Increased blood pressure variability predicts poor outcomes from endovascular treatment for aneurysmal subarachnoid hemorrhage / Aumento da variabilidade da pressão arterial prediz resultados ruins de tratamento endovascular para hemorragia subaracnóide aneurismática

ABSTRACT Background: Predictors of outcomes following endovascular treatment (ET) for aneurysmal subarachnoid hemorrhage (aSAH) are not well-defined. Identifying them would be beneficial in determining which patients might benefit from ET. Objective: To identify the predictive factors for poor outcomes following ET for aSAH. Methods: 120 patients with ruptured cerebral aneurysms underwent endovascular embolization between January 2017 and December 2018. Blood pressure variability was examined using the standard deviation of the 24-hour systolic blood pressure (24hSSD) and 24-hour diastolic blood pressure (24hDSD). Predictors were identified through univariate and multivariate regression analysis. All patients were followed up for three months. Results: At follow-up, 86 patients (71.7%) had good outcomes and 34 (28.3%) had poor outcomes. Patients with poor outcomes had significantly higher 24hSSD than those with good outcomes (19.3 ± 5.5 vs 14.1 ± 4.8 mmHg; P < 0.001). The 24hDSD did not differ significantly between patients with good outcomes and those with poor outcomes (9.5 ± 2.3 vs 9.9 ± 3.5 mmHg; P = 0.464). The following were significant risk factors for poor outcomes after endovascular embolization: age ≥ 65 years (odds ratio [OR] = 23.0; 95% confidence interval [CI]: 3.0-175.9; P = 0.002); Hunt-Hess grade 3-4 (OR = 6.8; 95% CI: 1.1-33.7; P = 0.039); Fisher grade 3-4 (OR = 47.1; 95% CI: 3.8-586.5; P = 0.003); postoperative complications (OR = 6.1; 95% CI: 1.1-34.8; P = 0.042); and 24hSSD ≥ 15 mmHg (OR = 14.9; 95% CI: 4.0-55.2; P < 0.001). Conclusion: Elevated 24hSSD is a possibly treatable predictive factor for poor outcomes after ET for aSAH.

RESUMO Antecedentes: Fatores preditores de resultados após tratamento endovascular (TE) para hemorragia subaracnóide aneurismática (HSA) não estão bem definidos. Identificá-los seria útil para determinar quais pacientes podem se beneficiar de TE. Objetivo: Identificar os fatores preditivos de resultados ruins após TE para HSA. Métodos: 120 pacientes com aneurismas cerebrais rompidos foram submetidos à embolização endovascular entre janeiro de 2017 e dezembro de 2018. A variabilidade da pressão arterial foi examinada usando-se o desvio padrão da PA sistólica de 24 horas (DPPAS- 24h) e da PA diastólica de 24 horas (DPPAD-24h). Os fatores preditores foram identificados por meio de análises de regressão univariada e multivariada. Todos os pacientes foram acompanhados por três meses. Resultados: No acompanhamento, 86 pacientes (71,7%) tiveram bons resultados e 34 (28,3%) tiveram resultados ruins. Pacientes com resultados ruins apresentaram DPPAS-24h significativamente maior do que aqueles com bons resultados (19,3 ± 5,5 vs 14,1 ± 4,8 mmHg; P <0,001). O DPPAD-24h não diferiu significativamente entre os pacientes com bons resultados e aqueles com resultados ruins (9,5 ± 2,3 vs 9,9 ± 3,5 mmHg; P = 0,464). Os fatores de risco significativos para resultados ruins após embolização endovascular foram os seguintes: idade ≥ 65 anos (razão de probabilidade [OR] = 23,0; intervalo de confiança de 95% [IC]: 3,0-175,9; P = 0,002); escala de Hunt-Hess 3-4 (OR = 6,8; IC 95%: 1,1-33,7; P = 0,039); escala de Fisher 3-4 (OR = 47,1; IC 95%: 3,8-586,5; P = 0,003); complicações pós-operatórias (OR = 6,1; IC 95%: 1,1-34,8; P = 0,042); e DPPAS 24h ≥ 15 mmHg (OR = 14,9; IC 95%: 4,0-55,2; P <0,001). Conclusão: O DPPAS 24h elevado é um fator preditivo possivelmente tratável para resultados ruins após TE para HSA.

Tasa de incidencia del accidente cerebrovascular en el Perú / Incidence rate of stroke in Peru

