Electrical Stimulation Prevents Muscular Atrophy and the Decrease of Interleukin-6 in Paralyzed Muscles after Spinal Cord Injury in Rats.

Objective To analyze the muscle trophism and expression of interleukin-6 in the biceps brachii muscle of rats with incomplete cervical spinal cord injury treated with neuromuscular electrical stimulation (NMES). Methods Adult rats underwent C5-C7 spinal cord hemisection and a 5-week NMES protocol. Trophism of the biceps brachii was assessed using muscle weight/body weight ratio and histological analysis. Interleukin-6 expression from biceps brachii was measured using the enzyme-linked immunosorbent assay technique. Results Preservation of the biceps brachii muscle trophism was found in the NMES treated group, along with prevention of the reduction of interleukin-6 levels. Conclusion Spinal cord injury causes muscle atrophy and decreases interleukin-6 levels. These alterations are partially prevented by NMES. The results suggest a possible NMES action mechanism and underscore the clinical use of this therapeutic tool.

Electrical Stimulation Prevents Muscular Atrophy and the Decrease of Interleukin-6 in Paralyzed Muscles after Spinal Cord Injury in Rats / A estimulação elétrica previne a atrofia muscular e a diminuição da interleucina-6 em músculos paralisados após lesão da medula espinal em ratos

Abstract Objective To analyze the muscle trophism and expression of interleukin-6 in the biceps brachii muscle of rats with incomplete cervical spinal cord injury treated with neuromuscular electrical stimulation (NMES). Methods Adult rats underwent C5-C7 spinal cord hemisection and a 5-week NMES protocol. Trophism of the biceps brachii was assessed using muscle weight/body weight ratio and histological analysis. Interleukin-6 expression from biceps brachii was measured using the enzyme-linked immunosorbent assay technique. Results Preservation of the biceps brachii muscle trophism was found in the NMES treated group, along with prevention of interleukin-6 level reduction. Conclusion Spinal cord injury causes muscle atrophy and decreases interleukin-6 levels. These alterations are partially prevented by NMES. The results suggest a possible NMES action mechanism and underscore the clinical use of this therapeutic tool.

Resumo Objetivo Analisar o trofismo muscular e a de interleucina-6 no músculo bíceps braquial de ratas com lesão medular cervical incompleta tratados com estimulação elétrica neuromuscular (EENM). Métodos Ratas adultas foram submetidas à hemissecção da medula espinal em C5-C7 e a um protocolo de EENM de 5 semanas. O trofismo do bíceps braquial foi avaliado pela relação peso muscular/peso corporal e análise histológica. A expressão de interleucina-6 no bíceps braquial foi medida usando ensaio de imunoabsorção enzimática. Resultados O grupo tratado com EENM apresentou preservação do trofismo muscular, assim como prevenção da redução dos níveis de interleucina-6. Conclusão A lesão da medula espinal causa atrofia muscular e diminui a expressão de interleucina-6. Essas alterações são parcialmente prevenidas pela EENM. Os resultados sugerem um possível mecanismo de ação da EENM e ressaltam o uso clínico desta ferramenta terapêutica.

Reperfusion therapy for acute ischemic stroke: where are we in 2023?

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.

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.

Trends in Intensive Care Admissions and Outcomes of Stroke Patients Over 10 Years in Brazil: Impact of the COVID-19 Pandemic.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic affected stroke care worldwide. Data from low- and middle-income countries are limited. RESEARCH QUESTION: What was the impact of the pandemic in ICU admissions and outcomes of patients with stroke, in comparison with trends over the last 10 years? STUDY DESIGN AND METHODS: Retrospective cohort study including prospectively collected data from 165 ICUs in Brazil between 2011 and 2020. We analyzed clinical characteristics and mortality over a period of 10 years and evaluated the impact of the pandemic on stroke outcomes, using the following approach: analyses of admissions for ischemic and hemorrhagic strokes and trends in in-hospital mortality over 10 years; analysis of variable life-adjusted display (VLAD) during 2020; and a mixed-effects multivariable logistic regression model. RESULTS: A total of 17,115 stroke admissions were analyzed, from which 13,634 were ischemic and 3,481 were hemorrhagic. In-hospital mortality was lower after ischemic stroke as compared with hemorrhagic (9% vs 24%, respectively). Changes in VLAD across epidemiological weeks of 2020 showed that the rise in COVID-19 cases was accompanied by increased mortality, mainly after ischemic stroke. In logistic regression mixed models, mortality was higher in 2020 compared with 2019, 2018, and 2017 in patients with ischemic stroke, namely, in those without altered mental status. In hemorrhagic stroke, the increased mortality in 2020 was observed in patients 50 years of age or younger, as compared with 2019. INTERPRETATION: Hospital outcomes of stroke admissions worsened during the COVID-19 pandemic, interrupting a trend of improvements in survival rates over 10 years. This effect was more pronounced during the surge of COVID-19 ICU admissions affecting predominantly patients with ischemic stroke without coma, and young patients with hemorrhagic stroke.

