RESUMO
BACKGROUND: F abry disease (FD) is an X-linked lysosomal storage disorder with accumulation of globotriosylceramide, causing neurologic involvement mainly as acroparesthesias and cerebrovascular disease. Aseptic meningitis has been reported in 11 patients with FD, but no prior study has correlated alpha-galactosidase (GLA) specific variants with meningitis. We present in this manuscript a family in which a novel GLA pathogenic variant was associated with aseptic meningitis in 2 of 5 family members. METHODS: This study began with identifying the proband, then screening family members for FD symptoms and evaluating symptomatic individuals for genetic and biochemical status. All patients underwent magnetic resonance imaging, and those with headache underwent cerebrospinal fluid (CSF) analysis. RESULTS: Five patients (3 females) from a single family were included in this study. Mean age at diagnosis was 20.6 years. Two patients (40%) had aseptic meningitis; one of them also had cerebrovascular events. C-reactive protein and erythrocyte sedimentation rate were elevated during aseptic meningitis episodes. Both patients responded to intravenous methylprednisolone with resolution of fever, headache, and vomiting. One of them recurred and needed chronic immunosuppression with azathioprine. CONCLUSION: We described aseptic meningitis in a family with a novel GLA variant. Meningitis might be a common phenomenon in FD and not a particularity of this variant. Understanding the mechanisms underlying meningitis and its association with cerebrovascular events may lead to a new paradigm of treatment for stroke in these patients. Further prospective studies with CSF collection in patients with FD and recurrent headache could help to elucidate this question.
Assuntos
Doença de Fabry , Meningite Asséptica , Feminino , Humanos , Doença de Fabry/complicações , Doença de Fabry/tratamento farmacológico , Doença de Fabry/genética , Meningite Asséptica/etiologia , Estudos Prospectivos , Fenótipo , Cefaleia/complicações , MutaçãoRESUMO
OBJECTIVES: To evaluate optic nerve sheath diameter in the acute phase of patients with malignant ischemic middle cerebral artery stroke submitted or not to decompressive craniectomy surgery. MATERIALS AND METHODS: Forty patients participated in the study and were evaluated bilaterally by ultrasound on admission and at 24h, 48h and 72 h after admission. Optic nerve sheath diameter values were correlated with tomographic and/or clinical criteria compatible with severe intracranial hypertension. RESULTS: A Receiver Operating Characteristic curve was drawn for each eye, determining a cut-off value for severe intracranial hypertension in the right eye of 5.4 mm (sensitivity: 62%; specificity: 100%; AUC: 0.82) and in the left eye 5.4 mm (sensitivity: 76%; specificity: 84%; AUC: 0.77). In patients undergoing craniectomy, there was a decrease in the mean value of 1.04mm in the right eye (pre: 5.84 ± 0.47 mm; post: 4.80 ± 0.84 mm; p = 0.001), while in the left, it decreased around 0.86mm (pre: 5.59 ± 0.69 mm; post: 4.73 ± 0.74 mm; p = 0.003). Patients with fatal outcome showed a persistent high mean ocular nerve sheath diameter. CONCLUSIONS: Monitoring optic nerve sheath by ultrasound can be considered a reliable method for identifying severe intracranial hypertension in patients with large vessel occlusion, as well as for monitoring patients undergoing craniectomy. Additional studies will be necessary to include this parameter in craniectomy indication algorithms in the future.
