ABSTRACT
ABSTRACT Background: The recognition of stroke symptoms by patients or bystanders directly affects the outcomes of patients with acute cerebrovascular disease. Objective: The objective of the study was to assess the predictive value of the medical history and clinical features recognized by the patients bystanders to classify neurovascular syndromes in pre-hospital settings. Methods: We included 150 stroke patients of two Mexican referral centers: 50 with acute ischemic stroke (AIS), 50 with intracerebral hemorrhage (ICH), and 50 with subarachnoid hemorrhage (SAH). The performance of clinical prediction rules (CPR) to identify the stroke types was evaluated with features recognized by the patients bystanders before hospital arrival. The impact of CPRs on early arrival and in-hospital mortality was also analyzed. Results: Overall, 72% of the patients had previous medical evaluations in other centers before final referral to our hospitals, and therefore, only 45% had a final onset-to-door time <6 h, even when the first medical assessment had occurred in ≤1 h in 75% of cases. Clinical features noticed by the patients bystanders had low positive predictive values (PPV) for any stroke type. The CPR language or speech disorder + focal motor deficit had 93% sensitivity and a negative predictive value (NPV) of 84% to distinguish AIS. In SAH, headache alone showed a sensitivity of 84% and NPV of 97%. No CPR had an adequate performance on ICH. CPRs were not associated with final onset-to-door time. Altered consciousness, age ≥65 years, indirect arrival with stops before final referral, and atrial fibrillation increased in-hospital mortality. Conclusion: Clinical features referred by the witness of a neurovascular emergency have limited PPV, but adequate NPV in ruling-out AIS and SAH among stroke types. The use of CPRs had no impact on onset-to-door time or in-hospital mortality when the final arrival to a third-level center occurs with previous medical referrals.
ABSTRACT
Objective: To obtain a blood pressure reading is mandatory during either the general or specialized physical examination. This study describes factors associated with the accomplishment of blood pressure measurement in the first neurological consultation. Methods: We studied first ambulatory neurology consultations in a Mexican referral hospital. Demographic characteristics, diagnostic category of referral, final diagnosis and data on physical examination were collected to establish a logistic regression analysis in order to identify factors associated with the accomplishment of blood pressure measurement. Results: Over 8 months 778 outpatients were studied. The most frequent diagnoses for first consultation were headache (26%), epilepsy (14%) and stroke (13%). Only in 39% (n = 301) of the outpatients blood pressure was registered, among them, 30% had normal blood pressure, 43% had 121-139/81-89mmHg, 20% had 140-159/90-99mmHg and 7% had ≥ 160/100mmHg. The independent factors that favored the practice of BP determination in multivariable analysis were >65 years of age (odds ratio: 2.26; 95% confidence interval: 1.52-3.36) and headache complaint (odds ratio: 1.81, 95% confidence interval: 1.30-2.53). Notably, only 43% of patients with stroke had blood pressure registration, even when these stroke patients had blood pressure readings, they had higher blood pressure than with other diagnoses (p< 0.05). Conclusion: Blood pressure registration was frequently omitted from the first neurological consultation, particularly in outpatients who might need it the most.
Objetivo: La medición de la presión arterial es mandatoria durante el examen físico general o especializado. Este estudio describe factores asociados al cumplimiento de la medición de la presión arterial en la primera consulta neurológica. Métodos: Realizamos un estudio sobre consultas neurológicas ambulatorias en un hospital de referencia mexicano. Se recolectaron características demográficas, categoría diagnóstica de referencia, diagnóstico final y datos sobre el examen físico para construir un análisis de regresión logística con el objetivo de identificar factores asociados con el cumplimiento de la medición de la presión arterial. Resultados: Durante 8 meses estudiamos a 778 pacientes. Los diagnósticos de envío más frecuentes fueron cefalea (26%), epilepsia (14%) y enfermedad cerebrovascular (13%). Solo en el 39% (n = 301) de los pacientes se midió la presión arterial y, de entre ellos, el 30% presentaron presión arterial normal, el 43% 121-139/81-89mmHg, el 20% 140-159/90-99mmHg y el 7% ≥ 160/100 mmHg. En un análisis multivariable, la edad > 65 años (razón de momios: 2.26, intervalo de confianza del 95%: 1.52-3.36) y cefalea como motivo de consulta (razón de momios: 1.81, intervalo de confianza del 95%: 1.30-2.53) fueron los factores independientes asociados al registro de la presión arterial. De manera notable, solo al 43% de los pacientes con enfermedad cerebrovascular se les había registrado la presión sanguínea; estos pacientes la tenían más elevada que los pacientes con otros diagnósticos (p <0.05). Conclusión: En este estudio con frecuencia se omitió el registro de la presión arterial en la primera consulta neurológica, especialmente en pacientes que podrían necesitarlo más.