Clinical and radiological features of severe acute respiratory syndrome coronavirus 2 meningo-encephalitis.

BACKGROUND AND PURPOSE: This case illustrates for the first time the clinical and radiological evolution of SARS-CoV-2 meningo-encephalitis. METHODS: A case of a SARS-CoV-2 meningo-encephalitis is reported. RESULTS: A 65-year-old man with COVID-19 presenting with meningo-encephalitis without respiratory involvement is described. He had fever, diarrhea and vomiting, followed by diplopia, urinary retention and sleepiness. Examination disclosed a convergence strabismus and ataxia. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis, oligoclonal bands and increased interleukin 6 level. SARS-CoV-2 was detected in the CSF through reverse transcriptase polymerase chain reaction, but not in nasopharyngeal, tracheal secretion and rectal samples. Brain magnetic resonance imaging showed lesions on white matter hemispheres, the body and splenium of the corpus callosum and resembling the projection of corticospinal tract, remarkably on cerebellar peduncles. CONCLUSIONS: This demonstrates the challenges in diagnosing COVID-19 in patients with neurological presentations.

Artificial Inteligence-Based Decision for the Prediction of Cardioembolism in Patients with Chagas Disease and Ischemic Stroke.

BACKGROUND: Chagas disease (CD) and ischemic stroke (IS) have a close, but poorly understood, association. There is paucity of evidence on the ideal secondary prophylaxis and etiological determination, with few cardioembolic patients being identified. AIMS: This study aimed to describe a multicenter cohort of patients with concomitant CD and IS admitted in tertiary centers and to create a predictive model for cardioembolic embolism in CD and IS. MATERIALS AND METHODS: We retrospectively studied data obtained from electronic medical and regular medical records of patients with CD and IS in several academic, hospital-based, and university hospitals across Brazil. Descriptive analyses of cardioembolic and non-cardioembolic patients were performed. A prediction model for cardioembolism was proposed with 70% of the sample as the derivation sample, and the model was validated in 30% of the sample. RESULTS: A total of 499 patients were analyzed. The median age was similar in both groups; however, patients with cardioembolic embolism were younger and tended to have higher alcoholism, smoking, and death rates. The predictive model for the etiological classification showed close relation with the number of abnormalities detected on echocardiography and electrocardiography as well as with vascular risk factors. CONCLUSIONS: Our results replicate in part those previously published, with a higher prevalence of vascular risk factors and lower median age in patients with cardioembolic etiology. Our new model for predicting cardioembolic etiology can help identify patients with higher recurrence rate and therefore allow an optimized strategy for secondary prophylaxis.

Epidemiology of concurrent Chagas disease and ischemic stroke in a population attending a multicenter quaternary rehabilitation network in Brazil.

