Pedro A.P. Jesus

Validation of the National Institutes of Health Stroke Scale, Modified Rankin Scale and Barthel Index in Brazil: The Role of Cultural Adaptation and Structured Interviewing

Background: We aimed to validate three widely used scales in stroke research in a multiethnic Brazilian population. Methods: The National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) were translated, culturally adapted and applied by two independent investigators. The mRS was applied with or without a previously validated structured interview. Interobserver agreement (kappa statistics) and intraclass correlation coefficients were calculated. Results: 84 patients underwent mRS (56 with and 28 without a structured interview), 57 BI and 62 NIHSS scoring. Intraclass correlation coefficient was 0.902 for NIHSS and 0.967 for BI. For BI, interobserver agreement was good (kappa = 0.70). For mRS, the structured interview improved interobserver agreement (kappa = 0.34 without a structured interview; 0.75 with a structured interview). Conclusion: The NIHSS, BI and mRS show good validity when translated and culturally adapted. Using a structured interview for the mRS improves interobserver concordance rates.

Cognitive dysfunction in congestive heart failure: transcranial Doppler evidence of microembolic etiology

Cognitive symptoms are common in patients with congestive heart failure (CHF) and are usually attributed to low cerebral blood flow. In the present study, we aimed to evaluate global cognitive function (Mini Mental State Exam MMSE) in relation to both cardiac function (evaluated by echocardiogram) and cerebrovascular hemodynamics (evaluated by transcranial Doppler TCD) in CHF patients. In 83 patients studied, no correlation was found between echocardiographic parameters and MMSE scores. In contrast, a significant correlation was found between right middle cerebral artery (RMCA) mean flow velocity and MMSE score (r=0.231 p=0.039), as well as between RMCA pulsatility index and MMSE score (rs= -0.292 p=0.015). After excluding patients with a previous history of stroke, only RMCA pulsatility index correlated with MMSE score (rs=-0,314 p=0,007). The relationship between high cerebrovascular resistance and worse cognitive scores suggest that microembolism may be responsible for a significant proportion of cognitive symptoms in CHF patients.

Stroke History and Chagas Disease Are Independent Predictors of Silent Cerebral Microembolism in Patients with Congestive Heart Failure

Background: Chagas disease is endemic in South and Central America, where 18 million individuals are infected by Trypanosoma cruzi, causing congestive heart failure (CHF) and cardioembolic stroke. Transcranial Doppler (TCD) is able to detect real-time microembolic signals (MES) to the brain vessels and may represent a surrogate marker of stroke risk. We aimed to determine predictors of MES in a population of patients with CHF. Methods: Consecutive CHF patients from a university-based cardiomyopathy clinic underwent TCD recording of the middle cerebral artery for 60 min by a single investigator who was blinded to all clinical data including cardiomyopathy etiology. Predictors of MES were sought by multivariable logistic regression analysis. Results: From April 2004 to February 2009, 144 patients were studied, including 62 (44.6%) patients with Chagas disease. MES were detected in 9 (6.2%) patients and were more frequent in patients with Chagas disease than in patients with other causes of CHF (12.9 vs. 1.2%, p = 0.005). In multivariate analysis corrected for age and left-ventricular ejection fraction, predictors of MES were Chagas disease (odds ratio = 1.15, 95% confidence interval = 1.05–1.26, p = 0.004) and stroke history (odds ratio = 1.27, 95% confidence interval = 1.08–1.50, p = 0.005). Conclusions: Chagas disease and stroke history are risk factors for MES independent of cardiac disease severity. Other mechanisms besides structural cardiac disease may be operative, increasing embolic risk in Chagas disease.

Hipertensão induzida farmacologicamente em paciente com isquemia em território vértebro-basilar associada com estenose vertebral bilateral

Hypertension is one of the main risk factors for stroke. However, treating hypertension in the acute phase may cause further neurological deterioration. We present a case of an 81-year-old woman, admitted after multiple infarcts in the posterior circulation. While fully anticoagulated, her neurological deficits worsened, coinciding with normalization of her blood pressure levels. Magnetic resonance angiography documented bilateral vertebral artery stenoses. Induced hypertension was followed by rapid clinical improvement. In this first report of induced hypertension in the Brazilian literature, we illustrate the potencial benefit of this therapeutic strategy in patients with documented hemodynamic mechanism of clinical deterioration.

