Nationwide access to endovascular treatment for acute ischemic stroke in portugal

Publisher Copyright: Copyright Ordem dos M dicos 2021.Introduction: Since the publication of endovascular treatment trials and European Stroke Guidelines, Portugal has re-organized stroke healthcare. The nine centers performing endovascular treatment are not equally distributed within the country, which may lead to differential access to endovascular treatment. Our main aim was to perform a descriptive analysis of the main treatment metrics regarding endovascular treatment in mainland Portugal and its administrative districts. Material and Methods: A retrospective national multicentric cohort study was conducted, including all ischemic stroke patients treated with endovascular treatment in mainland Portugal over two years (July 2015 to June 2017). All endovascular treatment centers contributed to an anonymized database. Demographic, stroke-related and procedure-related variables were collected. Crude endovascular treatment rates were calculated per 100 000 inhabitants for mainland Portugal, and each district and endovascular treatment standardized ratios (indirect age-sex standardization) were also calculated. Patient time metrics were computed as the median time between stroke onset, first-door, and puncture. Results: A total of 1625 endovascular treatment procedures were registered. The endovascular treatment rate was 8.27/100 000 inhabitants/year. We found regional heterogeneity in endovascular treatment rates (1.58 to 16.53/100 000/year), with higher rates in districts closer to endovascular treatment centers. When analyzed by district, the median time from stroke onset to puncture ranged from 212 to 432 minutes, reflecting regional heterogeneity. Discussion: Overall endovascular treatment rates and procedural times in Portugal are comparable to other international registries. We found geographic heterogeneity, with lower endovascular treatment rates and longer onset-to-puncture time in southern and inner regions. Conclusion: The overall national rate of EVT in the first two years after the organization of EVT-capable centers is one of the highest among European countries, however, significant regional disparities were documented. Moreover, stroke-onset-to-first-door times and in-hospital procedural times in the EVT centers were comparable to those reported in the randomized controlled trials performed in high-volume tertiary hospitalspublishersversionpublishe

Acesso a Tratamento Endovascular para Acidente Vascular Cerebral Isquémico em Portugal

Introduction: Since the publication of endovascular treatment trials and European Stroke Guidelines, Portugal has re-organized stroke healthcare. The nine centers performing endovascular treatment are not equally distributed within the country, which may lead to differential access to endovascular treatment. Our main aim was to perform a descriptive analysis of the main treatment metrics regarding endovascular treatment in mainland Portugal and its administrative districts. Material and Methods: A retrospective national multicentric cohort study was conducted, including all ischemic stroke patients treated with endovascular treatment in mainland Portugal over two years (July 2015 to June 2017). All endovascular treatment centers contributed to an anonymized database. Demographic, stroke-related and procedure-related variables were collected. Crude endovascular treatment rates were calculated per 100 000 inhabitants for mainland Portugal, and each district and endovascular treatment standardized ratios (indirect age-sex standardization) were also calculated. Patient time metrics were computed as the median time between stroke onset, first-door, and puncture. Results: A total of 1625 endovascular treatment procedures were registered. The endovascular treatment rate was 8.27/100 000 inhabitants/year. We found regional heterogeneity in endovascular treatment rates (1.58 to 16.53/100 000/year), with higher rates in districts closer to endovascular treatment centers. When analyzed by district, the median time from stroke onset to puncture ranged from 212 to 432 minutes, reflecting regional heterogeneity. Conclusion: The overall national rate of EVT in the first two years after the organization of EVT-capable centers is one of the highest among European countries, however, significant regional disparities were documented. Moreover, stroke-onset-to-first-door times and in-hospital procedural times in the EVT centers were comparable to those reported in the randomized controlled trials performed in high-volume tertiary hospitals.Introdução: A aprovação do tratamento endovascular para o acidente vascular cerebral isquémico obrigou à reorganização dos cuidados de saúde em Portugal. Os nove centros que realizam tratamento endovascular não estão distribuídos equitativamente pelo território, o que poderá causar acesso diferencial a tratamento. O principal objetivo deste estudo é realizar uma análise descritiva da frequência e métricas temporais do tratamento endovascular em Portugal continental e seus distritos. Material e Métodos: Estudo de coorte nacional multicêntrico, incluindo todos os doentes com acidente vascular cerebral isquémico submetidos a tratamento endovascular em Portugal continental durante um período de dois anos (julho 2015 a junho 2017). Foram colhidos dados demográficos, relacionados com o acidente vascular cerebral e variáveis do procedimento. Taxas de tratamento endovascular brutas e ajustadas (ajuste indireto a idade e sexo) foram calculadas por 100 000 habitantes/ano para Portugal continental e cada distrito. Métricas de procedimento como tempo entre instalação, primeira porta e punção foram também analisadas. Resultados: Foram registados 1625 tratamentos endovasculares, indicando uma taxa bruta nacional de tratamento endovascular de 8,27/100 000 habitantes/ano. As taxas de tratamento endovascular entre distritos variaram entre 1,58 e 16,53/100 000/ano, com taxas mais elevadas nos distritos próximos a hospitais com tratamento endovascular. O tempo entre sintomas e punção femural entre distritos variou entre 212 e 432 minutos. Conclusão: Portugal continental apresenta uma taxa nacional de tratamento endovascular elevada, apresentando, contudo, assimetrias regionais no acesso. As métricas temporais foram comparáveis com as observadas nos ensaios clínicos piloto

