Morbimortality and determinants of reperfusion in ischemic stroke

SUMMARY BACKGROUND: Cerebrovascular accident (or stroke) and ischemic heart disease are the the major causes of death in the world. It is estimated that about 85% of strokes are ischemic in origin. Reperfusion therapy in the acute phase of ischemic stroke with a recombinant human tissue plasminogen activator is effective, but some factors influence the success of this treatment. OBJECTIVE: The aim of this study was to evaluate clinical aspects and possible determinants for reperfusion after venous thrombolysis. METHODS: This is a retrospective, cross-sectional, observational study based on a review of hospital records of inpatients diagnosed with ischemic stroke treated with intravenous thrombolysis, the main outcome being reperfusion or not. RESULTS: Data from this study revealed a predominance of females in the group of reperfused patients and males in the non-reperfused group, both maintaining moderate severity on the National Institutes of Health Stroke Scale and admission without statistical significance (p>0.18). In addition, the mean admission severity score was 13.2 for the group of reperfused patients and 14.2 for those not reperfused, and the mean ejection fraction of both groups was within normal functionality, with a mean of 0.50 for reperfused patients and 0.62 for non-reperfused patients. CONCLUSION: We found an association between successful venous chemical thrombolysis reperfusion and lower mortality in patients with acute stroke.

Independência funcional, aspectos clínicos e fatores sociodemográficos em pacientes na fase aguda do Acidente Vascular Cerebral: uma análise de associação / Functional independence, clinical aspects, and sociodemographic factors in patients in the acute phase of stroke: an association analysis

RESUMO Objetivo Analisar a associação da independência funcional com aspectos clínicos de comprometimento neurológico, a localização e extensão do dano neuronal e os fatores sociodemográficos em pacientes na fase aguda do AVC. Método Estudo analítico de recorte transversal, realizado com 90 pacientes adultos e idosos acometidos por AVC isquêmico, que tiveram admissão no ambiente hospitalar nas primeiras 24 horas após o evento vascular. A coleta dos dados referentes aos aspectos clínicos e fatores sociodemográficos foi realizada pelo prontuário eletrônico e/ou entrevista para descrever o perfil dos pacientes, Oxfordshire Community Stroke Project, Alberta Stroke Programme Early CT Score, National Institute of Health Stroke Scale e a Medida de Independência Funcional. Resultados O comprometimento neurológico, de acordo com a National Institute of Health Stroke Scale, foi associado à funcionalidade nas primeiras 24 horas após o AVC. Além disso, a presença de hipertensão arterial, idade, trabalho inativo, tabagismo e extensão do dano neuronal estiveram associados à dependência funcional, mas não permaneceram no modelo final deste estudo. Conclusão A dependência funcional está associada à hipertensão arterial, idade, trabalho inativo, tabagismo, extensão do dano neuronal e grau de comprometimento neurológico nas primeiras 24 horas após o evento vascular. Além disso, um nível mais elevado de comprometimento neurológico foi independentemente associado a níveis aumentados de dependência funcional.

ABSTRACT Purpose To analyze the association of functional independence with clinical aspects of neurological impairment, the location and extent of neuronal damage and sociodemographic factors in patients in the acute phase of stroke. Methods Analytical cross-sectional study in 90 adult and older patients affected by ischemic stroke, admitted to the hospital within 24 hours of the vascular event. Sociodemographic factors and clinical aspects data were collected from electronic medical records and/or interviews in order to depict the patients'profile, Oxfordshire Community Stroke Project, Alberta Stroke Programme Early CT Score, National Institute of Health Stroke Scale, and Functional Independence Measure. Results Neurological impairment, according to the National Institute of Health Stroke Scale, was associated with functioning in the first 24 hours after the stroke. Furthermore, the presence of arterial hypertension, age, inactive work, smoking and extent of neuronal damage were associated with functional dependence, but did not remain in the final model of this study. Conclusion Functional dependence is associated with arterial hypertension, age, inactive work, smoking, extent of neuronal damage, and degree of neurological impairment in the first 24 hours after the vascular event. Furthermore, a higher level of neurological impairment was independently associated with increased levels of functional dependence.

Analysis on risk factors of clopidogrel resistance in patients with ischemic stroke / 药学实践杂志

Objective To investigate the risk factors of drug resistance in patients with ischemic stroke by clopidogrel therapy and provide references for promoting clinical individualized drug therapy. Methods A total of 202 inpatients diagnosed with ischemic stroke were admitted and given dual anti-treatment (aspirin+clopidogrel). CYP2C19 genotype was detected by microarray hybridization during hospitalization, and CYP2C19 gene polymorphisms were classified into fast metabolism group, medium metabolism group and slow metabolism group according to the type of drug metabolism. Patients were tested for platelet inhibition induced by adenosine diphosphate (ADP) according to thromboelastographic (TEG) on 7~14 d of drug administration. ADP <30% was classified as clopidogrel drug resistance group and ADP ≥30% as non-resistance group. Logistic regression analysis was used to study the risk factors for the development of clopidogrel resistance. Results Among 202 patients with ischemic stroke, 87 were in the resistant group and 115 in the non-resistant group. The proportion of patients with clopidogrel resistance combined with diabetes and the level of white blood cell count were higher than that in the non-resistant group, and the differences were statistically significant (P<0.05).The proportion of patients with clopidogrel resistance in the CYP2C19 intermediate metabolism group was significantly higher than that in the fast metabolism group, and the rate of platelet inhibition was also significantly lower than that in the fast metabolism group, all with statistically significant differences (P<0.05). Conclusion Combined diabetes mellitus, high white blood cell count levels and CYP2C19 mid-metabolic phenotype are independent risk factors for the development of clopidogrel resistance in patients with ischemic stroke.

