Ataque cerebrovascular isquémico agudo de territorio anterior: Tratamiento endovascular / Acute ischemic stroke in anterior territory: endovascular treatment

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) ≤ 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS ≤ 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) ≤ 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS ≤ 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

Association between statin use and mortality risks during the acute phase of ischemic stroke in patients admitted to an intensive care unit / Associação entre o uso de estatina e risco de mortalidade durante a fase aguda do acidente vascular cerebral isquêmico em pacientes admitidos em uma unidade de terapia intensiva

Abstract Ischemic stroke is a common cause of death. The role of statins in the secondary prevention of the chronic ischemic stroke phase has been established. However, evidence regarding their efficacy in this phase is limited and contradictory. Objective: To evaluate the association between statin use and mortality risk during the acute phase of ischemic stroke in patients admitted to an intensive care unit. Methods: This was an observational and prospective study of ischemic stroke patients aged ≥18, admitted to an intensive care unit. Medications used during the first 7 days after the ictus, as well as medications used previously, were recorded. The primary outcome was all-cause mortality during the first 7 days. Results: We screened 212 patients and included 97 patients with ischemic stroke in the study period. The mortality rate among patients who used statins during the acute IS phase [14% (9/63)] was significantly lower than that among patients who did not use statins [41% (14/34); p=0.007]. This was confirmed in logistical regression with an 0.19 Odds Ratio - OR [p=0.018; 95% confidence interval - 95%CI 0.05-0.75]. Patients who died were older, had a higher incidence of acute myocardial infarction, higher scores on the NIHSS and lower systolic blood pressure. Statins and angiotensin converting enzyme inhibitors were used more frequently among survivors. These associations persisted even after adjustment for confounding variables. Conclusion: Statins and angiotensin converting enzyme inhibitors use during hospitalization were independently associated to a lower rate of all-cause mortality in the first 7 days of intensive care unit admission.

Resumo O acidente vascular cerebral (AVC) isquêmico é uma causa comum de morte. O papel das estatinas na prevenção secundária da fase crônica do AVC isquêmico foi estabelecido. No entanto, as evidências sobre a sua eficácia na fase aguda do AVC isquêmico são limitadas e contraditórias. Objetivo: Avaliar a associação entre o uso de estatinas e o risco de mortalidade durante a fase aguda do AVC isquêmico em pacientes internados em uma unidade de terapia intensiva. Métodos: Estudo observacional e prospectivo de pacientes com AVC isquêmico com idade ≥18 anos, internados em uma unidade de terapia intensiva. Os medicamentos utilizados durante os primeiros 7 dias após o ictus, bem como os medicamentos utilizados anteriormente, foram registrados. O desfecho primário foi mortalidade por todas as causas durante os primeiros 7 dias. Resultados: Foram selecionados 212 pacientes e incluídos 97 pacientes com AVC isquêmico no período do estudo. A taxa de mortalidade entre os pacientes que usaram estatinas durante a fase aguda do AVC [14% (9/63)] foi significativamente menor do que a dos pacientes que não usaram estatinas [41% (14/34); p=0,007]. Isso foi confirmado na regressão logística com Odds Ratio - OR 0,19 [p=0,018; intervalo de confiança de 95% - IC95% 0,05-0,75]. Os pacientes que morreram eram mais velhos, apresentavam maior incidência de infarto agudo do miocárdio, escores mais altos na National Institute of Health Stroke Scale (NIHSS) e menor pressão arterial sistólica. Estatinas e inibidores da enzima conversora de angiotensina foram utilizados com maior frequência entre os sobreviventes. Essas associações persistiram mesmo após o ajuste para variáveis de confundimento. Conclusão: O uso de estatinas e inibidores da enzima conversora de angiotensina durante a hospitalização foram associados de forma independente à uma menor taxa de mortalidade por todas as causas nos primeiros 7 dias de internação na unidade de terapia intensiva.

Mecanismos de lesión cerebral en niños prematuros / Mechanisms of brain injury of the premature baby

Los nacimientos prematuros son uno de los principales indicadores de salud de un país. Están asociados a una alta mortalidad e importante morbilidad en niños con parálisis cerebral y otros trastornos del neurodesarrollo, incluyendo problemas cognitivos y del aprendizaje. Los principales tipos de lesión encefálica en los recién nacidos prematuros son: a) las lesiones de la sustancia blanca, generalmente asociadas a alteraciones neuronales y axonales en la corteza cerebral y otras zonas de sustancia gris; b) hemorragias intracraneanas que incluyen las de la matriz germinal, intraventriculares e intraparenquimatosas y c) del cerebelo. Las lesiones de sustancia blanca incluyen la leucomalacia periventricular quística, no quística (con focos de necrosis microscópicos) y lesiones difusas de sustancia blanca, no necróticas. Estas lesiones tienen múltiples factores etiológicos. Las características anatómicas y fisiológicas de las estructuras vasculares periventriculares predisponen a la sustancia blanca a ser muy vulnerable a las situaciones de isquemia cerebral y, en interacción con factores infecciosos/inflamatorios, activan a las microglías generando estrés oxidativo (por liberación de radicales libres del oxígeno y del nitrógeno), liberación de citoquinas proinflamatorias, liberación de glutamato, fallo energético y alteración de la integridad vascular. Todo lo anteriormente mencionado genera una particular vulnerabilidad de los pre-oligodendrocitos que termina alterando la mielinización. La hipoxia-isquemia también puede producir necrosis neuronal selectiva en diferentes regiones encefálicas. La matriz germinal es un área altamente vascularizada en la región subependimaria periventricular con una estructura capilar muy frágil que la predispone a las hemorragias.

