Joinville stroke biobank: study protocol and first year's results / Biobanco de acidente cerebrovascular de Joinville: protocolo de estudos e resultados dos primeiros anos

ABSTRACT Aiming to contribute to studies that use detailed clinical and genomic information of biobanks, we present the initial results of the first Latin American Stroke Biobank. Methods: Blood samples were collected from patients included in the Joinville Stroke Registry and four Brazilian cities. Demographic socio-economic data, cardiovascular risk factors, Causative Classification System for Ischemic Stroke, Trial of Org 10172 in Acute Stroke Treatment and National Institutes of Health scores, functional stroke status (modified Rankin) and brain images were recorded. Additionally, controls from both geographic regions were recruited. High-molecular-weight genomic DNA was obtained from all participants. Results: A total of 2,688 patients and 3,282 controls were included. Among the patients, 76% had ischemic stroke, 12% transient ischemic attacks, 9% hemorrhagic stroke and 3% subarachnoid hemorrhage. Patients with undetermined ischemic stroke were most common according the Trial of Org 10172 in Acute Stroke Treatment (40%) and Causative Classification System for Ischemic Stroke (47%) criteria. A quarter of the patients were under 55 years of age at the first-ever episode. Conclusions: We established the Joinville Stroke Biobank and discuss its potential for contributing to the understanding of the risk factors leading to stroke.

RESUMO Com o objetivo de contribuir para estudos que utilizam informações clínicas e genômicas de biobancos, apresentamos os resultados iniciais do primeiro Biobanco Latinoamericano em Acidente Vascular Cerebral (AVC). Métodos: Foram coletadas amostras de sangue de pacientes recrutados pelo Registro de AVC de Joinville e posteriormente de quatro cidades brasileiras. Foram registrados dados socioeconômicos demográficos, fatores de risco cardiovasculares, Causative Classification System (CCS), Trial of Org 10172 in Acute Stroke Treatment, National Institutes of Health, estado funcional (Rankin modificado) e imagens cerebrais. Adicionalmente, foram recrutados controles das regiões geográficas correspondentes. Obteve-se DNA genômico de todos participantes. Resultados: Foram incluídos 2688 pacientes e 3282 controles. Entre os pacientes, 76% tiveram AVC isquêmico, 12% ataques isquêmicos transitórios, 9% AVC hemorrágico e 3% hemorragia subaracnóidea. Os casos indeterminados foram os mais frequentes e classificados de acordo com TOAST (40%) e CCS (47%). Um quarto dos pacientes tinham menos de 55 anos no primeiro evento. Conclusões: Estabelecemos o Joinville Stroke Biobank, e discutimos aqui seu potencial na compreensão dos fatores de risco do AVC.

The direct first pass aspiration technique in the treatment of acute ischemic stroke resulting from large vessel occlusions / Técnica de aspiração primária no tratamento do acidente vascular cerebral isquêmico por oclusões de grandes vasos

ABSTRACT Mechanical thrombectomy using stent retrievers is the standard treatment for acute ischemic stroke that results from large vessel occlusions. The direct aspiration first pass technique (ADAPT) has been proposed as an efficient, fast, and cost-effective thrombectomy strategy. The aim of this study was to assess the safety and efficacy of ADAPT. Methods Recanalization was assessed using the modified thrombolysis in cerebral infarction (mTICI) score. Neurological outcomes were assessed using the National Institutes of Health Stroke Scale and modified Rankin Scale. Results Fifteen patients were evaluated. The mTICI score was 2b-3 in 80%, and it was 3 in 60% of patients. No intracranial hemorrhage was seen. At three months, modified Rankin Scale scores ≤ 2 were observed in 60% of patients and the mortality rate was 13.3%. Conclusions The ADAPT appears to be a safe, effective, and fast recanalization strategy for treatment of acute ischemic stroke resulting from large vessel occlusions.

RESUMO A trombectomia mecânica com stent retrievers é o tratamento padrão ouro do acidente vascular cerebral isquêmico agudo (AVCi) por oclusão de grandes artérias. A técnica de aspiração primária (ADAPT) tem sido proposta como uma estratégia de trombectomia rápida e com boa custo-efetividade. O objetivo deste estudo foi avaliar a segurança e eficácia da técnica ADAPT. Métodos A recanalização foi avaliada utilizando a escala mTICI. Os desfechos neurológicos foram avaliados utilizando as escalas do NIHSS e mRS. Resultados Quinze pacientes foram avaliados. Foram obtidas taxas de mTICI = 2b-3 em 80% e TICI = 3 em 60% dos pacientes. Não ocorreram hemorragias intracranianas. Em 3 meses as taxas de mRS≤2 e mortalidade foram respectivamente 60% e 13.3%. Conclusão A técnica ADAPT parece ser uma estratégia de recanalização rápida, segura e efetiva para o tratamento do AVC por oclusão de grandes artérias.