BACKGROUND AND PURPOSE: Chagas disease and ischemic stroke (IS) have a close but poorly understood correlation. In endemic settings, continued transmission over time has resulted in increasing prevalence of both asymptomatic infection and cardiomyopathy with increasing age. Latin America has made substantial progress towards Chagas disease control. Although several epidemiological studies have been conducted, information regarding epidemiology and distribution of IS in Chagas disease is still lacking. METHODS: We retrospectively studied the electronic medical record data of all patients with both IS and Chagas disease admitted at SARAH Hospitals across Brazil from 2009 to 2013 to make epidemiological quantifications and statistical inferences. RESULTS: A total of 279 patients with Chagas disease and IS were analyzed from 7729 IS-related admissions, indicating a median prevalence of 3.6% of Chagas disease in IS patients in our cohort. Mean age was 60 years, with female predominance (65%). Most of the cases were from Bahia (61%), followed by Minas Gerais (19%) and Goiás (9.7%). Low-income cities, with decreased access to healthcare, showed the highest number of cases. Distribution of vascular risk factors and outcome after stroke differed among the units. According to current guidelines, secondary prevention was inadequate in 60% of patients. CONCLUSIONS: Chagas disease was common in IS patients; prevalence of concurrent Chagas disease and IS was high in some regions of the country. However, the infection frequency seems to be reduced in the last few years. Public health issues for improving the treatment of Chagas disease and IS are urgently needed.

Machado de Assis' Original Sin.

Machado de Assis (1839-1908) suffered from temporal lobe epilepsy, probably with origin in the non-dominant hemisphere. The evidence for this is provided by the detailed reports of the characteristics of his seizures by his contemporaries and by his correspondence with other writers. He was treated with bromides and homeopathy. It is unclear whether his neurological disorder influenced his artistic performance. What is evident is that he was deeply ashamed of the disease - he avoided the word "epilepsy" and just wrote about it in his personal correspondence with friends in the last years of his life. Though controversial, he had no clear traces of personality disorders linked to his temporal lobe epilepsy. Despite all his adversities, including being "mulatto," having a stutter, being of humble origins, and epileptic in a period when there was no efficacious therapy and a profound stigma associated with the disease, Machado de Assis became one of the most important Brazilian writers of all times.

Mortality and Stroke Recurrence in a Rehabilitation Cohort of Patients with Cerebral Infarcts and Chagas Disease.

BACKGROUND: Chagas disease is related to ischemic stroke (IS), although few epidemiological studies have evaluated the associated mortality and recurrence. Our objective is to determine factors associated with mortality and recurrence of IS in patients with IS and Chagas disease. METHODS: We retrospectively studied data obtained from electronic medical records of patients admitted at SARAH Hospitals across Brazil between 2009 and 2013. Using Cox regression analysis for mortality and logistic regression for recurrence, we assessed primary population characteristics and statistical associations between risk factors and outcomes. RESULTS: We analyzed 279 patients who were followed up until 2016. The mean age at stroke onset was 61 with a 10% frequency of death. Multivariate analysis assessing mortality demonstrated that the associated factors were age at stroke (hazard ratio [HR] 1.04), initial modified Rankin Scale (mRS; HR 20.91), bladder dysfunction (HR 2.51), diabetes mellitus (DM; HR 3.64), and alcoholism (HR 3.37). Multivariate analysis assessing recurrence demonstrated that the associated factors were age at ictus (OR 0.96), cognitive deficit (OR 0.44), initial mRS (OR 1.84), cardioembolic etiology (OR 2.47), and female sex (OR 2.73). CONCLUSIONS: Cardiac conditions did not correlate with mortality or recurrence. Age was a protective factor against recurrence, probably due to cumulative risk of IS over time, while initial mRS was associated with both outcomes. Treating diseases such as DM and bladder dysfunction, and early treatment to reduce the initial mRS could potentially prevent both outcomes; also, establishing a correct etiological diagnosis is important.

Ischemic stroke classification and risk of embolism in patients with Chagas disease.