Preterm birth is one of the main country health indicators. It is associated with high mortality and significant morbidity in preterm newborns with cerebral palsy and potential long-term neurodevelopmental disabilities like cognitive and learning problems. The main lesions could be: a) white matter injuries, generally associated with cortical and other regions of grey matter neuronal-axonal disturbances; b) intracranial hemorrhage that includes germinal matrix, intraventricular and parenchymal, c) cerebellum injuries. The white matter lesions include cystic and non-cystic (with microscopic focal necrosis) periventricular leukomalacia and non-necrotic diffuse white matter injury. Multiple etiologic factors are associated with these injuries. Anatomical and physiological characteristics of periventricular vascular structures predispose white matter to cerebral ischemia and, interacting with infection/inflammation factors, activate microglia, generating oxidative stress (mediated by free oxygen and nitrogen radicals), pro-inflammatory cytokine and glutamate toxicity, energetic failure and vascular integrity disturbances. All these factors lead to a particular vulnerability of pre-oligodendrocytes that will affect myelination. Hypoxia-ischemia also may produce selective neuronal necrosis in different cerebral regions. Germinal matrix is a highly vascularized zone beneath ependymal or periventricular region that constitutes a capillary bed with a particular structural fragility that predispose it to hemorrhage.

The impact of acute kidney injury on fatality of ischemic stroke from a hospital-based population in Joinville, Brazil / O impacto da insuficiência renal aguda na letalidade do acidente vascular cerebral isquêmico de uma população de base hospitalar em Joinville, Brasil

Abstract Introduction: The occurrence of acute kidney injury (AKI) after ischemic stroke has been associated to a worse prognosis. There is a lack of Brazilian studies evaluating this issue. This study aimed to describe the impact of AKI after a first-ever ischemic stroke in relation to fatality rate in 30 days. Methods: This was a retrospective hospital-based cohort. We included patients who had their first ischemic stroke between January to December 2015. AKI was defined by an increase of serum creatinine in relation to baseline value at admission ≥ 0.3 mg/dL or a rise in serum creatinine level by 1.5 times the baseline value at any point in the first week after admission. We performed a univariate and multivariate analysis to evaluate the presence of AKI with fatality in 30 days. Results: The final study population (n=214) had mean age of 66.46 ± 13.73 years, 48.1% were men, the mean NIHSS was 6.33 ± 6.27 and 20 (9.3%) presented AKI. Patients with AKI were older, had a higher score on the NIHSS, and had higher creatinine values on hospital discharge. The 30-day mortality was higher in the AKI subgroup compared to non-AKI (35% vs. 6.2%, p < 0.001). AKI was an independent predictor of fatality after an ischemic stroke but limited by severity of stroke (NIHSS). Conclusion: The presence of AKI is an important complication after ischemic stroke. Despite its impact on 30-day fatality, the predictive strength of AKI was limited by the severity of stroke.

Resumo Introdução: A ocorrência de insuficiência renal aguda (IRA) após acidente vascular cerebral isquêmico (AVCI) está associada a pior prognóstico. Há uma deficiência de estudos brasileiros a respeito dessa questão. O presente estudo teve como objetivo descrever o impacto da IRA após o primeiro episódio de AVCI em relação à taxa de letalidade em 30 dias. Métodos: A presente coorte retrospectiva de base hospitalar incluiu pacientes que sofreram seu primeiro AVCI entre janeiro e dezembro de 2015. IRA foi definida por elevações da creatinina sérica em relação ao valor basal na internação ≥ 0.3 mg/dL ou aumento da creatinina sérica equivalente a 1,5 vez o valor basal em qualquer instante durante a primeira semana após a internação. Foi realizada análise univariada e multivariada para avaliar a presença de IRA com letalidade em 30 dias. Resultados: A população final do estudo (n = 214) apresentou média de idade de 66,46 ± 13,73 anos; 48,1% eram homens; a média de pontuação no NIHSS foi 6,33 ± 6,27; e 20 (9,3%) apresentaram IRA. Pacientes com IRA tinham idade mais avançada, pontuação maior na NIHSS e valores mais elevados de creatinina no momento da alta hospitalar. A mortalidade em 30 dias foi maior no subgrupo com IRA em comparação ao grupo sem IRA (35% vs. 6,2%, p < 0,001). IRA foi preditor independente de mortalidade após AVCI, porém limitado pela gravidade do acidente vascular cerebral (NIHSS). Conclusão: A presença de IRA é uma complicação importante após AVCI. Apesar de seu impacto na letalidade de 30 dias, a força preditiva da IRA foi limitada pela gravidade do AVC.