Prevalence and predictors of post stroke depression among elderly stroke survivors / Prevalência e preditores de depressão pós-AVC em idosos sobreviventes de acidente vascular cerebral

ABSTRACT Objective To identify the prevalence of post stroke depression (PSD) and their socio-demographic and clinical predictors among elderly stroke survivors after hospital discharge to home. Methods In this cross-sectional study, 90 elderly stroke survivors were evaluated 14 days after hospital discharge with the following scales: National Institutes of Health Stroke Scale, Functional Independence Measure, and Geriatric Depression Scale – 15 items (GDS-15). PSD was defined as a score > 5 on GDS-15. After univariate analyses, a multivariate logistic regression model was built to identify independent predictors of PSD. Results Fourteen days after hospital discharge, 27.7% (95%CI 18.1 to 37.2) of elderly stroke survivors had PSD. Functional dependence was the only independent predictor of PSD (OR: 1.04 95%CI: 1.01 to 1.09; p = 0.02). Conclusion After stroke, depressive symptoms are common among elderly survivors. The degree of functional dependency is the main predictor of PSD among elderly stroke patients in Brazil.

RESUMO Objetivos Identificar a prevalência de depressão pós-AVC (DPAVC) e seus preditores sócio-demográficos e clínicos nos idosos sobreviventes do acidente vascular cerebral (AVC) após alta hospitalar para casa. Métodos Nesse estudo transversal, 90 idosos sobreviventes do AVC foram avaliados 14 dias após alta hospitalar com as escalas a seguir: National Institutes of Health Stroke Scale, Medida da Independência Funcional (MIF), Escala de Depressão Geriátrica – 15 itens (EDG-15). DPAVC foi definida como escore > 5 na EDG-15. Depois da análise univariada, a regressão logística multivariada foi construída para identificar os preditores independentes da DPAVC. Resultados Quatorze dias após a alta hospitalar, 27,7% (IC95% = 18,1–37,2) dos idosos sobreviventes do AVC tinham DPAVC. A dependência funcional foi o único preditor independente da DPAVC (OR: 1.04 95%CI: 1,01–1,09; p = 0.02). Conclusão Após um AVC, sintomas depressivos são frequentes entre os idosos sobreviventes. O grau de dependência funcional é o principal preditor da DPAVC neste pacientes no Brasil.

Predictors of quality of life after moderate to severe traumatic brain injury / Preditores de qualidade de vida após trauma crânio-encefálico moderado a grave

ABSTRACT Objective To verify correlations between age, injury severity, length of stay (LOS), cognition, functional capacity and quality of life (QOL) six months after hospital discharge (HD) of victims of traumatic brain injury (TBI). Method 50 patients consecutively treated in a Brazilian emergency hospital were assessed at admission, HD and six months after HD. The assessment protocol consisted in Abbreviated Injury Scale, Injury Severity Score, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Mini Mental Test, Barthel Index and World Health Organization QOL - Brief. Results Strong negative correlation was observed between LOS and GCS and LOS and RTS. An almost maximal correlation was found between RTS and GCS and functional capacity and GCS at HD. Age and LOS were considered independent predictors of QOL. Conclusion Age and LOS are independent predictors of QOL after moderate to severe TBI.

RESUMO Objetivo Verificar correlações entre idade, gravidade do trauma, tempo de hospitalização (TH), cognição, capacidade funcional e qualidade de vida (QV) seis meses após alta hospitalar (AH) de vítimas de trauma crânio-encefálico (TCE). Método 50 pacientes tratados em um hospital de emergência brasileiro foram avaliados na admissão, AH e seis meses após AH. O protocolo de avaliação consistia em Escala Abreviada de Lesões, Índice de Gravidade de Lesão, Escala de Coma de Glasgow (ECG), Escore de Trauma Revisado (RTS), teste Mini-Mental, Índice de Barthel e Questionário Breve de QV da Organização Mundial de Saúde. Resultados Forte correlação negativa foi observada entre TH e ECG e TH e RTS. Correlação quase máxima foi observada entre RTS e ECG e capacidade funcional e ECG na AH. Idade e TH foram considerados preditores independentes de QV. Conclusão Idade e TH são preditores independentes de QV após TCE moderado e grave.