RESUMEN Objetivo: Determinar la tasa de incidencia del accidente cerebro vascular (ACV) total y por subtipos en el Perú entre 2017 y 2018. Materiales y métodos: Análisis de datos de morbilidad hospitalaria obtenidos de la Superintendencia Nacional de Salud (datos abiertos). A partir de los códigos CIE-10 se estudiaron la hemorragia subaracnoidea (I60), la hemorragia intracerebral atraumática (I61), el infarto cerebral (I63) y el ACV no especificado (I64). Se estimó la tasa de incidencia cruda y estandarizada por edad (comparando contra la población de la Organización Mundial de la Salud) y se usó como denominador el número de personas según año, edad y sexo de acuerdo con proyecciones nacionales. Resultados: En 2017, se registró un total de 10 570 casos de ACV, mientras que en 2018 hubo 12 835. Los eventos isquémicos fueron más frecuentes en ambos años. Independientemente del subtipo de ACV y del año, los varones fueron más afectados que las mujeres. En la población de 35 años a más, se evidenció un aumento en la incidencia cruda de ACV total entre 2017 y 2018, de 80,9 a 96,7 por 100 000 personas-año. La incidencia estandarizada mostró la misma tendencia, pero en mayor magnitud: de 93,9 a 109,8 por 100 000 personas-año. El ACV isquémico fue el que más aumentó, con una tasa estandarizada en mayores de 35 años de 35,2 en 2017 y de 46,3 en 2018 por 100 000 personas-año. Conclusiones: La incidencia de ACV es elevada en el Perú, con predominio de casos isquémicos y afectando desproporcionalmente a los varones. Estos resultados sugieren la necesidad de tener un sistema de vigilancia para cuantificar la incidencia de estos casos y entender sus determinantes.

ABSTRACT Objective: To determine the incidence of stroke, overall and by sub-types, in Peru between 2017 and 2018. Materials and Methods: Analysis of hospital morbidity data obtained from SUSALUD (open data). Using the ICD-10 codes, the following were studied: subarachnoid hemorrhage (I60), atraumatic intracerebral hemorrhage (I61), cerebral infarction (I63), and unspecified stroke (I64). The crude and age-standardized incidence was calculated according to the population of the World Health Organization and using the national projected population number of people according to year, age and sex as the denominator. Results: In 2017, a total of 10,570 stroke cases were recorded, whereas, in 2018, there were 12,835 cases. Ischemic events were more frequent in both years. Regardless of stroke subtype and year, men were more affected than women. In the 35+ year-old population, an increase in the crude incidence of total stroke was observed between 2017 and 2018, from 80.9 to 96.7 per 100,000 person-years. The age-standardized incidence showed the same trend, but in a greater magnitude: from 93.9 to 109.8 per 100,000 person-years. Ischemic stroke was the one that increased the most, with an age-standardized rate in people aged 35+ years of 35.2 in 2017 and 46.3 per 100,000 person-years in 2018. Conclusions: The incidence of stroke is high in Peru. Ischemic cases are the most frequent and they disproportionately affect men. Our results suggest the need for a surveillance system to robustly quantify the incidence of these cases and understand their determinants.

Risk factors for mortality after subarachnoid hemorrhage: a retrospective observational study / Fatores de risco para mortalidade após hemorragia subaracnoidea: estudo observacional retrospectivo

Abstract Background and objectives: Subarachnoid hemorrhage is an important cause of morbidity and mortality. The aim of the study was to determine predictors of mortality among patients with subarachnoid hemorrhage hospitalized in an Intensive Care Unit. Methods: This is a retrospective study of patients with subarachnoid hemorrhage admitted to the Intensive of our institution during a 7 year period (2009-2015). Data were collected from the Intensive Care Unit computerized database and the patients' chart reviews. Results: We included in the study 107 patients with subarachnoid hemorrhage. A ruptured aneurysm was the cause of subarachnoid hemorrhage in 76 (71%) patients. The overall mortality was 40% (43 patients), and was significantly associated with septic shock, midline shift on CT scan, inter-hospital transfer, aspiration pneumonia and hypernatraemia during the first 72 hours of Intensive Care Unit stay. Multivariate analysis of patients with subarachnoid hemorrhage following an aneurysm rupture revealed that mortality was significantly associated with septic shock and hypernatremia during the first 72 hours of Intensive Care Unit stay, while early treatment of aneurysm (clipping or endovascular coiling) within the first 72 hours was identified as a predictor of a good prognosis. Conclusions: Transferred patients with subarachnoid hemorrhage had lower survival rates. Septic shock and hypernatraemia were important complications among critically ill patients with subarachnoid hemorrhage and were associated increased mortality.

Resumo Justificativa e objetivos: A hemorragia subaracnoidea é uma causa importante de morbidade e mortalidade. O objetivo do estudo foi determinar os preditivos de mortalidade entre os pacientes com hemorragia subaracnoidea internados em uma Unidade de Terapia Intensiva. Métodos: Estudo retrospectivo de pacientes com hemorragia subaracnoidea internados na Unidade de Terapia Intensiva de nossa instituição de 2009 a 2015. Os dados foram coletados do banco de dados eletrônico da Unidade de Terapia Intensiva e de revisões dos prontuários dos pacientes. Resultados: Incluímos no estudo 107 pacientes com hemorragia subaracnoidea. A ruptura de aneurisma foi a causa da hemorragia subaracnoidea em 76 pacientes (71%). A mortalidade geral foi de 40% (43 pacientes) e esteve significativamente associada ao choque séptico, desvio da linha média na tomografia computadorizada, transferência inter-hospitalar, pneumonia por aspiração e hipernatremia durante as primeiras 72 horas de internação na Unidade de Terapia Intensiva. A análise multivariada dos pacientes com hemorragia subaracnoidea pós-ruptura de aneurisma revelou que a mortalidade esteve significativamente associada ao choque séptico e hipernatremia nas primeiras 72 horas de permanência na Unidade de Terapia Intensiva, enquanto o tratamento precoce do aneurisma (clipagem ou embolização endovascular) nas primeiras 72 horas foi identificado como preditivo de um bom prognóstico. Conclusões: Os pacientes com hemorragia subaracnoidea transferidos apresentaram taxas menores de sobrevivência. Choque séptico e hipernatremia foram complicações importantes entre os pacientes gravemente enfermos com hemorragia subaracnoidea e foram associados ao aumento da mortalidade.