Consequence of ischemic stroke after coronary surgery with cardiopulmonary bypass according to stroke subtypes

Abstract Introduction: The aim of this study was to determine the outcomes of patients developing ischemic stroke after coronary artery bypass grafting (CABG). Methods: From March 2012 to January 2017, 5380 consecutive patients undergoing elective coronary surgery were analyzed. Ninety-five patients who developed ischemic strokes after on-pump coronary surgery were included in the study, retrospectively. The cohort was divided into four subgroups [total anterior circulation infarction (TACI), partial anterior circulation infarction (PACI), posterior circulation infarction (POCI), and lacunar infarction (LACI)] according to the Oxfordshire Community Stroke Project (OCSP) classification. The primary endpoints were in-hospital mortality, total mortality, and survival analysis over an average of 30 months of follow-up. The secondary endpoints were the extent of disability and dependency according to modified Rankin Scale (mRS). Results: The incidence of stroke was 1.76% (n=95). The median age was 62.03±10.06 years and 68 (71.6%) patients were male. The groups were as follows: TACI (n=17, 17.9%), PACI (n=47, 49.5%), POCI (n=20, 21.1%), and LACI (n=11, 11.6%). Twenty-eight (29.5%) patients died in hospital and 34 (35.8%) deaths occurred. The overall mortality rate of the TACI group was significantly higher than that of the LACI group (64.7% vs. 27.3%, P=0.041). The mean mRS score of the TACI group was significantly higher than that of the other groups (P=0.003). Conclusion: Patients in the TACI group had higher in-hospital and cumulative mortality rates and higher mRS scores. We believe that use of the OCSP classification and the mRS may render it possible to predict the outcomes of stroke after coronary surgery.

Association between blood pressure and acute phase stroke case fatality rate: a prospective cohort study / Associação entre níveis de pressão arterial e letalidade na fase aguda do acidente vascular cerebral: estudo de coorte prospectivo

ABSTRACT Objective ed to investigate the association between blood pressure and acute phase stroke lethality in a Brazilian intensive care unit. Methods This was an observational, prospective cohort study of hemorrhagic and ischemic stroke intensive care patients. The primary outcome was all-cause mortality during the first seven days. Results There were 146 patients, aged 66 ± 13.4 years, 56% men, 89% Caucasian, 69% had ischemic stroke, and 80% were hypertensive. The median of the National Institutes of Health Stroke Scale score was 16. There were 101 ischemic stroke patients and 45 hemorrhagic stroke patients. In the ischemic stroke patients, logistic regression analysis identified low systolic blood pressure as an independent ominous prognostic factor and the optimal cut off was a mean of systolic blood pressure ≤ 131 mmHg during the first 48 hours from admission for prediction of death. No association was found for hemorrhagic stroke. Conclusions There was a negative association between systolic blood pressure and case fatality ratio of acute phase stroke in ischemic stroke intensive care patients.

RESUMO Objetivo Investigar a associação entre pressão arterial e letalidade do acidente vascular cerebral (AVC) em uma unidade de terapia intensiva brasileira. Métodos estudo de coorte prospectivo de pacientes com AVC hemorrágico (AVC-H) ou isquêmico (AVC-I) internados em terapia intensiva. O desfecho primário foi a letalidade por todas as causas nos primeiros sete dias. Resultados Avaliados 146 pacientes, idade: 66 ± 13,4 anos, 56% homens, 89% brancos, 69% AVC-I e 80% hipertensos. A mediana do NIH foi de 16. Os pacientes com AVC-I foram 101 e 45 com AVC-H. Para AVC-I, a análise de regressão logística identificou baixa pressão arterial sistólica como um fator prognóstico negativo e o melhor corte foi uma média da pressão arterial sistólica nas primeiras 48 h de admissão ≤ 131 mmHg para a predição da morte. Para o AVC-H, nenhuma correlação foi encontrada. Conclusões houve associação negativa entre a pressão arterial sistólica e a letalidade do AVC-I em fase aguda em pacientes de terapia intensiva.

Performance of four ischemic stroke prognostic scores in a Brazilian population / Desempenho de quatro escalas de prognóstico de AVCI em uma população brasileira

ABSTRACT Objective Ischemic stroke (IS) prognostic scales may help clinicians in their clinical decisions. This study aimed to assess the performance of four IS prognostic scales in a Brazilian population. Method We evaluated data of IS patients admitted at Hospital Paulistano, a Joint Commission International certified primary stroke center. In-hospital mortality and modified Rankin score at discharge were defined as the outcome measures. The performance of National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL), and Totaled Health Risks in Vascular Events (THRIVE) were compared. Results Two hundred six patients with a mean ± SD age of 67.58 ± 15.5 years, being 55.3% male, were included. The four scales were significantly and independently associated functional outcome. Only THRIVE was associated with in-hospital mortality. With area under the curve THRIVE and NIHSS were the scales with better performance for functional outcome and THRIVE had the best performance for mortality. Conclusion THRIVE showed the best performance among the four scales, being the only associated with in-hospital mortality.