Application of multidisciplinary in situ simulation training in the treatment of acute ischemic stroke: a quality improvement project / 世界急诊医学杂志（英文）

@#BACKGROUND: Ischemic stroke refers to a disorder in the blood supply to a local area of brain tissue for various reasons and is characterized by high morbidity, mortality, and disability. Early reperfusion of brain tissue at risk of injury is crucial for the treatment of acute ischemic stroke. The purpose of this study was to evaluate comfort levels in managing acute stroke patients with hypoxemia who required endotracheal intubation after multidisciplinary in situ simulation training and to shorten the door-to-image time. METHODS: This quality improvement project utilized a comprehensive multidisciplinary in situ simulation exercise. A total of 53 participants completed the two-day in situ simulation training. The main outcome was the self-reported comfort levels of participants in managing acute stroke patients with hypoxemia requiring endotracheal intubation before and after simulation training. A 5-point Likert scale was used to measure participant comfort. A paired-sample t-test was used to compare the mean self-reported comfort scores of participants, as well as the endotracheal intubation time and door-to-image time on the first and second days of in situ simulation training. The door-to-image time before and after the training was also recorded. RESULTS: The findings indicated that in situ simulation training could enhance participant comfort when managing acute stroke patients with hypoxemia who required endotracheal intubation and shorten door-to-image time. For the emergency management of hypoxemia or tracheal intubation, the mean post-training self-reported comfort score was significantly higher than the mean pre-training comfort score (hypoxemia: 4.53±0.64 vs. 3.62±0.69, t= -11.046, P<0.001; tracheal intubation: 3.98±0.72 vs. 3.43±0.72, t= -6.940, P<0.001). We also observed a decrease in the tracheal intubation and door-to-image time and a decreasing trend in the door-to-image time, which continued after the training. CONCLUSION: Our study demonstrates that the implementation of in situ simulation training in a clinical environment with a multidisciplinary approach may improve the ability and confidence of stroke team members, optimize the first-aid process, and effectively shorten the door-to-image time of stroke patients with emergency complications.

Effect of Salvianolic Acid B Combined with Puerarin on Pyroptosis of SH-SY5Y Cells Injured by Oxygen-glucose Deprivation/Reoxygenation / 中国实验方剂学杂志

ObjectiveTo investigate the effect and mechanism of salvianolic acid B combined with puerarin in protecting the SH-SY5Y cells from the damage by oxygen-glucose deprivation/reoxygenation （OGD/R） based on pyroptosis. MethodSH-SY5Y cells were used to establish the model of OGD/R， and cells were classified into the control， OGD/R， 10 μmol·L-1 salvianolic acid B， 100 μmol·L-1 puerarin， 10 μmol·L-1 salvianolic acid B + 100 μmol·L-1 puerarin， and 10 μmol·L-1 NOD-like receptor protein 3 （NLRP3） inhibitor MCC950 groups. Except the control group， other groups were rapidly reoxygenated for 12 h after 6 h OGD for modeling. The cell survival rate was determined by the methyl thiazolyl tetrazolium （MTT） assay. An optical microscope was used to observe the cell morphology. A spectrophotometer was used to determine the content of lactic dehydrogenase （LDH） in culture supernatant. Cell damage was measured by Hoechst/PI staining. The mRNA levels of NLRP3， cysteinyl aspartate specific proteinase-1 （Caspase-1）， gasdermin D （GSDMD）， apoptosis-associated speck-like protein （ASC）， and interleukin-1β （IL-1β） were determined by real-time fluorescence quantitative polymerase chain reaction （Real-time PCR）. The protein activation of Caspase-1 and NLRP3 was detected by immunofluorescence. Western blot was employed to determine the protein levels of IL-1β， ASC， NLRP3， Caspase-1， and cleaved Caspase-1. ResultCompared with the control group， the OGD/R group showed decreased cell survival rate （P<0.01）， damaged cell morphology， increased leakage rate of LDH （P<0.01）， up-regulated mRNA levels of NLRP3， Caspase-1， GSDMD， ASC， and IL-1β （P<0.01）， and up-regulated protein levels of IL-1β， ASC， NLRP3， Caspase-1， and cleaved Caspase-1 （P<0.01）. Compared with the OGD/R group， salvianolic acid B， puerarin， and salvianolic acid B combined with puerarin improved cell survival rate （P<0.01）， and the combined treatment group outperformed salvianolic acid B and puerarin used alone （P<0.01）. Salvianolic acid B combined with puerarin and MCC950 both improved cell morphology， reduced the leakage of LDH （P<0.01）， alleviated cell damage， and down-regulated the mRNA levels of NLRP3， Caspase-1， GSDMD， ASC， and IL-1β （P<0.05， P<0.01） and also the protein levels of IL-1β， ASC， NLRP3， Caspase-1， and cleaved Caspase-1 （P<0.05， P<0.01）. ConclusionThe results indicated that salvianolic acid B combined with puerarin can alleviate the OGD/R-induced damage of SH-SY5Y cells by inhibiting pyroptosis.

Impacto de la inteligencia artificial en las métricas terapéuticas del ataque cerebrovascular durante la pandemia COVID-19 / Impact of artificial intelligence on therapeutic metrics of cerebrovascular attack during the COVID-19 pandemic

Resumen Introducción : El inicio de la pandemia COVID-19, obligó a implementar cambios en el sistema de aten ción de los servicios de emergencia. Coincidentemente, en nuestra institución, implementamos el software de inteligencia artificial (IA), RAPID.AI, para el análisis de imágenes en el ataque cerebrovascular isquémico (ACVi). Nuestro objetivo fue evaluar el impacto del uso de la IA junto a los cambios en el triage durante la pandemia por COVID-19 en pacientes con ACVi por oclusión de gran vaso cerebral (OGVC). Métodos : Se crearon 2 grupos de pacientes con ACVi por OGVC tratados con terapia de reperfusión endovenosa más endovascular o terapia endovascu lar directa. Grupo 1: pacientes de enero 2019 a junio 2020; Grupo 2: pacientes de julio 2020 a diciembre de 2021, estudiados con RAPID.AI. Se analizaron datos clínicos, y métricas temporales. Se compararon según hora de arribo de 08:00 a 20:00 h (diurno) vs. 20:01 a 7:59 h (nocturno). Resultados : El grupo 1 comprendió 153 pacientes y el grupo 2 133. En el grupo 2 la métrica puerta-imagen y adquisición de la imagen fueron menores, con menor tiempo puerta-inicio de imagen y puerta-recanalización; los pacientes en horario nocturno presentaron mayor NIHSS y tiempos inicio-ingreso con menor proporción de independencia funcional a 90 días. Conclusiones : El uso de la IA para el análisis de imá genes junto a un menor tiempo puerta-fin de imagen, permitió acortar el intervalo hasta la punción inguinal. En el análisis por horarios durante la pandemia, los pacientes ingresados en horario diurno presentaron métricas puerta-imagen, tiempo de imagen y puerta-recanalización significativamente menores.

