Background Malignant cerebral artery strokes have a poor prognosis, with nearly 80% of mortality ... more Background Malignant cerebral artery strokes have a poor prognosis, with nearly 80% of mortality in some series despite intensive care. After a large randomized trial, decompressive hemicraniectomy has been performed more often in stroke patients. Here, we describe patients in a tertiary teaching hospital in Brazil, emphasizing the impact of age on outcomes. Methods A retrospective cohort of patients, with malignant strokes which received a decompressive hemicraniectomy, from paper and electronic medical records, from January 2010 to December 2013 was divided into two groups according to age. Results The final analysis included 60 patients. The overall mortality was higher among patients older than 60 yrs (67% vs. 41%; p = 0.039), whose group also had a worse outcome (76% with mRS 5 or 6) at 90 days (OR 3.91 CI95% 1.30-11.74), whereas only 24% had mRS of 0-4 (p = 0.015). All patients who presented with sepsis died (p = 0.003). The incidence of pulmonary infection was very high in the elderly group (76%) with significant intergroup differences (p = 0.027, OR 8.32 CI95% 0.70-98.48). Conclusions Older patients present more commonly with infections, more disabilities and a higher mortality, highlighting very poor results in elderly population. These results should be proved with a South American trial, and if confirmed, it can impact on future decisions regarding decompressive craniectomy for acute ischemic stroke in our region.
RESUMO -Com o propósito de analisar os aspectos clínicos da hidrocefalia (HDC) na neurocisticerco... more RESUMO -Com o propósito de analisar os aspectos clínicos da hidrocefalia (HDC) na neurocisticercose (NCC), realizou-se o estudo retrospectivo de 47 prontuários de pacientes com HDC e NCC. Verificou-se que 70,2% eram homens, entre 21 e 50 anos. A hipertensão intracraniana (HIC) ocorreu em todos os pacientes, cefaléia (CEF) em 89,4%, meningoencefalite (ME) em 80,8% e distúrbios psíquicos (PSI) em 74,5%. A síndrome liquórica da NCC foi detectada em 65,9% pacientes. Além da HDC, as tomografias computadorizadas de crânio (TC) mostraram lesões císticas e edema cerebral difuso em 59,6% cada, calcificações em 55,3%. Dos 41 pacientes (87,2%) com derivação ventriculoperitoneal (DVP), em 22 (53,7%) deles foram necessárias uma a sete revisões/paciente (média=3). A evolução foi satisfatória em 51,1% e fatal em 31,9%. Conclui-se que a hidrocefalia é mais comum no sexo masculino em idade produtiva, tendo a HIC, CEF, MN e PSI como manifestações freqüentes e que, a necessidade de revisões de DVP, piora o prognóstico.
To develop an experimental model of neurocysticercosis-induced hydrocephalus There were used 17 r... more To develop an experimental model of neurocysticercosis-induced hydrocephalus There were used 17 rats. Ten animals were inoculated with Taenia crassiceps cysts into the subarachnoid. Five animals were injected with 0.1ml of 25% kaolin (a standard solution for the development of experimental hydrocephalus) and two animals were injected with saline. Magnetic resonance imaging (MRI) was used to evaluate enlargement of the ventricles after one or three months of inoculation. Volumetric study was used to quantify the ventricle enlargement. Seven of the 10 animals in the cyst group developed hydrocephalus, two of them within one month and five within three months after inoculation. Three of the five animals in the kaolin group had hydrocephalus and none in the saline group. Ventricle volumes were significantly higher in the 3-months MRI cyst subgroup than in the 1-month cyst subgroup. Differences between cyst subgroups and kaolin group did not reach statistical significance. The developed model may reproduce the human condition of neurocysticercosis-related hydrocephalus, which exhibits a slowly progressive chronic course.
We refer to the effectiveness (known as pragmatic or real world) and efficacy (known as explanato... more We refer to the effectiveness (known as pragmatic or real world) and efficacy (known as explanatory or desired or ideal world) of interventions. However, these terms seem to be randomly chosen by investigators who design clinical trials and do not always reflect the true purpose of the study. A pragmatic-explanatory continuum indicator summary tool was thus developed with the aim of identifying the characteristics of clinical trials that distinguish between effectiveness and efficacy issues. We verified whether clinical trials used the criteria proposed by the indicator summary tool, and we categorized these clinical trials according to a new classification. A systematic survey of randomized clinical trials was performed. We added a score ranging from 0 (more efficacious) to 10 (more effective) to each domain of the indicator summary tool and proposed the following classifications: high efficacy (<25), moderate efficacy (25-50), moderate effectiveness (51-75), and high effectiven...