Ischemic stroke (IS) and Chagas disease are strongly related. Nevertheless, little attention has been paid to this association and its natural history. The current guidelines concerning the management and secondary prevention of IS are largely based on the incomplete information or extrapolation of knowledge from other stroke etiologies. We performed a retrospective study which compared stroke etiologies among a cohort of hospitalized patients with IS and Chagas disease. The Instituto de Pesquisa Evandro Chagas/Fundação Oswaldo Cruz (IPEC/FIOCRUZ) embolic score was also used to identify and evaluate the risk of embolism in this population. A total of 86 patients were included in the analysis. The mean age of the study population was 58 years, and 60 % were men. According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) Classification, 45 % of the strokes were of undetermined etiology and 45 % of cardioembolic origin, while the Stop Stroke Study/Causative Classification System (SSS/CCS) TOAST indicated that 34 % were undetermined and 50 % cardioembolic (p < 0.01); 44 % of these patients were classified as having a high embolic risk according to the IPEC/FIOCRUZ score. Among the undetermined causes, 83.3 % fulfilled the criteria for embolic stroke of undetermined source (ESUS). The SSS/CCS TOAST etiological classification system was superior to the classical TOAST criteria in identifying a cardioembolic etiology in patients with ischemic stroke and Chagas disease. The IPEC/FIOCRUZ score did not correlate with the number of patients who were determined to have cardioembolic stroke etiologies. The current guidelines for stroke prevention should be reviewed in this population.

Degree of knowledge of health care professionals about pain management and use of opioids in pediatrics.

OBJECTIVE: To evaluate the degree of knowledge about pain management and opioids use by professionals working at three pediatric units. DESIGN: This is a cross-sectional study. SETTING: This study was carried out at three pediatric units (pediatrics, intensive care unit, and oncology) of Hospital de Clínicas de Porto Alegre, which is a university hospital located in southern Brazil. SUBJECT: The subjects of this study include physicians, pharmacists, physiotherapists, nurses, nursing technicians, and nursing assistants. METHODS: Cross-sectional study carried out in a university hospital in southern Brazil. A self-applicable semi-structured questionnaire was handed out to 182 professionals from December 2011 to March 2012. RESULTS: The response rate was 67% (122); the average percentage of correct answers was 63.2 ± 1.4%. The most frequent errors were: an opioid must not be used if the cause of pain is unknown (47%; 54/115); patients often develop respiratory depression (42.3%; 22/52); and confusion about symptoms of withdrawal, tolerance, and dependency syndromes (81.9%; 95/116). Only 8.8% (10/114) reported the use of pain scales to identify pain in children. The most often cited hindrance to control pain was the difficulty to measure and spot pain in pediatric patients. Finally, 50.8% (62/122) of them did not have any previous training in pain management. CONCLUSIONS: Problems in the processes of pain identification, measurement, and treatment have been found. Results suggest that there is a need for both an investment in continuing education of professionals and the development of protocols to optimize the analgesic therapy, thus preventing increased child suffering.

Delayed-onset post-stroke delusional disorder: a case report.

Although the prevalence of neuropsychiatric disorders among patients with cerebrovascular illness is relatively high, there are only few case reports describing post-stroke psychotic symptoms. In general, post-stroke psychoses have been reported to emerge few days after the vascular event and to vanish soon afterwards. In this report, we describe delayed-onset post-stroke delusional disorder, persecutory type. A middle-aged female patient developed a persistent delusional disorder with homicidal behavior about one year after a cerebrovascular accident affecting the right fronto-temporo-parietal region and a long period of chronic post-stroke mixed anxiety and depressive symptoms. Our case suggests that there might be long intervals between stroke and the appearance of psychotic symptoms.

Aphasia and other language disorders.

Aphasia refers to a disorder of language processing caused by a dysfunction in specific brain regions. It is common after stroke and associated with relevant disability and higher mortality. Evaluation of language function (spontaneous speech, auditory comprehension, naming, repetition, reading and writing), allows classification of aphasia. Most patients present some degree of recovery. Speech and language therapy is an effective treatment for aphasia following stroke. Other approaches, e.g. pharmacotheraphy, transcranial magnetic stimulation, are being investigated. Other language disorders are mentioned.

Treatment of vascular dementia. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology.

Scientific Department of Cognitive Neurology and Aging of ABN had a consensus meeting to write recommendations on treatment of vascular dementia, there was no previous issue. This disease has numerous particularities and can be considered a preventable dementia. Prevention treatment is primary care of vascular risk factors or a secondary prevention of factors that could cause recurrence of ischemic or hemorrhagic brain modifications. In these guidelines we suggested only symptomatic treatment, pharmacologic or non-pharmacologic. We have reviewed current publications on MEDLINE (PubMed), LILACS e Cochrane Library databases. Recommendations are concern to the following factors and their prevention evidences, association, or treatment of vascular dementia: physical activity, tobacco use, diet and food supplements, arterial hypertension, diabetes mellitus, obesity, statins, cardiac failure, atrial fibrillation, antithrombotics, sleep apnea, carotid revascularization, symptomatic pharmacological treatment.