Abstract Introduction : The start of the COVID-19 pandemic forced the implementation of changes in the emergency services care system. Concomitantly, at our institution, we implemented the artificial intelligence (AI) software, RAPID.AI, for image analysis in ischemic stroke (IS). Our objective was to evaluate the impact of the use of AI together with the changes in the triage during the COVID-19 pandemic in patients with stroke due to large vessel occlusion (LVO). Methods : We included patients with IS due to LVO treated with intravenous reperfusion therapy plus en dovascular or direct endovascular therapy. Results : Two groups were created. Group 1: patients from January 2019 to June 2020; Group 2: patients from July 2020 to December 2021, studied with RAPID.AI. Clini cal data and temporal metrics were analyzed. They were compared according to arrival time from 08:00 to 20:00 (daytime) vs 20:01 to 7:59 (night). Results: We included 286 patients, 153 in group 1 and 133 in group 2. In group 2, door-image metric and image duration were lower, with shorter door-image onset and door-recanalization times; patients who arrived at night had higher NIHSS and longer time from onset-to-door with lower propor tion of functional independence at 90 days (mRS ≤ 2). Conclusions : The use of AI for image analysis along with a shorter door to end of image time allowed to reduce the interval to groin puncture. In the analysis by hours during the pandemic, patients admitted in daytime hours had significantly lower door to image, image time acquisition, and door to recanalization metrics.

Disección carotídea espontánea: Presentación de un caso clínico con revisión de la literatura / Carotid Artery Dissection. Case Report and Literature Review

Resumen Introducción: La disección carotídea consiste en el desgarro de la pared del vaso. Es una patología infrecuente, pero es la causa más común de enfermedad vascular cerebral (EVC) isquémica en personas menores de 45 años. Las manifestaciones clínicas son muy variables. Método: Utilizamos las recomendaciones CARE para el reporte de casos clínicos. Caso clínico: Hombre de 45 años previamente sano, con debilidad aguda de la extremidad torácica derecha sin causa aparente. La tomografía simple de cráneo no evidenció alteraciones. La resonancia magnética mostró una oclusión completa de la arteria carótida interna en todos sus segmentos y disminución del flujo de la arteria cerebral media izquierda. La evolución clínica fue desfavorable. Conclusión: La disección carotídea debe sospecharse en personas con EVC sin factores de riesgo cardiovascular.

Abstract Introduction: Carotid dissection consists of a tear in the vessel wall. It is a rare pathology, but it is the most common cause of ischemic cerebral vascular disease (CVD) in people under 45 years of age. The clinical manifestations are very variable. Method: We used CARE recommendations for reporting clinical cases. Clinical case: Previously, a healthy 45-year-old man with acute weakness of the right thoracic extremity without apparent cause. The simple skull tomography did not show any alterations. MRI showed complete occlusion of the internal carotid artery in all its segments and decreased flow of the left middle cerebral artery. The clinical evolution was unfavorable. Conclusion: Carotid dissection should be suspected in people with CVD without cardiovascular risk factors.

Corrélation of EQ-5D and mRS in ischémie stroke: a multicenter cross-sectional study

Introduction: Assessing Health-Related Quality of Life (HRQOL), in addition to evaluating functional status in stroke patients could complement clinician practice. Objective: To assess HRQOL, applying EuroQol-5-dimensions (EQ-5D) in Colombian patients with stroke and correlating its results with the modified Rankin Scale (mRS). Methods: Analytical cross-sectional study in a cohort of ischemic stroke patients in Colombia at three months as a median follow-up (Q1: 1- Q3:3) after their event. We correlated EQ-5D domains, EQ-5D index, mRS with EQ-5D VAS score. We generated a simple linear regression robust model to evaluate the variability between using r2. Results: A total of 91 patients completed the EQ-5D questionnaire, with a mean age of 71.2 years; 59.3% were male. We identified an inverse correlation between EQ-5D VAS and EQ-5D domains with the highest for mobility (rs = -0.69) and the lowest for pain/discomfort (rs -0.52, p<0.001). The r2 ranged from 0.25 (pain/discomfort) to 0.47 (EQ-5D index). Patients with mRS ≥ 3 significantly reduced their EQ-5D VAS score by 25.64 points (95% CI -33.04, -18.24). Variability in EQ-5D VAS scores occurred by EQ-5D index (47%) and by mRS (34%). Conclusions: The correlation between EQ-5D and mRS was favorable. Although EQ-5D and mRS evaluated different spheres on stroke patients, applying the EQ-5D instrument in real-world clinical settings might contribute multidimensional information on how life is affected after a stroke. This kind of information serves to orientate rehabilitation strategies on specific domains such as depression, self-care, anxiety, and pain. This is especially relevant for patients with disabilities (mRS ≥ 3).

Introducción: La evaluación de la Calidad de Vida Relacionada con la Salud (CVRS) y el estado funcional de pacientes con Ataque Cerebrovascular (ACV), podría complementar la práctica clínica. Objetivo: Evaluar la CVRS, aplicando EuroQol-5-dimensiones (EQ-5D) en pacientes colombianos con ACV y correlacionar sus resultados con la escala de Rankin Modificada (mRS). Métodos: Estudio de corte transversal analítico anidado a una cohorte de pacientes con ACV isquémico en Colombia con mediana de 3 meses de seguimiento (Q1: 1- Q3:3) post-ictus. Correlacionamos los dominios del EQ-5D, índice EQ-5D y mRS con la puntuación de EQ-5D VAS. Generamos un modelo de regresión lineal simple para evaluar la variabilidad usando r2. Resultados: Un total de 91 pacientes con una edad media 71,2 años; 59,3 % hombres. Se encontró correlación inversa entre los dominios EQ-5D, mayor para movilidad (rs = -0,69) y menor para dolor/malestar (rs -0,52, p < 0,001). El r2 osciló entre 0,25 (dolor/malestar) y 0,47 (índice EQ-5D). Los pacientes con mRS ≥ 3 redujeron significativamente su puntuación EQ-5D VAS en 25,64 puntos (IC 95%: -33,04; -18,24). La variabilidad en las puntuaciones EQ-5D VAS se produjo por el índice EQ-5D (47 %) y por mRS (34 %). Conclusiones: La correlación entre EQ-5D y mRS fue favorable. Aunque EQ-5D y mRS evalúan diferentes esferas en los pacientes con ACV, la aplicación del EQ-5D en podría aportar información multidimensional sobre cómo se afecta la vida después de un ictus, así como orientar estrategias de rehabilitación en esferas como depresión, autocuidado, ansiedad y dolor; especialmente relevante para pacientes con discapacidades (mRS ≥ 3).

