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- Tratamento Endovascular no Acidente Vascular Cerebral Isquémico: “Urgência na Redução das Assimetrias”Publication . Nzwalo, Hipólito; Botelho, Ana; Gil, Inês; Baptista, Alexandre; Fidalgo, Ana PaulaLemos com bastante satisfação o estudo de Dias et al1 publicado na Acta Médica Portuguesa que revelou as assimetrias nacionais no acesso ao tratamento endovascular (TEV) no acidente vascular cerebral (AVC) isquémico por oclusão de grande vaso proximal (OVP). Felizmente, no período em análise houve melhoria nacional das taxas de TEV, mais evidente nos distritos próximos de hospitais com TEV (HCTEV), tendo-se demonstrado a disparidade regional nos tempos de atraso da TEV. Nesse sentido, realçamos que a mediana do tempo AVC - primeira porta de entrada na via verde foi 13 minutos inferior nos doentes transferidos num hospital sem TEV (HSTEV) em comparação com os doentes cuja primeira porta foi um HCTEV. É um dado que possivelmente reflete a pressão de seleção com prejuízo dos doentes que chegam no limite temporal para TEV nos HSTEV.
- Admission severity of atrial-fibrillation-related acute ischemic stroke in patients under anticoagulation treatment: a systematic review and meta-analysisPublication . Garcia, Catarina; Silva, Marcelo; Araújo, Mariana; Henriques, Mariana; Margarido, Marta; Vicente, Patrícia; Nzwalo, Hipólito; Macedo, AnaIn non-valvular-associated atrial fibrillation (AF), direct oral anticoagulants (DOAC) are as effective as vitamin K antagonists (VKA) for the prevention of acute ischemic stroke (AIS). DOAC are associated with decreased risk and severity of intracranial hemorrhage. It is unknown if different pre-admission anticoagulants impact the prognosis of AF related AIS (AF-AIS). We sought to analyze the literature to assess the association between pre-admission anticoagulation (VKA or DOAC) and admission severity of AF-AIS. Methods: A Systematic literature search (PubMed and ScienceDirect) between January 2011 to April 2021 was undertaken to identify studies describing the outcome of AF-AIS. Results: A total of 128 articles were identified. Of 9493 patients, 1767 were on DOAC, 919 were on therapeutical VKA, 792 were on non-therapeutical VKA and 6015 were not anticoagulated. In comparison to patients without anticoagulation, patients with therapeutical VKA and under DOAC presented with less severe stroke (MD −1.69; 95% CI [−2.71, −0.66], p = 0.001 and MD −2.96; 95% Cl [−3.75, −2.18], p < 0.00001, respectively). Patients with non-therapeutical VKA presented with more severe stroke (MD 1.28; 95% Cl [0.45, 2.12], p = 0.003). Conclusions: In AF-AIS, patients under therapeutical VKA or DOAC have reduced stroke severity on admission in comparison to patients without any anticoagulation, with higher magnitude of protection for DOAC.
- Organizational factors determining access to reperfusion therapies in Ischemic Stroke-Systematic literature reviewPublication . Botelho, Ana; Rios, Jonathan; Fidalgo, Ana Paula; Ferreira, Eugénia; Nzwalo, HipólitoBackground: After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS. Methodology: Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale. Results: A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART. Conclusions: Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.
- Stroke due to Percheron artery occlusion: description of a consecutive case series from Southern PortugalPublication . Reis, Diana; Cerullo, Giovanni; Florêncio, André; Frias, Catarina; Aleluia, Leonor; Drago, José; Nzwalo, Hipólito; Fidalgo, Ana P.The artery of Percheron (AOP) is an abnormal variant of the arterial supply of the thalamus. Stroke caused by AOP occlusion is seldom reported. AOP leads to bilateral thalamic and rostral midbrain infarct presenting with unspecific manifestations. There are few descriptions of case series of stroke caused by AOP. We sought to review the clinicoradiological characteristics of AOP infarction from Algarve, Southern Portugal. Eight consecutive cases were retrospectively identified by searching the electronic clinical charts, as well as the stroke Unit database (2015–2020). Sociodemographic (age and gender) and clinicoradiological characteristics (etiological classification, admission severity, manifestations, and short- and long-term prognoses) were retrieved. The corresponding frequency of AOP infarction was 0.17% (95% confidence interval: 0.05–0.28). The mean age was 67.1 (range: 60–80) years. The range of stroke severity evaluated assessed by the National Institute of Health Stroke Scale ranged from 5 to 23 (median ¼ 7.5). None of the patients receive acute ischemic stroke reperfusion treatment. AOP patterns were isolated bilateral paramedian thalamic (n ¼ 2), bilateral paramedian and anterior thalamic (n ¼ 2), and bilateral paramedian thalamic with rostral midbrain (n ¼ 4). Two patients (20%) died on the short term (30 days). At hospital discharge, six patients had functional disability of 2 on the modified Rankin scale. In the follow-up at 6 months, half (n ¼ 3) of the survivors had persistent hypersomnia and two had vascular dementia. Stroke from AOP presents with variable clinical and radiological presentations and patients do not receive alteplase. The shortterm survivor and the long-term functional independency can be compromised after AOS infarct.