Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I / Diretrizes da Academia Brasileira de Neurologia para reabilitação do acidente vascular cerebral: parte I

ABSTRACT The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.

RESUMO As Diretrizes Brasileiras para Reabilitação do AVC são fruto de um esforço conjunto do Departamento Científico de Reabilitação Neurológica da Academia Brasileira de Neurologia com o objetivo de orientar os profissionais envolvidos no processo de reabilitação para a redução da incapacidade funcional e aumento da autonomia dos indivíduos. Membros do grupo acima participaram de fóruns de discussão na web com pré-temas, seguidos de reuniões por videoconferência em que as controvérsias foram discutidas, levando a um consenso. Essas diretrizes, divididas em duas partes, focam as implicações de recentes ensaios clínicos, revisões sistemáticas e metanálises sobre reabilitação do AVC. O objetivo principal é servir de orientação a médicos, fisioterapeutas, fonoaudiólogos, terapeutas ocupacionais, enfermeiros, nutricionistas e demais profissionais envolvidos no cuidado pós-AVC. As recomendações e níveis de evidência foram adaptados de acordo com a literatura disponível atualmente. Aqui é apresentada a Parte I sobre tópicos de reabilitação na fase aguda, prevenção e tratamento de doenças e comorbidades frequentes após o AVC.

Outcomes of carotid artery stenting at a high-volume Brazilian interventional neuroradiology center

OBJECTIVES: Carotid artery stenting is an emerging revascularization alternative to carotid endarterectomy. However, guidelines have recommended carotid artery stenting only if the rate of periprocedural stroke or death is < 6% among symptomatic patients and < 3% among asymptomatic patients. The aim of this study is to evaluate and compare clinical outcomes of symptomatic and asymptomatic patients who had undergone carotid artery stenting as a first-intention treatment. METHOD: A retrospective analysis of patients who underwent carotid artery stenting by our interventional neuroradiology team was conducted. Patients were divided into two groups: symptomatic and asymptomatic patients. The primary endpoints were ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage and major adverse cardiac and cerebrovascular events at 30 days. The secondary endpoints included ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage, ipsilateral transient ischemic attack and major adverse cardiac and cerebrovascular events between the 1- and 12-month follow-ups. RESULTS: A total of 200 consecutive patients were evaluated. The primary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral stroke (2.4% vs. 2.7%, p = 1.00), ipsilateral parenchymal hemorrhage (0.8% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (4.7% vs. 2.7%, p = 0.71). The secondary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral ischemic stroke (0.0% vs. 0.0%), ipsilateral parenchymal hemorrhage (0.0% vs. 0.0%), ipsilateral TIA (0.0% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (11.2% vs. 4.1%, p = 0.11). CONCLUSIONS: In this retrospective study, carotid artery stenting was similarly safe and effective when performed as a first-intention treatment in both symptomatic and asymptomatic patients. The ...

Frequency and predictors of symptomatic intracranial hemorrhage after intravenous thrombolysis for acute ischemic stroke in a Brazilian public hospital

OBJECTIVE: Scarce data are available on the occurrence of symptomatic intracranial hemorrhage related to intravenous thrombolysis for acute stroke in South America. We aimed to address the frequency and clinical predictors of symptomatic intracranial hemorrhage after stroke thrombolysis at our tertiary emergency unit in Brazil. METHOD: We reviewed the clinical and radiological data of 117 consecutive acute ischemic stroke patients treated with intravenous thrombolysis in our hospital between May 2001 and April 2010. We compared our results with those of the Safe Implementation of Thrombolysis in Stroke registry. Univariate and multiple regression analyses were performed to identify factors associated with symptomatic intracranial transformation. RESULTS: In total, 113 cases from the initial sample were analyzed. The median National Institutes of Health Stroke Scale score was 16 (interquartile range: 10-20). The median onset-to-treatment time was 188 minutes (interquartile range: 155-227). There were seven symptomatic intracranial hemorrhages (6.2%; Safe Implementation of Thrombolysis in Stroke registry: 4.9%; p = 0.505). In the univariate analysis, current statin treatment and elevated National Institute of Health Stroke Scale scores were related to symptomatic intracranial hemorrhage. After the multivariate analysis, current statin treatment was the only factor independently associated with symptomatic intracranial hemorrhage. CONCLUSIONS: In this series of Brazilian patients with severe strokes treated with intravenous thrombolysis in a public university hospital at a late treatment window, we found no increase in the rate of symptomatic intracranial hemorrhage. Additional studies are necessary to clarify the possible association between statins and the risk of symptomatic intracranial hemorrhage after stroke thrombolysis.