Evaluación de parámetros inflamatorios, trombóticos y variantes genéticas en pacientes con ataque cerebrovascular isquémico que se asisten en un hospital de Uruguay

Introducción: El ataque cerebrovascular es la segunda causa de muerte en adultos en el mundo occidental y una de las principales causas de discapacidad permanente, aumentando su frecuencia con la edad, el 85 % es de tipo isquémico. Objetivos: Analizar parámetros trombofílicos, hipofibrinolíticos y genéticos en pacientes con ataque cerebrovascular isquémico y evaluar la posible asociación de estos con factores de riesgo cardiovascular. Metodología: Se utilizó un cuestionario para evaluar la presencia de factores de riesgo cardiovascular en 114 pacientes incluidos en el estudio con diagnóstico de ataque cerebrovascular isquémico. Proteína C y antitrombina fueron determinados mediante métodos cromogénicos, resistencia a la proteína C activada e inhibidor lúpico mediante métodos coagulométricos y proteína S libre, inhibidor del activador del plasminógeno-1, homocisteína y lipoproteína (a) por métodos inmunoquímicos. Fibrinógeno fue determinado por coagulometría y proteína C reactiva por inmunoturbidimetría, ambos contra un grupo control. Las variantes genéticas factor V Leiden, protrombina G20210A, rs1205 (gen PCR), rs1800779 (gen NOS3) y rs2257073 (gen ASB10) fueron analizadas mediante real-time PCR, comparando los últimos tres con una población de referencia. La alteración de las frecuencias de las variables fue determinada por análisis estadístico chi-cuadrado. Resultados: Tres de los cuatro pacientes jóvenes estudiados presentaron indicadores de trombofilia. El resto de los parámetros alterados fueron homocisteína 30.1% (22.4-39.1), lipoproteína (a) 32.1% (24.1-41.4), inhibidor del activador del plasminógeno-1 36.0% (27.8-45.1), fibrinógeno 12.3% (7.5-19.6) y proteína C reactiva 78.1% (69.6-84.7). Se encontró asociación (p < 0.05) entre ciertos factores de riesgo cardiovascular y los parámetros evaluados como hipertensión/proteína C reactiva, dislipemia/lipoproteína (a), arritmia/lipoproteína (a) y arritmia/fibrinógeno. Para pacientes con ataque cerebrovascular isquémico solo la variante rs1205 mostró una frecuencia más alta del alelo T. Conclusiones: Este estudio revela la importancia de analizar la trombofilia en pacientes jóvenes, especialmente en aquellos sin factores de riesgo cardiovascular, así como el rol de la hipofibrinolisis, inflamación y algunas variantes genéticas en el desarrollo de ataque cerebro vascular isquémico.

Introduction: Stroke is the second cause of death in adults in the Western world and one of the main causes of permanent disability, increasing in frequency with age; 85% are ischemic. Objectives: To analyze thrombophilic, hypofibrinolytic, inflammatory, and genetic parameters in patients with ischemic stroke and evaluate possible associations with vascular risk factors. Methodology: Questionnaires were used to evaluate vascular risk factors in 114 patients included in the study with ischemic stroke diagnosis. Protein C and Antithrombin were determined by chromogenic assays, Activated Protein C Resistance and Lupus Anticoagulant were determined with by coagulometry and Free Protein S, Plasminogen activator inhibitor-1, Homocysteine and Lipoprotein (a) by immunochemistry. Fibrinogen was assayed by coagulometry and C-reactive protein by immunoturbidimetry, both against a control group. Factor V Leiden, Prothrombin G20210A, rs1205 (CRP gene), rs1800779 (NOS3 gene) and rs2257073 (ASB10 gene) genetic variants were analyzed by Real-Time PCR, comparing the last three with a reference population. Alteration frequencies of the variables were determined by chi-square statistical analysis. Results: Three out of four of the young patients studied presented indicators of thrombophilia. The rest of the altered parameters were Homocysteine 30.1% (22.4-39.1), Lipoprotein (a) 32.1% (24.1-41.4), Plasminogen activator inhibitor-1 36.0% (27.8-45.1), Fibrinogen 12.3% (7.5-19.6) and C-reactive protein 78.1% (69.6-84.7). Associations were found (p<0.05) between certain vascular risk factors and parameters evaluated, namely hypertension/C-reactive protein, dyslipidemia/lipoprotein (a), arrhythmia/lipoprotein (a) and arrhythmia/fibrinogen. For ischemic stroke patients only the genetic variant rs1205 showed higher frequency of the T allele. Conclusions: This study reveals the importance of analyzing thrombophilia in young patients, especially those without vascular risk factors, as well as the role of hypofibrinolysis, inflammation and some genetic variants in the development of ischemic stroke.

Introdução: O AVC é a segunda causa de morte em adultos no mundo ocidental e uma das principais causas de incapacidade permanente, aumentando de frequência com a idade; 85% são isquémicos. Metas: Analisar os parâmetros trombofílicos, hipofibrinolíticos e genéticos em pacientes com acidente vascular cerebral isquêmico e avaliar a possível associação com fatores de risco cardiovascular. Metodologia: Um questionário foi utilizado para avaliar a presença de fatores de risco cardiovascular em 114 pacientes incluídos no estudo com diagnóstico de acidente vascular cerebral isquêmico. Proteína C e antitrombina foram determinadas por métodos cromogênicos, resistência à proteína C ativada e inibidor de lúpus por métodos coagulométricos e proteína S livre, inibidor do ativador do plasminogênio-1, homocisteína e lipoproteína (a) por métodos imunoquímicos. O fibrinogênio foi determinado por coagulometria e a proteína C-reativa por imunoturbidimetria, ambos contra um grupo controle. As variantes genéticas fator V Leiden, protrombina G20210A, rs1205 (gene PCR), rs1800779 (gene NOS3) e rs2257073 (gene ASB10) foram analisadas por PCR em tempo real, comparando as três últimas com uma população de referência. As frequências de alteração das variáveis ​​foram determinadas pela análise estatística qui-quadrado. Resultados: Três dos quatro pacientes jovens estudados apresentaram indicadores de trombofilia. O resto dos parâmetros alterados foram homocisteína 30,1% (22,4-39,1), lipoproteína (a) 32,1% (24,1-41,4), inibidor do ativador de plasminogênio-1 36,0% (27,8-45,1), fibrinogênio 12,3% (7,5-19,6) e proteína C reativa 78,1% (69,6-84,7). Foi encontrada associação (p<0,05) entre alguns fatores de risco cardiovascular e os parâmetros avaliados como hipertensão/proteína C reativa, dislipidemia/lipoproteína (a), arritmia/lipoproteína (a) e arritmia/fibrinogênio. Para pacientes com acidente vascular cerebral isquêmico apenas a variante rs1205 apresentou maior frequência do alelo T. Conclusões: Este estudo revela a importância de analisar a trombofilia em pacientes jovens, especialmente aqueles sem fatores de risco cardiovascular, bem como o papel da hipofibrinólise, inflamação e algumas variantes genéticas no desenvolvimento do acidente vascular cerebral isquêmico.

