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1.
Acta Neurochir Suppl ; 127: 161-164, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31407078

RESUMO

BACKGROUND: Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Recently, we reported the possibility that computational fluid dynamics (CFD) could predict DCI in terms of the cross-sectional area and flow velocity of the ipsilateral extracranial internal carotid and distal parent arteries in a single-center retrospective study. METHODS: This is a multicenter, prospective, cohort study. Patients with aneurysmal SAH will undergo CFD analyses using preoperative three-dimensional computed tomography angiography, and we will investigate hemodynamic features of cerebral arteries in an acute stage of SAH. Primary outcome measures will be CFD features in patients with subsequent occurrence of DCI. Secondary outcome measures will be CFD features in patients with subsequent occurrence of cerebral vasospasm and cerebral infarction and the relationships with eventual modified Rankin scale score at 3 months. CONCLUSIONS: The present protocol for a multicenter prospective study is expected to provide a novel diagnostic method to predict DCI before aneurysmal obliteration in an acute stage of SAH.


Assuntos
Isquemia Encefálica , Infarto Cerebral , Hidrodinâmica , Hemorragia Subaracnóidea , Isquemia Encefálica/diagnóstico , Infarto Cerebral/diagnóstico , Estudos de Coortes , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Hemorragia Subaracnóidea/diagnóstico
2.
West Afr J Med ; 36(3): 286-289, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31622495

RESUMO

Stroke is a leading cause of disability and mortality globally. In the first few hours after ischaemic stroke, the severity and irreversibility of brain injury increase as time passes. The primary goal of the emergent management of acute ischaemic stroke is stabilization and reperfusion of the ischaemic penumbra if eligibility criteria are met and contraindications are ruled out. The primary reperfusion strategies are administration of intravenous tissue plasminogen activator (IV tPA) and endovascular thrombectomy (EVT). Close monitoring is warranted prior to, during, and after these reperfusion procedures to detect early neurologic deterioration that may signify complications from treatment.


Assuntos
Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/métodos , Fibrinolíticos/administração & dosagem , Reperfusão/métodos , Acidente Vascular Cerebral/cirurgia , Ativador de Plasminogênio Tecidual/administração & dosagem , Doença Aguda , Administração Intravenosa , Isquemia Encefálica/diagnóstico , Humanos , Acidente Vascular Cerebral/diagnóstico , Resultado do Tratamento
3.
West Afr J Med ; 36(3): 290-293, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31625582

RESUMO

Stroke is a leading cause of disability and mortality globally. In the first few hours after ischaemic stroke, the severity and irreversibility of brain injury increase as time passes. The primary goal of the emergent management of acute ischaemic stroke is stabilization and reperfusion of the ischaemic penumbra if eligibility criteria are met and contraindications are ruled out. The primary reperfusion strategies are administration of intravenous tissue plasminogen activator (IV tPA) and endovascular thrombectomy (EVT). Close monitoring is warranted prior to, during, and after these reperfusion procedures to detect early neurologic deterioration that may signify complications from treatment.


Assuntos
Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/métodos , Fibrinolíticos/administração & dosagem , Reperfusão/métodos , Acidente Vascular Cerebral/cirurgia , Ativador de Plasminogênio Tecidual/administração & dosagem , Doença Aguda , Administração Intravenosa , Isquemia Encefálica/diagnóstico , Humanos , Acidente Vascular Cerebral/diagnóstico , Resultado do Tratamento
4.
Adv Clin Exp Med ; 28(10): 1419-1424, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31538415

RESUMO

BACKGROUND: Anemia is associated with adverse outcomes in patients with acute myocardial infarction and congestive heart failure. Additionally, it has been shown that anemia increases the short-term mortality risk in patients with acute stroke. OBJECTIVES: The aim of our study was to determine the importance of anemia as a long-term mortality risk factor by itself or in combination with other risk factors. MATERIAL AND METHODS: We included 390 Caucasian patients with acute ischemic stroke in our study. Their progress was followed from the day of their admission until their death or a max. of 1,669 days. Stroke and anemia were defined according to the World Health Organization (WHO) criteria. RESULTS: Anemia was present in 57 (14.6%) patients. The patients with anemia were older (p < 0.01) and more likely to be female (p < 0.001). They had higher NIHSS scores on admission (p < 0.001) and discharge (p < 0.001), lower estimated glomerular filtration rates (eGFRs) (p < 0.001), lower serum LDL cholesterol (p < 0.01) and lower serum albumin levels (p < 0.001), while their serum C-reactive protein (CRP) levels were higher (p < 0.001). The Kaplan-Meier curves showed that patients with anemia had higher mortality (p < 0.001). Cox's regression analysis revealed that anemia at admission was a predictor of long-term mortality in these patients (hazard ratio (HR) = 2.448, 95% confidence interval (95% CI) = 1.773-3.490; p < 0.001). Anemia remained a strong predictor of mortality after adjusting for other risk factors as well. CONCLUSIONS: Anemia was frequent among our patients and was an independent predictor of long-term mortality even after adjusting for other risk factors.