RESUMO Objetivo Escalas de avaliação prognóstica do acidente vascular cerebral isquêmico (AVCI) podem ajudar decisões clinicas. O objetivo deste estudo foi avaliar o desempenho de quatro escalas prognósticas em uma população brasileira. Método Foram avaliados os dados de pacientes admitidos com AVCI no Hospital Paulistano, um hospital acreditado pela “Joint Commission International”. A mortalidade intra-hospitalar e a escala de Rankin foram definidos como desfechos de evolução clínica. O desempenho de quatro escalas: National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL) e Totaled Health Risks in Vascular Events (THRIVE) foi comparado. Resultados Foram incluídos duzentos e seis pacientes, com uma idade média de 67,58 ± 15,5 anos, sendo 55,3% dos sexo masculino. Todas as quatro escalas associaram-se de forma independente com prognóstico funcional. Apenas o THRIVE correlacionou-se com a mortalidade hospitalar. O THRIVE e o NIHSS tiveram melhor desempenho para prognóstico funcional e o THRIVE teve o melhor desempenho para mortalidade pela área sob a curva. Conclusão O THRIVE mostrou-se a escala com melhor performance, sendo a única correlacionada com a mortalidade hospitalar.

Risk factors for perioperative ischemic stroke in cardiac surgery / Fatores de risco para acidente vascular cerebral isquêmico no perioperatório de cirurgia cardíaca

AbstractObjective:The purpose of this study was to evaluate the risk factors for ischemic stroke in patients undergoing cardiac surgery.Methods:From January 2010 to December 2012, 519 consecutive patients undergoing cardiac surgery were analyzed prospectively. The sample was divided into two groups: patients with stroke per and postoperative were allocated in Group GS (n=22) and the other patients in the group CCONTROL (n=497). The following variables were compared between the groups: gender, age, carotid stenosis > 70%, diabetes on insulin, chronic obstructive pulmonary disease, peripheral arteriopathy, unstable angina, kidney function, left ventricular function, acute myocardial infarction, pulmonary arterial hypertension, use of cardiopulmonary bypass. Ischemic stroke was defined as symptoms lasting over 24 hours associated with changes in brain computed tomography scan. The variables were compared using Fisher’s exact test, Chi square, Student’s t-test and logistic regression.Results:Stroke occurred in 4.2% of patients and the risk factors statistically significant were: carotid stenosis of 70% or more (P=0.03; OR 5.07; IC 95%: 1.35 to 19.02), diabetes on insulin (P=0.04; OR 2.61; IC 95%: 1.10 to 6.21) and peripheral arteriopathy (P=0.03; OR 2.61; 95% CI: 1.08 to 6.28).Conclusion:Risk factors for ischemic stroke were carotid stenosis of 70% or more, diabetes on insulin and peripheral arteriopathy.

ResumoObjetivo:O objetivo do presente trabalho foi avaliar os fatores de risco para acidente vascular encefálico isquêmico em pacientes submetidos à cirurgia cardíaca.Métodos:Entre janeiro de 2010 e dezembro de 2012, foram analisados prospectivamente 519 pacientes consecutivos submetidos à cirurgia cardíaca. A amostra foi dividida em dois grupos: os pacientes com acidente vascular encefálico isquêmico (AVEi) trans e pós-operatório foram alocados no grupo GAVEi (n=22) e os demais pacientes no grupo CControle (n=497). As seguintes variáveis foram comparadas entre os grupos: sexo, idade, estenose carotídea >70%, diabetes em uso de insulina, doença pulmonar obstrutiva crônica, arteriopatia periférica, função renal, angina instável, função do ventrículo esquerdo, infarto agudo do miocárdio recente, hipertensão arterial pulmonar, uso de circulação extracorpórea. Acidente vascular encefálico isquêmico foi definido como presença de sintomas de duração maior que 24 horas associados à alteração em tomografia de crânio. As variáveis foram comparadas, por meio do teste exato de Fisher, Qui quadrado, teste t de Student e regressão logística.Resultados:Verificou-se a ocorrência de acidente vascular encefálico isquêmico em 4,2% dos pacientes e os fatores de risco estatisticamente significativos foram: estenose carotídea de 70% ou mais (P=0,03; OR 5,07; IC 95%: 1,35 a 19,02), diabetes em uso de insulina (P=0,04; OR 2,61; IC 95%: 1,10 a 6,21) e arteriopatia periférica (P=0,03; OR 2,61; IC 95%: 1,08 a 6,28).Conclusão:Foram fatores de risco para acidente vascular encefálico isquêmico: estenose carotídea de 70% ou mais, presença de diabetes em uso de insulina e presença de arteriopatia periférica.

