Keywords
Cerebrovascular Disorders - Mortality - Risk Factors - Stroke - Thrombolytic Therapy
Palavras-chave
Transtornos Cerebrovasculares - Mortalidade - Fatores de Risco - Acidente Vascular
Cerebral - Terapia Trombolítica
INTRODUCTION
Stroke is a major national health problem in Brazil. Recently, data has shown that
cardiovascular disease continues to be the main cause of mortality, as per the Brazilian
Institute of Geography and Statistics (IBGE).[1]
There has been a downward trend in stroke mortality, mainly in the southern and southeastern
regions.[2]
[3]
One of the most effective interventions after stroke is patient referral to an organized
Stroke Unit Care (SUC) during the acute phase, with evidence indicating that it increases
independence, survival, and rates of living at home by 12 months. The SUC improves
functional outcomes and decreases the length of hospital stay when compared to patients
admitted elsewhere.[4]
[5]
[6]
The goal of the present study is to show the experience of a SUC in the Brazilian
Northeast countryside, comparing its first, second, and third years of service.
METHODS
Study setting and participants
Data on consecutive stroke admissions to the SUC were prospectively collected from
July 31st, 2018, to July 31st, 2019, which was considered year one; August 1st, 2019, to July 31st, 2020, year two, and August 1st, 2020, to July 31st, 2021, year three.
The inclusion criteria used were patients treated at a SUC; diagnosis of stroke, transient
ischemic attack (TIA), or cerebral venous thrombosis; and less than 72 h of symptom
onset.
The World Health Organization's (WHO) definition of stroke[7] was used; however, patients diagnosed with stroke but with symptom resolution within
24h due to treatment with intravenous thrombolysis were still classified as having
a stroke.
Stroke unit
Our stroke unit is localized in the Brazil's Central Arid Northeast countryside, and
it is composed by a multidisciplinary team of neurologists, nurses, nursing assistants,
physiotherapists, occupational therapists, phonoaudiologists, nutritionists, clinical
pharmacists. Neurosurgeons, psychologists, and social service workers are available
on demand.
The unit is composed by 10 monitored hospital beds and is reference to 20 countryside
cities in the area.
Year one was integrated by neurologists but also clinical physicians on duty with
daily neurologist survey (nowadays, all physicians on duty are neurologists). At that
time, there were no neurosurgeons in the hospital. Surgical patients were transferred
to another support hospital. Thrombolysis was done in the SUC, after the patient returned
from computed tomography (CT).
Nowadays, since year two, there are neurosurgeons in the stroke team, available when
necessary, and thrombolyses are initiated in the tomography room.
The dose of recombinant tissue plasminogen activator (tPA) used in our protocol is
0.9 mg/kg (maximum 90 mg).
Outcomes and measures
The primary outcome in this study was door-to-needle time (DNT). The second outcome
was the number of thrombolyses.
Stroke severity on admission was prospectively assessed for each patient. During the
3 years of the study, the National Institutes of Health Stroke Scale (NIHSS) was the
severity stroke scale.[8] Severity cutt-offs were mild (NIHSS: 0–5), moderate (NIHSS: 6–14), and severe (NIHSS:
15–42).[9] The primary stroke type was determined via imaging (ischemic vs. hemorrhagic). Reduced
consciousness at admission was defined by a Glasgow Coma Scale score of ≤ 10. Length
of stay was recorded.
Patient demographics and medication use were registered at admission. The stroke risk
factors registered were previous cerebrovascular disease (transient ischemic attack
or stroke), myocardial infarction, treated hypertension or diabetes, dyslipidemia,
overweight/obesity, any cancer diagnosis, alcohol use, and current smoking status.
Atrial fibrillation was considered present if previously diagnosed or shown on electrocardiogram
during admission or stay. Level of function poststroke at discharge was graded using
the modified Rankin Scale (mRS), and patients were classified as being independent
by an mRS score ≤ 2.[9]
[10]
Complications related to intravenous thrombolysis have been reported. Symptomatic
hemorrhagic transformation was defined when it was associated with a worsening of
four or more points in NIHSS. Other complications investigated were orolingual angioedema
and symptomatic hypotension.
Statistical analysis
A descriptive analysis was made. The Shapiro-Wilk test was used to determine the normality
of quantitative variables, which were then described using the median and percentiles.
For the analyses of the door-to-CT time and DNT, we choose to add the mean because
it is classically used. Categorical variables were presented as frequency and percentage.
The IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY, USA) was
used for all analyses.
Ethical considerations
Consent was obtained prior to recruitment with permission for data use.
RESULTS
A total of 1,925 patients were included in the analysis: 553 patients in year 1, 688
in year 2, and 684 in year 3. The distribution of the most common diagnoses in the
SUC along those 3 years are displayed in [Figure 1].
Figure 1 Distribution of most common diagnosis in stroke unit at Brazil's Central Arid Northeast
on the first 3 years, from July 2018 to July 2021.
There were 1,374 ischemic-stroke patients. Most were men, with a mean age of 69.9.
The most common risk factors were hypertension, being a current smoker, and presence
of diabetes. Demographics, risk factors, and clinical features of these patients are
exposed in [Table 1].