Assuntos
Anemia/complicações , Isquemia Encefálica/complicações , Acidente Vascular Cerebral/complicações , Idoso , Anemia/diagnóstico , Anemia/mortalidade , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/terapia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio , Prognóstico , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
5.
Arch Cardiovasc Dis ; 112(8-9): 532-542, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31378692

RESUMO

BACKGROUND: Unlike previous randomized clinical trials (RCTs), recent trials and meta-analyses have shown that transcatheter closure of patent foramen ovale (PFO) reduces stroke recurrence risk in young and middle-aged adults with an otherwise unexplained PFO-associated ischaemic stroke. AIM: To produce an expert consensus on the role of transcatheter PFO closure and antithrombotic drugs for secondary stroke prevention in patients with PFO-associated ischaemic stroke. METHODS: Five neurologists and five cardiologists with extensive experience in the relevant field were nominated by the French Neurovascular Society and the French Society of Cardiology to make recommendations based on evidence from RCTs and meta-analyses. RESULTS: The experts recommend that any decision concerning treatment of patients with PFO-associated ischaemic stroke should be taken after neurological and cardiological evaluation, bringing together the necessary neurovascular, echocardiography and interventional cardiology expertise. Transcatheter PFO closure is recommended in patients fulfilling all the following criteria: age 16-60 years; recent (≤6 months) ischaemic stroke; PFO associated with atrial septal aneurysm (>10mm) or with a right-to-left shunt>20 microbubbles or with a diameter≥2mm; PFO felt to be the most likely cause of stroke after thorough aetiological evaluation by a stroke specialist. Long-term oral anticoagulation may be considered in the event of contraindication to or patient refusal of PFO closure, in the absence of a high bleeding risk. After PFO closure, dual anti-platelet therapy with aspirin (75mg/day) and clopidogrel (75mg/day) is recommended for 3 months, followed by monotherapy with aspirin or clopidogrel for≥5 years. CONCLUSIONS: Although a big step forward that will benefit many patients has been taken with recent trials, many questions remain unanswered. Pending results from further studies, decision-making regarding management of patients with PFO-associated ischaemic stroke should be based on a close coordination between neurologists/stroke specialists and cardiologists.


Assuntos
Isquemia Encefálica/prevenção & controle , Cateterismo Cardíaco/normas , Cardiologia/normas , Forame Oval Patente/terapia , Prevenção Secundária/normas , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Consenso , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Medição de Risco , Fatores de Risco , Dispositivo para Oclusão Septal/normas , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Resultado do Tratamento , Adulto Jovem
6.
J Stroke Cerebrovasc Dis ; 28(9): 2398-2406, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31311696

RESUMO

BACKGROUND: Coated-platelets are a subset of highly procoagulant platelets observed after dual agonist stimulation with collagen and thrombin. Coated-platelet levels are increased in acute stroke compared to controls, and higher levels are associated with stroke recurrence. We examined whether coated-platelet levels measured at the time of the stroke correlate with cognitive scores at 3 months following the brain infarction. METHODS: Coated-platelets were assayed in consecutive patients with nonlacunar stroke. Cognitive screening was performed using the Mini-Mental State Examination (MMSE) at 3 months after discharge. Linear regression, with adjustment for individual covariates, was used to model the association between coated-platelet levels and MMSE scores. RESULTS: One hundred and twenty-eight patients with a mean MMSE score of 26 points (range 14-30, standard deviation [SD] 3.1) and mean coated-platelet levels of 40.9% (range 5.2-76.2, SD 13.3), completed cognitive screening. An inverse linear association was found between coated-platelet levels and MMSE score, with higher levels seen in patients with lower MMSE scores (r = -.34, R2 = .12, P < .0001). This association remained despite adjustment for potential confounding factors. In the final model, higher coated-platelet levels (coefficient -.078, 95% confidence interval [CI]: -.12 to -.041, P < .0001), presence of hypertension (coefficient -2.42, 95% CI: -3.90 to -.95, P = .0015), and anticoagulant use at discharge (coefficient -1.48, 95% CI: -2.56 to -.39, P = .0079) were predictive of lower MMSE. CONCLUSIONS: These findings support a link between increased platelet procoagulant potential at the time of the stroke and development of cognitive impairment following cerebral infarction.