Assuntos
Infarto da Artéria Cerebral Média , Hipertensão Intracraniana , Nervo Óptico , Olho/diagnóstico por imagem , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Hipertensão Intracraniana/diagnóstico por imagem , Nervo Óptico/diagnóstico por imagem , UltrassonografiaRESUMO
BACKGROUND AND PURPOSE: Hemorrhagic transformation (HT) is a common neurological complication after ischemic stroke. The influence of symptomatic HT upon clinical outcomes post-stroke is well established, however, the role of asymptomatic HT upon prognosis is still unclear. We aimed to analyze the relationship between HT, clinical complications and outcomes in patients not submitted to reperfusion therapies (RT). METHODS: We included 448 randomly selected patients admitted with acute ischemic stroke to a tertiary hospital stroke unit from 2015 to 2017. Patients submitted to RT were excluded. All patients were evaluated with computed tomography (CT) at admission and within 7 days from the initial CT. Patients with HT were divided into two groups: symptomatic and asymptomatic cases based on the ECASS II definition. A good clinical outcome was defined as a modified Rankin Scale (mRS) 0-2 at discharge. RESULTS: A total of 95 patients (21.2%) had HT (51 asymptomatic and 44 symptomatic). Age, NIHSS at admission and symptomatic HT were associated with a higher risk of developing pneumonia and seizures during hospitalization. Symptomatic HT was also associated with a prolonged length of hospitalization and death and inversely associated with good clinical outcomes at discharge (OR 0.96, 95% CI 0.94-0.98, p<0.001). In an adjusted analysis, even asymptomatic HT was independently associated with worse clinical outcomes at discharge (mRS 4-6) (OR 5.99, 95% CI 1.83-19.58, pâ¯=â¯0.003). CONCLUSIONS: Symptomatic HT is associated with a higher risk of clinical complications, prolonged hospitalization, death and worse clinical outcome at discharge. Furthermore, even patients with asymptomatic HT had a higher chance of worse clinical outcomes at discharge.
Assuntos
Isquemia Encefálica/complicações , Hemorragias Intracranianas/etiologia , Acidente Vascular Cerebral/etiologia , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/terapia , Avaliação da Deficiência , Feminino , Mortalidade Hospitalar , Humanos , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/terapia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Well studied in patients with ischemic stroke after reperfusion therapies (RT), hemorrhagic transformation (HT) is also common in patients not treated with RT and can lead to disability even in initially asymptomatic cases. The best predictors of HT in patients not treated with RT are not well established. Therefore, we aimed to identify predictors of HT in patients not submitted to RT and create a user-friendly predictive score (PROpHET). MATERIAL AND METHODS: Patients admitted to a Comprehensive Stroke Center from 2015 to 2017 were prospectively evaluated and randomly selected to the derivation cohort. A multivariable logistic regression modeling was built to produce a predictive grading score for HT. The external validation was assessed using datasets from 7 Comprehensive Stroke Centers using the area under the receiver operating characteristic curve (AUROC). RESULTS: In the derivation group, 448 patients were included in the final analysis. The validation group included 2,683 patients. The score derived from significant predictors of HT in the multivariate logistic regression analysis was male sex (1 point), ASPECTS ≤ 7 (2 points), presence of leukoaraiosis (1 point), hyperdense cerebral middle artery sign (1 point), glycemia at admission ≥180 mg/dL (1 point), cardioembolism (1 point) and lacunar syndrome (-3 points) as a protective factor. The grading score ranges from -3 to 7. A Score ≥3 had 78.2% sensitivity and 75% specificity, and AUROC of 0.82 for all cases of HT. In the validation cohort, our score had an AUROC of 0.83. CONCLUSIONS: The PROpHET is a simple, quick, cost-free, and easy-to-perform tool that allows risk stratification of HT in patients not submitted to RT. A cost-free computerized version of our score is available online with a user-friendly interface.
Assuntos
Isquemia Encefálica/diagnóstico , Técnicas de Apoio para a Decisão , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Brasil/epidemiologia , Feminino , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologiaRESUMO
BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification has been widely used to assess ischemic stroke patients based on clinical characteristics alone. However, the correlation between the clinical presentation evaluated using OCSP and imaging findings is yet to be determined. Our study aimed to describe the baseline characteristics of the OCSP subtypes of patients admitted with ischemic stroke and evaluate the predictors of the relationship between clinical and neuroimaging findings. METHODS: Patients with a confirmed diagnosis of ischemic stroke admitted to a comprehensive stroke center in Brazil between February 2015 and October 2017 were eligible for the study. All participants underwent computed tomography (CT) at admission and follow-up neuroimaging within seven days, per the institutional protocol. Trained staff classified patients according to the OCSP at hospital admission. The radiographic OCSP classification was retrospectively assessed based on the last follow-up neuroimaging by investigators unaware of the clinical classification. RESULTS: The overall agreement rates ranged from 65.5% to 88.7%. Lower NIHSS scores, absent hyperdense MCA sign, higher ASPECTS, and absent brainstem symptoms were related to a higher risk of misclassification. Treatment with intravenous tPA was associated with reclassification in patients with total anterior circulation syndrome. For predicting radiographic posterior circulation involvement, vertigo (OR 2.9, 95% CI 1.7-5.1, p < 0.001) and brainstem symptoms (OR 35, 95% CI 20.5-60.2, p < 0.001) were directly associated with correct classification, but motor and higher cerebral function were not correlated. CONCLUSION: The clinical OCSP classification presented good congruency rates with the neuroimaging findings. However, patients with lacunar syndromes are often misclassified when radiological criteria are considered.
