS: A total of 43,242 patients were in the non-statin, 2858 in the pre-stroke statin and 4640 in post-stroke statin groups. Comparing the risk for recurrent stroke and CAD among the three groups, the pre-stroke statin and post-stroke statin groups did not exhibit a significant difference compared with the non-statin group. In terms of ICH risk, the statin group had a lower risk for ICH (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.68-0.90; p = 0.0007) compared with the non-statin group. The overall 1-year mortality in both statin subgroups was lower than that in the non-statin group (pre-stroke statin, OR 0.55 [95% CI 0.49-0.61]; p < 0.0001 versus post-stroke statin, OR 0.53 [95% CI 0.48-0.58]; p < 0.0001). CONCLUSIONS: Statin therapy reduced the risk of ICH and 1-year mortality in AF patients who experienced acute ischemic stroke.


Assuntos
Fibrilação Atrial/complicações , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hemorragias Intracranianas/epidemiologia , Acidente Vascular Cerebral/etiologia , Idoso , Isquemia Encefálica/etiologia , Feminino , Humanos , Hemorragias Intracranianas/etiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Taiwan
14.
Neurology ; 93(6): e578-e589, 2019 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-31308151

RESUMO

OBJECTIVE: To define the role and risks associated with white matter hyperintensity (WMH) load in a stroke population with respect to recurrent stroke and mortality after ischemic stroke. METHODS: A total of 7,101 patients at a network of university hospitals presenting with ischemic strokes were followed up for 1 year. Multivariable Cox proportional hazards model and competing risk analysis were used to examine the independent association between quartiles of WMH load and stroke recurrence and mortality at 1 year. RESULTS: Overall recurrent stroke risk at 1 year was 6.7%/y, divided between 5.6%/y for recurrent ischemic and 0.5%/y for recurrent hemorrhagic strokes. There was a stronger association between WMH volume and recurrent hemorrhagic stroke by quartile (hazard ratio [HR] 7.32, 14.12, and 33.52, respectively) than for ischemic recurrence (HR 1.03, 1.37, and 1.61, respectively), but the absolute incidence of ischemic recurrence by quartile was higher (3.8%/y, 4.5%/y, 6.3%/y, and 8.2%/y by quartiles) vs hemorrhagic recurrence (0.1%/y, 0.4%/y, 0.6%/y, and 1.3%/y). All-cause mortality (10.5%) showed a marked association with WMH volume (HR 1.06, 1.46, and 1.60), but this was attributable to nonvascular rather than vascular causes. CONCLUSIONS: There is an association between WMH volume load and stroke recurrence, and this association is stronger for hemorrhagic than for ischemic stroke, although the absolute risk of ischemic recurrence remains higher. These data should be helpful to practitioners seeking to find the optimal preventive/treatment regimen for poststroke patients and to individualize risk-benefit ratios.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Leucoaraiose/diagnóstico por imagem , Leucoaraiose/etiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Substância Branca/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/mortalidade , Feminino , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/mortalidade , Estimativa de Kaplan-Meier , Leucoaraiose/mortalidade , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , República da Coreia/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade , Análise de Sobrevida , Resultado do Tratamento
15.
Medwave ; 19(6): e7668, 2019 Jul 23.
Artigo em Espanhol | MEDLINE | ID: mdl-31348768

RESUMO

Introduction: Stroke is the leading cause of death and disability in Chile. Objective: To analyze the epidemiological characteristics of hospitalized patients with a diagnosis of stroke in our hospital unit (Complejo Asistencial Víctor Ríos Ruiz). Methods: We performed an observational, cross-sectional study. We included patients who were discharged from our hospital with a diagnosis of stroke between 2014 and 2017. We extracted data on stroke-related ICD codes, demographic variables, types of stroke, case fatality rates, and hospital stay. Quantitative variables were expressed as averages with standard deviation (± SD), and categorical variables were expressed as absolute and relative frequencies. Differences were analyzed using Student t-distribution and ANOVA. We defined a p-value of < 0.05 as statistically significant. Results: In total, 1856 patients were discharged of which 58.6% were male, with an average age of 66.9 (± 13.9) years, and an average stay of 10.4 (± 16.7) days. In the female population, the average age was 69.9 (± 16), and the average hospitalization was 11.1 (± 16.5) days. 55.5% of stroke cases was ischemic, and 17.4% was hemorrhagic. The main risk factors were hypertension (72%) and type 2 diabetes (33%). We found an overall in-hospital case fatality rate of 10.6%. Both the case fatality rate and prolonged in-hospital stay were associated with subarachnoid hemorrhage and hemorrhagic stroke (p < 0.05). Conclusions: Prevalence of stroke is similar in both men and women. Hypertension was the leading risk factor associated with acute stroke. Although ischemic stroke was the most frequent diagnosis, both subarachnoid hemorrhage and hemorrhagic stroke were related to an increased case fatality rate and a more extended hospital stay.


Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Hospitalização , Hipertensão/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Chile , Estudos Transversais , Grupos Diagnósticos Relacionados , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Hemorragia Subaracnóidea/epidemiologia
17.
Neurology ; 93(3): e283-e292, 2019 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-31209178

RESUMO

OBJECTIVE: To assess whether complete reperfusion after IV thrombolysis (IVT-R) would result in similar clinical outcomes compared to complete reperfusion after endovascular thrombectomy (EVT-R) in patients with a large vessel occlusion (LVO). METHODS: EVT-R patients were matched by age, clinical severity, occlusion location, and baseline perfusion lesion volume to IVT-R patients from the International Stroke Perfusion Imaging Registry (INSPIRE). Only patients with complete reperfusion on follow-up imaging were included. The excellent clinical outcome rates at day 90 on the modified Rankin Scale (mRS) were compared between EVT-R vs IVT-R patients within quintiles of increasing baseline ischemic core and penumbral volumes. RESULTS: From INSPIRE, there were 141 EVT-R patients and 141 matched controls (IVT-R) who met the eligibility criteria. In patients with a baseline core <30 mL, EVT-R resulted in a lower odds of achieving an excellent outcome at day 90 compared to IVT-R (day 90 mRS 0-1 odds ratio 0.01, p < 0.001). The group with a baseline core <30 mL contained mostly patients with distal M1 or M2 occlusions, and good collaterals (p = 0.01). In patients with a baseline ischemic core volume >30 mL (internal carotid artery and mostly proximal M1 occlusions), EVT-R increased the odds of patients achieving an excellent clinical outcome (day 90 mRS 0-1 odds ratio 1.61, p < 0.001) and there was increased symptomatic intracranial hemorrhage in the IVT-R group with core >30 mL (20% vs 3% in EVT-R, p = 0.008). CONCLUSION: From this observational cohort, LVO patients with larger baseline ischemic cores and proximal LVO, with poorer collaterals, clearly benefited from EVT-R compared to IVT-R alone. However, for distal LVO patients, with smaller ischemic cores and better collaterals, EVT-R was associated with a lower odds of favorable outcome compared to IVT-R alone.


Assuntos
Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Idoso , Idoso de 80 Anos ou mais , Circulação Cerebrovascular , Estudos de Coortes , Circulação Colateral , Procedimentos Endovasculares , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/terapia , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Acidente Vascular Cerebral/diagnóstico por imagem
18.
Stroke ; 50(7): 1661-1668, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31167624

RESUMO

Background and Purpose- Circulating metals synchronously reflect multiple metal exposures from both natural and anthropogenic sources, which may be linked with the risk of stroke. However, there is a lack of prospective studies investigating the associations of multiple metal exposures with incident stroke. Methods- We performed a nested case-control study within the ongoing Dongfeng-Tongji cohort launched in 2008. A total of 1304 incident stroke cases (1035 ischemic strokes and 269 hemorrhagic strokes) were prospectively identified by December 31, 2016, and matched to incident identity sampled controls according to age (within 1 year), sex, and blood sampling date (within 1 month). We determined the concentrations of 24 plasma metals and assessed the associations of plasma multiple metal concentrations with incident stroke using conditional logistic regression and elastic net model. Results- The average follow-up was 6.1 years. After adjusting for established risk confounders, copper, molybdenum, and titanium were significantly associated with higher risk of ischemic stroke (odds ratios according to per interquartile range increase, 1.29 [95% CI, 1.13-1.46], 1.19 [95% CI, 1.05-1.35], and 1.30 [95% CI, 1.07-1.59]), whereas rubidium and selenium were associated with lower risk of hemorrhagic stroke (odds ratios according to per interquartile range increase, 0.66 [95% CI, 0.50-0.87] and 0.68 [95% CI, 0.51-0.91]). The predictive plasma metal scores based on multiple metal exposures were significantly associated with higher risk of ischemic and hemorrhagic stroke (adjusted odds ratios according to per interquartile range increase, 1.37 [95% CI, 1.20-1.56] and 1.53 [95% CI, 1.16-2.01]). Conclusions- Plasma copper, molybdenum, and titanium were associated with higher risk of ischemic stroke, whereas plasma rubidium and selenium were associated with lower risk of hemorrhagic stroke. These findings may have important public health implications given the ever-increasing burden of stroke worldwide.