Dissecando a dissecção carotídea : revisão e casuística

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2015As Dissecções Carotídeas constituem uma causa importante de AVC, especialmente nos jovens. Quanto à etiologia, podem classificar-se em traumáticas ou espontâneas admitindo-se, especialmente nestas últimas, que estejam subjacentes factores predisponentes variados, muitas vezes não identificados. As suas manifestações clínicas clássicas incluem dor cervical, facial ou cefálica, síndrome de Claude Bernard-Horner, paralisia de pares cranianos e manifestações cerebrais isquémicas, as quais podem ocorrer horas ou até dias depois da restante sintomatologia. Porém, ocorrem apresentações atípicas e a variabilidade temporal no surgimento de sintomas neurológicos ou inclusive a ausência destes, podem ser responsáveis pelo atraso ou mesmo omissão do seu diagnóstico. Este assenta, assim, no elevado grau de suspeição clínica e na sua confirmação por meios complementares de imagem, realizados em tempo oportuno, que podem passar por Eco-Doppler carotídeo, angiografia ou os métodos mais recentes de angio-TC e angio-RM e, actualmente considerada o exame de 1ª linha, a RM com supressão de gordura. Neste trabalho apresentamos uma revisão da literatura, acompanhada de uma casuística de doentes internados no Serviço de Neurologia do Hospital de Santa Maria, com destaque para as suas formas de apresentação.Carotid Artery Dissections are an important cause for stroke, mainly in young patients. They may be associated with trauma or occur spontaneously. In such cases, it appears to be due to little-known predisposing factors. The classic manifestations include cervical or facial pain, headache, Claude Bernard-Horner Syndrome, cranial nerve palsies and ischemic symptoms which may occur from hours to days later. However, atypical presentations, along with the delay or even absence of neurologic symptoms, are responsible for its late diagnosis or even its omission. Thus, definite confirmation relies on clinical suspicion and imaging investigations including carotid ultrasound, angiography in its several modalities (including CTA and MRA) and, being currently held as the first-line imaging study, MRI with fat suppression. In this paper we present a literature review and a case series based on patients admitted to the Neurology Department in Hospital de Santa Maria, regarding their clinical presentation

Early plasma biomarker dynamic profiles are associated with acute ischemic stroke outcomes

BACKGROUND: Early outcome prediction after Acute ischemic stroke (AIS) might be improved with blood-based biomarkers. We investigated if the longitudinal profile of a multi-marker panel could predict the outcome of successfully recanalized AIS patients. METHODS: We used ultrasensitive Single-molecule array (Simoa) to measure glial fibrillary acidic protein (GFAP), neurofilament light chain (NfL), total-tau (t-tau) and ELISA for brevican in a prospective study of AIS patients with anterior circulation large vessel occlusion successfully submitted to thrombectomy. Plasma was obtained at admission, upon treatment, 24 and 72-hours after treatment. Clinical and neuroimaging outcome were assessed independently. RESULTS: Thirty-five patients (64.8%) had good early clinical or neuroimaging outcome. Baseline biomarker levels did not distinguish between outcomes. However, longitudinal intra-individual biomarker changes followed different dynamic profiles with time and according to outcome: GFAP levels exhibited an early and prominent increase between admission and just after treatment, NfL increase was less pronounced between admission and up to 24h. T-tau increased between treatment and 24h. Interestingly, GFAP rate-of-change (pg/mL/h) between admission and immediately after recanalization had a good discriminative capacity between clinical outcomes (AUC=0.88,p<0.001), which was higher than admission CT-ASPECTS (AUC=0.75,p<0.01). T-tau rate-of-change provided moderate discriminative capacity (AUC=0.71,p<0.05). Moreover, in AIS patients with admission CT-ASPECTS<9 both GFAP and NfL rate-of-change were good outcome predictors (AUC=0.82 and 0.77,p<0.05). CONCLUSION: Early GFAP, t-tau and NfL rate-of-change in plasma can predict AIS clinical and neuroimaging outcome after successful recanalization. Such dynamic measures match and anticipate neuroimaging predictive capacity, potentially improving AIS patient stratification for treatment, targeting individualized stroke care