The cost of stroke in private hospitals in Brazil: a one-year prospective study / O custo do AVC em hospitais privados no Brasil: um estudo prospectivo

ABSTRACT Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. Objective To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. Methods Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. Results We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). Conclusions Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

RESUMO Poucos estudos determinam o custo do AVC em países de baixa e média renda nos setores privados. Objetivos Mensurar o custo hospitalar do tratamento do(a): AVC isquêmico com e sem reperfusão cerebral, hemorragia intracerebral primária (HIP), hemorragia subaracnóidea e ataque isquêmico transitório (AIT) em hospitais privados de Joinville, Brasil. Métodos Estudo prospectivo de custo de doença. Os custos médicos e não médicos dos pacientes admitidos com qualquer tipo de AVC ou AIT foram consecutivamente verificados em 2016-17. Os valores foram ajustados ao índice do deflator do produto interno bruto e à paridade do poder de compra. Resultados Nós incluímos 173 pacientes. A mediana de custo por paciente foi de US$ 3.827 (IQR: 2.800-8.664) para os 131 pacientes com AVC isquêmico; US$ 2.315 (1.692-2.959) para os 27 pacientes com AIT; US$ 16.442 (5.108-33.355) para os 11 pacientes com HIP e US$ 28.928 (12.424-48.037) para os quatro pacientes com HSA (p < 0,00001). Para seis pacientes submetidos à trombólise intravenosa, a mediana do custo por paciente foi de US$ 11.463 (8.931-14.291) e, para quatro pacientes submetidos à trombectomia intra-arterial, a mediana de custo por paciente foi de US$ 35.092 (31.833-37.626; p < 0,0001). Uma correlação direta foi encontrada entre custo e tempo de permanência (r = 0,67, p < 0,001). Conclusão O AVC é uma doença cara. Em ambiente privado, os custos da reperfusão cerebral foram de três a dez vezes superiores aos tratamentos habituais do AVC isquêmico. Portanto, estudos de custo-efetividade são urgentemente necessários em países de baixa e média rendas.

The cost of stroke in a public hospital in Brazil: a one-year prospective study / Custo do AVC em um hospital público no Brasil: um estudo prospectivo de um ano

ABSTRACT Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. Objective To measure the costs of stroke care in a public hospital in Joinville, Brazil. Methods We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. Results We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. Conclusions Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

RESUMO Os países de baixa e media renda enfrentam orçamentos apertados na saúde, não somente devido aos novos recursos terapêuticos, mas relacionado ao custo oneroso do tratamento do acidente vascular cerebral. No entanto, poucos dados prospectivos sobre os custos do AVC, incluindo reperfusão cerebral de países de baixa e média renda estão disponíveis. Objetivo Mensurar os custos do atendimento ao AVC em um hospital público. Métodos Avaliamos prospectivamente todos os custos médicos e não médicos de pacientes internados com diagnóstico de acidente vascular cerebral ou AIT durante 1 ano, analisamos os custos por tipo de AVC e tratamento, tempo de permanência e comparamos os custos hospitalares com o reembolso governamental. Resultados Foram avaliados 274 pacientes. O custo total em um ano foi de US$ 1.307,114; o governo reembolsou o hospital no valor de US$ 1.095.118. Encontramos uma correlação linear significativa entre LOS e custos (r = 0,71). A mediana do custo do AVCI em 134 pacientes que não sofreram reperfusão cerebral (National Institutes of Health Stroke Scale [NIHSS] mediana = 3) foi de US$ 2.803; para pacientes submetidos a alteplase intravenosa (IV) (NIHSS 10), a mediana foi de US$ 5.099 e para os pacientes submetidos a trombectomia intra-arterial (IA) (NIHSS > 10), o custo mediano foi de US$ 10.997. A mediana do custo de uma hemorragia intracerebral primária, hemorragia subaracnóidea e AIT foram de US$ 2.436, US$ 8.031 e US$ 2.677, respectivamente. Conclusões Os tratamentos de reperfusão foram duas a quatro vezes mais caros do que o tratamento conservador. Estudo de custo-efetividade para o tratamento do AVC são necessários.

Caracterización epidemiológica de pacientes con enfermedad cerebral vascular aguda en un hospital de Chile en base a registros de grupos relacionados al diagnóstico / An epidemiological characterization of patients with acute stroke in a single Chilean hospital using diagnosis-related group registers