Mortality predictors of epilepsy and epileptic seizures among hospitalized elderly / Preditores de mortalidade de epilepsia e crises epilépticas entre idosos hospitalizados

Epilepsy and epileptic seizures are common brain disorders in the elderly and are associated with increased mortality that may be ascribed to the underlying disease or epilepsy-related causes. Objective To describe mortality predictors of epilepsy and epileptic seizures in elderly inpatients.Method Retrospective analysis was performed on hospitalized elderly who had epilepsy or epileptic seizures, from January 2009 to December 2010. One hundred and twenty patients were enrolled.Results The most common etiology was ischemic stroke (37%), followed by neoplasias (13%), hemorrhagic stroke (12%), dementias (11.4%) and metabolic disturbances (5.5%). In a univariate analysis, disease duration (p = 0.04), status epilepticus (p < 0.001) and metabolic etiology (p = 0.005) were associated with mortality. However after adjustment by logistic regression, only status epilepticus remained an independent predictor of death (odds ratio = 13; 95%CI = 2.3 to 72; p = 0.004).Conclusion In this study status epilepticus was an independent risk factor for death during hospitalization.

Epilepsia e crises epilépticas são transtornos cerebrais comuns em idosos e estão associadas com uma taxa de mortalidade elevada que pode ser atribuída à etiologia ou a causas relacionadas à epilepsia. Objetivo Descrever preditores de mortalidade em pacientes idosos internados com epilepsia e crise epiléptica.Método Estudo retrospectivo, envolvendo idosos hospitalizados, de 60 anos ou mais, que foram admitidos de janeiro de 2009 a dezembro de 2010 por terem apresentado epilepsia e crises epilépticas durante a hospitalização. Cento e vinte pacientes foram incluídos no estudo.Resultados A etiologia mais comum foi o acidente vascular cerebral isquêmico (37%), seguido por neoplasias (13%), acidente vascular cerebral hemorrágico (12%), demências (11,4%) e distúrbios metabólicos (5,5%). Na análise univariada, duração da doença (p = 0,04), estado de mal epiléptico (p < 0,001) e etiologia metabólica (p = 0,005) estiveram associados com mortalidade. Entretanto, após ajuste por regressão logística, apenas estado de mal epiléptico permaneceu como preditor independente de morte (odds ratio = 13; IC95% = 2,3 a 72; p = 0,004).Conclusão Neste estudo, estado de mal epiléptico foi um fator independente de risco para morte durante hospitalização.

Long-Term Mortality According to the Characteristics of Early Neurological Deterioration in Ischemic Stroke Patients

PURPOSE: Although early neurological deterioration (END) during the acute stroke period is known to be associated with poor functional outcomes, there is little data regarding the impact of END on long-term outcomes according to the characteristics of END. The aim of this study was to investigate whether there are differences in long-term mortality according to the characteristics of END among acute ischemic stroke or transient ischemic attack patients. MATERIALS AND METHODS: END was defined as any increase (> or =1) in National Institute of Health Stroke Scale score within 7 days after admission. We assessed the characteristics of END, such as the etiology and severity of END, as well as recovery after END. The relationship between 30-day or long-term mortality and each characteristic of END was investigated using multiple logistic analysis or Cox regression model. RESULTS: Among 2820 patients, END was observed in 344 patients (12.2%). After adjustment for age, sex, underlying cardiovascular diseases, stroke severity, and stroke subtypes, END was associated with long-term mortality, whether it was mild or severe and whether or not it was followed by recovery. However, 30-day mortality was strongly related to the severity of END or the absence of recovery after END. Among the causes of END, recurrent stroke and medical illness were related to 30-day mortality, as well as long-term mortality, while brain herniation and intracranial hemorrhagic complications were only associated with 30-day mortality. CONCLUSION: The results of the present study demonstrated that END is associated with higher mortality and the effects of END on short-term and long-term mortality depend on END characteristics.

Impact of stroke unit in a public hospital on length of hospitalization and rate of early mortality of ischemic stroke patients / Impacto da unidade de AVC em hospital publico sobre a hospitalizacao e mortalidade no acidente vascular cerebral isquemico

We ascertained whether a public health stroke unit reduces the length of hospitalization, the rate of inpatient fatality, and the mortality rate 30 days after the stroke. Methods We compared a cohort of stroke patients managed on a general neurology/medical ward with a similar cohort of stroke patients managed in a str oke unit. The in-patient fatality rates and 30-day mortality rates were analyzed. Results 729 patients were managed in the general ward and 344 were treated at a comprehensive stroke unit. The in-patient fatality rates were 14.7% for the general ward group and 6.9% for the stroke unit group (p<0.001). The overall mortality rate 30 days after stroke was 20.9% for general ward patients and 14.2% for stroke unit patients (p=0.005). Conclusions We observed reduced in-patient fatalities and 30-day mortality rates in patients managed in the stroke unit. There was no impact on the length of hospitalization. .