Low Ankle-Brachial Index is a Simple Physical Exam Sign Predicting Intracranial Atherosclerotic Stenosis in Ischemic Stroke Patients

BACKGROUND The investigation of ischemic stroke etiology is commonly limited to the heart and extracranial vessels. Nevertheless, the diagnosis of intracranial stenosis may carry important therapeutic implications. The aims of this study were to determine the prevalence and clinical predictors of intracranial atherosclerotic stenosis (ICAS) in a sample of patients with ischemic stroke. METHODS Consecutive patients admitted to a university-based outpatient stroke clinic underwent CT angiography of the intracranial and extracranial brain vessels. Clinical, demographic, and laboratory characteristics were compared between patients with increasing levels of stenosis. Ankle-brachial index (ABI) was measured to quantify peripheral arterial disease, defined as an ABI less than or equal to .9. Multivariable ordinal logistic regression was constructed to predict increasing stenosis grades (none, 1%-49%-mild, 50%-69%-moderate, 70%-100%-severe). RESULTS We studied 106 subjects, mean age 62 ± 15 years, 54% female. ICAS was present in 38 (36%) patients: 19 (50%) mild, 7 (18%) moderate, and 12 (32%) severe. Of 74 patients where ABI was measured, low ABI was found more frequently with increasing ICAS severity (26%, 42%, 67%, and 89% of patients with none, mild, moderate, and severe ICAS, respectively). In univariable analysis, higher age, presence of diabetes, abdominal obesity, and low ABI correlated with increasing stenosis grades. In multivariable analysis, only low ABI remained independently associated with increasing stenosis grades. CONCLUSIONS The ABI is independently associated with increasing severity of ICAS, making it a potentially useful triaging tool for more invasive test selection.

Proposal for a New Predictive Scale for Recurrent Risk of Fall in a Cohort of Community-Dwelling Patients with Stroke

OBJECTIVES This study aimed to determine risk factors related to the occurrence of falls in stroke patients and to propose a new predictive scale for falls. METHODS Demographic and clinical data were collected and the following scales were applied: Barthel Index, Timed Up and Go Test (TUG), and National Institutes of Health Stroke Scale (NIHSS). Subjects were followed prospectively for 2 years for the occurrence of recurrent (≥2) falls. Kaplan-Meier curves were constructed and univariable associations were tested using log-rank test. Two separate multivariable models were then used: the first used Cox proportional hazards regression and the second used Poisson regression. In each model, significant associations were considered present with a P value less than .05. RESULTS We evaluated 150 individuals and the final analysis included 131 patients; the average age of the patients was 55.8 ± 13 years, 52% were women, and the median NIHSS score was 2 (interquartile range = 1-5). Falls occurred in 17% of patients, with a median of 23 months of follow-up (interquartile range = 16-26 months). In the multivariable Cox regression model, only TUG quartile, female gender, and posterior circulation territory involvement remained significant predictors of recurrent falls. We used the predictors from the Cox regression model to propose a new recurrent fall risk scale. The area under the receiver operating characteristic curve was 73%, 95% confidence interval = 62%-83%, P = .001, with 81.3% sensitivity and 41.8% specificity. CONCLUSIONS The new predictive scale for recurrent risk (including TUG, posterior circulation territory involvement, and female gender) is presented as an instrument for monitoring the risk of recurrent falls.

Clinical assessment, neuroimaging and immunomarkers in Chagas disease study (CLINICS). Rationale, study design and preliminary findings

Chagas disease (CD) is an important cause of cardiomyopathy and stroke in Brazil. Brain infarcts and atrophy seem to occur independently of cardiomyopathy severity and cognitive impairment is understudied. Objective Compare the prevalence of brain magnetic resonance imaging abnormalities between patients with or without CD; determine if inflammatory biomarkers are increased in CD; and determine the efficacy of aspirin in reducing the rate of microembolization in these patients. Methods 500 consecutive patients with heart failure will undergo a structured cognitive evaluation, biomarker collection and search for microembolic signals on transcranial Doppler. The first 90 patients are described, evaluated with cognitive tests and brain magnetic resonance imaging to measure N-acetyl aspartate (NAA), choline (Cho), myo-inositol (MI) and creatine (Cr). Results Mean age was 55±11 years, 51% female, 38 (42%) with CD. Mean NAA/Cr ratio was lower in patients with CD as compared to other cardiomyopathies. Long-term memory and clock-drawing test were also significantly worse in CD patients. In the multivariable analysis correcting for ejection fraction, age, sex and educational level, reduced NAA/Cr (p=0.006) and cognitive dysfunction (long-term memory, p=0.023; clock-drawing test, p=0.015) remained associated with CD. Conclusion In this preliminary sample, CD was associated with cognitive impairment and decreased NAA/Cr independently of cardiac function or educational level.