Resumen Introducción Las enfermedades cerebrales vasculares son la primera causa específica de muerte y discapacidad en Chile. Objetivo Analizar características epidemiológicas de pacientes hospitalizados con diagnóstico de accidentes vasculares cerebrales en el Complejo Asistencial Víctor Ríos Ruiz. Metodología Estudio observacional, transversal. Se analizaron los egresos hospitalarios con diagnóstico de accidentes vasculares cerebrales entre 2014 y 2017. Se recolectaron datos sobre el diagnóstico de accidentes vasculares cerebrales mediante registro CIE 10, datos demográficos, tipo de accidentes vasculares cerebrales y datos respecto de la letalidad y estadía intrahospitalaria. Las variables cuantitativas fueron expresadas mediante promedios y desviación estándar (± DS) mientras que las variables categóricas fueron evaluadas mediante frecuencias absolutas y relativas. Las diferencias entre las variables fueron analizadas mediante T de Student y ANOVA de un factor. Se consideraron resultados significativos los valores p < 0,05. Resultados Se caracterizó un total de 1856 egresos, 58,6% fueron hombres, edad media de 66,9 (± 13,9) años y estadía media de 10,4 (± 16,7) días. En mujeres, la edad media fue 69,9 (± 16) años y estadía media 11,1 (± 16,5) días. El 55,5% correspondió a accidentes vasculares cerebrales isquémicos y 17,4% accidentes vasculares cerebrales hemorrágicos. Los principales factores de riesgo fueron hipertensión arterial (72%) y diabetes mellitus (33%). La letalidad intrahospitalaria global fue de 10,6%. Tanto la letalidad y estadía prolongada estuvieron asociadas a hemorragia subaracnoidea y accidentes vasculares cerebrales hemorrágicos (valor p < 0,05). Conclusiones La prevalencia de accidentes vasculares cerebrales es similar en hombres y mujeres. La hipertensión arterial fue el factor de riesgo más prevalente. A pesar de que el accidente vascular cerebral isquémico fue el más frecuente, la hemorragia subaracnoidea y el accidente cerebral vascular hemorrágico fueron relacionados con una mayor letalidad y estadía prolongada.

Abstract 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.

Risk factors for early-onset ventilator-associated pneumonia in aneurysmal subarachnoid hemorrhage patients

This study aimed to investigate the risk factors related to ventilator-acquired pneumonia (VAP) in aneurysmal subarachnoid hemorrhage (SAH) patients. From January 2011 to December 2015, a single-center retrospective study including 200 SAH patients requiring mechanical ventilation (MV) ≥48 h was performed. The clinical data of these patients were collected and analyzed. The age range of the patients were 41-63 and 72 (36%) were male. The Glasgow coma scale score range was 5-15 and the Simplified Acute Physiology Score II range was 31-52. One hundred and forty-eight (74%) patients had a World Federation of Neurosurgeons (WNFS) score ≥III. Aneurysm was secured with an endovascular coiling procedure in 168 (84%) patients and 94 (47%) patients presented VAP. Male gender (OR=2.25, 95%CI=1.15-4.45), use of mannitol (OR=3.02, 95%CI=1.53-5.94) and enteral feeding above 20 kcal·kg−1·day−1 (OR=2.90, 95%CI=1.26-6.67) after day 7 were independent factors for VAP. Patients with early-onset VAP had a longer duration of sedation (P=0.03), MV (P=0.001) and ICU length of stay (P=0.003) and a worse Glasgow Outcome Scale score (P<0.001), but did not have a higher death rate.

Clinical outcomes of surgical clipping for intracranial aneurysms in patients with a Hunt and Hess grade 4 or 5 / Desfechos clínicos da clipagem cirúrgica de aneurismas intracranianos de graus 4 e 5 segundo a escala de Hunt & Hess

ABSTRACT We retrospectively evaluated the records of 49 grade 4 and 5 patients with 42 intracranial aneurysms treated within 72 h of subarachnoid hemorrhage (SAH). In total, 35 patients (71%) were grade 4, and 14 (29%) were grade 5. A total of 42 (85%) patients had one aneurysm, 6 (12%) had two aneurysms, and 1 (3%) had three aneurysms. Out of 49 patients, one technical (2%) and one clinical (2%) complication occurred at surgery. Twenty-one (43%) patients recovered well, including 7 with postoperative hematoma requiring an immediate evacuation of a clot. Fourteen (29%) patients had hydrocephalus and required a ventriculo-peritoneal shunt; 12 patients underwent tracheotomy postoperatively due to coma and pulmonary infection. We found that patients with Hunt and Hess grade 4 and 5 aneurysms can undergo successful neurosurgical clipping of the aneurysms after SAH. However, the morbidity and mortality rates remain high because of their poor clinical condition and a high incidence of vasospasm during treatment.

RESUMO Avaliamos retrospectivamente os registros de 49 pacientes com 42 aneurismas intracranianos de graus 4 e 5, tratados nas primeiras 72 horas após uma hemorragia subaracnóidea (HSA). Trinta e cinco pacientes (71%) apresentavam grau 4 e catorze (29%) grau 5. Quarenta e dois pacientes (85%) tinham um único aneurisma, seis (12%) tinham dois aneurismas, e um paciente (3%) tinha três aneurismas. Dos 49 pacientes, uma complicação técnica (2%) e uma complicação clínica (2%) ocorreram durante a cirurgia. Vinte e um pacientes (43%) recuperaram-se bem, incluindo sete que tiveram hematomas pós-operatórios que requereram a imediata evacuação do coágulo. Catorze pacientes (29%) tiveram hidrocefalia e submeteram-se à derivação ventrículo-peritoneal; doze pacientes submeteram-se à traqueostomia no pós-operatório, devido a coma e infecção pulmonar. Pacientes com aneurismas de graus 4 e 5, segundo a escala de Hunt & Hess podem submeter-se com sucesso à clipagem dos aneurismas após HSA. Entretanto, as taxas de morbidade e mortalidade ainda são altas, devido à condição clínica precária e à alta incidência de vasoespasmo durante o tratamento.