Assuntos
Metais/sangue , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/epidemiologia , Adulto , Fatores Etários , Idoso , Grupo com Ancestrais do Continente Asiático , Isquemia Encefálica/complicações , Isquemia Encefálica/epidemiologia , Estudos de Casos e Controles , China/epidemiologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Incidência , Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Fatores Sexuais
19.
J Stroke Cerebrovasc Dis ; 28(8): 2159-2167, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31103554

RESUMO

BACKGROUND: Patients with cerebral microbleeds have increased risk of intracranial hemorrhage and ischemic stroke. No trial specifically informs antithrombotic therapy for patients with cerebral microbleeds and atrial fibrillation. We investigated the safety of anticoagulation versus no anticoagulation with regard to cerebrovascular outcomes and mortality. METHODS: All consecutive atrial fibrillation patients from 2015 to 2018 with MRI evidence of ≥1 cerebral microbleed at time of imaging were reviewed. Patients were treated with warfarin, direct oral anticoagulants, or neither. Primary outcome was all-cause mortality informed by National Death Registry and the composite of ischemic and hemorrhagic stroke. All statistical tests were 2-sided and significant at P < .05. RESULTS: The median interval from patient identification until the end of electronic health record surveillance was 9.93 months (interquartile range, 2.83-19.17 months). We identified 308 atrial fibrillation patients with cerebral microbleeds; 128(41.6%) were on warfarin, 88(28.6%) on direct oral anticoagulants, and 92(29.9%) on neither. Over the surveillance interval, 87 deaths, 51 ischemic strokes, and 14 hemorrhagic strokes occurred. The estimated likelihoods of the composite stroke outcome and ischemic stroke only did not differ significantly among the 3 groups. However, patients taking direct oral anticoagulants had a significantly smaller likelihood of all-cause mortality than patients who were not anticoagulated (adjusted hazard ratio: .44[.23, .83], P=.012). CONCLUSIONS: In patients with coprevalent atrial fibrillation and cerebral microbleeds, we did not detect differences in subsequent ischemic stroke, hemorrhagic stroke, or both, comparing warfarin, direct oral anticoagulants, or neither. Patients treated with direct oral anticoagulants had better survival than nonanticoagulated patients.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Isquemia Encefálica/prevenção & controle , Hemorragias Intracranianas/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Varfarina/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/mortalidade , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Tomada de Decisão Clínica , Registros Eletrônicos de Saúde , Feminino , Florida/epidemiologia , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/mortalidade , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento , Varfarina/efeitos adversos
20.
Stroke ; 50(6): 1356-1363, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31092165

RESUMO

Background and Purpose- Predictors of stroke and transient ischemic attack (TIA) in patients with peripheral artery disease (PAD) are poorly understood. The primary aims of this analysis were to (1) determine the incidence of ischemic/hemorrhagic stroke and TIA in patients with symptomatic PAD, (2) identify predictors of stroke in patients with PAD, and (3) compare the rate of stroke in ticagrelor- and clopidogrel-treated patients. Methods- EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) randomized 13 885 patients with symptomatic PAD to receive monotherapy with ticagrelor or clopidogrel for the prevention of major adverse cardiovascular events (cardiovascular death, myocardial infarction, or ischemic stroke). Ischemic/hemorrhagic stroke and TIA were adjudicated and measured as incidence rates postrandomization and cumulative incidence (per patient-years). Post hoc multivariable competing risk hazards analyses were performed using baseline characteristics to determine factors associated with all-cause stroke in patients with PAD. Results- A total of 458 cerebrovascular events in 424 patients (317 ischemic strokes, 39 hemorrhagic strokes, and 102 TIAs) occurred over a median follow-up of 30 months, for a cumulative incidence of 0.87, 0.11, and 0.27 per 100 patient-years, respectively. Age, prior stroke, prior atrial fibrillation/flutter, diabetes mellitus, geographic region, ankle-brachial index <0.60, prior amputation, and systolic blood pressure were independent baseline factors associated with the occurrence of all-cause stroke. After adjustment for baseline factors, the rates of ischemic stroke and all-cause stroke remained lower in patients treated with ticagrelor as compared with those receiving clopidogrel. There was no significant difference in the incidence of hemorrhagic stroke or TIA between the 2 treatment groups. Conclusions- In patients with symptomatic PAD, ischemic stroke and TIA occur frequently over time. Comorbidities such as age, prior stroke, prior atrial fibrillation/flutter, diabetes mellitus, higher blood pressure, prior amputation, lower ankle-brachial index, and geographic region were each independently associated with the occurrence of all-cause stroke. Use of ticagrelor, as compared with clopidogrel, was associated with a lower adjusted rate of ischemic and all-cause stroke. Further study is needed to optimize medical management and risk reduction of all-cause stroke in patients with PAD. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01732822.


Assuntos
Clopidogrel/administração & dosagem , Hemorragias Intracranianas/prevenção & controle , Ataque Isquêmico Transitório/prevenção & controle , Doença Arterial Periférica/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Ticagrelor/administração & dosagem , Idoso , Clopidogrel/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/etiologia , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/complicações , Doença Arterial Periférica/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Ticagrelor/efeitos adversos
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