Avaliar o impacto da unidade de AVC (acidente vascular cerebral) no sistema público de saúde sobre o tempo de internação, mortalidade hospitalar e mortalidade após 30 dias do AVC agudo. Métodos Comparamos uma coorte de pacientes com AVC agudo tratados em enfermaria neurológica ou geral (EG) com uma coorte similar de pacientes com AVC tratados em uma unidade de AVC (UAVC), em um mesmo hospital público. Resultados 729 pacientes foram conduzidos na EG e 344 foram tratados em uma UAVC. A mortalidade inicial foi de 14,7% na EG e 6,9% na UAVC (p<0,001). A mortalidade geral em 30 dias após o AVC foi de 20.9% nos pacientes tratados na EG e 14,2% naqueles tratados na UAVC (p=0,005). Conclusão Observamos significante redução da mortalidade inicial e da mortalidade após 30 dias do AVC nos pacientes tratados na UAVC. Não houve impacto sobre o tempo de internação. .

Asociación entre factores socioeconómicos y mortalidad intrahospitalaria por accidente cerebrovascular isquémico en una cohorte hospitalaria de Colombia, 2003-2006 / Correlation between socioeconomic factors and in-hospital mortality from ischemic stroke in a hospital cohort in Colombia, 2003-2006

OBJETIVO: Determinar si existe asociación entre las condiciones socioeconómicas y la mortalidad intrahospitalaria (MIH) por accidente cerebrovascular (ACV) isquémico en una muestra de población colombiana e identificar la cadena de eventos que determinan esa asociación. MÉTODOS: Estudio prospectivo de una cohorte hospitalaria de pacientes con ACV isquémico registrados en cuatro instituciones clínicas de referencia colombianas -ubicadas en Floridablanca, Bucaramanga, Bogotá y Medellín- entre febrero de 2003 y diciembre de 2006. Mediante análisis jerárquico se evaluaron las variables socioeconómicas agrupadas en tres niveles para determinar su relación con la MIH por ACV isquémico en un modelo de riesgos proporcionales de Cox. RESULTADOS: En los 253 pacientes incluidos, la MIH fue de 9,4 %. En el análisis por niveles, la mortalidad estuvo inversamente asociada con el nivel educacional (estudios superiores a primaria), los ingresos mensuales (≥ salario mínimo) y la vinculación al régimen contributivo. En el análisis jerárquico, al combinar los 3 niveles, solo la asociación inversa con la afiliación al régimen contributivo mantuvo su significación estadística (RR 0,35; IC95%: 0,13-0,96; P = 0,04). CONCLUSIONES: Los resultados indican que en Colombia, el estar afilado al régimen contributivo de salud es un factor protector independiente contra la MIH tras un ACV isquémico. La secuencia educación-ingresos-acceso a servicios de salud constituye una vía de explicación de la relación entre las condiciones socioeconómicas y el desenlace clínico de estos eventos. Se deben diseñar estrategias para mitigar las diferencias en la calidad y la distribución de los servicios de salud en la población colombiana.

OBJECTIVE: To determine if there is a correlation between socioeconomic conditions and in-hospital mortality (IHM) from ischemic stroke in a sample of the Colombian population and identify the chain of events that determine that association. METHODS: Prospective study of a hospital cohort of patients with ischemic stroke in four Colombian clinical referral institutions-located in Floridablanca, Bucaramanga, Bogotá, and Medellín-between February 2003 and December 2006. Hierarchical analysis was used to group the socioeconomic variables into three levels, and their relationship to IHM due to ischemic stroke was assessed in a Cox proportional hazards model. RESULTS: The IHM rate was 9.4% in the 253 patients included in the study. In the analysis by levels, mortality was inversely associated with educational level (advanced to primary), monthly income (≥ minimum wage), and participation in the contributory health system. When the three levels were combined in the hierarchical analysis, affiliation with the contributory system was the only association that maintained its statistical significance (RR 0.35; CI 95%: 0.13-0.96; P = 0.04). CONCLUSIONS: The results indicate that, in Colombia, being affiliated with the contributory health system is an independent protective factor against IHM after an ischemic stroke. The education-income-access to health services sequence is a possible explanation for the relationship between socioeconomic conditions and the clinical outcome of these events. Strategies should be designed to mitigate the differences in the quality and distribution of health services in the Colombian population.

Early stroke case-fatality rates in three hospital registries in the Northeast and Southeast of Brazil / Taxas de letalidade precoce por acidente vascular cerebral em três registros hospitalares no nordeste e sudeste do Brasil

Few studies have addressed early cerebrovascular lethality in Brazil. OBJECTIVE: To evaluate 10 and 28-day stroke case-fatality rates in three hospitals in three Brazilian cities. METHODS: We described the stroke registries in São Paulo, João Pessoa, and Natal. RESULTS: Out of a total of 962 first-ever events (mean age, 68.1 years-old; 53% men), 83.6% (804 cases) were classified as ischemic and 16.4% (158) as hemorrhagic stroke. Overall, the case-fatality rates and 95% confidence intervals (95%CI) for hemorrhagic stroke events were higher than for ischemic events, both at 10 (12.3%; 95%CI 7.2-17.4 versus 7.0%; 95%CI 5.3-8.8) and at 28 days (19.8%; 95%CI 13.6-26.0 versus 11.1%; 95%CI 8.9-13.3). CONCLUSIONS: We did not find any substantial differences in early case-fatality rates according to stroke subtypes, when comparing the three centers.