Hemorragia subaracnóidea espontânea não aneurismática: perimesencefálica versus não perimesencefálica / Non-aneurysmal spontaneous subarachnoid hemorrhage: perimesencephalic versus non-perimesencephalic

RESUMO Objetivo: Comparar a evolução clínica da hemorragia subaracnóidea perimesencefálica com a da hemorragia subaracnóidea não perimesencefálica. Métodos: Estudo retrospectivo, que incluiu pacientes portadores de hemorragia subaracnóidea sem causa conhecida em um hospital terciário localizado na região norte de Portugal. Os dados epidemiológicos, clínicos e de imagem foram analisados estatisticamente, levando em conta a divisão dos pacientes em duas categorias: hemorragia subaracnóidea perimesencefálica e hemorragia subaracnóidea não perimesencefálica. Resultados: Cumpriram os critérios de inclusão 62 pacientes, 46,8% deles com hemorragia subaracnóidea perimesencefálica e 53,2% com hemorragia subaracnóidea não perimesencefálica. As caraterísticas demográficas, assim como os antecedentes clínicos, foram similares entre os grupos. As complicações foram observadas mais comumente no grupo com hemorragia subaracnóidea não perimesencefálica, sendo que 84,8% desses pacientes tiveram, no mínimo, uma complicação, comparados a 48,3% dos pacientes com hemorragia subaracnóidea perimesencefálica. Vasoespasmo, infecções e hidrocefalia foram as complicações mais comuns - todas observadas mais frequentemente nos pacientes com hemorragia subaracnóidea não perimesencefálica. Dois pacientes vieram a falecer, ambos com hemorragia subaracnóidea não perimesencefálica. A mediana do tempo de permanência no hospital foi maior nos pacientes com hemorragia subaracnóidea não perimesencefálica (21 dias, em comparação aos 14 dias observados nos pacientes com hemorragia subaracnóidea perimesencefálica). Não se observaram recidivas de sangramento durante o acompanhamento (tempo médio de 15 ± 10,3 meses). Conclusão: As hemorragias subaracnóideas perimesencefálica e não perimesencefálica tiveram formas diferentes de evolução clínica, principalmente no que se referiu à taxa de complicações e ao tempo mediano de permanência no hospital. Assim, a abordagem dessas duas formas de hemorragia subaracnóidea deve ser distinta, tanto em busca de melhorar o tratamento dos pacientes quanto para obter um melhor aproveitamento dos recursos de saúde.

ABSTRACT Objective: To compare the clinical evolution of perimesencephalic subarachnoid hemorrhage and non-perimesencephalic subarachnoid hemorrhage. Methods: The study was conducted retrospectively in a tertiary hospital center in the north region of Portugal. Included patients had no identifiable cause for subarachnoid hemorrhage. Several epidemiologic, clinical and imaging aspects were statistically analyzed, taking into account the differences in perimesencephalic subarachnoid hemorrhage and non-perimesencephalic subarachnoid hemorrhage. Results: Sixty-two patients met the inclusion criteria (46.8% - perimesencephalic subarachnoid hemorrhage; 53.2% - non-perimesencephalic subarachnoid hemorrhage). Demographic and clinical background characteristics were similar in both groups. Complications were more frequent in patients with non-perimesencephalic subarachnoid hemorrhage - 84.8% of the patients had at least one complication versus 48.3% in perimesencephalic subarachnoid hemorrhage. Vasospasm, infection and hydrocephaly were the most common complications (each was detected more frequently in the non-perimesencephalic subarachnoid hemorrhage group than in perimesencephalic subarachnoid hemorrhage group). Two patients died, both had a non-perimesencephalic subarachnoid hemorrhage. The median inpatient time was longer in the non-perimesencephalic subarachnoid hemorrhage group (21 versus 14 days). No incidents of rebleeding were reported during the follow-up period (mean time of 15 ± 10.3 months). Conclusion: Perimesencephalic subarachnoid hemorrhage and non-perimesencephalic subarachnoid hemorrhage are two different entities that have different clinical outcomes, namely in terms of complication rate and median inpatient time. The management of these patients should respect this difference to improve treatment and optimize health care resources.

Natural course of subarachnoid hemorrhage is worse in elderly patients / A história natural da hemorragia subaracnóide é pior em pacientes idosos

Aging is a major risk factor for poor outcome in patients with ruptured or unruptured intracranial aneurysms (IA) submitted to treatment. It impairs several physiologic patterns related to cerebrovascular hemodynamics and homeostasis. Objective Evaluate clinical, radiological patterns and prognostic factors of subarachnoid hemorrhage (SAH) patients according to age. Method Three hundred and eighty nine patients with aneurismal SAH from a Brazilian tertiary institution (Hospital do Servidor Público Estadual de São Paulo) were consecutively evaluated from 2002 to 2012 according to Fisher and Hunt Hess classifications and Glasgow Outcome Scale. Results There was statistically significant association of age with impaired clinical, radiological presentation and outcomes in cases of SAH. Conclusion Natural course of SAH is worse in elderly patients and thus, proper recognition of the profile of such patients and their outcome is necessary to propose standard treatment. .