Risk factors for swallowing dysfunction in stroke patients / Fatores de risco para disfunção da deglutição em pacientes com acidente vascular encefálico

CONTEXT: Stroke is a frequent cause of dysphagia. OBJECTIVE: To evaluate in a tertiary care hospital the prevalence of swallowing dysfunction in stroke patients, to analyze factors associated with the dysfunction and to relate swallowing dysfunction to mortality 3 months after the stroke. METHODS: Clinical evaluation of deglutition was performed in 212 consecutive patients with a medical and radiologic diagnosis of stroke. The occurrence of death was determined 3 months after the stroke. RESULTS: It was observed that 63% of the patients had swallowing dysfunction. The variables gender and specific location of the lesion were not associated with the presence or absence of swallowing dysfunction. The patients with swallowing dysfunction had more frequently a previous stroke, had a stroke in the left hemisphere, motor and/or sensitivity alterations, difficulty in oral comprehension, alteration of oral expression, alteration of the level of consciousness, complications such as fever and pneumonia, high indexes on the Rankin scale, and low indexes on the Barthel scale. These patients had a higher mortality rate. CONCLUSIONS: Swallowing evaluation should be done in all patients with stroke, since swallowing dysfunction is associated with complications and an increased risk of death.

CONTEXTO: Disfagia orofaríngea é consequência frequente do acidente vascular encefálico (AVE). OBJETIVOS: Avaliar clinicamente a prevalência de alterações da deglutição, analisar os fatores associados com a disfunção e relacionar a presença de dificuldade de deglutição com a mortalidade após 3 meses do acidente vascular em pacientes com AVE. MÉTODO: A deglutição foi avaliada clinicamente em 212 pacientes consecutivos com diagnóstico médico e radiológico de AVE. Após 3 meses foi verificada a ocorrência de óbito. RESULTADOS: Entre os pacientes estudados, 63% apresentaram alteração da deglutição. As variáveis gênero e localização específica da lesão não estavam associadas à presença ou não de dificuldade de deglutição. Os pacientes com dificuldade de deglutição tinham: prévios episódios de AVE, AVE no hemisfério esquerdo, alterações motoras e/ou de sensibilidade, alterações na compreensão oral, expressão oral e nível de consciência, complicações como febre e pneumonia, e índices altos na escala de Rankin e baixos na escala de Barthel. Esses pacientes apresentaram maior mortalidade. CONCLUSÕES: A deglutição deve ser avaliada em todos os pacientes com AVE, considerando que alterações na deglutição estão associadas com complicações e com aumento na mortalidade.

Avaliação fonoaudiológica e cintilográfica da deglutição de pacientes pós acidente vascular encefálico / Clinical and scintigraphic swallowing evaluation of post-stroke patients

TEMA: a deglutição em pacientes pós Acidente Vascular Encefálico (AVE). OBJETIVO: estudar a deglutição de pacientes pós-AVE através de avaliação clínica fonoaudiológica e do método cintilográfico. MÉTODO: estudou-se 26 pacientes, sendo o primeiro AVE ocorrido há no máximo dois meses; o grupo controle continha 15 voluntários saudáveis; ambos grupos foram submetidos a avaliação clínica e cintilográfica da deglutição, ingerindo 5ml de líquido e 5ml de pastoso. A avaliação clínica constou de anamnese, avaliação estrutural (sem alimento) e funcional (com alimento). RESULTADOS: durante avaliação fonoaudiológica, o grupo controle apresentou elevação laríngea ineficiente e sinais clínicos de aspiração em um indivíduo. Quanto aos pacientes, 27 por cento apresentaram, na fase oral, um preparo ineficiente do líquido e 42 por cento do pastoso. Na fase faríngea, 12 por cento apresentaram tosse e engasgo. Na avaliação cintilográfica, três pacientes foram excluídos da análise, pois dois deles não deglutiram durante o tempo de aquisição do exame e um engoliu antes da instrução da pesquisadora. Os pacientes apresentaram maior quantidade de resíduo oral e menor duração de trânsito faríngeo na deglutição de pastoso, comparado ao grupo controle. CONCLUSÃO: a complementaridade da avaliação clínica e instrumental no estudo da deglutição de pacientes com AVE é necessária e importante para o desempenho do trabalho fonoaudiológico e para o paciente que será reabilitado. O método cintilográfico deve ser mais utilizado como instrumento de pesquisa para quantificar o tempo de trânsito, o resíduo e o tempo de depuração em cada fase da deglutição, estabelecendo-se parâmetros para outros estudos.