Assuntos
Coagulação Sanguínea , Plaquetas/metabolismo , Isquemia Encefálica/complicações , Transtornos Cognitivos/etiologia , Cognição , Ativação Plaquetária , Acidente Vascular Cerebral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/psicologia , Transtornos Cognitivos/sangue , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/psicologia , Feminino , Humanos , Masculino , Testes de Estado Mental e Demência , Pessoa de Meia-Idade , Projetos Piloto , Contagem de Plaquetas , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/psicologia , Fatores de Tempo
7.
J Stroke Cerebrovasc Dis ; 28(9): 2563-2568, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31281112

RESUMO

BACKGROUND: This study explored the associations of blood pressure (BP) with various stroke outcomes and investigated their changes by the elapsed time after stroke onset. METHODS: Patients who arrived within 48 hours of stroke onset between April 2008 and September 2014 were consecutively enrolled. For 10 days of hospitalization, all measured systolic BP (SBP) was summarized into mean at acute (first 3 days) and subacute stage (afterward to 7 days) for each patient. Coprimary outcomes were unfavorable outcome (modified Rankin Scale >2) at discharge and time to composite cardiovascular event of stroke, myocardial infarction, and vascular death for 1-year follow-up. Adjusted odds ratios (AOR) through SBPmean in both acute and subacute stages were interpolated using restricted cubic spline technique and adopted logistic regression models with predetermined covariates. The adjusted hazard ratios for cardiovascular event by SBPmean in both stages were interpolated. RESULTS: The study enrolled 3723 subjects (mean age, 66.7 ± 13.2 years old and median baseline National Institute of Health Stroke Scale score, 3). SBPmean in both stages showed linear trends for risks of unfavorable outcome, while the increase of AOR was observed explicitly in acute stage rather than subacute stage, especially in higher values. In contrast, SBPmean demonstrated the U-shaped associations with cardiovascular event in subacute stage rather than acute stage. CONCLUSIONS: In ischemic stroke, association patterns of BP would be different depending on stroke outcomes. The risky interval of BP would be changed by the elapsed time after stroke onset.


Assuntos
Pressão Sanguínea , Isquemia Encefálica/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/terapia , Causas de Morte , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Recuperação de Função Fisiológica , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Fatores de Tempo , Resultado do Tratamento
8.
J Stroke Cerebrovasc Dis ; 28(9): 2517-2524, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31296477

RESUMO

BACKGROUND: The purpose of this study was to validate and pilot the use of the four-variable screening tool (4V) and modified 4V tools to identify acute ischemic stroke and transient ischemic attack (TIA) patients at high risk of obstructive sleep apnea (OSA). METHODS: Two modified scales, 4V-1 (ie, using neck circumference instead body mass index, regardless of gender) and 4V-2 (ie, as above but scored differently according to gender) were designed. These tools were used in a consecutive cohort of 124 acute ischemic stroke/TIA patients, together with the 4V-1, 4V-2, 4V, as well as the STOP-BANG, the Berlin questionnaire, and the Epworth Sleepiness Scale (ESS). Objective level 2 or level 3 polysomnography was used to confirm OSA and its severity. Both questionnaires and polysomnography were completed within 1 week from symptom onset. RESULTS: Area under the curve (AUC) of 4V was 0.807 (P< .0001) while AUC of STOP-BANG, Berlin Questionnaire and ESS were .701 (P< .0001), .704 (P< .0001) and .576 (P = .1556), respectively. AUC of 4V was greater than of STOP-BANG (z = 2.200, P = .0220), Berlin (z = 2.024, P = .0430) and ESS (z = 3.363, P = .0003). AUC of modified 4V-1 and modified 4V-2 were .824 (P< .001) and .835 (P< .001), respectively. Performance of modified 4V-2 was higher versus modified 4V-1 (z = 2.111, P = .0348) and higher but not significantly so to regular 4V (z = 1.784, P = .0744). CONCLUSIONS: Neck circumference scored by gender is a useful substitution to body mass index in the 4V when screening OSA at early stages of ischemic stroke/TIA patients.