A idade é considerada fator de risco de mau prognóstico em pacientes com aneurismas intracranianos rotos ou não-rotos; com o aumento da idade, ficam prejudicados vários padrões fisiológicos relacionados à hemodinâmica cerebral e homeostase. Objetivo Estudar o quadro clínico, os dados radiológicos e o prognóstico nos pacientes com hemorragia subaracnóide aneurismática em relação à idade. Método Foram avaliados consecutivamente, de 2002 a 2012, 389 pacientes com hemorragia subaracnóide aneurismática oriundos de uma instituição terciária brasileira. Resultados Houve associação da idade com pior quadro clínico, radiológico e prognóstico nos pacientes com hemorragia subaracnóide aneurismática. Conclusão O curso natural da hemorragia subaracnoidea é pior em pacientes idosos. O reconhecimento adequado do perfil desses pacientes e seu prognóstico é importante para estabelecer um tratamento adequado. .

Morphological distinguish of rupture status between sidewall and bifurcation cerebral aneurysms / Caracterización morfológica del estado de ruptura entre aneurismas cerebrales en paredes laterales y bifurcaciones

We suspect that morphological change of two types of aneurysms in ruptured and unruptured aneurysms are distinguishing because of different location and haemodynamics. So it is necessary to discuss sidewall and bifurcation type aneurysms in ruptured and unruptured state respectively. We used 209 consecutive aneurysms (144 ruptured, 65 bifurcation type) to assess the following parameters in 3D: maximum diameter (Dmax), maximum height (Hmax), aspect ratio (AR), size ratio (SR), height/width ratio (HW), bottleneck factor (BNF, width/neck) and inflow angle (IR). These aneurysms were divided into four groups by whether ruptured and sidewall or bifurcation. 4 groups were pairwise compared by univariate analysis and some parameters with significant variation were analyzed by multinomial logistic. Hmax (P=0.014) and HW (P=0.001) were different significantly between ruptured bifurcation and sidewall by multinomial logistic. There was no difference between unruptured bifurcation and sidewall (P>0.05) except for SR (P=0.002) by multinomial logistic. All data of ruptured aneurysms are different significantly from unruptured aneurysms (P<0.05) except for sidewall HW (P=0.414) by univariate analysis. But only SR (P < 0.001) and IR (P=0.006) of sidewall and SR (P=0.011) and HW (P=0.001) of bifurcation was significantly different by multinomial logistic. Volume of sidewall aneurysms are larger than bifurcation aneurysms and stretch characteristic of bifurcation is more obvious in ruptured aneurysms. Flow angle is the important criteria to predict fracture not in bifurcation aneurysms but in sidewall aneurysms. Size ratio is always a very important parameter to predict rupture of aneurysm no matter in bifurcation and sidewall type.

Sospechamos que el cambio morfológico de dos tipos de aneurismas, con y sin ruptura, son distinguibles por diferencias en su hemodinamia y ubicación. Por esto, es necesario discutir sobre el estado de ruptura en los aneurismas ubicados en una pared lateral o bifurcación, respectivamente. Utilizamos 209 aneurismas consecutivos (144 con ruptura y 65 de bifurcación) para evaluar los siguientes parámetros en tres dimensiones: diámetro máximo (Dmax), altura máxima (Amax), relación de aspecto (RA), relación de tamaño (RT), relación de altura/ancho (AA), factor de cuello de botella (FCB, ancho/cuello) y ángulo de entrada (AE). Los aneurismas se dividieron en cuatro grupos por su estado de ruptura (rotos y no rotos) y ubicación (pared lateral y bifurcación). Los grupos se compararon por pares mediante análisis univariado y quienes presentaran variación significativa fueron analizados por logística multinomial. La Amax (P=0,014) y AA (P=0,001) mostraron diferencias significativas entre aneurismas con ruptura en bifurcación y pared lateral, según la logística multinomial. No hubo diferencias entre los aneurismas sin ruptura en bifurcación y pared lateral (P>0,05), excepto para RT (P=0,002) por logística multinomial. Todos los datos de aneurismas con ruptura mostraron diferencias significativas con los sin ruptura (P<0,05), excepto para la AA en la pared lateral (P=0,414) según el análisis univariado. Sólo las RT (P<0,001) y AE (P=0,006) de la pared lateral, y RT (P=0,011) y AA (P=0,001) en bifurcación tuvieron diferencias significativas mediante logística multinomial. El volúmen de los aneurismas de pared lateral fue mayor que los de bifurcación, así como la ruptura fue más evidente en el tramo característico de la bifurcación. El AE es un criterio importante para predecir la rotura en los aneurismas de pared lateral. La RT siempre es un parámetro importante para predecir la rotura de un aneurisma, tanto para los que ocurren en bifurcación y en la pared lateral.

