Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil.

Background: The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods: Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results: A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion: Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.

Disparities in Stroke Patient-Reported Outcomes Measurement Between Healthcare Systems in Brazil.

Introduction: Acute stroke interventions, such as stroke units and reperfusion therapy, have the potential to improve outcomes. However, there are many disparities in patient characteristics and access to the best stroke care. Thus, we aim to compare patient-reported outcome measures (PROMs) after stroke in two stroke centers representing the public and private healthcare systems in Brazil. Methods: PROMs through the International Consortium for Health Outcomes Measures (ICHOM) were assessed at 90 days after the stroke to compare two Brazilian hospitals in southern Brazil: a public university and a private stroke center, both with stroke protocols and stroke units. Results: When compared with the private setting (n = 165), patients from the public hospital (n = 175) were younger, had poorer control of risk factors, had more frequent previous strokes, and arrived with more severe strokes. Both hospitals had a similar percentage of IV thrombolysis treatment. Only 5 patients received mechanical thrombectomy (MT), all in the private hospital. Public hospital patients presented significantly worse outcomes at 3 months, including worse quality of life and functional dependence (60 vs. 48%, p = 0.03). Poor outcome, as measured by the mRS score, was significantly associated with older age, higher NIHSS score, and the presence of heart failure. However, the public practice was a strong predictor of any self-reported disability. Conclusion: Patients assisted at a good quality public stroke center with the same protocol used in the private hospital presented worse disability as measured by mRS and patient-reported outcome measures, with greater inability to communicate, dress, toilet, feed, and walk.

Risk Factors for Epilepsy After Thrombolysis for Ischemic Stroke: A Cohort Study.

The effects of thrombolysis in seizure and epilepsy after acute ischemic stroke have been poorly explored. In this study, we examine risk factors and consequences of intravenous rt-PA for treatment of acute ischemic stroke. In a retrospective cohort study we evaluate risk factors for seizure and epilepsy after stroke thrombolysis, as well as the impact of seizures and epilepsy in outcome of stroke patients. In our cohort, mean age of patients was 67.2 years old (SD = 13.1) and 79 of them (51.6%) were male and. Initial NIHSS mean score were 10.95 (SD = 6.25). Three months NIHSS mean score was 2.09 (SD = 3.55). Eighty seven (56.9%) patients were mRS of 0-1 after thrombolysis. Hemorrhagic transformation was observed in 22 (14.4%) patients. Twenty-one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation (OR = 3.26; 95% CI = 1.08-9.78; p = 0.035) and with mRS ≥ 2 at 3 months after stroke (OR = 3.51; 95% CI = 1.20-10.32; p = 0.022). Hemorrhagic transformation (OR = 3.55; 95% CI = 1.11-11.34; p = 0.033) and mRS ≥ 2 at 3 months (OR = 5.82; 95% CI = 1.45-23.42; p = 0.013) were variables independently associated with post-stroke epilepsy. In our study, independent risks factors for poor outcome in stroke thrombolysis were age (OR = 1.03; 95% CI = 1.01-1.06; p = 0.011), higher NIHSS (OR = 1.08; 95% CI = 1.03-1.14; p = 0.001), hemorrhagic transformation (OR = 2.33; 95% CI = 1.11-4.76; p = 0.024), seizures (OR = 3.07; 95% CI = 1.22-7.75; p = 0.018) and large cortical area (ASPECTS ≤ 7) (OR = 2.04; 95% CI = 1.04-3.84; p = 0.036). Concluding, in this retrospective cohort study, the neurological impairment after thrombolysis (but not before) and hemorrhagic transformation remained independent risk factors for seizures or post-stroke epilepsy after thrombolysis. Moreover, we observed that seizures emerged as an independent risk factor for poor outcome after thrombolysis therapy in stroke patients (OR = 3.07; 95% CI = 1.22-7.75; p = 0.018).

Early Manipulation of Arterial Blood Pressure in Acute Ischemic Stroke (MAPAS): Results of a Randomized Controlled Trial.