Assuntos
AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , RadiografiaRESUMO
BACKGROUND: Aspirin is widely used as secondary prophylaxis for acute ischemic stroke. However, its influence on the risk of spontaneous hemorrhagic transformation (HT) is still unclear. Predictive scores of HT have been proposed. We hypothesized that an increased aspirin dose might be harmful in patients at a high risk of HT. This study aimed to analyze the relationship between in-hospital daily aspirin dose (IAD) and HT in patients with acute ischemic stroke. METHODS: We conducted a retrospective cohort study of patients admitted to our comprehensive stroke center between 2015 and 2017. The attending team defined IAD. All included patients underwent either computed tomography or magnetic resonance imaging within 7 days of admission. The risk of HT was assessed using the predictive score of HT in patients not undergoing reperfusion therapies. Regression models were used to evaluate the correlations between HT and IAD. RESULTS: A total of 986 patients were included in the final analysis. The prevalence of HT was 19.2%, and parenchymatous hematomas type-2 (PH-2) represented 10% (n=19) of these cases. IAD was not associated with HT ( P =0.09) or PH-2 ( P =0.06) among all patients. However, in patients at a higher risk for HT (patients not undergoing reperfusion therapies ≥3), IAD was associated with PH-2 (odds ratio 1.01,95% CI 1.001-1.023, P =0.03) in an adjusted analysis. Taking 200 versus 300 mg aspirin was protective against PH-2 (odds ratio 0.102, 95% CI 0.018-0.563, P =0.009). CONCLUSION: An increased in-hospital aspirin dose is associated with intracerebral hematoma in patients at a high risk of HT. Stratifying the risk of HT may lead to individualized daily aspirin dose choices. However, clinical trials on this topic are required.
Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Isquemia Encefálica/complicações , Estudos Retrospectivos , AVC Isquêmico/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Fatores de Risco , Aspirina/efeitos adversos , Terapia Trombolítica/efeitos adversos , HospitaisRESUMO
Background: Noncontrast CT (NCCT) is used to evaluate for intracerebral hemorrhage (ICH) and ischemia in acute ischemic stroke (AIS). Large vessel occlusions (LVOs) are a major cause of AIS, but challenging to detect on NCCT. Aims: The purpose of this study is to evaluate an AI software called RAPID NCCT Stroke (RAPID, iSchemaView, Menlo Park, CA) for ICH and LVO detection compared to expert readers. Methods: In this IRB approved retrospective, multicenter study, stand-alone performance of the software was assessed based on the consensus of 3 neuroradiologists and sensitivity and specificity were determined. The platform's performance was then compared to interpretation by readers comprised of eight general radiologists (GR) and three neuroradiologists (NR) in detecting ICH and hyperdense vessel sign (HVS) indicating LVO. Results: A total of 244 cases were included. Of the 244, 115 were LVOs and 26 were ICHs. One hundred three cases did not have LVO nor ICH. Stand-alone performance of the software demonstrated sensitivities and specificities of 96.2 and 99.5% for ICH and 63.5 and 95.1% for LVO detection. Compared to all 11 readers and eight GR readers only respectively, the software demonstrated superiority, achieving significantly higher sensitivities (63.5% versus 43.6%, p < 0.0001 and 63.5% versus 40.9%, p = 0.001). Conclusion: The RAPID NCCT Stroke platform demonstrates superior performance to radiologists for detecting LVO from a NCCT. Use of this software platform could lead to earlier LVO detection and expedited transfer of these patients to a thrombectomy capable center.
