Acidente vascular cerebral isquêmico em pacientes com doença de Chagas: estudo multicêntrico na Rede Sarah de hospitais de reabilitação

A doença de Chagas é uma condição infecciosa parasitária causada pela infecção pelo protozoário Trypanosoma cruzi. Há relação da doença de Chagas com acidentes vasculares encefálicos isquêmicos (AVCi), porém existem poucos estudos avaliando a etiologia dos AVCs, assim como a morbidade, a mortalidade e a recorrência de eventos cerebrovasculares nessa populaçãoChagas disease is an infectious condition caused by infection with the protozoan Trypanosoma cruzi. It has correlation with ischemic stroke (IS), however there is little evidence and few studies addressing the etiology, morbidity, mortality and recurrence of cerebrovascular events in this population76f

Estudo multicêntrico e modelo preditivo de embolia em pacientes com acidente vascular cerebral isquêmico e Doença de Chagas

Introdução: A doença de Chagas é uma condição infecciosa parasitária causada pela infecção pelo protozoário Trypanosoma cruzi. Há relação da doença de Chagas com acidentes vasculares cerebrais isquêmicos (AVEi), porém existem poucos estudos avaliando a descrição, mecanismos de classificação dos AVCs, assim a sua mortalidade e recorrência. Objetivos: Os objetivos dessa tese são descrever as características do AVCi em pacientes com doença de Chagas admitidos em vários centros de reabilitação, assistência e ensino do país e elaborar uma escala de predição de cardiembolia em pacientes com AVEi prévioe critérios diagnósticos para AVC de origem indeterminada nesses pacientes. Os objetivos secundários são: 1) Avaliar mortalidade e desfechos funcionais em pacientes com AVCi e doença de Chagas e 2) comparar as características clínicas dos pacientes com doença de Chagas e AVCi de etiologia cardioembólica com os de etiologia não cardioembólica. Métodos: Trata-se de um estudo multicêntrico, usando dados de várias instituições de assistência, ensino e pesquisa do país, cada um com metodologia diferente (transversal ou coorte histórica), que utilizou dados de prontuários eletrônicos ou físicos de pacientes atendidos entre 2009 e 2016. Os pacientes foram seguidos até 2018 na rede SARAH de reabilitação (66% da amostra) e o restante foi trabalhado com dados da admissão (corte transversal). Os critérios de inclusão foram pacientes com doença de Chagas e AVCi. Para identificar o mecanismo do AVCi foi utilizado o modelo Stop Stroke Study TOAST (SSS TOAST). Foi realizada aplicação da escala de risco de embolia e dos critérios clássicos para embolia 8 de fonte indeterminada. Testes estatísticos foram realizados para determinar se a variável tinha distribuição normal ou não, e escolhidos testes paramétricos ou não paramétricos de acordo com a resposta. Para a realização a escala de predição de AVCi cardioembólico foi usado modelo de árvore de decisão com uso de inteligência artificial com o programa “wake” com metodologia de “machine learning” supervisionada. Resultados: Foi de 61 anos e houve 10% de óbitos no período. A maioria dos pacientes eram provenientes de cidades de baixa renda e das regiões Nordeste e Sudeste. A aplicação do escore de embolia em pacientes cardioembólicos foi considerada de baixo risco em 65% dos pacientes. Dos pacientes com AVCi de causa indeterminada, 85% se classificaram como AVC embólico de origem indeterminada. Em relação a etiologia, a classificação Causative Classification System (CCS) TOAST demonstrou uma predominância de causas cardioembólicas (57%). Houve predominância de fatores de risco vasculares e piores desfechos de recorrência e mortalidade na população cardioembólica comparado com a não cardioembólica. O modelo preditivo de etiologia cardioembólica apresentou relação com número de alterações nos exames cardiológicos e com os fatores de risco vasculares, além de sexo e histórico prévio de AVCi. Conclusões: A população com AVCi e doença de Chagas possui diferentes características dependendo da etiologia. Há maior gravidade e fatores de risco nos pacientes com mecanismos cardioembólicos do AVCi. Nosso modelo preditivo usando “machine learning” parece ser um bom instrumento para a classificação desses pacientesIntroduction: Chagas disease is a parasitic infectious condition caused by infection with the protozoan Trypanosoma cruzi. There is a relationship between Chagas disease and ischemic strokes (IS), but there are few studies evaluating the description, mechanisms of cardioembolic classification of strokes, its mortality and recurrence Our objectives are to describe the IS characteristics in patients with Chagas' disease admitted to various rehabilitation, care and teaching centers in the country and to develop an cardioembolism prediction scalein patients with IS and diagnostic criteria for stroke of undetermined origin in these patients. The secondary objectives are: 1) To evaluate mortality and outcome in patients with IS and Chagas disease and 2) to compare the clinical characteristics of patients with Chagas disease and IS of cardioembolic etiology with those of non-cardioembolic etiology. Methods:It is a multicentric study, using data from several assistance, teaching and research institutions in the country, each with a different methodology (cross-sectional or historical cohort) used data from electronic or physical records of patients seen between 2009 and 2016. Patients were followed until 2018 in the rehabilitation SARAH network (66% of the sample), the rest was worked with admission data (cross-section). Inclusion criteria were patients with Chagas disease and IS. IS were classified according to the Stop Stroke Study TOAST (SSS TOAST) model. The embolism risk scale and the classic criteria for embolism from an undetermined source were applied. Statistical tests were performed to determine whether the variable had a normal distribution or not, and parametric or 11 nonparametric tests were chosen according to the response. To perform the cardioembolic stroke prediction scale, a decision tree model with the use of artificial intelligence was used with the “wake” program with supervised machine learning methodology. Results: 499 patients were included in the study, of which 65% were women. The average age was 61 years and there were 10% of deaths in the period. Most of the patients came from low income cities and from the Northeast and Southeast regions. The application of the embolism score in cardioembolic patients was considered low risk in 65% of the patients. Of the patients with stroke of undetermined cause, 85% were classified as embolic stroke of undetermined origin. Regarding the etiology, the Causative Classification System (CCS) TOAST classification demonstrated an increase in cardioembolic causes (57%). There was a predominance of vascular risk factors, as well as worse outcomes of stoke recurrence and mortality, in the cardioembolic population compared to not cardioembolic. The predictive model of cardioembolic etiology was related to the number of alterations in cardiac exams and vascular risk factors, in addition to sex and previous history of stroke. Conclusions: The population with IS and Chagas disease have different characteristics between etiologies. There is greater severity and risk factors in cardioembolic patients. Our predictive model using machine learning seems to be a good classification tool for these patients65f