Purpose] The study aimed to characterize patients treated by rehabilitation section after establi... more Purpose] The study aimed to characterize patients treated by rehabilitation section after establishment of an acute stroke unit. [Subjects and Methods] Medical consultation records of individuals with ischemic stroke were studied retrospectively, excluding individuals with hemorrhagic stroke, thrombolysis, previous Modified Rankin Scale ≥ 1, prior stroke, structural bone deformities, associated neurological disease, and prior cognitive deficit. The data evaluated were age, gender, etiology, localization, treatment received, ictus onset, hospitalization time, discharge date, and date of first evaluation at the rehabilitation center. The Modified Rankin Scale in 90 days after ictus was utilized to measure functional incapacity with the individuals divided into two groups, before and after acute stroke unit implementation (2010). Functional incapacity was compared between before and after acute stroke unit implementation by the Mann-Whitney test, χ 2 test and Fisher's exact test.
The present work aimed to evaluate the pattern of CSF alterations in patients diagnosed with neur... more The present work aimed to evaluate the pattern of CSF alterations in patients diagnosed with neurocysticercosis (NCC) in racemose form. Method: This is a retrospective cohort study of patients with diagnosis of NCC in racemose form. CSF samples from 26 patients were analyzed. After patient-chart analysis was performed descriptive analysis of case studies and comparison between sexes in relation to variables were obtained with CSF by Mann-Whitney and Student's t-tests. Results: The sexes did not differ statistically when compared to pleocytosis in CSF. Eosinophils were present in 31% in samples while the ELISA test presented 80% sensitivity in this case series. Of the patient total, 24 presented a meningitis pattern with lymphocytic predominance. Conclusion: There was no difference in inflammatory pattern between the sexes, with predominance of lymphocytic meningitis and 80% sensitivity by ELISA test of CSF patients with racemose form of NCC.
Journal of Stroke and Cerebrovascular Diseases, 2015
Background: The present study aimed to evaluate the relation between the National Institutes of H... more Background: The present study aimed to evaluate the relation between the National Institutes of Health Stroke Scale (NIHSS) score and the presence of laryngeal penetration and/or laryngotracheal aspiration in ischemic stroke patients and to verify what factors are predictors of the occurrence of pneumonia in the evaluated patients.
Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. ... more Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. The ABCD2 clinical risk prediction score is recommended for patient triage by stroke risk, but its ability to stratify by known risk factors and effect on clinic workload are unknown. We performed a systematic review and meta-analysis of all studies published between January 2005 and September 2014 that reported proportions of true TIA/minor stroke or mimics, risk factors, and recurrent stroke rates, dichotomized to ABCD2 score </≥4. We calculated the effect per 1,000 patients triaged on stroke prevention services. Twenty-nine studies, 13,766 TIA patients (range 69-1,679), were relevant: 48% calculated the ABCD2 score retrospectively; few reported on the ABCD2 score's ability to identify TIA mimics or use by nonspecialists. Meta-analysis showed that ABCD2 ≥4 was sensitive (86.7%, 95% confidence interval [CI] 81.4%-90.7%) but not specific (35.4%, 95% CI 33.3%-37.6%) for recurrent s...
The aim of this study was to relate the presence of a temporal acoustic window (TAW) to the varia... more The aim of this study was to relate the presence of a temporal acoustic window (TAW) to the variables sex, age and race. This observational study was conducted in patients under etiologic investigation after stroke, sicklecell anemia and hospitalization in an intensive therapy neurologic unit. TAW presence was confirmed by bilateral assessment by two neurologists via transcranial Doppler (TCD). Multiple logistic regression was performed to explain the presence of the window as a function of sex, age and race. In 20% of the 262 patients evaluated, a TAW was not present. The incidence of TAW presence was greater in men (odds ratio [OR] 5 5.4, 95% confidence interval [CI] 5 2.5-11.7, p , 0.01); lower with increased age (OR 5 0.9, 95% CI 5 0.92-0.97, p , 0.01); and lower among those of African and Asian descent (OR 5 0.32, 95% CI 5 0.14-0.70, p 5 0.005). On the basis of the results, more men than women had TAWs, and the decrease in TAWs was associated with increased age and African or Asian
With the purpose to verify clinical aspects of hydrocephalus (HC) in patients with neurocysticerc... more With the purpose to verify clinical aspects of hydrocephalus (HC) in patients with neurocysticercosis (NCC), a retrospective study of 47 patients was performed. The majority of patients (70.2%) were men aging 21-50 years. Intracranial hypertension (ICH) occurred in all patients, headache (HA) in 42 (89.4%), meningoencephalitis (ME) in 38 (80.8%) and psychiatric disorders (PD) in 34 (72.3%). The cerebrospinal fluid syndrome of NCC was detected in 31 patients (65.9%). In addition to HC, computed tomography (CT) scans showed cystic lesions in 28 (59.6%) patients, diffuse brain edema also in 28 (59.6%), and calcifications in 26 (55.3%). Shunts were inserted in 41 (87.2%) patients and 22 (53.7%) of them were submitted to 1-7 surgical revision/patient (mean=3) that were higher (mean=4) in those who died than in survivors (mean=2). Evolution was satisfactory in 24 (51.1%) patients and fatal in 15 (31.9%). It is possible to conclude that, in patients with NCC, HC occurs predominantly in men...