C-reactive protein and vasospasm after aneurysmal subarachnoid hemorrhage1

PURPOSE: To evaluate the relationship between C reactive protein levels and clinical and radiological parameters with delayed ischemic neurological deficits and outcome after aneurysmal subarachnoid hemorrhage. METHODS: One hundred adult patients with aneurismal SAH were prospectively evaluated. Besides the baseline characteristics, daily C-reactive protein levels were prospectively measured until day 10 after subarachnoid hemorrhage. The primary end point was outcome assessed by Glasgow Outcome Scale, the secondary was the occurrence of delayed ischemic neurological deficits (DINDs). RESULTS: A progressive increase in the CRP levels from the admission to 3rd postictal day was observed, followed by a slow decrease until the 9th day. Hemodynamic changes in TCD were associated with higher serum CRP levels. Patients with lower GCS scores presented with increased CRP levels. Patients with higher Hunt and Hess grades on admission developed significantly higher CRP serum levels. Patients with higher admission Fisher grades showed increased levels of CRP. A statistically significant inverse correlation was established in our series between CRP serum levels and GOS on discharge and CRP levels. CONCLUSIONS: Higher C-reactive protein serum levels are associated with worse clinical outcome and the occurrence of delayed ischemic neurological deficits. Because C-reactive protein levels were significantly elevated in the early phase, they might be a useful parameter to monitor. .

Avaliação radiológica imediata, aos seis meses e aos 18 meses, do uso do copolímero etileno vinil álcool (Onyx®) no tratamento endovascular de aneurismas saculares intracranianos de colo largo / Radiological evaluation on immediate, 6 and 18 month control on the use of Onyx® in the endovascular treatment of wide neck intracranial aneurysms

Introdução: A alta incidência de oclusão incompleta e recanalização dos aneurismas intracranianos de colo largo tratados por via endovascular levaram ao desenvolvimento de novas técnicas, entre elas o uso do Onyx ®. Objetivos: avaliar a eficiência do agente embólico líquido Onyx® em produzir oclusão completa dos aneurismas intracranianos de colo largo e avaliar a estabilidade do tratamento aos 6 meses e aos 18 meses, por meio de controles angiográficos. Casuística e métodos: Esta tese foi realizada na Seção de Neuroradiologia Intervencionista da Med Imagem, do Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficência de São Paulo, através da revisão de dados clínicos e radiológicos de 69 pacientes tratados pelo autor, com 84 aneurismas intracranianos de colo largo no período de julho de 2002 a fevereiro de 2006. Dez pacientes eram do sexo masculino e 59 do sexo feminino, com idade variando de 24 anos a 86 anos (mediana de 52 anos). Todos os aneurismas tinham origem lateral à artéria e apresentavam pelo menos um dos critérios usados para definir colo largo - colo maior que 4 mm de diâmetro e relação saco/colo menor que 1,5. Cinqüenta aneurismas eram pequenos, 30 grandes e quatro gigantes (diâmetro máximo menor que 12mm, de 12mm a 25mm e maiores que 25mm, respectivamente). As apresentações clínicas mais comuns foram: achado incidental em 34 pacientes, pós-hemorragia sub aracnóide e recanalização após tratamento com espirais destacáveis em 10. A maioria dos aneurismas era da artéria carótida interna (76 aneurismas). Controles angiográficos foram feitos ao final, aos seis meses e aos 18 meses do tratamento (controles I, II e III respectivamente), sendo analisados principalmente o grau de oclusão (completa ou incompleta), incidência de recanalização e complicações clínicas. Avaliação estatística foi feita pelo método de Kaplan-Meier para o percentual cumulativo de oclusão completa e percentual de recanalização e análise univariada e...

Introduction: The high rate of incomplete occlusion and intracranial large neck aneurysms recanalization lead to the development of new techniques, including the use of Onyx®. Purpose: to evaluate the efficacy of the liquid embolic system Onyx ® to produce completes occlusion of the intracranial large neck aneurysms and evaluates the stability of the treatment at 6 month and 18 month angiographic control. Materials and Methods: this thesis has been performed at Section of Interventional Neuroradiology of Med Imagem, at the Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficência de São Paulo, based on a review of clinical and radiological records of 69 patients treated by the author, harboring 84 large neck intracranial aneurysms between July 2002 and February 2006. Ten patients were male and 59 female, with age ranging from 24 to 86 years old. All aneurysms were lateral to the parent vessel and were wide neck (neck > 4 mm and/or domus to neck ratio < 1.5). Fifty aneurysms were small (<12 mm), 30 were large (12 to 25 mm) and 4 were giant (> 25 mm). Thirty four aneurysms were incidental, 10 were ruptured and 10 were recanalized after coil treatment and the majority was located in the internal carotid artery (76). Angiographic follow-up was done at the end of the procedure, at six month and at 18 month (controls I, II and III respectively), analyzing the rate of complete occlusion, recanalization and clinical complication. Statically analysis were done by Kaplan-Meier method for cumulative percentage of complete aneurysm occlusion and for recanalization, and univariate and multivariate analysis of predictive factors of immediate and late complete occlusion through logistic regression. Results: Complete aneurysm occlusion was achieved in 65.5% on immediate control, in 84.6% at 6 month, and in 90.3% at 18 month follow-up periods for all aneurysms. This rate was 74%, 95.1% and 95.2% for small and 53.3%, 70% and 80% for large aneurysms...