Clinical and epidemiological profiles from a case series of 26 Brazilian CADASIL patients

Background Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a genetic cause of ischemic stroke and the most common form of non-atherosclerotic stroke. Despite being the most prevalent vascular hereditary disease, clinical data regarding the Brazilian population are scarce. Considering that the Brazilian population has one of the most heterogeneous genetic constitutions in the world, knowledge about genetic and epidemiological profiles is mandatory. The present study aimed to elucidate the epidemiological and clinical features of CADASIL in Brazil. Methods We performed a case series study comprising 6 rehabilitation hospitals in Brazil and reported the clinical and epidemiological data from the medical records of patients admitted from 2002 to 2019 with genetic confirmation. Results We enrolled 26 (16 female) patients in whom mutations in exons 4 and 19 were the most common. The mean age at the onset of the disease was of 45 years. Ischemic stroke was the first cardinal symptom in 19 patients. Cognitive impairment, dementia, and psychiatric manifestations were detected in 17, 6, and 16 patients respectively. In total, 8 patients had recurrent migraines, with aura in 6 (75%) of them. White matter hyperintensities in the temporal lobe and the external capsule were found in 20 (91%) and 15 patients (68%) respectively. The median Fazekas score was of 2. Lacunar infarcts, microbleeds, and larger hemorrhages were observed in 18 (82%), 9, and 2 patients respectively. Conclusion The present is the most extensive series of Brazilian CADASIL patients published to date, and we have reported the first case of microbleeds in the spinal cord of a CADASIL patient. Most of our clinical and epidemiological data are in accordance with European cohorts, except for microbleeds and hemorrhagic strokes, for which rates fall in between those of European and Asian cohorts

Global Differences in Risk Factors, Etiology, and Outcome of Ischemic Stroke in Young Adults: A Worldwide Meta-analysis: The GOAL-Initiative.

BACKGROUND AND OBJECTIVES There is a worldwide increase in the incidence of stroke in young adults, with major regional and ethnic differences. Advancing knowledge of ethnic and regional variation in causes and outcomes will be beneficial in implementation of regional healthcare services. To study the global distribution of risk factors, causes and 3-month mortality of young ischemic stroke patients, by performing a patient data meta-analysis form different cohorts worldwide. METHODS We did a pooled analysis of individual patient data from cohort studies which included consecutive ischemic stroke patients aged 18-50 years. We studied differences in prevalence of risk factors and causes between different ethnic and racial groups, geographic regions and countries with different income levels. We investigated differences in 3-month mortality by mixed-effects multivariable logistic regression. RESULTS We included 17,663 patients from 32 cohorts in 29 countries. Hypertension and diabetes were most prevalent in Blacks (hypertension, 52.1%; diabetes, 20.7%) and Asians (hypertension 46.1%, diabetes, 20.9%). Large vessel atherosclerosis and small vessel disease were more often cause of stroke in high-income countries (HICs; both p<0.001), whereas ''other determined stroke'' and ''undetermined stroke'' were higher in low and middle-income countries (LMICs; both p<0.001). Patients in LMICs were younger, had less vascular risk factors, and despite this, more often died within 3 months than those from HICs (OR 2.49; 95% CI 1.42-4.36). DISCUSSION The ethnoracial and regional differences in risk factors and causes of stroke at young age provide an understanding of ethnic and racial, and regional differences in incidence of ischemic stroke. Our results also visualize the dissimilarities in outcome after stroke in young adults that exist between LMICs and HICs, which should serve as call to action to improve healthcare facilities in LMICs