Reperfusion therapy for acute ischemic stroke: where are we in 2023? / Terapia de reperfusão para o acidente vascular isquêmico agudo: onde estamos em 2023?

Abstract Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.

Resumo Nas últimas três décadas, o tratamento do AVC sofreu transformações significativas, impulsionadas principalmente pela introdução das terapias de reperfusão e pela organização dos serviços de AVC. Os pacientes que recebem tratamento em um serviço de AVC bem estruturado têm uma probabilidade muito maior de resultados favoráveis, diminuindo assim a incapacidade funcional e a mortalidade. Neste artigo, revisamos as evidências científicas para as terapias de reperfusão do AVC, incluindo trombólise e trombectomia e sua implementação no sistema público de saúde no Brasil.

Estatinas en la prevención primaria, secundaria y terciaria del ictus isquémico

Introducción: El ictus isquémico representa la tercera causa de mortalidad en el mundo y la primera causa de discapacidad. Objetivos: Describir los efectos beneficiosos de la prescripción de las estatinas en la prevención primaria, secundaria y terciaria del ictus isquémico. Métodos: Se realizó una revisión bibliográfica sobre la prescripción de estatinas en la prevención primaria, secundaria y terciaria del ictus isquémico. Se revisaron más de 400 artículos publicados en PubMed, Cochrane y Medline. Conclusiones: El empleo de estatinas disminuye la mortalidad en la prevención primaria y secundaria, se utiliza precozmente en la fase aguda (prevención terciaria), disminuye el área infartada, existe una mejoría clínica y disminuyen los reactantes de la fase aguda como la proteína C reactiva.

Introduction: Ischemic stroke represents the third cause of mortality worldwide and the first cause of disability. Objective: To describe the beneficial effects of the prescription of statins in the primary, secondary and tertiary prevention of ischemic stroke. Methods: A bibliographic review on the prescription of statins in the primary, secondary and tertiary prevention of ischemic stroke was carried out. More than 400 articles published in MEDLINE/PubMed and Cochrane were reviewed. Only 50 articles met the selection criteria, which were published from May 2021 to June 2022. Conclusions: The use of statins decreases mortality in primary and secondary prevention. If they are used early in the acute phase (tertiary prevention), the infarcted area decreases, there is clinical improvement and acute phase reactants such as C-reactive protein decrease.

Enfermedad de pequeño vaso. Relación con deterioro funcional, cognitivo y afectivo en adultos mayores con enfermedad cerebrovascular / Small vessel disease. Relationship with functional, cognitive and affective impairment in elderly adults with cerebrovascular disease

INTRODUCCIÓN: La enfermedad cerebral de pequeño vaso es una causa principal de pérdida funcional, discapacidad y deterioro cognitivo. OBJETIVO: Determinar la prevalencia de la enfermedad de pequeño vaso y características clínicas que se asocian a mayor deterioro funcional, cognitivo y afectivo en adultos mayores con enfermedad cerebrovascular atendidos en el Servicio de Neurología del Hospital Carlos Andrade Marín en el período 2020 ­ 2021. METODOLOGÍA: Estudio observacional, analítico transversal con 80 pacientes mayores de 65 años con enfermedad cerebrovascular previamente diagnosticada. Se determinó cuáles presentaban enfermedad cerebral de pequeño vaso. Se compararon los dos grupos el de enfermedad cerebro vascular isquémico con y sin enfermedad cerebral de pequeño vaso. Se midió el grado de deterioro funcional con escala de Barthel; Lawton y Brody. El deterioro cognitivo con test de Montreal Cognitive Assessment ­Basic, estado afectivo con escala de Yesavage. Se utilizó razón de momios y se consideró significativo un valor p <0,05. Se utilizó el programa Statistical Package for Social Sciences versión 25. RESULTADOS: Los hombres representaron el 51,2%. La edad promedio fue 76,2 años. Prevalencia de enfermedad cerebral de pequeño vaso (87,5%). Escala de Fazekas grado 1 (46,3%), Factores asociados con enfermedad cerebral de pequeño vaso: tabaquismo [RR: 7,27; IC 95%: 1,69-31,3); enfermedad renal crónica [RR: 4,0; IC 95%: 1,01-15,7]. Dependencia moderada [RR: 6,42; IC 95%: 1,02-40,3]. Factores asociados con pérdida funcionalidad: gravedad del ictus. Factores asociados con deterioro cognitivo: infarto con doble territorio. Factores asociados con deterioro afectivo: infarto con doble territorio y síndrome metabólico (p<0,05). CONCLUSIÓN: La enfermedad cerebral de pequeño vaso tiene una elevada prevalencia entre los adultos mayores con enfermedad cerebrovascular y representó un deterioro cognitivo, funcional y afectivo considerable, en relación a los pacientes sin esta enfermedad.

INTRODUCTION: Cerebral small vessel disease is a leading cause of functional loss, disability, and cognitive impairment. OBJECTIVE: To determine the prevalence of small vessel disease and clinical characteristics associated with greater functional, cognitive and affective impairment in older adults with cerebrovascular disease attended at the Neurology Service of the Carlos Andrade Marín Hospital in the period 2020 - 2021. METHODOLOGY: Observational, analytical cross-sectional study with 80 patients over 65 years of age with previously diagnosed cerebrovascular disease. It was determined which patients had cerebral small vessel disease. The two groups of ischemic cerebrovascular disease with and without cerebral small vessel disease were compared. The degree of functional impairment was measured with the Barthel, Lawton and Brody scales. Cognitive impairment was measured with the Montreal Cognitive Assessment-Basic test, and affective state with the Yesavage scale. Odds ratio was used and a p value <0,05 was considered significant. Statistical Package for Social Sciences version 25 was used. RESULTS: Males represented 51,2%. Mean age was 76,2 years. Prevalence of cerebral small vessel disease (87,5%). Fazekas scale grade 1 (46,3%), Factors associated with cerebral small vessel disease: smoking [RR: 7,27; 95% CI: 1,69-31,3); chronic kidney disease [RR: 4,0; 95% CI: 1,01-15,7]. Moderate dependence [RR: 6,42; 95% CI: 1,02-40,3]. Factors associated with loss of function: severity of stroke. Factors associated with cognitive impairment: infarction with double territory. Factors associated with affective impairment: dual territory infarction and metabolic syndrome (p<0.05). CONCLUSION: Cerebral small vessel disease has a high prevalence among older adults with cerebrovascular disease and represented a considerable cognitive, functional and affective deterioration, in relation to patients without this disease.