INTRODUCTION: There is uncertainty over the optimal level of systolic blood pressure (SBP) in the setting of acute ischemic stroke (AIS). The aim of this study was to determine the efficacy of the early manipulation of SBP in non-thrombolised patients. The key hypothesis under investigation was that clinical outcomes vary across ranges of SBP in AIS. METHODS: 218 patients were randomized within 12 h of AIS to maintain the SBP during 24 h within three ranges: Group 1 140-160 mmHg, Group 2 161-180 mmHg or Group 3 181-200 mmHg. Vasoactive drugs and fluids were used to achieve these targets. Good outcome was defined as a modified Rankin score 0-2 at 90-days. RESULTS: The median SBP in the three groups in 24 h was: 153 mmHg, 163 mmHg, and 178 mmHg, respectively, P < 0.0001. Good clinical outcome did not differ among the different groups (51% vs 52% vs 39%, P = 0.27). Symptomatic intracranial hemorrhage (SICH) was more frequent in the higher SBP range (1% vs 2.7% vs 9.1%, P = 0.048) with similar mortality rates. No patient had acute neurological deterioration related to the SBP reduction in the first 24 h. In our logistic regression analysis, the odds of having good clinical outcome was higher in Group 2 (OR 2.83) after adjusting for important confounders. Regardless of the assigned group, the probability of good outcome was 47% in patients who were manipulated to increase the BP, 42% to decrease and 62% in non-manipulated (P = 0.1). Adverse effects were limited to Group 2 (4%) and Group 3 (7.6%) and were associated with the use of norepinephrine (P = 0.05). CONCLUSIONS: Good outcome in 90 days was not significantly different among the 3 blood pressure ranges. After logistic regression analysis, the odds of having good outcome was greater in Group 2 (SBP 161-180 mmHg). SICH occurred more frequently in Group 3 (181-200 mmHg).

Risk factors among stroke subtypes in Brazil.

Stroke is a leading cause of mortality and disability in Brazil. Among the risk factors for cerebrovascular disease, some have more influence than others in certain stroke subtypes. Little data are available in the literature on the prevalence of stroke subtypes in Latin America. We analyzed data from 688 patients with acute ischemic stroke (52.3% women; mean age, 65.7 years) who were enrolled in a stroke data bank. Standardized data assessment and stroke subtype classification were used. The most common stroke subtype was large-artery atherosclerosis (n = 223; 32.4%), followed by cardioembolism (n = 195; 28.3%), and microangiopathy (n = 127; 18.5%). Stroke risk factors differ among stroke subtypes. The population of South America is ethnically diverse, and few previous studies have describe the distribution of risk factors among stroke subtypes in this population. In this study, the most important risk factors were hypertension and dyslipidemia.

Thrombolytic therapy for acute stroke in the elderly: an emergent condition in developing countries.

Elderly patients may represent an important group when considering new stroke treatments, particularly in developing countries. The aim of this study was to analyze the use of recombinant tissue plasminogen activator (rtPA) in elderly Brazilian patients with acute ischemic stroke. Clinical and neuroimaging parameters at admission, frequency of symptomatic intracranial hemorrhage, and outcome were compared between elderly (≥80 years) and nonelderly (<80 years) stroke patients treated with rtPA in the Porto Alegre Stroke Network. We evaluated 183 nonelderly patients (mean age, 63 ± 12 years) and 55 elderly patients (mean age, 84 ± 3 years). Female sex, hypertension, congestive heart failure, atrial fibrillation, and previous history of stroke or transient ischemic attack were more frequent in the elderly patients. Elderly patients also presented with higher mean systolic blood pressure (P = .03) and National Institutes of Health Stroke Scale (NIHSS) score (P < .0001), whereas the nonelderly patients had a higher serum glucose level (P = .03). The rate of symptomatic intracranial hemorrhage was 10.9% in the elderly patients and 6.6% in the nonelderly patients (P = .28), and a substantial proportion of the elderly patients achieved a favorable outcome (modified Rankin Scale score ≤1) at 90 days, although this proportion was lower than that in the nonelderly patients (42% vs 58%; P = .04). Poorer outcomes were generally seen in elderly patients with an anterior circulation stroke, a higher NIHSS score, hypoattenuation in ≥1/3 lf the middle cerebral artery territory, and an Alberta Stroke Program Early CT score of ≤7 on an initial computed tomography scan. Our results support the administration of intravenous rtPA in selected elderly stroke patients presenting early to the hospital in developing countries.

[Reliability of neurological assessment scales in patients with stroke]. / Confiabilidade de escalas de comprometimento neurológico em pacientes com acidente vascular cerebral.

Scales for the assessment of neurological impairment are employed in clinical trials, outcome evaluation and in therapeutic decisions. We evaluated the reliability of the Portuguese version of the Rankin Scale (RS), Barthel Index (BI) and the NIHSS (National Institute of Health Stroke Scale) in 51 stroke patients, estimating the agreement of the results for examiners. The interrater reliability was measured using the Kappa Coefficient and Intraclass Correlation Coefficient. The RS showed moderate, substantial and excellent coefficients of agreement. The BI showed from substantial to excellent coefficients of agreement as a whole and also for its constituents. This scale was stratified in prognostic and functional groups, both presenting coefficients of agreement from substantial to excellent. The NIHSS presented excellent agreement on its total and substantial agreements on its individual items. The NIHSS was also stratified in groups of points, which presented moderate or excellent coefficient, and in groups of congruous items, wich showed a moderate to excellent agreement. These results suggest that the Portuguese version of the RS, BI and the NIHSS present adequate reliability.