Frequency of stroke types at an emergency hospital in Natal, Brazil

We performed a cross-sectional study of stroke type frequency at a local emergency hospital, in Natal, Brazil. The sample consisted of all patients who were admitted to an emergency hospital with a presumptive diagnosis of stroke. Of the 416 patients, 328 were studied, 88 were excluded for not meeting inclusion criteria, 74.7 percent (n= 245) had ischemic stroke 17.7 percent (n=58) had intracerebral hemorrhage, 7.6 percent (n=25) had subarachnoid hemorrhage; 173 were men (52.7 percent). Mean age was 64.1 years. The intrahospital mortality rate was 10.2 percent, 17.2 percent and 36 percent for ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage, respectively. The most prevalent modifiable risk factor was hypertension for ischemic stroke (67.6 percent) and hemorrhage stroke (57.8 percent). Logistic regression analysis identified diabetes (OR=3.70; CI=1.76-7.77) as independent risk factor for ischemic stroke. The ischemic stroke was most common type of stroke. Hypertension and diabetes were important risk factors for stroke.

Realizamos um estudo de prevalência para determinar a freqüência dos tipos de acidente vascular cerebral (AVC) num hospital de urgência de Natal. Estudaram-se todos os pacientes que foram admitidos no hospital de urgência com diagnóstico presuntivo de AVC. Dos 416 pacientes, 328 foram estudados, 88 foram excluídos por não cumprirem os critérios de inclusão, 74,7 por cento (n= 245) tiveram AVC isquêmico, 17,7 por cento (n=58) hemorragia intracerebral e 7,6 por cento (n=25) hemorragia subaracnóidea. O gênero mais prevalente foi o masculino (52,7 por cento). A média de idade foi 64,1 anos. A letalidade intra-hospitalar foi de 10,2 por cento, 17,2 por cento e 36 por cento para o tipo isquêmico, hemorrágico e hemorragia subaracnóide, respectivamente. O principal fator de risco modificável foi a hipertensão arterial sistêmica (HAS) para AVC isquêmico (67,6 por cento) e AVC hemorrágico (57,8 por cento). A regressão logística identificou diabetes como fator de risco independente para AVC isquêmico (OR=3,70; IC=1,76-7,77). O AVC isquêmico foi o tipo mais comum. HAS e diabetes foram importantes fatores de risco.

Perfil de mortalidad en Junín (B): enfermedad cerebrovascular (sept/1991 - enero/1993) / Mortality profile in Junin (B): cerebrovascular disorders (sept/1991 - Jan/1993)

El objetivo de la investigación fue determinar el perfil de mortalidad comunitario, a partir del análisis de las actas de defunción. El estudio se realizó en Junín (B), ciudad de 84.295 habitantes (52 por ciento mujeres y 48 por ciento hombres, Censo Nacional 1991), desde el 1/9/91 al 31/1/93. Se consideraron 1088 actas de defunción (documento fuente), relevadas mensualmente del Registro Provincial de Identificación Civil. Las causas básicas de muerte y afecciones concomitantes se corroboraron con el médico firmante, el médico de cabecera, y datos de las historias clínicas, y exámenes complementarios del sistema de efectores de salud. La mortalidad por enfermedades del aparato circulatorio (CIE-9 390-459) fue del 41,1 por ciento. El rubro "Otras formas de enfermedad del corazón" (CIE-9 420-429) representó el 15,4 por ciento; la enfermedad cerebrovascular (CIE-9 430-438) el 14,4 por ciento, y la enfermedad isquémica del corazón (CIE-9 410-414) el 6,5 por ciento del total de todas las muertes. Para la ECV no hubo diferencias entre ambos sexos. Sin embargo, analizados los tipos de ACV, en la hemorragia intracerebral (CIE-9 431.0-431.9) hubo predominio del sexo femenino. Considerando la variable edad para la ECV, se observó un marcado incremento de las defunciones a partir de los 65 años. La información obtenida sirve como orientación para implementar programas regionales de prevención entre los grupos de mayor riesgo

Tratamento cirúrgico dos aneurismas intracranianos: comparaçäo entre cirurgias precoce e tardia / Surgical treatment of intracranial aneurysms: comparison between early and late surgeries

Neste estudo säo analisadas as evoluçöes clínicas de 225 pacientes que apresentaram hemorragia subaracnóidea (HSA) por ruptura de aneurismas, atendidos no período de 1985 a 1990. A idade dos pacientes variou de 7 a 84 anos, com predomínio na faixa de 30 a 50 anos (60//). Quanto ao sexo, houve predomínio do feminino (62,2//). Quanto à localizaçäo dos aneurismas rotos, os pacientes distribuiram-se em: 75 na artária carótida interna, 66 na comunicante anterior, 61 na cerebral média, 14 na circulaçäo posterior, 1 na cerebral anterior distal; e 8 em localizaçäo näo identificada. Quarenta e cinco pacientes (20//) apresentaram mais de um aneurisma. Quarenta e quatro pacientes foram submetidos a tratamento cirúrgico nas primeiras 72 horas após a HSA, 40 no período de 4 a 7 dias, 16 no período de 8 a 10 dias e 57 após o 10§ dia. As evoluçöes clínicas dos pacientes estudados säo analisadas, baseadas na época da cirurgia em relaçäo à HSA