Assuntos
Isquemia Encefálica/diagnóstico , Técnicas de Apoio para a Decisão , Ataque Isquêmico Transitório/diagnóstico , Pescoço/patologia , Apneia Obstrutiva do Sono/etiologia , Acidente Vascular Cerebral/diagnóstico , Idoso , Pressão Sanguínea , Índice de Massa Corporal , Isquemia Encefálica/complicações , Isquemia Encefálica/fisiopatologia , Feminino , Humanos , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Polissonografia , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia , Ronco/fisiopatologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Inquéritos e Questionários
9.
J Stroke Cerebrovasc Dis ; 28(9): 2388-2397, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31320270

RESUMO

OBJECTIVE: Improve prehospital identification of acute ischemic stroke patients with large vessel occlusion (LVO) by using a trauma system-based emergency communication center (ECC) to guide the emergency medical service (EMS). METHODS: We trained 24 ECC paramedics in the Emergency Medical Stroke Assessment (EMSA). ECC-guided EMS in performance of the EMSA on patients with suspected stroke. During the second half of the study, we provided focused feedback to ECC after reviewing recorded ECC-EMS interactions. We compared the sensitivity, specificity, and area under the receiver operator characteristics curve (AUC) and 95% confidence interval of ECC-guided EMSA to the NIH Stroke Scale (NIHSS) for predicting a discharge diagnosis of LVO. RESULTS: We enrolled 569 patients from September 2016 through February 2018. Of 463 patients analyzed, 236 (51%) had a discharge diagnosis of stroke and 227 (49%) had a nonstroke diagnosis. There were 45 (19%) stroke patients with LVO. For predicting LVO, there was no significant difference between the EMSA AUC = .68 (.59-.77) and the NIHSS AUC = .73 (.65-.81). An EMSA score greater than or equal to 4 had sensitivity = 75.6 (60.5-87.1) and specificity = 62.4 (57.6-67.1) for LVO. During the first 9 months of the study, the EMSA AUC = .61 (.44-.77) compared to an AUC = .74 (.64-.84) during the second 9 months. CONCLUSIONS: ECC-guided prehospital EMSA is feasible, has similar ability to predict LVO compared to the NIHSS, and has sustained performance over time.


Assuntos
Arteriopatias Oclusivas/diagnóstico , Isquemia Encefálica/diagnóstico , Competência Clínica , Sistemas de Comunicação entre Serviços de Emergência , Serviços Médicos de Emergência/métodos , Auxiliares de Emergência/educação , Capacitação em Serviço/métodos , Acidente Vascular Cerebral/diagnóstico , Idoso , Arteriopatias Oclusivas/fisiopatologia , Arteriopatias Oclusivas/psicologia , Arteriopatias Oclusivas/terapia , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/psicologia , Isquemia Encefálica/terapia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Fatores de Risco , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/psicologia , Acidente Vascular Cerebral/terapia , Tempo para o Tratamento
10.
Int Heart J ; 60(4): 822-829, 2019 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-31257338

RESUMO

Atrial fibrillation (AF) is an independent risk factor for intracranial hemorrhage in patients receiving recombinant-tissue-type plasminogen activator (rt-PA) thrombolytic therapy. Research showed that patients with acute ischemic stroke (AIS) could benefit from multimode computed-tomography- (CT-) guided intravenous thrombolysis over 4.5 hours. The medical data of patients with AIS in our center were retrospectively reviewed, and the data of the multimode CT-guided thrombolytic therapy or nonthrombolytic therapy within different time windows (3-9 hours) were evaluated. 134 AIS cases were selected successfully and divided into three groups: patients with AF treated by rt-PA (AF rt-PA), patients with AF not treated by rt-PA (AF non-rt-PA), and patients without AF treated by rt-PA (non-AF rt-PA). After correcting for the baseline NIH Stroke Scale (NIHSS), sex, age, and hypertension data, the comparison results showed that the NIHSS improved significantly at hospital discharge for rt-PA-treated patients (n = 47) compared to non-rt-PA-treated patients with AIS (n = 31) with AF (P = 0.0156). The NIHSS evaluation at 90 days of follow-up also improved in rt-PA-treated patients (P = 0.0157). The NIHSS at hospital discharge was higher in AF rt-PA-treated patients compared to non-AF rt-PA-treated patients (P = 0.0167) after correction; the difference was not statistically significant at 90 days of follow-up (P = 0.091). Our research showed that the neural function improved after 3-9 hours of thrombolytic therapy with rt-PA in patients with AIS and AF. If there is no thrombolytic taboo, the patients could benefit from the thrombolytic therapy, although the onset time window has been extended to 9 hours.


