RESUMO
BACKGROUND: Randomized trials involving patients with stroke have established that outcomes are improved with the use of thrombectomy for large-vessel occlusion. These trials were performed in high-resource countries and have had limited effects on medical practice in low- and middle-income countries. METHODS: We studied the safety and efficacy of thrombectomy in the public health system of Brazil. In 12 public hospitals, patients with a proximal intracranial occlusion in the anterior circulation that could be treated within 8 hours after the onset of stroke symptoms were randomly assigned in a 1:1 ratio to receive standard care plus mechanical thrombectomy (thrombectomy group) or standard care alone (control group). The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. RESULTS: A total of 300 patients were enrolled, including 79 who had undergone thrombectomy during an open-label roll-in period. Approximately 70% in the two groups received intravenous alteplase. The trial was stopped early because of efficacy when 221 of a planned 690 patients had undergone randomization (111 to the thrombectomy group and 110 to the control group). The common odds ratio for a better distribution of scores on the modified Rankin scale at 90 days was 2.28 (95% confidence interval [CI], 1.41 to 3.69; P = 0.001), favoring thrombectomy. The percentage of patients with a score on the modified Rankin scale of 0 to 2, signifying an absence of or minor neurologic deficit, was 35.1% in the thrombectomy group and 20.0% in the control group (difference, 15.1 percentage points; 95% CI, 2.6 to 27.6). Asymptomatic intracranial hemorrhage occurred in 51.4% of the patients in the thrombectomy group and 24.5% of those in the control group; symptomatic intracranial hemorrhage occurred in 4.5% of the patients in each group. CONCLUSIONS: In this randomized trial conducted in the public health care system of Brazil, endovascular treatment within 8 hours after the onset of stroke symptoms in conjunction with standard care resulted in better functional outcomes at 90 days than standard care alone. (Funded by the Brazilian Ministry of Health; RESILIENT ClinicalTrials.gov number, NCT02216643.).
Assuntos
Acidente Vascular Cerebral/cirurgia , Trombectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Terapia Combinada , Procedimentos Endovasculares , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Hemorragias Intracranianas/etiologia , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Método Simples-Cego , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/métodos , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Stroke is a leading cause of morbidity and mortality in Brazil, where there are significant imbalances in access to specialized stroke care. Telemedicine networks allow patients to receive neurological evaluation and intravenous thrombolysis in underserved areas, where performance measures are challenging. AIMS: To describe the impact caused by adequate stroke care training, using realistic simulation, in a developing country telestroke network. METHODS: Retrospective observational study comparing the number of all stroke diagnoses, thrombolysis rate, door-to-needle time and symptomatic intracranial hemorrhage after intravenous thrombolysis, during one year providing just algorithms and orientation in stroke care to spoke facilities (phase 1), with the results achieved along one year after the beginning of ongoing live training sessions (phase 2). RESULTS: The mean number of patients diagnosed with stroke increased from 7.5 to 16.58 per month (P = 0.019) rising from 90 patients during phase 1 to 199 in phase 2. There was a reduction in the mean door-to-needle time from 137.1 to 95.5 min (-41.58; 95% CI -62.77 to -20.40). The thrombolysis and symptomatic intracranial hemorrhage rates had a non-significant decrease from 21.31% to 18.18% (OR 0.82; 95% CI 0.39 to 1.71) and 12.5% to 7.69% (OR 0.58; 95% CI 0.046 to 7.425), respectively. CONCLUSIONS: Realistic simulation stroke care training provided by stroke centers to spoke facilities seems to significantly reduce door-to-needle time and enhance adherence in a telestroke network.
Assuntos
Treinamento por Simulação/estatística & dados numéricos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Telemedicina/estatística & dados numéricos , Brasil/epidemiologia , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Terapia Trombolítica/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricosRESUMO
These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.
Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/normas , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Brasil , HumanosRESUMO
ABSTRACT These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.