Table 1
Epidemiological profile of 1,374 stroke patients from the stroke unit in Brazil's
Central Arid Northeast from July 2018 to July 2021
|
Characteristics
|
N (%)
|
Median
|
|
Total
|
1,374 (100)
|
–
|
|
Age in years, mean (SD)
|
–
|
71 (61-80)#
|
|
Male sex
|
782 (56.9)
|
–
|
|
Hypertension
|
985 (71.68)
|
–
|
|
Current smoker
|
422 (30.71)
|
–
|
|
Diabetes
|
384 (27.9)
|
–
|
|
Prior stroke
|
292 (21.25)
|
–
|
|
Antiplatelets/anticoagulants
|
257 (18.7)
|
–
|
|
Cardiopathy
|
248 (18)
|
–
|
|
Alcohol user
|
235 (17.1)
|
–
|
|
Dyslipidemia
|
224 (16.3)
|
–
|
|
Overweight/obesity
|
217 (15.8)
|
–
|
|
Cancer
|
9 (0.7)
|
–
|
Notes: #(25th–75th percentile).
In the 1st year, 130 patients arrived in the therapeutic time window. In the next year, it was
219 patients and, in the 3rd year, 270 patients. Mean and median time were described on [Table 2]. There were 42 intravenous thrombolyses in the 1st year, 100 in the 2nd year and 114 in the 3rd year. Of these, 28 (10.9%) intravenous thrombolyses were performed for patients with
NIHSS between 0 and 5, but with deficits considered potentially disabling, and 228
(89.1%) intravenous thrombolyses were performed for patients with severity stroke
moderate or severe. The main reasons for not performing intravenous thrombolysis were
stroke mimics, minor non-disabling deficits, large ischemia, or hemorrhage on admission
CT scan. The comparison of service performance over the 3 years is described in [Table 2].
Table 2
Comparison of performance in stroke unit at Brazil's Central Arid Northeast for the
first 3 years, from July 2018 to July 2021
|
Year 1
|
Year 2
|
Year 3
|
|
Patients in therapeutic time window (n/%)*1
|
130/23.5
|
219/31.8
|
270/39.5
|
|
Door-to-computed tomography time (minutes)
|
|
Mean
|
14
|
11
|
13.3
|
|
Median
|
14 (10–20)#
|
11 (8–15)#
|
9.6 (7–12)#
|
|
Door-to-needle time (minutes)
|
|
Mean
|
44.6
|
26.8
|
20.3
|
|
Median
|
39.5 (29.5–60.8)#
|
22 (17–30)#
|
17 (14–22)#
|
|
Thrombolysis (n/%)*2
|
42/10.5
|
100/19.8
|
114/24.1
|
Notes*1:Considering all patients admited *2;Considering only patients with ischemic stroke; #(25th–75th percentile).
Six patients (2.3%) had major complications due to thrombolysis: 1 orolingual angioedema,
without clinical repercussion, and 5 symptomatic hemorrhagic transformations.
The median hospitalization time was 10.5 days, 9.4 days, and 8.3 days in year 1, 2,
and 3, respectively. The Rankin and NIHSS scales of admission and discharge during
those 3 years are presented in [Figures 2] and [3]. Currently, the in-hospital mortality rate of ischemic stroke in our SUC is 9.05%.
Figure 2 Percentage of Modified Rankin Scale distribution at Admission and Discharge in stroke
unit at Brazil's Central Arid Northeast on the first 3 years, from July 2018 to July
2021.
Figure 3 Percentage of NIH score distribution at Admission and Discharge in stroke unit at
Brazil's Central Arid Northeast on the first 3 years, from july 2018 to july 2021.
DISCUSSION
Age, gender, and the most frequent risk factors were aligned with previous reports
on demographic findings.[11]
According to worldwide epidemiology, our DNT is better than average.[12]
[13]
[14] Our data shows lower mortality with better times than average due to considerable
work done to improve DNT in our unit.[15]
The most effective strategies include prenotification of arrival by emergency medical
services (EMS), single-call activation of the stroke team, postponement of the registration
process, going straight to CT on EMS stretcher, and administration of alteplase in
the scanner as reported by other places.[12] We also accomplished neurologist acquisition on duty every day, acquisition of neurosurgeon
staff and team training, since the second year.
Our in-hospital mortality rate was lower than previous reports in Brazil, such as
the Botucatu stroke unit, with 12.7% on discharge, and others, with measure at 6 to
12 months from stroke (25%), but higher than Germany, with 5.4%.[16]
[17]
There was an increase of 23.8% in SUC demand, with higher proportion of thrombolyses
in the 2nd year, probably due to prehospital education. Training was carried out for hospital
and emergency room teams from most of the countryside cities for which we are the
reference. During stroke protocol, reception, transportation assistant, radiology
and stroke unit teams, all gather forces and stay alert for the arrival of the patient.
In spite of the pandemic in the third year, our proportion of thrombolyses still improved.
The present study had some limitations, such as the lack of information of asymptomatic
hemorrhagic transformations after thrombolysis, premorbid Rankin scale, mortality
rate 90 days after discharge, and some lost data among cases. However, this was the
first report of stroke data in Brazil's Central Arid Northeast.
In conclusion, it is a fact that the SUC improves the quality of care to users due
to significant reduction of the sequelae generated by the disease and its mortality
rate.
Hospital participation in a multidimensional quality initiative was associated with
improvement on alteplase administration time.
There are many exciting areas of future direction, including reduction of DNT by improvement
of prehospital response times and acquisition of endovascular treatment, to accomplish
an even better outcome.