Assuntos
Fibrilação Atrial/complicações , Isquemia Encefálica/tratamento farmacológico , Tomografia Computadorizada Multidetectores/métodos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Doença Aguda , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Feminino , Fibrinolíticos/administração & dosagem , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
11.
Ther Adv Cardiovasc Dis ; 13: 1753944719860676, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31319783

RESUMO

BACKGROUND: The role of cancer-specific factors for ischemic stroke and mortality in patients with cancer and atrial fibrillation (AF) is unknown. We evaluated the utility of a previously validated risk tool for venous thromboembolism (VTE) in cancer outpatients [Khorana score (KS)] in predicting stroke and mortality in cancer patients with AF. METHODS: We conducted a retrospective cohort study of patients with cancer and AF at the Cleveland Clinic from 2008 to 2014. Outcomes, CHADS2, CHA2DS2-VASc, and KS scores were calculated from date of cancer diagnosis. Prognostic factors were identified with Fine and Gray regression (for stroke) or Cox proportional hazards analysis (for mortality). RESULTS: The study population comprised 1181 patients. Genitourinary (19%), lung (18%), and gastrointestinal (13%) were the most frequent cancers. Overall, 67% had CHADS2 ⩾ 2, 57% had an intermediate KS (1-2), and 7% high KS (⩾3). Median follow up was 26.5 months (range 0.03-76). At a median of 8.2 months (range 0-61), 45 patients (3.8%) developed a stroke and 418 (35%) died. In multivariable analysis a high KS (HR 4.5, 95% CI 3.2-6.3, p < 0.001) was associated with a quadruple risk of death and every point increase in CHADS2 score had a 20% increased risk of death (HR 1.19, 95% CI 1.1-1.2, p < 0.001). The addition of KS did not improve risk stratification for ischemic stroke to CHADS2. CONCLUSION: In patients with cancer and AF, CHADS2 and CHA2DS2-VASc but not KS were predictive of ischemic stroke. A high KS represented a unique predictor of mortality beyond traditional risk scores.


Assuntos
Fibrilação Atrial/complicações , Isquemia Encefálica/etiologia , Técnicas de Apoio para a Decisão , Neoplasias/complicações , Acidente Vascular Cerebral/etiologia , Tromboembolia Venosa/etiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/mortalidade , Ohio , Valor Preditivo dos Testes , Prognóstico , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade
12.
J Stroke Cerebrovasc Dis ; 28(9): 2475-2480, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31256984

RESUMO

STUDY OBJECTIVE: Stroke mimics may be difficult distinguish from acute ischemic strokes and are often treated with alteplase though not by intent. We report the characteristics, frequency, and outcomes of stroke mimics treated at our institution. Using our data, we then explore how the inclusion of stroke mimics in stroke outcomes research may be an important source of bias. METHODS: We retrospectively identified all patients treated with alteplase in our emergency department from August 2013 to December 2017 for suspected acute ischemic stroke. We collected the following variables: gender, age, risk factors (hypertension, diabetes, and atrial fibrillation), admission glucose, admission National Institute of Health Stroke Scale, admission mean arterial pressure, onset-to-treatment time, adverse events, discharge diagnosis, length of stay, discharge NIHSS, discharge destination, and 3 month modified Rankin score. RESULTS: One hundred and eighteen patients were treated with alteplase for suspected acute ischemic stroke of which 33 (27.9%) were stroke mimics. Compared to ischemic strokes, stroke mimics were younger (median age 53 versus 69; P < .0003); were less likely to have vascular risk factors (hypertension [51.5% versus 78.8%; P < .005] diabetes (9.1% versus 32.9%; P < .007), and atrial fibrillation (3.0% versus 23.5%; P < .006). The most common stroke mimic was transient ischemic attack (33.3%). Stroke mimics were significantly more likely to be discharged home (75.8% versus 41.2%; P < .002). Outcomes unadjusted for stroke mimics led to artificial inflation of a favorable discharge destination. CONCLUSIONS: Inclusion of stroke mimics led to an artificial inflation of a favorable discharge destination for our entire cohort. Our study highlights the potential for bias in reporting favorable outcomes if appropriate adjustment accounting for stroke mimics does not occur.


Assuntos
Pesquisa Biomédica/métodos , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Projetos de Pesquisa , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Adulto , Idoso , Viés , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Diagnóstico Diferencial , Avaliação da Deficiência , Serviço Hospitalar de Emergência , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
13.
J Stroke Cerebrovasc Dis ; 28(9): 2488-2495, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277995