Asociación de marcadores inflamatorios y de disfunción endotelial con la depresión en la enfermedad cerebrovascular isquémica

Fundamento: la depresión es una de las complicaciones no neurológicas más frecuentes en la enfermedad cerebrovascular isquémica. Objetivo: determinar la asociación de marcadores inflamatorios y de disfunción endotelial con la depresión en pacientes con enfermedad cerebrovascular isquémica. Métodos: se realizó un estudio analítico, prospectivo de corte transversal en pacientes con enfermedad cerebrovascular isquémica en fase aguda (N=22) y no aguda (N=37); atendidos en el Instituto de Neurología y Neurocirugía y el Hospital Manuel Fajardo, de La Habana, Cuba. Se recogieron variables demográficas, factores de riesgo, etiología y localización del infarto, deficiencia neurológica, discapacidad para las actividades de la vida diaria (índice de Barthel), neuropsicológicas (depresión por inventario de Beck y test de Hamilton). Se determinó proteína C-reactiva, alfa-1-antitripsina, complementos C3 y C4 y microalbuminuria. Resultados: las puntuaciones de las pruebas neuropsicológicas no tuvieron diferencias significativas entre la fase aguda y no aguda, pero hubo un aumento estadístico de la frecuencia de pacientes sin depresión y con ligera depresión en la fase no aguda. En la fase aguda, el complemento C4 y en la fase no aguda el complemento C3, la proteína C-reactiva y el alfa-1-antitripsina se correlacionaron directamente con la puntuación del inventario de Beck. La proteína C-reactiva y C3 se correlacionaron estadísticamente con la puntuación del test de Hamilton. En el análisis multivariado, la proteína C-reactiva mostró asociación independiente con el grado de depresión por el test de Hamilton. Conclusiones: la proteína C-reactiva pudiera estar relacionada con la severidad de la depresión, quizás por asociación con la discapacidad para las actividades de vida diaria.

Foundation: depression in ischemic cerebrovascular disease is one of the most frequent non-neurological complications. Objective: to determine the association of inflammatory markers and endothelial dysfunction with depression in patients with ischemic cerebrovascular disease. Methods: an analytical, prospective, cross-sectional study was carried out in patients with acute (N=22) and non-acute (N=37) ischemic cerebrovascular disease; treated at the Institute of Neurology and Neurosurgery; and the Manuel Fajardo Hospital, in Havana, Cuba. Demographic variables, risk factors, etiology and location of the infarction, neurological deficiency, disability for activities of daily living (Barthel index), neuropsychological (depression by Beck inventory and Hamilton test) were collected. C-reactive protein, alpha-1-antitrypsin, C3 and C4 complements, and microalbuminuria were determined. Results: the scores of the neuropsychological tests did not have significant differences between the acute and non-acute phase, but there was a statistical increase in the frequency of patients without depression and with slight depression in the non-acute phase. In the acute phase, C4, and in the non-acute phase, C3, C-reactive protein and alpha-1-antitrypsin were directly correlated with the Beck inventory score. C-reactive protein and C3 were statistically correlated with the Hamilton test score. In the multivariate analysis, C-reactive protein showed an independent association with the degree of depression by the Hamilton test. Conclusions: C-reactive protein could be related to the severity of depression, perhaps by association with the disability for activities of daily living.

Estudo sobre a prevalência de doença carotídea detectada por ultrassonografia nos casos de AVC isquêmico de um hospital público de Santa Catarina / Study on the prevalence of carotid artery disease detected by ultrasonography in cases of ischemic stroke at a public hospital in Santa Catarina

Fundamento: Acidentes Vasculares Cerebrais Isquêmicos (AVCi) representam significativa parcela dentre as causas da morbimortalidade mundial. Estenose das artérias carótidas e vertebrais são consideradas fator de risco para tal desfecho. A Ultrassonografia com Doppler (USG Doppler) das artérias extracranianas pode ser útil na identificação de pacientes com estenose significativa por ser um método inócuo e acessível. Objetivos: avaliar a prevalência de estenose nas artérias extracranianas diagnosticadas através do estudo com USG Doppler e a prevalência de fatores associados em pacientes com quadro de AVCi. Métodos: Trata-se de estudo retrospectivo, transversal, a partir da análise de prontuários dos pacientes internados com quadro de AVCi no Hospital Regional de São José, Santa Catarina, Brasil. O estudo ocorreu entre janeiro de 2020 e dezembro de 2021. A análise ultrassonográfica foi realizada por médicos radiologistas habilitados, a partir do uso de aparelho validado (GE Logic P9 com transdutor linear multifrequencial 6-15MHz). Resultados: Dentre os 239 pacientes incluídos, destaca-se a significativa prevalência de comorbidades associadas ao AVCi, como hipertensão arterial sistêmica (78,2%) e tabagismo (40,6%). A distribuição entre os sexos foi homogênea (58,2 versus 41,8%) e 70,3% dos pacientes possuíam idade superior a 60 anos de idade. A taxa de pacientes com alterações hemodinamicamente significativas (estenose >50% da luz do vaso) das artérias carótidas e vertebrais foi de 29,2%. O tabagismo foi o único fator de risco que se correlacionou estatisticamente com a ocorrência de AVCi decorrente do acometimento das artérias carótidas ou vertebrais (RP 1,708; IC 1,057-2,761; p=0,028). Conclusão: O USG com Doppler das artérias extracranianas é ferramenta útil na investigação dos casos de AVCi, visto que a prevalência de doença significativa dos grandes vasos extracranianos (estenose>50%) se aproxima de 30%.

Background: Ischemic Strokes represent a sizable portion among the causes of morbidity and mortality worldwide. Stenosis of the carotid and vertebral arteries represent a risk factor to this outcome. Ultrasonography with Doppler of the extracranial arteries can be useful in identifying patients with significant stenosis because it is a harmless and accessible method. Objectives: To assess the prevalence of stenosis in the extracranial arteries diagnosed through Doppler ultrasound examination and the prevalence of associated factors in patients with ischemic stroke Methods: This is a retrospective, cross-sectional study based on the analysis of medical records of patients admitted with ischemic stroke at the Regional Hospital of São José, Santa Catarina, Brazil. The study was conducted between January 2020 and December 2021. Ultrasonographic analysis was performed by qualified radiologists, using a validated device (GE Logic P9 with a multi-frequency linear transducer 6-15MHz). Results: Among the 239 included patients, there is a significant prevalence of comorbidities associated with ischemic stroke, such as systemic arterial hypertension (78.2%) and smoking (40.6%). The distribution between genders was homogeneous (58.2% versus 41.8%), and 70.3% of the patients were over 60 years old. The rate of patients with hemodynamically significant alterations (stenosis >50% of the vessel lumen) in the carotid and vertebral arteries was 29.2%. Smoking was the only risk factor that statistically correlated with the occurrence of ischemic stroke resulting from the involvement of the carotid or vertebral arteries (PR 1.708; CI 1.057-2.761; p=0.028). Conclusion: Ultrasonography with Doppler of the extracranial arteries is a useful tool in the investigation of ischemic stroke cases, given that the prevalence of significant disease in the large extracranial vessels (stenosis >50%) approaches 30%.