Poucos estudos abordaram a letalidade cerebrovascular precoce no Brasil. OBJETIVO: Avaliar taxas de letalidade por acidente vascular cerebral (AVC) em 10 e 28 dias após evento em três hospitais em três cidades brasileiras. MÉTODOS: Foram descritos os registros de AVC em São Paulo, João Pessoa e Natal. RESULTADOS: De um total de 962 primeiros eventos (idade média de 68,1 anos; 53% homens), 83,6% (804 casos) foram classificados como AVC isquêmico e 16,4% (158) como hemorrágico. As taxas de letalidade e intervalos de confiança de 95% (IC95%) para eventos de AVC hemorrágico foram maiores que para os isquêmicos em: 10 (12,3%; IC95% 7,2-17,4 versus 7,0%; IC95% 5,3-8,8) e 28 dias (19,8%; IC95% 13,6-26,0 versus 11,1%; IC95% 8,9-13,3). CONCLUSÕES: Não foram encontradas diferenças substanciais nas taxas de letalidade precoce por subtipo de AVC ao comparar os três centros estudados.

Qualidade do cuidado ao acidente vascular cerebral isquêmico no SUS / Quality of care for ischemic stroke in the Brazilian Unified National Health System

A taxa de mortalidade hospitalar é uma medida do resultado do cuidado, utilizada como indicador da qualidade do cuidado para o acidente vascular cerebral (AVC). A tomografia computadorizada é o principal método de imagem utilizado para o diagnóstico e condução terapêutica dessa patologia. O objetivo deste artigo é avaliar a qualidade do cuidado hospitalar ao AVC isquêmico (AVCi) agudo no SUS, considerando o perfil de gravidade dos casos e a realização de tomografia computadorizada. Análise multivariada foi empregada para ajustar a mortalidade por risco, avaliar o uso de tomografia e classificar o desempenho dos hospitais no período entre abril de 2006 e dezembro de 2007. 16.879 internações foram analisadas. A realização de, pelo menos, um exame de tomografia computadorizada equivaleu a 28,6 por cento das internações. A taxa de mortalidade bruta foi 34,3 por cento, e a taxa ajustada, 31,2 por cento. A realização de exame de tomografia computadorizada apresentou um efeito protetor: OR ajustado de 0,27 para um exame e de 0,32 para a realização de dois exames. A subutilização da tomografia computadorizada é um dos fatores limitantes para a boa prática médica no tratamento do AVCi no SUS.

The hospital mortality rate is an outcome measure of care used as an indicator of quality of care for stroke. Computerized tomography is the main imaging method for diagnosing and managing stroke. This study aimed to assess the quality of hospital care for acute ischemic stroke (AIS) in the Brazilian Unified National Health System (SUS), considering the severity of cases and use of computerized tomography. Multivariate analysis was used to adjust the mortality risk, evaluate the use of computerized tomography, and rank the performance of hospitals from April 2006 to December 2007. 16,879 admissions were analyzed, and at least one CT scan was performed in 28.6 percent of the admissions. The crude mortality rate was 34.3 percent, and the adjusted rate was 31.2 percent. Performance of a CT scan showed a protective effect: the adjusted OR was 0.27 for one test and 0.32 for two tests. Under-utilization of computerized tomography is one of the limiting factors for good medical practice in the management of ischemic stroke in the SUS.

Characterization of hospitalized ischemic stroke patients in Palestine

Stroke is a major health problem, yet no studies on stroke have been reported from Palestine. This one-year, hospital-based study was conducted to determine the prevalence of risk factors and the in-hospital mortality rate in patients with ischemic stroke. All patients admitted to Al-Watani government hospital and diagnosed with ischemic stroke between September 2006 and August 2007 were included in the study. Data were obtained by retrospective review of medical charts. Pearson Chi-square and independent t test were used in the univariate analysis. Multiple logistic regression analysis was used to determine the independent predictors of in-hospital mortality rates among the patients. Statistical testing and graphics were carried out using SPSS 15. We identified 153 ischemic stroke patients [83 females and 70 males] of whom 92 were having a first-ever stroke [FES]. Patients had several prevalent modifiable risk factors such as hypertension [HTN] [66%], diabetes mellitus [DM] [45.8%], and renal reduced renal function [crcl < 60 ml/ min] [33.9%]. Twenty-six [17%] of the patients died during hospitalization. Four variables were significantly associated with in-hospital mortality: history of previous stroke [P= 0.004], crcl at admission [P=0.004], number of post-stroke complications [P=0.001], and age [P=0.043]. Multiple logistic regression analysis indicated that the number of post-stroke complications [P= 0.001] and previous stroke [P=0.03] were significant independent predictors of in-hospital mortality. Screening and better control of risk factors, especially HTN, DM and renal dysfunction, are required to decrease the incidence and in-hospital mortality among patients with ischemic stroke

