Por Maramélia Miranda
Foi publicado em 29 de dezembro último, no meio das festas de final de ano.
Já contempla a indicação de Fingolimode. Porém não como terapia de primeira linha, mas quando há falha de interferons e glatiramer e contraindicação ao natalizumabe (?).
Links abaixo.
Protocolos terapêuticos do Ministério da Saúde (em ordem alfabética)
Novo Protocolo Clínico e Diretrizes Terapêuticas em Esclerose Múltipla – MS
Por Daniel Fialho **
Devemos esperar uma “gestação” para liberar nossos pacientes pós-AVCi para uma cirurgia não-cardíaca (exceto revascularização carotídea) eletiva ???
Hoje, as avaliações neurológicas estão ainda literalmente “em gestação”, reclusas aos grandes centros ou ao ambiente acadêmico, mas, com certeza, tornar-se-ão rotina, como é a avaliação cardíaca.
E vocês, qual o intervalo indicam entre um evento cerebral isquêmico e uma cirurgia eletiva?
Vejam o artigo da JAMA abaixo:
Jornal: JAMA
Autores e Local: Jørgensen et al (Copenhagen, Dinamarca)
Abstract
Importance: The timing of surgery in patients with recent ischemic stroke is an important and inadequately addressed issue.
Objective: To assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality.
Design, Setting, and Participants: Danish nationwide cohort study (2005-2011) including all patients aged 20 years or older undergoing elective noncardiac surgeries (n=481 183 surgeries).
Exposures: Time elapsed between stroke and surgery in categories and as a continuous measure.
Main Outcomes and Measures: Risk of major adverse cardiovascular events (MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality) and all-cause mortality up to 30 days after surgery. Odds ratios (ORs) were calculated by multivariable logistic regression models.
Results: Crude incidence rates of MACE among patients with (n = 7137) and without (n = 474 046) prior stroke were 54.4 (95% CI, 49.1-59.9) vs 4.1 (95% CI, 3.9-4.2) per 1000 patients. Compared with patients without stroke, ORs for MACE were 14.23 (95% CI, 11.61-17.45) for stroke less than 3 months prior to surgery, 4.85 (95% CI, 3.32-7.08) for stroke 3 to less than 6 months prior, 3.04 (95% CI, 2.13-4.34) for stroke 6 to less than 12 months prior, and 2.47 (95% CI, 2.07-2.95) for stroke 12 months or more prior. MACE risks were at least as high for low-risk (OR, 9.96; 95% CI, 5.49-18.07 for stroke <3 months) and intermediate-risk (OR, 17.12; 95% CI, 13.68-21.42 for stroke <3 months) surgery compared with high-risk surgery (OR, 2.97; 95% CI, 0.98-9.01 for stroke <3 months) (P = .003 for interaction). Similar patterns were found for 30-day mortality: ORs were 3.07 (95% CI, 2.30-4.09) for stroke less than 3 months prior, 1.97 (95% CI, 1.22-3.19) for stroke 3 to less than 6 months prior, 1.45 (95% CI, 0.95-2.20) for stroke 6 to less than 12 months prior, and 1.46 (95% CI, 1.21-1.77) for stroke 12 months or more prior to surgery compared with patients without stroke. Cubic regression splines performed on the stroke subgroup supported that risk leveled off after 9 months.
Conclusions and Relevance: A history of stroke was associated with adverse outcomes following surgery, in particular if time between stroke and surgery was less than 9 months. After 9 months, the associated risk appeared stable yet still increased compared with patients with no stroke. The time dependency of risk may warrant attention in future guidelines.
** Daniel Fialho é neurologista, chefe do serviço de Neurologia do Hospital São Francisco, em Concórdia, SC.
Abstract saído do forno, super highlight do congresso da AHA de Chicago, na semana passada… Exemplo claro de como obviedades podem ser jogadas no lixo com simples matemática e estatística.
Autores::: Dion Stub et al.
Local::: Australia.
Abstract
Background: Oxygen is commonly administered to patients with ST-elevation myocardial infarction (STEMI) despite previous studies suggesting a possible increase in myocardial injury due to coronary vasoconstriction and heightened oxidative stress.
Methods: We conducted a multicenter, prospective, randomized, controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with STEMI diagnosed on paramedic 12-lead electrocardiogram. Of 638 patients randomized, 441 were confirmed STEMI patients who underwent primary endpoint analysis. The primary endpoint was myocardial infarct size as assessed by cardiac enzymes, troponin (cTnI) and creatine kinase (CK). Secondary endpoints included recurrent myocardial infarction, cardiac arrhythmia and myocardial infarct size assessed by cardiac magnetic resonance (CMR) imaging at 6 months.