RESUMO
BACKGROUND: Hemorrhagic transformation (HT) is a complication in ischemic strokes, regardless of use of reperfusion therapy (RT). There are many predictive scores for estimating the risk of HT. However, most of them include patients also treated with RT. Therefore, this may lead to a misinterpretation of the risk of HT in patients who did not undergo RT. OBJECTIVE: We aimed to review published predictive scores and analyze their accuracy in our dataset. METHODS: We analyzed the accuracy of seven scales. Our dataset was derived from a cohort of 1,565 consecutive patients from 2015 to 2017 who were admitted to a comprehensive stroke center. All patients were evaluated with follow-up neuroimaging within seven days. Comparison of area under the curve (AUC) was performed on each scale, to analyze differences between patients treated with recombinant tissue plasminogen activator (tPA) and those without this treatment. RESULTS: Our dataset provided enough data to assess seven scales, among which six were used among patients with and without tPA treatment. HAT (AUC 0.76), HTI (0.73) and SEDAN (0.70) were the most accurate scores for patients not treated with tPA. SPAN-100 (0.55) had the worst accuracy in both groups. Three of these scores had different cutoffs between study groups. CONCLUSIONS: The predictive scores had moderate to fair accuracy for predicting HT in patients treated with tPA. Three scales were more accurate for predicting HT in patients not treated with tPA. Through standardizing these characteristics and including more patients not treated with RT in a large multicenter series, accurate predictive scores may be created.
Assuntos
Isquemia Encefálica , Hemorragia Cerebral , AVC Isquêmico , Isquemia Encefálica/complicações , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/etiologia , Estudos de Coortes , Humanos , AVC Isquêmico/complicações , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêuticoRESUMO
Mechanical thrombectomy (MT) has become the gold-standard for patients with acute large vessel occlusion strokes (LVOS). MT is highly effective in the treatment of embolic occlusions; however, underlying intracranial atherosclerotic disease (ICAD) represents a therapeutic challenge, often requiring pharmacological and/or mechanical rescue treatment. Glycoprotein IIb/IIIa inhibitors have been suggested as the best initial approach, if reperfusion can be achieved after thrombectomy, with angioplasty and/or stenting being reserved for the more refractory cases. In this review, we focus on the therapeutic considerations surrounding the endovascular treatment of ICAD-related acute LVOS.
RESUMO
INTRODUCTION: Posterior Circulation (PC) stroke represents one-fifth of all ischemic strokes, with peculiar physiological characteristics. Hemorrhagic Transformation (HT) is a dreaded complication among stroke patients. Many predictive scores of this complication have been proposed, but none is designed specifically for PC stroke patients - therefore, patients who are not eligible for reperfusion therapies (RT) represent about 80% of hospitalized cases. We propose a scoring system to assess the HT risk in PC stroke patients not submitted to RT. METHODS: We retrospectively evaluated data of patients diagnosed with PC stroke not treated with RT from 5 Comprehensive Stroke Centers (four in Brazil, 1 in the US) from 2015 to 2018. All patients underwent CT scan or MRI at admission and a follow-up neuroimaging within seven days. Independent variables identified in a logistic regression analysis were used to produce a predictive grading score. RESULTS: We included 952 patients in the final analysis. The overall incidence of HT was 8.7%. Male gender (1 point), NIH Stroke Scale at admission ≥ 5 points (1), blood glucose at admission ≥ 160 mg/dL (1), and cardioembolism (2) were independently associated with HT. The AUC of the grading score (0 to 5 points) was 0.713 (95% CI 0.65-0.78). Subjects with a score ≥ 3 points had an OR of 4.8 (95% CI 2.9-7.9, p < 0.001) for HT. CONCLUSIONS: Our score has good accuracy in identifying patients at higher risk of HT. This score may be useful for evaluating secondary prevention and stratifying patients in the context of even clinical trials.
Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Humanos , Incidência , Masculino , Reperfusão , Estudos Retrospectivos , Fatores de RiscoRESUMO
INTRODUCTION: The Oxfordshire Community Stroke Project (OCSP) proposed a clinical classification for Stroke patients. This classification has proved helpful to predict the risk of neurological complications. However, the OCSP was initially based on findings on the neurological assesment, which can pose difficulties for classifying patients. We aimed to describe the development and the validation step of a computer-based algorithm based on the OCSP classification. MATERIALS AND METHODS: A flow-chart was created which was reviewed by five board-certified vascular neurologists from which a computer-based algorithm (COMPACT) was developed. Neurology residents from 12 centers were invited to participate in a randomized trial to assess the effect of using COMPACT. They answered a 20-item questionnaire for classifying the vignettes according to the OCSP classification. Each correct answer has been attributed to 1-point for calculating the final score. RESULTS: Six-two participants agreed to participate and answered the questionnaire. Thirty-two were randomly allocated to use our algorithm, and thirty were allocated to adopt a list of symptoms alone. The group who adopted our algorithm had a median score of correct answers of 16.5[14.5, 17]/20 versus 15[13, 16]/20 points, p = 0.014. The use of our algorithm was associated with the overall rate of correct scores (p = 0.03). DISCUSSION: Our algorithm seemed a useful tool for any postgraduate year Neurology resident. A computer-based algorithm may save time and improve the accuracy to classify these patients. CONCLUSION: An easy-to-use computer-based algorithm improved the accuracy of the OCSP classification, with the possible benefit of further improvement of the prediction of neurological complications and prognostication.
RESUMO
BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study's objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.
Assuntos
COVID-19 , Aneurisma Intracraniano , Hemorragia Subaracnóidea , Estudos Transversais , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/terapia , Pandemias , Estudos Prospectivos , Estudos Retrospectivos , SARS-CoV-2 , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/epidemiologia , Resultado do TratamentoRESUMO
The benefit of mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel intracranial occlusions is directly related to the technical success of the procedures in achieving fast and complete reperfusion. While a precise definition of refractoriness is lacking in the literature, it may be considered when there is reperfusion failure, long procedural times, or high number of passes with the MT devices. Detailed knowledge about the causes for refractory MT in AIS is limited; however, it is most likely a multifaceted problem including factors related to the vascular anatomy and the underlying nature of the occlusive lesion amongst other factors. We aim to review the impact of several key unfavorable anatomical factors that may be encountered during endovascular AIS treatment and discuss potential bail-out strategies to these challenging situations.
RESUMO
BACKGROUND: Hemorrhagic transformation (HT) is a common complication after ischemic stroke. It may be associated to poor outcomes. Some predictors of HT have been previously identified, but there remain controversies. OBJECTIVE: To describe the risk factors for HT more frequently reported by a panel of experts surveyed for this project. METHODS: We sent a standard questionnaire by e-mail to specialists in Vascular Neurology from 2014 to 2018. Forty-five specialists were contacted and 20 of them responded to the invitation. Predictors cited by three or more specialists were included in a table and ranked by the frequency in which they appeared. A review of the literature looking for published predictive scores of HT was performed, comparing to the answers received. RESULTS: The 20 responding specialists cited 23 different risk factors for HT. The most frequent factors in the order of citation were the volume of ischemia, previous use of antithrombotic medication, neurological severity, age, hyperglycemia at presentation, hypertension on admission, and cardioembolism. Most variables were also found in previously published predictive scores, but they were reported by the authors with divergences of frequency. CONCLUSION: Although many studies have evaluated HT in patients with acute ischemic stroke, the published risk factors were neither uniform nor in agreement with those cited by the stroke specialists. These findings may be helpful to build a score that can be tested with the goal of improving the prediction of HT.
Assuntos
Isquemia Encefálica/diagnóstico , Hemorragia Cerebral/diagnóstico , Acidente Vascular Cerebral/complicações , Hemorragia Cerebral/patologia , Humanos , Fatores de Risco , Acidente Vascular Cerebral/etiologiaRESUMO
Objective To perform the translation and cross-cultural adaptation to Brazilian Portuguese of the Non-Communicating Children's Pain Checklist - Postoperative Version (NCCPC-PV) instrument, which assesses acute pain in individuals with severe intellectual disability (ID) who present great cognitive impairment and inability to communicate (CIIC). Method In the adaptation process, the original NCCPC-PV was translated, back-translated, its versions were discussed by a committee of experts, and the resulting tool was tested in 20 health professionals and 20 caregivers of CCIC patients regarding its semantic clarity. Results Data from the present study and its participants were analyzed and their results were described. Thus, "Lista de Verificação de Dor em Crianças Não Comunicantes - Versão Pós-operatória" (Br-NCCPC-PV) was obtained as the final version in Brazilian Portuguese. Conclusion After the present study, the Br-NCCPC-PV was considered adequate for use in the Brazilian population.