RESUMO Estas diretrizes são o resultado de um esforço conjunto de membros da Sociedade Brasileira de Doenças Cerebrovasculares (SBDCV), Departamento científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia (ABN), Rede Brasil AVC (RBAVC) e da Sociedade Brasileira de Neurorradiologia Diagnóstica e Terapêutica (SBNR). Membros destas 4 entidades participaram de fórum de discussões por internet de temas pré-definidos, seguidos de encontros de videoconferência para discussão de pontos controversos e das recomendações, em busca de um consenso final. Estas diretrizes tem seu foco sobre as implicações dos recentes ensaios clínicos de tratamento endovascular do acidente vascular cerebral (AVC) isquêmico agudo relacionado a oclusão de artérias proximais. O texto final foi elaborado para servir de orientação no manejo destes pacientes AVC isquêmico pelos diferentes profissionais de saúde, gestores de saúde pública e de saúde complementar no Brasil.
Assuntos
Humanos , Isquemia Encefálica/terapia , Acidente Vascular Cerebral/terapia , Procedimentos Endovasculares/normas , Fibrinolíticos/administração & dosagem , BrasilRESUMO
OBJECTIVE: Carotid intima-media thickness (IMT) is a noninvasive measurement of early atherosclerosis. Most IMT studies have involved populations with low rates of racial blending. The aim of the present article is to describe IMT value distributions and analyze the influence of sex and race on IMT values in a large Brazilian sample, a setting with a high rate of racial admixture. METHODS: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a multicenter cohort of 15,105 adult (aged 35-74 years) civil servants in six Brazilian cities. Baseline assessment included IMT measurements in both common carotid arteries. Race was self-reported. We studied the association between sex and race with IMT values using multiple linear regression models. We conducted analyses in all and low-risk individuals, defined as those without classical cardiovascular risk factors. RESULTS: We analyzed complete IMT data from 10,405 ELSA-Brasil participants. We present nomograms by age for all and low-risk individuals, stratified by sex and race. We found that men had significantly higher maximal IMT values compared with women (ß = 0.058; P < 0.001). This association remained for low-risk individuals (ß = 0.027; P = 0.001). In addition, Brown and White individuals had lower maximal IMT values compared with Black individuals for all (ß = -0.034 and ß = -0.054, respectively; P < 0.001) and low-risk individuals (ß = -0.027; P = 0.013 and ß = -0.035; P < 0.001, respectively). CONCLUSION: We found significantly higher IMT values in men. We found significantly higher IMT values in Black individuals than White and Brown individuals. These results persisted when analyses were restricted to low-risk individuals.
Assuntos
Artéria Carótida Primitiva/patologia , Espessura Intima-Media Carotídea , Adulto , Fatores Etários , Idoso , População Negra , Brasil , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etnologia , Etnicidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Fatores Sexuais , População BrancaRESUMO
OBJECTIVE: To determine the prevalence and the prognostic value of exercise-induced ventricular arrhythmia (EIVA) in chronic Chagas' heart disease. STUDY DESIGN AND SETTING: An open prospective cohort of 130 clinically stable patients at a University Hospital outpatient unit in Rio de Janeiro, Brazil, was followed up at scheduled clinical visits from 1990 through 2007. The endpoint was total cardiovascular mortality. Survival curves (Kaplan-Meier) and a multivariate Cox proportional hazard model were adjusted to determine the association between EIVA and mortality. RESULTS: The median duration of follow-up was 9.9 years (range, 132 days to 17 years). EIVA prevalence was 43.1% (95% CI: 34.5-51.7). Thirty-three cardiovascular deaths (25.4%) occurred. The hazard ratio of EIVA for cardiovascular death, after adjustment for age, was 1.84 (P = 0.09). An interaction was found between EIVA and cardiomegaly on x-ray. In the group with cardiomegaly, the hazard of dying was four times greater in the presence of EIVA (P for interaction = 0.05). CONCLUSION: In clinically stable chagasic subjects with cardiomegaly, EIVA is a clinically significant marker of total cardiovascular mortality and may be a useful risk stratification tool in this population.