RESUMO

BACKGROUND AND OBJECTIVE: Current standard practice guidelines recommend ICU admission for ischemic stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). More recently, the trend in stroke care is to broaden eligibility for IV thrombolysis. Two examples are a more liberal inclusion criteria known as SMART criteria (sIV-tPA), and the transfer of patients to comprehensive stroke centers (CSC). The present study characterizes ICU interventions in these patients. Understanding which stroke patients that require ICU-level care may allow for placement of patients in the appropriate level of care at hospital admission. METHODS: We performed a retrospective review of consecutive transfer and nontransfer sIV-tPA-treated patients admitted to the ICU at a CSC. We evaluated the frequency, timing, and nature of ICU interventions. RESULTS: Three hundred and thirty one patients were treated with sIV-tPA and 42% required ICU interventions during ICU admission. Of patients requiring ICU interventions, 98% had an ICU intervention performed in triage, prior to admission. National Institute of Health Stroke Scale score only had a moderate association to requirement of ICU interventions. Neither transferring patients to a CSC nor the number of standard IV-tPA contraindications increased ICU interventions. CONCLUSIONS: Liberalized IV-tPA administration did not increase ICU interventions. Nearly all patients that required ICU interventions declared this need in triage, prior to ICU admission. This timing of ICU intervention use during triage is highly sensitive for whether a patient will require ongoing ICU-level care during hospital admission. Identifying ICU intervention use in triage may allow for more effective placement of post-IV-tPA patients in the appropriate inpatient care setting, leading to better utilization of scarce ICU resources.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Unidades de Terapia Intensiva , Admissão do Paciente , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Triagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva/normas , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Seleção de Pacientes , Transferência de Pacientes , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/normas , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Triagem/normas
14.
BMC Neurol ; 19(1): 155, 2019 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-31288770

RESUMO

BACKGROUND: Intravenous thrombolysis has been recently introduced in Nepal for the management of acute ischemic stroke. Pre-hospital delay is one of the main reasons that hinder thrombolytic therapy. The objective of this study was to evaluate the status of prehospital delay and thrombolysis in Nepal. METHODS: Data were prospectively collected from patients of both genders, age >  18 years who arrived at the emergency department (ED) with symptoms and neuroimaging findings consistent with an ischemic stroke. Patient data were obtained from ED form and standard questionnaires were used to assess factors resulting in prehospital delay. Modified Rankin scale and National Institute of Health stroke scale were used to assess the degree of disability and severity of stroke respectively. RESULTS: A total of 228 patients were enrolled in the study between August 2017 and August 2018. Only 46 (20.17%) patients arrived within the time frame for thrombolysis. Onset at daytime (OR: 4.07; 95% CI: 1.65-10.1; p = 0.001), stroke symptoms facial deviation (OR: 5.03; 95% CI: 2.47 to 10.26; p = 0.000) and speech disturbances (OR: 2.34; 95% CI: 1.06 to 5.1; p = 0.021), identification of stroke (OR: 22.36; 95% CI: 9.42-53.04;p = 0.000), rushing to ED after onset of symptoms (OR: 2.93; 95% CI: 1.5-5.7; p = 0.001), awareness of treatment of stroke (OR: 10.21; 95% CI: 4.8-21.6; p = 0.000), direct presentation (OR: 4.2; 95% CI: 2.09-8.66; p = 0.000), the distance less than 20 km (OR: 7.9; 95% CI: 3.8-16.5; p = 0.000), and education above high school (OR:4.85; 95% CI: 2.2-10.5; p = 0.000) were associated with early arrival. Heavy traffic, income below 1000 USD per annum and diabetes mellitus were associated with delayed arrival to ED. Out of 46 early arrival patients, only 30 patients (13.15%) received tissue plasminogen activator during the study period, while others were deprived because of their inability to afford the treatment cost. CONCLUSION: Community-based intervention to spread awareness, establishing comprehensive stroke centers, training specialists, improving emergency services, establishment of telestroke facilities and encouraging the use of low-cost tenecteplase as an alternative to alteplase can help improve care for stroke patients in Nepal.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/uso terapêutico , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Serviços Médicos de Emergência , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Nepal , Estudos Prospectivos , Acidente Vascular Cerebral/diagnóstico , Fatores de Tempo
15.
J Clin Neurosci ; 67: 276-277, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31266715

RESUMO

High altitude exposure could be related to neurological events such as stroke-like episodes, even if the exact pathogenic mechanism is still debated. We describe the case of a caucasian woman who had a bilateral insular ischemic stroke after a rapid ascent above 4000 m in which a secondary embolic dissemination due to a right insular stroke, maybe related to high altitude hemoconcentration, could be hypothesized. In our opinion a prolonged cardiac rhythm monitoring have to be considered especially when no other embolic sources are found and for lesions involving the insular cortex.