New role of astrocytes in neuroprotective mechanisms after ischemic stroke / Novo papel dos astrócitos nos mecanismos neuroprotetores após acidente vascular cerebral isquêmico

Abstract Astrocytes are the most abundant cell subtypes in the central nervous system. Previous studies believed that astrocytes are supporting cells in the brain, which only provide nutrients for neurons. However, recent studies have found that astrocytes have more crucial and complex functions in the brain, such as neurogenesis, phagocytosis, and ischemic tolerance. After an ischemic stroke, the activated astrocytes can exert neuroprotective or neurotoxic effects through a variety of pathways. In this review, we will discuss the neuroprotective mechanisms of astrocytes in cerebral ischemia, and mainly focus on reactive astrocytosis or glial scar, neurogenesis, phagocytosis, and cerebral ischemic tolerance, for providing new strategies for the clinical treatment of stroke.

Resumo Os astrócitos são os subtipos de células mais abundantes no sistema nervoso central. Estudos anteriores acreditavam que os astrócitos são células de suporte no cérebro, que apenas fornecem nutrientes para os neurônios. No entanto, estudos recentes descobriram que os astrócitos têm funções mais cruciais e complexas no cérebro, como neurogênese, fagocitose e tolerância isquêmica. Após um acidente vascular cerebral isquêmico, os astrócitos ativados podem exercer efeitos neuroprotetores ou neurotóxicos através de uma variedade de vias. Nesta revisão, discutiremos os mecanismos neuroprotetores dos astrócitos na isquemia cerebral, e focaremos principalmente na astrocitose reativa ou cicatriz glial, neurogênese, fagocitose e tolerância isquêmica cerebral, para fornecer novas estratégias para o tratamento clínico do acidente vascular cerebral.

Farmacoterapia en rehabilitación temprana posterior al accidente cerebrovascular isquémico / Pharmacological treatment in early rehabilitation after ischemic stroke

Resumen Existe una gran cantidad de información sobre el tratamiento de apoyo farmacológico temprano para la rehabilitación posterior a un accidente cerebrovascular isquémico agudo. El objetivo de esta revisión es ofrecer a los profesionales de la salud involucrados en la rehabilitación de los pacientes un resumen de la evidencia disponible que colabore con la toma de decisiones en su práctica clínica diaria. Se realizó una búsqueda de ensayos clínicos aleatorizados y estudios observacionales publicados entre el 1/1/2000 y el 28/8/2022 utilizando como motor de búsqueda PubMed, Cochrane y Epistemonikos con restricción de idioma a ingles y español. Los estudios seleccionados incluyeron pacientes mayores de 18 años con un accidente cerebrovascular isquémico agudo sometidos a rehabilitación temprana. Los desenlaces considerados para eficacia fueron: función motora, lenguaje y dolor. Las intervenciones farmacológicas seleccionadas fueron: cerebrolisina, levodopa, selegilina, anfetaminas, fluoxetina, citalopram, escitalopram, antipsicóticos, memantine, pregabalina, amitriptilina y lamotrigina. Se realizó síntesis y evaluación de la evidencia utilizando metodología GRADE. Esta revisión proporcionó un resumen de evidencia sobre el tratamiento de apoyo farmacológico en la neuro-rehabilitación temprana de pacientes post accidente cerebrovascular isquémico agudo. Esto permitirá mejorar las recomendaciones actuales con el objetivo de colaborar con la toma de decisiones en salud para esta población.

Abstract There is a wealth of information on early pharmacological supportive treatment for early rehabilitation following acute ischemic stroke. This review aims to provide healthcare professionals involved in rehabilitating patients with a summary of the available evidence to assist with decision-making in their daily clinical practice. A search for randomized clinical trials and observational studies published between 1/1/2000 and 28/8/2022 was performed using PubMed, Cochrane and Epistemonikos as search engines with language restriction to english and spanish. The selected studies included patients older than 18 with acute ischemic stroke undergoing early rehabilitation. The outcomes considered for efficacy were: motor function, language, and central pain. The selected pharmacological interventions were: cerebrolysin, levodopa, selegiline, amphetamines, fluoxetine, citalopram, escitalopram, antipsychotics, memantine, pregabalin, amitriptyline and lamotrigine. Evidence synthesis and evaluation were performed using the GRADE methodology. This review provided a summary of the evidence on pharmacological supportive care in early rehabilitation of post-acute ischemic stroke patients. This will make it possible to improve current recommendations with the aim of collaborating with health decision-making for this population.

Mecanismos de acción y tratamiento del accidente cerebrovascular isquémico por COVID-19

Diversos mecanismos inflamatorios y protrombóticos pueden contribuir al aumento del riesgo de eventos cardiovasculares y accidentes cerebrovasculares en pacientes con COVID-19, afectando el enfoque del tratamiento y manejo de la enfermedad. La evidencia relacionada con los mecanismos fisiopatológicos del COVID-19 y su asociación con los accidentes cerebrovasculares son relevantes para guiar el tratamiento y el manejo de los pacientes, considerados como desafíos terapéuticos que surgen durante períodos de contagio masivo. Objetivo. Describir el mecanismo de acción y tratamiento del evento cerebro vascular isquémico por COVID-19. Metodología. Se realizó una revisión exhaustiva de la literatura mediante una revisión sistemática, en conformidad con las directrices establecidas por la declaración PRISMA. Se recopiló información de múltiples bases de datos científicas, utilizando términos y palabras clave ("Mecanismos de acción" OR "Mecanismos fisiopatológicos") AND ("Accidente cerebrovascular isquémico" OR "ACV isquémico") relacionados con los mecanismos de acción y tratamiento del accidente cerebrovascular isquémico asociado al COVID-19. Resultados. En total se obtuvo 41 entre PubMed y Science direct, previo a criterios 12 fueron seleccionados. Conclusión. Se determinaron los mecanismos de acción desencadenados por el COVID-19 para la formación de trombos y su relación con los accidentes cerebrovasculares. Además, se comprendió cómo el tratamiento de los accidentes cerebrovasculares afectaba a los pacientes que también padecían COVID-19. Se encontró que la tormenta de citocinas era un mecanismo influyente en la fisiopatología del COVID-19. En cuanto al tratamiento, la identificación de la enfermedad infecciosa causada por el virus SARS-CoV-2 resultó crucial en la gestión de los pacientes con accidente cerebrovascular.