Four cases of suggestive inflammatory aneurysms in patients with neurocysticercosis have been des... more Four cases of suggestive inflammatory aneurysms in patients with neurocysticercosis have been described. We report a case of a 49-year-old woman who presented with subarachnoid haemorrhage from a right middle cerebral artery bifurcation aneurysm and had a casual relationship with neurocysticercosis. At surgery, a viable cysticercus without signs of inflammation or thickened leptomeninges was found in the distal position of the aneurysm. Postoperatively, the patient received albendazole and dextrochlorpheniramine. In the subsequent three years, the patient was asymptomatic and took drugs to prevent convulsion and arterial hypertension. The relationship between NCC and the presence of cerebral aneurysm is discussed.
Hamamoto Filho PT, Vital RB, Luvizutto GJ, Bazan R, Zanini MA. Hemicraniectomy after stroke in a ... more Hamamoto Filho PT, Vital RB, Luvizutto GJ, Bazan R, Zanini MA. Hemicraniectomy after stroke in a Brazillian multiethnic population: the role of aging. Background: Stroke is the leading cause of death in Brazil. Stroke of the middle cerebral artery (MCA) can lead to malignant infarction.
Background Malignant cerebral artery strokes have a poor prognosis, with nearly 80% of mortality ... more Background Malignant cerebral artery strokes have a poor prognosis, with nearly 80% of mortality in some series despite intensive care. After a large randomized trial, decompressive hemicraniectomy has been performed more often in stroke patients. Here, we describe patients in a tertiary teaching hospital in Brazil, emphasizing the impact of age on outcomes. Methods A retrospective cohort of patients, with malignant strokes which received a decompressive hemicraniectomy, from paper and electronic medical records, from January 2010 to December 2013 was divided into two groups according to age. Results The final analysis included 60 patients. The overall mortality was higher among patients older than 60 yrs (67% vs. 41%; p = 0.039), whose group also had a worse outcome (76% with mRS 5 or 6) at 90 days (OR 3.91 CI95% 1.30-11.74), whereas only 24% had mRS of 0-4 (p = 0.015). All patients who presented with sepsis died (p = 0.003). The incidence of pulmonary infection was very high in the elderly group (76%) with significant intergroup differences (p = 0.027, OR 8.32 CI95% 0.70-98.48). Conclusions Older patients present more commonly with infections, more disabilities and a higher mortality, highlighting very poor results in elderly population. These results should be proved with a South American trial, and if confirmed, it can impact on future decisions regarding decompressive craniectomy for acute ischemic stroke in our region.
RESUMO -Com o propósito de analisar os aspectos clínicos da hidrocefalia (HDC) na neurocisticerco... more RESUMO -Com o propósito de analisar os aspectos clínicos da hidrocefalia (HDC) na neurocisticercose (NCC), realizou-se o estudo retrospectivo de 47 prontuários de pacientes com HDC e NCC. Verificou-se que 70,2% eram homens, entre 21 e 50 anos. A hipertensão intracraniana (HIC) ocorreu em todos os pacientes, cefaléia (CEF) em 89,4%, meningoencefalite (ME) em 80,8% e distúrbios psíquicos (PSI) em 74,5%. A síndrome liquórica da NCC foi detectada em 65,9% pacientes. Além da HDC, as tomografias computadorizadas de crânio (TC) mostraram lesões císticas e edema cerebral difuso em 59,6% cada, calcificações em 55,3%. Dos 41 pacientes (87,2%) com derivação ventriculoperitoneal (DVP), em 22 (53,7%) deles foram necessárias uma a sete revisões/paciente (média=3). A evolução foi satisfatória em 51,1% e fatal em 31,9%. Conclui-se que a hidrocefalia é mais comum no sexo masculino em idade produtiva, tendo a HIC, CEF, MN e PSI como manifestações freqüentes e que, a necessidade de revisões de DVP, piora o prognóstico.