Assuntos
Doença da Altitude/complicações , Isquemia Encefálica/diagnóstico , Montanhismo , Acidente Vascular Cerebral/diagnóstico , Isquemia Encefálica/etiologia , Córtex Cerebral/diagnóstico por imagem , Córtex Cerebral/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Acidente Vascular Cerebral/etiologia
16.
J Stroke Cerebrovasc Dis ; 28(8): 2280-2286, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174955

RESUMO

BACKGROUND: Early diagnosis of stroke optimizes reperfusion therapies, but behavioral measures have incomplete accuracy. Electroencephalogram (EEG) has high sensitivity for immediately detecting brain ischemia. This pilot study aimed to evaluate feasibility and utility of EEG for identifying patients with a large acute ischemic stroke during Emergency Department (ED) evaluation, as these data might be useful in the prehospital setting. METHODS: A 3-minute resting EEG was recorded using a dense-array (256-lead) system in patients with suspected acute stroke arriving at the ED of a US Comprehensive Stroke Center. RESULTS: An EEG was recorded in 24 subjects, 14 with acute cerebral ischemia (including 5 with large acute ischemic stroke) and 10 without acute cerebral ischemia. Median time from stroke onset to EEG was 6.6 hours; and from ED arrival to EEG, 1.9 hours. Delta band power (P = .004) and the alpha/delta frequency band ratio (P = .0006) each significantly distinguished patients with large acute ischemic stroke (n = 5) from all other patients with suspected stroke (n = 19), with the best diagnostic utility coming from contralesional hemisphere signals. Larger infarct volume correlated with higher EEG power in the alpha/delta frequency band ratio within both the ipsilesional (r = -0.64, P = .013) and the contralesional (r = -0.78, P = .001) hemispheres. CONCLUSIONS: Within hours of stroke onset, EEG measures (1) identify patients with large acute ischemic stroke and (2) correlate with infarct volume. These results suggest that EEG measures of brain function may be useful to improve diagnosis of large acute ischemic stroke in the ED, findings that might be useful to pre-hospital applications.


Assuntos
Isquemia Encefálica/diagnóstico , Ondas Encefálicas , Encéfalo/fisiopatologia , Eletroencefalografia , Serviço Hospitalar de Emergência , Acidente Vascular Cerebral/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Encéfalo/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Estudos de Casos e Controles , Diagnóstico Precoce , Estudos de Viabilidade , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Tomografia Computadorizada por Raios X
18.
J Stroke Cerebrovasc Dis ; 28(8): 2273-2279, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31160218

RESUMO

BACKGROUND: Embolic stroke of undetermined source (ESUS) identifies patients with cryptogenic ischemic stroke presumed due to embolism from several unidentified sources. Among patients with recent ESUS, we sought to determine independent predictors of recurrent ischemic stroke during treatment with aspirin or rivaroxaban and to assess the relative effects of these treatments according to risk. METHODS: Exploratory analyses of 7213 participants in the NAVIGATE ESUS international trial who were randomized to aspirin 100 mg/day or rivaroxaban 15 mg/day and followed for a median of 11 months, during which time there were 309 first recurrent ischemic strokes (4.6% per year). Baseline features were correlated with recurrent stroke by multivariate analysis. RESULTS: The 7 independent predictors of recurrent stroke were stroke or transient ischemic attack (TIA) prior to the qualifying stroke (hazard ratio [HR] 2.03 95% confidence internal [CI] 1.58-2.60), current tobacco user (HR 1.62, 95% CI 1.24-2.12), age (HR 1.02 per year increase, 95%CI 1.01-1.03), diabetes (HR 1.28, 95% CI 1.01-1.64), multiple acute infarcts on neuroimaging (HR 1.49, 95% CI 1.09-2.02), aspirin use prior to qualifying stroke (HR 1.34, 95% CI 1.02-1.70), and time from qualifying stroke to randomization (HR .98, 95% CI .97-.99). The rate of recurrent stroke rate was 2.6% per year for participants without any of these risk factors, and increased by an average of 45% for each independent predictor (P < .001). There were no significant interactions between treatment effects and independent stroke predictors or stroke risk status. CONCLUSIONS: In this large cohort of ESUS patients, several features including prior stroke or TIA, advanced age, current tobacco user, multiple acute infarcts on neuroimaging, and diabetes independently identified those with an increased risk of ischemic stroke recurrence. The relative effects of rivaroxaban and aspirin were similar across the spectrum of independent stroke predictors and recurrent stroke risk status.