BACKGROUND: deglutition of post-stroke patients. AIM: to study the swallowing of post-stroke patients through clinical and scintigraphic evaluations. METHOD: participants were 26 patients, who had suffered their first stroke within the last two months. The control group was composed by 15 healthy volunteers. Both groups were submitted to a clinical and scintigraphic evaluation of swallowing; using 5ml of liquid (water) and 5ml of paste bolus. Clinical evaluation was composed by an interview, an assessment of the oral structures (without food) and by a functional assessment (with food). RESULTS: during the clinical evaluation, one individual of the control group presented inefficient larynx elevation and clinical signs of aspiration. As for the group of post-stroke patients, 27 percent presented inefficient prepare of the liquid bolus and 42 percent presented inefficient prepare of the paste bolus, in the oral phase. Considering the pharyngeal phase, 12 percent presented cough and choked. In the scintigraphy evaluation, three post-stroke patients were excluded from this analysis for the following reasons: two did not swallow during the exam acquisition time and one swallowed before the instruction given by the researcher. The group of post-stroke patients presented more oral residues and shorter pharyngeal transit with the paste bolus when compared to the control group. CONCLUSION:clinical and objective swallowing evaluations of post-stroke patients are necessary and important to determine therapy intervention and possible outcomes. Patients who have suffered stroke have more residues and shorter pharyngeal transit than healthy individuals. The scintigraphic method should be used more often as a research instrument to quantify the residue, transit time and clearance in each of the swallowing phases.

Correlação entre os achados clínicos da deglutição e os achados da tomografia computadorizada de crânio em pacientes com acidente vascular cerebral isquêmico na fase aguda da doença / Relation between clinical evaluation of deglutition and the computed tomography in acute ischemic stroke patients

O acidente vascular cerebral (AVC) é uma das principais causas de lesões permanentes em adultos, podendo provocar seqüelas motoras globais, alterações de fala, linguagem e deglutição. Durante a fase aguda, a detecção do risco de aspiração é fundamental para prevenir complicações pulmonares e permitir apropriadas intervenções terapêuticas, possibilitando alimentação por via oral precoce e segura. Na literatura, as correlações entre o distúrbio da deglutição e a localização da lesão em pacientes com AVC são inespecíficas. Desta forma, o objetivo do presente estudo foi determinar se existe correlação entre a localização das lesão vascular encefálica e a dificuldade de deglutição em pacientes com AVC isquêmico (AVCI). Foram incluídos 27 pacientes com AVCI que foram submetidos à avaliação clínica da deglutição no leito. Os resultados foram confrontados com resultados obtidos pela tomografia computadorizada do crânio, relacionados à localização das lesões. Na avaliação clínica, 48 por cento dos pacientes apresentaram disfagia orofaríngea e 52 por cento deglutição funcional. Em 84 por cento dos pacientes disfágicos foram observadas alterações no território carotídeo, sendo 76 por cento na artéria cerebral média (ACM). Nos pacientes com deglutição funcional 57 por cento apresentaram alterações em ACM e 22 por cento em artéria cerebral posterior. O hemisfério esquerdo foi afetado em 50 por cento dos pacientes com deglutição funcional e em 46 por cento dos disfágicos. Em conclusão, a localização hemisférica não está associada com a presença ou não de disfagia, porém a maioria dos pacientes disfágicos apresentou alterações no território carotídeo, notadamente na ACM.

Stroke is one of the main causes of permanent lesions in adults and can provoke global motor sequels, speech and language alterations, and swallowing. During the acute phase, the detection of aspiration risks is essential to prevent lung complications and to allow appropriate therapeutic interventions, making possible precocious oral feeding. In the literature, the correlations between the disturbance of the deglutition and the location of the lesion in patients with stroke are not specific. This way, the objective of the present study was to determine if correlation exists between the location of the vascular lesion and dysphagia in acute ischemic stroke patients. Bedside clinical evaluation of deglutition was made in 27 patients with acute ischemic stroke and the results were compared with the computed tomography findings. In the clinical evaluation, 48 percent patients were dysphagic and 52 percent had functional deglutition. In dysphagic patients, 84 percent had lesion in carotid territory, with 76 percent in the middle cerebral artery. In patients with functional deglutition, 57 percent had lesion in the middle cerebral artery and 22 percent in the posterior cerebral artery. In 50 percent of the patients with functional deglutition and in 46 percent of the dysphagics the lesion was in the left hemisphere. In conclusion, the hemispherical location is not associated with the presence or not of dysphagia, however most of the dysphagic patients presented alterations in the carotid territory, especially in the middle cerebral artery.