Long-Term Outcomes of Acute Ischemic Stroke in Patients Aged 80 Years and Older

PURPOSE: Short life expectancy influences decision-making when treating very old patients with acute ischemic stroke (AIS). We investigated mortality and survival duration in very old AIS patients (> or =80 years) who received hospital care. PATIENTS AND METHODS: Mortality data were obtained from medical records, structured telephone inquiries, death certificates from the Korean National Statistical Office, and social security data 5+/-1.9 years after stroke onset. Age, gender, vascular risk factors, and functional outcomes from modified Rankin scales (MRS) at discharge were analyzed as predictors of mortality. RESULTS: Among 134 patients, 92 (68.7%) died. On Kaplan- Meier analysis, duration of survival of patients aged 80-84 years was longer than those aged 85-89 or 90-94 (24+/-6.4, 8+/-7.3, 7+/-2.0 months, respectively, p=0.002). Duration of survival of patients discharged in a state of MRS 0-1 was longer than the remaining groups at 47+/-4.8 months (p<0.001). In Cox proportional hazard analysis, age and MRS at discharge were independent predictors of mortality. CONCLUSION: Long-term outcomes of very old patients with AIS are not uniformly grave, therefore predictors of mortality and estimated duration of survival should be considered during decision- making for treatment.

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

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

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

Combination of acute stroke unit and short-term stroke ward with early supported discharge decreases mortality and complications after acute ischemic stroke.

BACKGROUND: The stroke unit has been established as a standard care for stroke. However, it has not been widely established in developing countries due to the lack of understanding and limited resources. OBJECTIVE: To compare the complications and mortality of stroke patients admitted in the stroke unit and short-term ward with those admitted in the general medical ward. MATERIAL AND METHOD: The authors prospectively collected data of acute stroke patients who were admitted after the set up of the stroke unit and stroke short-term ward in 2003, and compared with the data of those who were admitted in a general medical ward in 2001. All acute stroke patients who presented within seven days of the onset were admitted and those who had final diagnosis of ischemic stroke or transient ischemic attack (TIA) were studied. Patients in the stroke unit were taken care of by a multidisciplinary team approach under clinical guidelines and a care map. The short-term ward is a part of the general medical ward and stroke patients were treated by a multidisciplinary team followed by homecare treatment. The endpoints were mortality rate, neurological and medical complications during admissions, and the mean length of stay. RESULTS: Seven hundred and ninety-four patients were studied. Three hundred and eighty-seven patients were admitted in 2001 and 407 patients in 2003. Among patients presented 2003, three hundred and one cases were treated in the acute stroke unit whereas 106 were admitted in the short-term ward. There was no difference in stroke risk factors and stroke subtypes between the two groups, except for dyslipidemia and cigarette smoking, which were more prevalent in patients admitted in 2003. Patients in the stroke unit and the short-term ward had significantly less mortality than those in the general medical ward (8.9 and 2.1%). Overall complications in the stroke unit and the short-term ward were 16.8%, compared to 26% of those admitted into the general medical ward. Significantly less brain edema, hemorrhagic infarction, urinary tract infection, pneumonia, and pressure sore were also observed. The length of hospital stay of the patients admitted in 2001 and 2003 was 11.26 and 8.09 days, respectively. CONCLUSION: Combination of organized acute stroke unit and short-term ward with early supported discharge reduces the mortality and complications of ischemic stroke patients during admission as well as the length of stay when compared to the general medical ward. The present study reassures that the combination is useful for hospitals in developing countries, which have limited number of beds in their stroke units.

Effect of body temperature on mortality of acute stroke.

OBJECTIVES: The exact relation between body temperature and mortality of acute stroke victims is poorly understood. However, body temperature can affect the outcome of stroke cases in relation to mortality. In the initial (4-12 hrs) hours of stroke, the temperature rise is often neurogenic in origin and mortality is also higher with raised body temperature. Though the anatomical lesion or nature of lesion along with other established risk factors influence the mortality of stroke cases, change in temperature does affect the outcome of stroke cases. We sought to find out the significance of stroke victim's body temperature (within 4-12 hrs) with respect to short-term mortality rate in our study. METHODS: We selected 100 ischemic and 100 hemorrhagic stroke patients proved by CT scan of brain and 2-hrly oral temperature was strictly recorded for the initial 4-12 hrs of admission. RESULTS: It was evident from the study that hyperthermia (>37.5 degrees C) was associated with highest mortality rate in both hemorrhagic (51.78%) and ischemic (56.66%) cases. In normothermic group, mortality was 13.5% and 8.8% in hemorrhagic and ischemic group respectively, whereas hypothermia (<36.5 degrees C) was associated with 0 % mortality. CONCLUSION: Hyperthermia in acute stroke victim carries a bad prognostic parameter in short term basis.