Carotid artery stenting in the context of endovascular treatment of acute ischemic stroke / Angioplastia com stent de carótida no contexto do tratamento endovascular do acidente vascular cerebral isquêmico agudo

ABSTRACT Mechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH.

RESUMO Trombectomia mecânica com stentrievers associada a trombólise endovenosa com rTPA é o tratamento padrão-ouro do acidente vascular cerebral isquêmico agudo (AVCi) devido à oclusões de grandes vasos. No entanto, a melhor estratégia terapêutica para oclusões carotídeas combinadas ainda permanece controversa. Método Vinte paciente receberam tratamento endovascular. O desfecho primário foi a taxa de recanalização completa sem sangramento intracraniano sintomático. Os desfechos secundários foram os tempos de recanalização, duração dos procedimentos e desfechos clínicos em 3 meses. Resultados O desfecho primário foi alcançado em 17 (85%) pacientes. A taxa de recanalização foi de 90% (19/20) e a taxa de HIS foi de 5% (1/20). Em três meses, foi obtido bom desfecho neurológico em 35% (7/20) dos pacientes e a mortalidade foi de 20% (4/20). Conclusão A angioplastia com stent de carotída associada ao tratamento endovascular para oclusões combinadas agudas de carótida parece ser efetiva sem um aumento de HIS.

Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population

OBJECTIVE: Large vessel occlusion in acute ischemic stroke is associated with low recanalization rates under intravenous thrombolysis. We evaluated the safety and efficacy of the Solitaire AB stent in treating acute ischemic stroke. METHODS: Patients presenting with acute ischemic stroke were prospectively evaluated. The neurological outcomes were assessed using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Time was recorded from the symptom onset to the recanalization and procedure time. Recanalization was assessed using the thrombolysis in cerebral infarction score. RESULTS: Twenty-one patients were evaluated. The mean patient age was 65, and the National Institutes of Health Stroke Scale scores ranged from 7 to 28 (average 17±6.36) at presentation. The vessel occlusions occurred in the middle cerebral artery (61.9%), distal internal carotid artery (14.3%), tandem carotid occlusion (14.3%), and basilarartery (9.5%). Primary thrombectomy, rescue treatment and a bridging approach represented 66.6%, 28.6%, and 4.8% of the performed procedures, respectively. The mean time from symptom onset to recanalization was 356.5±107.8 minutes (range, 80-586 minutes). The mean procedure time was 60.4±58.8 minutes (range, 14-240 minutes). The overall recanalization rate (thrombolysis in cerebral infarction scores of 3 or 2b) was 90.4%, and the symptomatic intracranial hemorrhage rate was 14.2%. The National Institutes of Health Stroke Scale scores at discharge ranged from 0 to 25 (average 6.9±7). At three months, 61.9% of the patients had a modified Rankin Scale score of 0 to 2, with an overall mortality rate of 9.5%. CONCLUSIONS: Intra-arterial thrombectomy with the Solitaire AB device appears to be safe and effective. Large randomized trials are necessary to confirm the benefits of this approach in acute ischemic stroke.

Pushing behavior and hemiparesis: which is critical for functional recovery in pusher patients?: case report

We report a sequential neuroimaging study in a 48-years-old man with a history of chronic hypertension and lacunar strokes involving the ventral lateral posterior nucleus of the thalamus. The patient developed mild hemiparesis and severe contraversive pushing behavior after an acute hemorrhage affecting the right thalamus. Following standard motor physiotherapy, the pusher behavior completely resolved 3 months after the onset and, at that time, he had a Barthel Index of 85, although mild left hemiparesis was still present. This case report illustrates that pushing behavior itself may be severely incapacitating, may occur with only mild hemiparesis and affected patients may have dramatic functional improvement (Barthel Index 0 to 85) after resolution pushing behavior without recovery of hemiparesis.

Relatamos o estudo de neuroimagem seqüencial de um homem de 48 anos com história de hipertensão arterial crônica e acidentes vasculares cerebrais (AVCs) lacunares nos núcleos ventral lateral posterior do tálamo. O paciente desenvolveu hemiparesia leve e síndrome do empurrador (SE) grave após AVC hemorrágico no tálamo direito, sendo tratado com fisioterapia motora convencional. Três meses após o ictus, os sinais da síndrome haviam desaparecido e o paciente apresentava índice de Barthel 85, apesar da permanência da hemiparesia leve. Este caso demonstra que a síndrome do empurrador isolada pode ser gravemente incapacitante, pode ocorrer associada a hemiparesia leve e que os pacientes com esta síndrome podem apresentar recuperação funcional importante (índice de Barthel inicial 0 e final 85) após a resolução da SP sem alteração do grau de hemiparesia.