To develop an experimental model of neurocysticercosis-induced hydrocephalus There were used 17 r... more To develop an experimental model of neurocysticercosis-induced hydrocephalus There were used 17 rats. Ten animals were inoculated with Taenia crassiceps cysts into the subarachnoid. Five animals were injected with 0.1ml of 25% kaolin (a standard solution for the development of experimental hydrocephalus) and two animals were injected with saline. Magnetic resonance imaging (MRI) was used to evaluate enlargement of the ventricles after one or three months of inoculation. Volumetric study was used to quantify the ventricle enlargement. Seven of the 10 animals in the cyst group developed hydrocephalus, two of them within one month and five within three months after inoculation. Three of the five animals in the kaolin group had hydrocephalus and none in the saline group. Ventricle volumes were significantly higher in the 3-months MRI cyst subgroup than in the 1-month cyst subgroup. Differences between cyst subgroups and kaolin group did not reach statistical significance. The developed model may reproduce the human condition of neurocysticercosis-related hydrocephalus, which exhibits a slowly progressive chronic course.
We refer to the effectiveness (known as pragmatic or real world) and efficacy (known as explanato... more We refer to the effectiveness (known as pragmatic or real world) and efficacy (known as explanatory or desired or ideal world) of interventions. However, these terms seem to be randomly chosen by investigators who design clinical trials and do not always reflect the true purpose of the study. A pragmatic-explanatory continuum indicator summary tool was thus developed with the aim of identifying the characteristics of clinical trials that distinguish between effectiveness and efficacy issues. We verified whether clinical trials used the criteria proposed by the indicator summary tool, and we categorized these clinical trials according to a new classification. A systematic survey of randomized clinical trials was performed. We added a score ranging from 0 (more efficacious) to 10 (more effective) to each domain of the indicator summary tool and proposed the following classifications: high efficacy (<25), moderate efficacy (25-50), moderate effectiveness (51-75), and high effectiven...
Purpose] The study aimed to characterize patients treated by rehabilitation section after establi... more Purpose] The study aimed to characterize patients treated by rehabilitation section after establishment of an acute stroke unit. [Subjects and Methods] Medical consultation records of individuals with ischemic stroke were studied retrospectively, excluding individuals with hemorrhagic stroke, thrombolysis, previous Modified Rankin Scale ≥ 1, prior stroke, structural bone deformities, associated neurological disease, and prior cognitive deficit. The data evaluated were age, gender, etiology, localization, treatment received, ictus onset, hospitalization time, discharge date, and date of first evaluation at the rehabilitation center. The Modified Rankin Scale in 90 days after ictus was utilized to measure functional incapacity with the individuals divided into two groups, before and after acute stroke unit implementation (2010). Functional incapacity was compared between before and after acute stroke unit implementation by the Mann-Whitney test, χ 2 test and Fisher's exact test.
The present work aimed to evaluate the pattern of CSF alterations in patients diagnosed with neur... more The present work aimed to evaluate the pattern of CSF alterations in patients diagnosed with neurocysticercosis (NCC) in racemose form. Method: This is a retrospective cohort study of patients with diagnosis of NCC in racemose form. CSF samples from 26 patients were analyzed. After patient-chart analysis was performed descriptive analysis of case studies and comparison between sexes in relation to variables were obtained with CSF by Mann-Whitney and Student's t-tests. Results: The sexes did not differ statistically when compared to pleocytosis in CSF. Eosinophils were present in 31% in samples while the ELISA test presented 80% sensitivity in this case series. Of the patient total, 24 presented a meningitis pattern with lymphocytic predominance. Conclusion: There was no difference in inflammatory pattern between the sexes, with predominance of lymphocytic meningitis and 80% sensitivity by ELISA test of CSF patients with racemose form of NCC.
Journal of Stroke and Cerebrovascular Diseases, 2015
Background: The present study aimed to evaluate the relation between the National Institutes of H... more Background: The present study aimed to evaluate the relation between the National Institutes of Health Stroke Scale (NIHSS) score and the presence of laryngeal penetration and/or laryngotracheal aspiration in ischemic stroke patients and to verify what factors are predictors of the occurrence of pneumonia in the evaluated patients.
Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. ... more Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. The ABCD2 clinical risk prediction score is recommended for patient triage by stroke risk, but its ability to stratify by known risk factors and effect on clinic workload are unknown. We performed a systematic review and meta-analysis of all studies published between January 2005 and September 2014 that reported proportions of true TIA/minor stroke or mimics, risk factors, and recurrent stroke rates, dichotomized to ABCD2 score </≥4. We calculated the effect per 1,000 patients triaged on stroke prevention services. Twenty-nine studies, 13,766 TIA patients (range 69-1,679), were relevant: 48% calculated the ABCD2 score retrospectively; few reported on the ABCD2 score's ability to identify TIA mimics or use by nonspecialists. Meta-analysis showed that ABCD2 ≥4 was sensitive (86.7%, 95% confidence interval [CI] 81.4%-90.7%) but not specific (35.4%, 95% CI 33.3%-37.6%) for recurrent s...
The aim of this study was to relate the presence of a temporal acoustic window (TAW) to the varia... more The aim of this study was to relate the presence of a temporal acoustic window (TAW) to the variables sex, age and race. This observational study was conducted in patients under etiologic investigation after stroke, sicklecell anemia and hospitalization in an intensive therapy neurologic unit. TAW presence was confirmed by bilateral assessment by two neurologists via transcranial Doppler (TCD). Multiple logistic regression was performed to explain the presence of the window as a function of sex, age and race. In 20% of the 262 patients evaluated, a TAW was not present. The incidence of TAW presence was greater in men (odds ratio [OR] 5 5.4, 95% confidence interval [CI] 5 2.5-11.7, p , 0.01); lower with increased age (OR 5 0.9, 95% CI 5 0.92-0.97, p , 0.01); and lower among those of African and Asian descent (OR 5 0.32, 95% CI 5 0.14-0.70, p 5 0.005). On the basis of the results, more men than women had TAWs, and the decrease in TAWs was associated with increased age and African or Asian
With the purpose to verify clinical aspects of hydrocephalus (HC) in patients with neurocysticerc... more With the purpose to verify clinical aspects of hydrocephalus (HC) in patients with neurocysticercosis (NCC), a retrospective study of 47 patients was performed. The majority of patients (70.2%) were men aging 21-50 years. Intracranial hypertension (ICH) occurred in all patients, headache (HA) in 42 (89.4%), meningoencephalitis (ME) in 38 (80.8%) and psychiatric disorders (PD) in 34 (72.3%). The cerebrospinal fluid syndrome of NCC was detected in 31 patients (65.9%). In addition to HC, computed tomography (CT) scans showed cystic lesions in 28 (59.6%) patients, diffuse brain edema also in 28 (59.6%), and calcifications in 26 (55.3%). Shunts were inserted in 41 (87.2%) patients and 22 (53.7%) of them were submitted to 1-7 surgical revision/patient (mean=3) that were higher (mean=4) in those who died than in survivors (mean=2). Evolution was satisfactory in 24 (51.1%) patients and fatal in 15 (31.9%). It is possible to conclude that, in patients with NCC, HC occurs predominantly in men...
Four cases of suggestive inflammatory aneurysms in patients with neurocysticercosis have been des... more Four cases of suggestive inflammatory aneurysms in patients with neurocysticercosis have been described. We report a case of a 49-year-old woman who presented with subarachnoid haemorrhage from a right middle cerebral artery bifurcation aneurysm and had a casual relationship with neurocysticercosis. At surgery, a viable cysticercus without signs of inflammation or thickened leptomeninges was found in the distal position of the aneurysm. Postoperatively, the patient received albendazole and dextrochlorpheniramine. In the subsequent three years, the patient was asymptomatic and took drugs to prevent convulsion and arterial hypertension. The relationship between NCC and the presence of cerebral aneurysm is discussed.
Hamamoto Filho PT, Vital RB, Luvizutto GJ, Bazan R, Zanini MA. Hemicraniectomy after stroke in a ... more Hamamoto Filho PT, Vital RB, Luvizutto GJ, Bazan R, Zanini MA. Hemicraniectomy after stroke in a Brazillian multiethnic population: the role of aging. Background: Stroke is the leading cause of death in Brazil. Stroke of the middle cerebral artery (MCA) can lead to malignant infarction.
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