Assuntos
Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Isquemia Encefálica/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Embolia Intracraniana/tratamento farmacológico , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Idoso , Anticoagulantes/efeitos adversos , Aspirina/efeitos adversos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Método Duplo-Cego , Inibidores do Fator Xa/efeitos adversos , Feminino , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , Masculino , Pessoa de Meia-Idade , Recidiva , Medição de Risco , Fatores de Risco , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
19.
J Stroke Cerebrovasc Dis ; 28(8): 2302-2310, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174954

RESUMO

BACKGROUND: Aggregation of platelets is a trigger for additional development of larger thrombi. This study aimed to identify factors that may affect platelet aggregability and their role in clinical outcomes in acute ischemic stroke. METHODS: Consecutive acute ischemic stroke patients (n = 352) who were transferred within 24 hours after its onset were enrolled. Peripheral venous blood was sampled to measure platelet aggregability and other parameters. RESULTS: Mean values of spontaneous small-sized platelet aggregates and collagen- or adenosine diphosphate (ADP)-induced large-sized aggregates were elevated in acute ischemic stroke. In atherothrombotic stroke (n = 178), collagen and ADP-induced large-sized aggregates were positively correlated with HbA1c, respectively. High incidence of the modified Rankin Scales (mRS) 5-6 at discharge was associated with diabetes complication (odds ratio [OR] 8.77, 95% confidence interval [CI] 1.32-57.56). The proportion of patients who were functionally independent (the mRS 0-2) at discharge was lower in the middle tertile of collagen and ADP-induced large-sized aggregates than their low tertile (OR 2.46, 95% CI 1.09-5.58; OR 2.43, 95% CI 1.05-5.59, respectively). Prestroke administration of aspirin recovered the proportion of independence at discharge (OR 0.25, 95% CI 0.06-0.99), and ameliorated incidence of the mRS 5-6. On logistic regression analysis, diabetes, HbA1c, collagen-induced large-sized aggregates, and prestroke administration of aspirin remained independent predictors of clinical outcomes in atherothrombotic stroke. In cardioembolic and lacunar stroke, no relations with clinical outcomes were found. CONCLUSIONS: High plasma level of HbA1c is involved in enhanced platelet aggregability in acute atherothrombotic stroke patients, and prestroke administration of aspirin may be beneficial to clinical outcomes.


Assuntos
Aspirina/uso terapêutico , Plaquetas/efeitos dos fármacos , Isquemia Encefálica/tratamento farmacológico , Diabetes Mellitus/sangue , Hemoglobina A Glicada/metabolismo , Inibidores da Agregação de Plaquetas/uso terapêutico , Agregação Plaquetária/efeitos dos fármacos , Testes de Função Plaquetária/métodos , Acidente Vascular Cerebral/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Biomarcadores/sangue , Plaquetas/metabolismo , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Comorbidade , Estudos Transversais , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Avaliação da Deficiência , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima
20.
J Stroke Cerebrovasc Dis ; 28(8): 2292-2301, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31200963

RESUMO

BACKGROUND AND PURPOSE: Although endovascular thrombectomy combined with recombinant tissue-type plasminogen activator is effective for treatment of acute ischemic stroke, regional disparities in implementation rates of those treatments have been reported. Drive and retrieve system, where a qualified neurointerventionist travels to another primary stroke center for endovascular thrombectomy, has been practiced in parts of Hokkaido, Japan. This study aims to simulate the cost effectiveness of the drive and retrieve system, which can be a method to enhance equality and cost effectiveness of treatments for acute ischemic stroke. MATERIALS AND METHODS: The number of patients who had acute ischemic stroke in 2015 is estimated. Those patients are generated according to the population distribution, and thereafter patient transport time is analyzed in the 3 scenarios (1) 60-minute drive scenario, (2) 90-minute drive scenario, in which the drive and retrieve system operates within 60-minute or 90-minute driving distance (3) without the system, using geographic information system. Incremental cost-effectiveness rate, quality-adjusted life years, and medical and nursing care costs are estimated from the analyzed transport time. FINDINGS: The incremental cost-effectiveness rate by implementing the system was dominant. Cost reductions of $213,190 in 60-minute drive scenario, and $247,274 in the 90-minute scenario were expected, respectively. Such benefits are the most significant in Soya, Emmon, Rumoi, and Kamikawahokubu medical areas. CONCLUSIONS: The drive and retrieve system could enhance regional equality and cost effectiveness of ischemic stroke treatments in Hokkaido, which can be achieved using existing resources. Further studies are required to clarify its cost effectiveness from hospital perspective.


Assuntos
Condução de Veículo , Isquemia Encefálica/terapia , Procedimentos Endovasculares/economia , Sistemas de Informação Geográfica/economia , Custos de Cuidados de Saúde , Neurologistas/economia , Regionalização/economia , Acidente Vascular Cerebral/terapia , Trombectomia/economia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Redução de Custos , Análise Custo-Benefício , Prestação Integrada de Cuidados de Saúde/economia , Sistemas de Informação Geográfica/organização & administração , Disparidades em Assistência à Saúde/economia , Humanos , Japão/epidemiologia , Neurologistas/organização & administração , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Regionalização/organização & administração , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Tempo para o Tratamento/economia , Resultado do Tratamento
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