Various inflammatory and prothrombotic mechanisms may contribute to the increased risk of cardiovascular events and stroke in patients with COVID-19, affecting the approach to treatment and management of the disease. Evidence regarding the pathophysiological mechanisms of COVID-19 and its association with stroke are relevant to guide the treatment and management of patients, considered as therapeutic challenges arising during periods of massive contagion. Objective. To describe the mechanism of action and treatment of ischemic cerebrovascular event by COVID-19. Methodology. A comprehensive review of the literature was performed by means of a systematic review, in accordance with the guidelines established by the PRISMA statement. Information was collected from multiple scientific databases, using terms and keywords ("Mechanisms of action" OR "Pathophysiological mechanisms") AND ("Ischemic stroke" OR "Ischemic stroke") related to the mechanisms of action and treatment of COVID-19-associated ischemic stroke. Results. A total of 41 were obtained between PubMed and Science direct, prior to criteria 12 were selected. Conclusion. The mechanisms of action triggered by COVID-19 for thrombus formation and its relation to stroke were determined. In addition, we gained insight into how stroke treatment affected patients who also had COVID-19. Cytokine storm was found to be an influential mechanism in the pathophysiology of COVID-19. In terms of treatment, identification of infectious disease caused by SARS-CoV-2 virus proved crucial in the management of stroke patients.

Vários mecanismos inflamatórios e pró-trombóticos podem contribuir para o aumento do risco de eventos cardiovasculares e acidente vascular cerebral (AVC) em pacientes com COVID-19, afetando a abordagem do tratamento e o manejo da doença. As evidências sobre os mecanismos fisiopatológicos da COVID-19 e sua associação com o AVC são relevantes para orientar o tratamento e o manejo dos pacientes, considerados como desafios terapêuticos que surgem durante períodos de contágio em massa. Objetivo. Descrever o mecanismo de ação e o tratamento do evento cerebrovascular isquêmico devido à COVID-19. Metodologia. Uma revisão abrangente da literatura foi realizada por meio de uma revisão sistemática, de acordo com as diretrizes estabelecidas pela declaração PRISMA. As informações foram coletadas de vários bancos de dados científicos, usando termos e palavras-chave ("Mechanisms of action" OR "Pathophysiological mechanisms") AND ("Ischaemic stroke" OR "Ischaemic stroke") relacionados aos mecanismos de ação e tratamento do acidente vascular cerebral isquêmico associado à COVID-19. Resultados. Foram obtidos 41 artigos no PubMed e no Science direct, e 12 foram selecionados de acordo com os critérios. Conclusão. Foram determinados os mecanismos de ação desencadeados pela COVID-19 para a formação de trombos e sua relação com o AVC. Além disso, entendemos como o tratamento do AVC afetou os pacientes que também tinham COVID-19. Descobriu-se que a tempestade de citocinas é um mecanismo influente na fisiopatologia da COVID-19. Em termos de tratamento, a identificação da doença infecciosa causada pelo vírus SARS-CoV-2 foi crucial no tratamento de pacientes com AVC.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology / Desfecho de AVC recorrente em pacientes com fibrilação atrial de acordo com etiologia presumida

Abstract Background Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. Objective The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. Methods We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. Results We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). Conclusions In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

Resumo Antecedentes Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes. Objetivo O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC. Métodos Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como "Cardioembólicos", sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia "Indeterminada" por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes. Resultados Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2-16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3-18) versus 3 (1-8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65-3,15). Conclusões Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Perspectiva neurológica en la elección del anticoagulante oral directo para la prevención del accidente cerebrovascular en fibrilación auricular / Neurological perspective in the choice of direct oral an ticoagulants for prevention of stroke in atrial fibrillation

Resumen La fibrilación auricular no valvular (FA) es la arritmia con potencial embolígeno más prevalente y una de las principales y crecientes causas de accidente cerebrovas cular isquémico (ACVi). El principal objetivo del uso de la anticoagulación en pacientes con FA es la prevención del ACVi. Hasta hace poco tiempo, la anticoagulación con antagonistas de la vitamina K (AVKs) era la única opción disponible. Los anticoagulantes orales directos (DOACs) como el inhibidor directo de la trombina, dabigatrán, o los inhibidores directos del factor Xa, rivaroxabán, apixa bán y edoxabán, tienen un perfil de efectividad/seguridad más favorable en comparación con los AVKs. No existen estudios que comparen la efectividad de los DOACs entre sí. La elección del DOAC depende de múltiples factores específicos del paciente, preferencias del médico, costos y accesibilidad. Entre 1-2% de los pacientes correctamente tratados con un DOAC intercurre con un ACVi cada año. La posibilidad de contar con un agente reversor debería ser tenida en cuenta al momento de la elección del DOAC, especialmente por el riesgo residual de ocurrencia de ACVi. En la actualidad, en nuestro país solo el dabigatrán cuenta con un agente reversor disponible y lo convierte en el único DOAC que no contraindica el uso de trombolisis intraveno sa con rtPA. Esta situación debería ser considerada en el momento de la elección del DOAC para la prevención de eventos tromboembólicos en pacientes con FA.

Abstract Non-valvular atrial fibrillation (AF) is the most preva lent arrhythmia with high embolic potential, and one of the main and growing causes of stroke. The main objec tive of anticoagulation in patients with AF is prevention of stroke. Until recently, anticoagulation with vitamin K antagonists (VKAs) was the only available option. Direct oral anticoagulants (DOACs), such as the direct thrombin inhibitor dabigatran, or the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, have a more favor able effectiveness/safety profile compared to VKAs. There are no studies comparing the efficacy of DOACs with each other. The choice of a DOAC arose from patient car achterictis, physician preferences, cost, and accessibility. Between 1-2% of patients correctly treated with a DOAC experience a stroke each year. The possibility of having a reversal agent should be taken into account when choos ing a DOAC, especially due to the residual risk of stroke occurrences even under DOACs. Currently, in our country only dabigatran has a reversing agent available, making it the only DOAC that does not contraindicate the use of intravenous thrombolysis. This should be taken into account when choosing the DOAC for the prevention of thromboembolic events in patients with AF.

Ischemic Stroke in Dengue Fever: Unusual Complication of a Common Disease

Dengue fever is an arboviral infection, which is highly prevalent in tropical and subtropical climates. It is frequently associated with neurological complications but its association with ischemic stroke is ill defined. We present a case of an apparently healthy young male admitted with dengue fever complicated by ischemic infarct in corpus callosum. Our patient was managed conservatively, improved clinically and discharged in satisfactory condition.