O DC de Neurologia Cognitiva e do Envelhecimento da ABN reuniu-se para escrever recomendações para o tratamento da demência vascular, uma vez que não havia nenhuma recomendação neste sentido. Esta doença tem inúmeras particularidades e pode ser considerada uma das demências que pode ser prevenida. O tratamento para sua prevenção é o de cuidados primários para os fatores de risco vasculares, ou a prevenção secundária dos fatores que levam a recorrência de alterações isquêmicas ou hemorrágicas cerebrais. Nestas recomendações sugerimos apenas o tratamento sintomático, medicamentoso ou não. Baseamo-nos nas evidências disponíveis, através da revisão das publicações nas bases MEDLINE (PubMed), LILACS e Cochrane Library. As recomendações dizem respeito aos seguintes fatores e suas evidências na prevenção, associação ou tratamento da demência vascular: atividade física, álcool, tabagismo, dieta e suplementos, hipertensão arterial, diabetes mellitus, obesidade, estatinas, insuficiência cardíaca, fibrilação atrial, antiagregantes, apneia do sono, revascularização carotídea e tratamento farmacológico sintomático.

Safety of autologous bone marrow mononuclear cell transplantation in patients with nonacute ischemic stroke.

AIMS: To assess the safety and feasibility of intra-arterial transplantation of autologous bone marrow mononuclear cells in patients with middle cerebral artery ischemic stroke within 90 days of symptom onset. PATIENTS & METHODS: Six patients were included in the study, and they received 1-5 × 10(8) bone marrow mononuclear cell and were evaluated using blood tests, neurological and imaging examination before treatment, and 1, 3, 7, 30, 60, 90, 120 and 180 days after transplantation. Scintigraphies were carried out 2 and 24 h after the procedure to analyze the biodistribution of labeled cells. Electroencephalogram was conducted within 7 days after transplantation. RESULTS: No patients exhibited any complication or adverse events during the procedure. There was no worsening in the neurological scales until the end of the follow-up. CONCLUSION: Intra-arterial bone marrow mononuclear cell transplantation is feasible and safe in patients with nonacute ischemic strokes of the middle cerebral artery. Further studies are required to evaluate the efficacy of this therapy.

Migration and homing of bone-marrow mononuclear cells in chronic ischemic stroke after intra-arterial injection.

Cell-based treatments have been considered a promising therapy for neurological diseases. However, currently there are no clinically available methods to monitor whether the transplanted cells reach and remain in the brain. In this study we investigated the feasibility of detecting the distribution and homing of autologous bone-marrow mononuclear cells (BMMCs) labeled with Technetium-99 m ((99m)Tc) in a cell-based therapy clinical study for chronic ischemic stroke. Six male patients (ages 24-65 years) with ischemic cerebral infarcts within the middle cerebral artery (MCA) between 59 and 82 days were included. Cell dose ranged from 1.25x10(8) to 5x10(8). Approximately 2x10(7) cells were labeled with (99m)Tc and intra-arterially delivered together with the unlabeled cells via a catheter navigated to the MCA. None of the patients showed any complications on the 120-day follow-up. Whole body scintigraphies indicated cell homing in the brain of all patients at 2 h, while the remaining uptake was mainly distributed to liver, lungs, spleen, kidneys and bladder. Moreover, quantification of uptake in Single-Photon Emission Computed Tomography (SPECT) at 2 h showed preferential accumulation of radioactivity in the hemisphere affected by the ischemic infarct in all patients. However, at 24 h homing could only distinguished in the brains of 2 patients, while in all patients uptake was still seen in the other organs. Taken together, these results indicate that labeling of BMMCs with (99m)Tc is a safe and feasible technique that allows monitoring the migration and engraftment of intra-arterially transplanted cells for at least 24 h.