RESUMO
BACKGROUND: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. OBJECTIVE: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. METHODS: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. RESULTS: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4â5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). CONCLUSION: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.
Assuntos
Craniectomia Descompressiva , Acidente Vascular Cerebral , Brasil , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/cirurgia , Estudos Prospectivos , Acidente Vascular Cerebral/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: Although the 2019 severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2, COVID-19) pandemic poses new challenges to the healthcare system to provide support for thousands of patients, there is special concern about common medical emergencies, such as stroke, that will continue to occur and will require adequate treatment. The allocation of both material and human resources to fight the pandemic cannot overshadow the care for acute stroke, a time-sensitive emergency that with an inefficient treatment will further increase mortality and long-term disability. OBJECTIVE: This paper summarizes the recommendations from the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Society of Cerebrovascular Diseases and the Brazilian Society of Neuroradiology for management of acute stroke and urgent neuro-interventional procedures during the COVID-19 pandemic, including proper use of screening tools, personal protective equipment (for patients and health professionals), and patient allocation.
Assuntos
Infecções por Coronavirus/prevenção & controle , Coronavirus , Gerenciamento Clínico , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Transmissão de Doença Infecciosa do Profissional para o Paciente/prevenção & controle , Neurologia/normas , Pneumonia Viral/prevenção & controle , Acidente Vascular Cerebral/terapia , Betacoronavirus , Brasil , COVID-19 , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Sociedades MédicasRESUMO
Deficits in motor skills and depressive symptoms are common effects observed after stroke, so it is necessary to understand how these variables interact with each other. Therefore, the aim of this study was to investigate the relationship between these two variables in post-ischemic stroke patients. We evaluated 135 patients with a mean age of 60 years (± 15). The Fugl-Meyer assessment of motor function was used to assess motor skills in the upper limbs, lower limbs, balance, and sensitivity and the Beck Depression Inventory was applied to evaluate depressive symptoms. To assess the relationship between both components, Spearman's correlation was performed. Depressive symptoms were negatively correlated with all variables of motor skills. This study suggests that higher motor skills in post-stroke patients may be associated with fewer depressive symptoms. Thus, a better understanding of how post-stroke symptoms are interrelated may improve patient treatment and care, contributing to a better quality of life.
Assuntos
Depressão/etiologia , Transtornos das Habilidades Motoras/etiologia , Transtornos das Habilidades Motoras/psicologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/psicologia , Fatores Etários , Idoso , Extremidades/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Qualidade de Vida/psicologia , Valores de Referência , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Reabilitação do Acidente Vascular Cerebral/psicologia , Inquéritos e Questionários , Fatores de TempoRESUMO
BACKGROUND: Little has been published about the epidemiology of Granulomatosis with polyangiitis (GPA) in South America, especially in the intertropical zone, and no epidemiological data from Brazil are available. The purpose of the present study was to draw a clinical and demographic profile of GPA patients living in Northeastern Brazil based on laboratory, histological and imaging findings, and evaluate the frequency of organic involvement. METHODS: Clinical, epidemiological and treatment data of GPA patients were collected retrospectively and compared with the literature. RESULTS: The cohort included 25 GPA patients (84% female) aged 45.8 ± 16.1 years. Renal and ear-nose-throat (ENT) manifestations were the most common (both 64%). One third (32%) of the patients had 24-h proteinuria > 1 g, 50% had creatinine clearance < 50 mL/min at the time of diagnosis, and 33% had recurrent kidney damage during disease progress. The affected organs included lungs (60%), joints (44%), skin (32%), peripheral nervous system (28%), eyes (28%) and heart (16%). ENT involvement (n = 16/64%) was less frequent in our region than in São Paulo (n = 115/85.8%). Renal (n = 16/64%) and pulmonary (n = 15/60%) involvement was less frequent in our region than in the U.K. (renal n = 30/90%; pulmonary n = 28/84.8%). CONCLUSION: Most of our patients were female, presented the generalized form and were diagnosed late. The frequency of the main clinical manifestations (ENT, renal and pulmonary) was lower than that observed at higher latitudes, suggesting the existence of a Northeast Brazilian clinical and epidemiological profile and adding to our knowledge of this rare condition.
Assuntos
Granulomatose com Poliangiite/complicações , Injúria Renal Aguda/etiologia , Corticosteroides/uso terapêutico , Adulto , Artrite/etiologia , Brasil/epidemiologia , Creatinina/metabolismo , Estudos Transversais , Diagnóstico Tardio/estatística & dados numéricos , Progressão da Doença , Oftalmopatias/etiologia , Feminino , Gastroenteropatias/etiologia , Granulomatose com Poliangiite/diagnóstico , Granulomatose com Poliangiite/epidemiologia , Granulomatose com Poliangiite/metabolismo , Cardiopatias/etiologia , Humanos , Pneumopatias/etiologia , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/etiologia , Proteinúria/etiologia , Estudos Retrospectivos , Dermatopatias/etiologiaRESUMO
ABSTRACT Background: Hemorrhagic transformation (HT) is a complication in ischemic strokes, regardless of use of reperfusion therapy (RT). There are many predictive scores for estimating the risk of HT. However, most of them include patients also treated with RT. Therefore, this may lead to a misinterpretation of the risk of HT in patients who did not undergo RT. Objective: We aimed to review published predictive scores and analyze their accuracy in our dataset. Methods: We analyzed the accuracy of seven scales. Our dataset was derived from a cohort of 1,565 consecutive patients from 2015 to 2017 who were admitted to a comprehensive stroke center. All patients were evaluated with follow-up neuroimaging within seven days. Comparison of area under the curve (AUC) was performed on each scale, to analyze differences between patients treated with recombinant tissue plasminogen activator (tPA) and those without this treatment. Results: Our dataset provided enough data to assess seven scales, among which six were used among patients with and without tPA treatment. HAT (AUC 0.76), HTI (0.73) and SEDAN (0.70) were the most accurate scores for patients not treated with tPA. SPAN-100 (0.55) had the worst accuracy in both groups. Three of these scores had different cutoffs between study groups. Conclusions: The predictive scores had moderate to fair accuracy for predicting HT in patients treated with tPA. Three scales were more accurate for predicting HT in patients not treated with tPA. Through standardizing these characteristics and including more patients not treated with RT in a large multicenter series, accurate predictive scores may be created.
RESUMO Background: Transformação hemorrágica (TH) é uma complicação frequente no acidente vascular cerebral (AVC) isquêmico independente do uso de terapia de reperfusão (TR). Diversos escores preditivos de TH foram elaborados. Entretanto, a maioria desses escores incluíram pacientes submetidos a TR — o que pode levar à má interpretação do risco de TH nos pacientes não submetidos a TR. Objetivo: Nosso objetivo é revisar escores preditivos já publicados e analisar a sua acurácia em nossa amostra. Métodos: Analisamos a acurácia de sete escores. Nosso banco foi criado de uma coorte de 1.565 pacientes consecutivos, admitidos entre 2015 e 2017 em um centro avançado de AVC. Os pacientes realizaram neuroimagem de controle em até sete dias. Uma comparação entre áreas abaixo da curva/característica de operação do receptor (AUC) foi realizada, analisando-se as diferenças entre grupos de pacientes tratados ou não com ativador de plasminogênio tecidual recombinante (tPA). Resultados: Nosso banco de dados proporcionou informação suficiente para avaliar sete escores, dos quais seis foram aplicados em pacientes tratados ou não com tPA. HAT (AUC 0,76), HTI (0,73) e SEDAN (0,70) foram os escores mais acurados em pacientes não tratados com tPA. SPAN-100 (0,55) teve a pior acurácia nos grupos. Três desses escores apresentaram diferentes valores de corte entre os grupos. Conclusões: Os escores apresentaram de boa a moderada acurácia na predição de TH em pacientes tratados com tPA. Três escores foram mais acurados em pacientes não tratados com tPA. A parametrização dessas características e a inclusão de mais pacientes não tratados com TR em um estudo multicêntrico poderia levar a escores mais acurados.