Results: There was a significant increase in mean peak CK in the oxygen group compared to the no oxygen group (1948 U/Lvs.1543 U/L; means ratio, 1.27; 95% CI, 1.04 to 1.52; P= 0.01). Mean peak troponin was similar in the oxygen and no oxygen groups (57.4 mcg/L vs. 48.0 mcg/L; ratio, 1.20; 95% confidence interval [CI], 0.92 to 1.56;P=0.18).There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared to the no oxygen group (5.5%vs.0.9%, P=0.006) and an increase in frequency of cardiac arrhythmia (40.4%vs.31.4%; P=0.05). At 6-months the oxygen group had an increase in myocardial infarct size on CMR n=139;20.3grams vs. 13.1grams; P=0.04).
Conclusion: Supplemental oxygen therapy in patients with STEMI but without hypoxia increased early myocardial injury and was associated with larger myocardial infarct size assessed at six months.
Para o coração, faz mal. E para o cérebro?
Mais uma “siglinha” para se decorar… Guardem: É um dos Hot Topics de 2014.
Critérios clínicos do AVC do tipo ESUS:
Estou falando grego pra você? Viajou na maionese? Corra. Vá estudar! Hart RG et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014.
Epilepsy surgery in children and adults
Autores: Ryvlin, Cross & Rheims.
Revista: Lancet Neurology (artigo de revisão)
Summary: Epilepsy surgery is the most effective way to control seizures in patients with drug-resistant focal epilepsy, often leading to improvements in cognition, behaviour, and quality of life. Risks of serious adverse events and deterioration of clinical status can be minimised in carefully selected patients. Accordingly, guidelines recommend earlier and more systematic assessment of patients’ eligibility for surgery than is seen at present. The effectiveness of surgical treatment depends on epilepsy type, underlying pathology, and accurate localisation of the epileptogenic brain region by various clinical, neuroimaging, and neurophysiological investigations. Substantial progress has been made in the methods of presurgical assessment, particularly in patients with normal features on MRI, but evidence is scarce for the indication and effect of most presurgical investigations, with no biomarker precisely delineating the epileptogenic zone. A priority for the development of epilepsy surgery is the generation of high-level evidence to promote the harmonisation and dissemination of best practices.
Determinants of antithrombotic choice for patent foramen ovale in cryptogenic stroke
Autores::: Thaler et al.
Local: Boston, MA; Germany; Girona, Spain; University of Bern; Zurich, Switzerland; Cambridge University, UK; Columbia University, NY; Switzerland; University of Bern, Switzerland; Cleveland, OH.
Revista: Neurology 2014.
Abstract
Objective: We examined the influence of clinical, radiologic, and echocardiographic characteristics on antithrombotic choice in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), hypothesizing that features suggestive of paradoxical embolism might lead to greater use of anticoagulation.
Methods: The Risk of Paradoxical Embolism Study combined 12 databases to create the largest dataset of patients with CS and known PFO status. We used generalized linear mixed models with a random effect of component study to explore whether anticoagulation was preferentially selected based on the following: (1) younger age and absence of vascular risk factors, (2) “high-risk” echocardiographic features, and (3) neuroradiologic findings.
Results: A total of 1,132 patients with CS and PFO treated with anticoagulation or antiplatelets were included. Overall, 438 participants (39%) were treated with anticoagulation with a range (by database) of 22% to 54%. Treatment choice was not influenced by age or vascular risk factors. However, neuroradiologic findings (superficial or multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, and septal hypermobility) were predictors of anticoagulation use.
Conclusion: Both antithrombotic regimens are widely used for secondary stroke prevention in patients with CS and PFO. Radiologic and echocardiographic features were strongly associated with treatment choice, whereas conventional vascular risk factors were not. Prior observational studies are likely to be biased by confounding by indication.
Efficacy and Safety of Novel Oral Anticoagulants in Patients with Cervical Artery Dissections
Autor: Caprio et al. Revista: Cerebrovasc Diseases 2014.
Local::: Departments of aNeurology and bRadiology, Northwestern University, Feinberg School of Medicine, Chicago, Ill., cDepartment of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, Tex., USA
Abstract
Background: American and European guidelines support antiplatelet agents and anticoagulants as reasonable treatments of cervical artery dissection (CAD), though randomized clinical trials are lacking. The utility of novel oral anticoagulants (NOAC), effective in reducing embolic stroke risk in non-valvular atrial fibrillation (NVAF), has not been reported in patients with CAD. We report on the use, safety, and efficacy of NOACs in the treatment of CAD.
Methods: We retrospectively identified patients diagnosed with CAD at a single academic center between January 2010 and August 2013. Patients were categorized by their antithrombotic treatment at hospital discharge with a NOAC (dabigatran, rivaroxaban, or apixaban), traditional anticoagulant (AC: warfarin or treatment dose low-molecular weight heparin), or antiplatelet agent (AP: aspirin, clopidogrel, or aspirin/extended-release dypyridamole). Using appropriate tests, we compared the baseline medical history, presenting clinical symptoms and initial radiographic characteristics among patients in the 3 treatment groups. We then evaluated for the following outcomes: recurrent stroke, vessel recanalization, and bleeding complications. p values <0.05 were considered significant.
Results: Of the 149 included patients (mean age 43.4 years; 63.1% female; 70.5% vertebral artery CAD), 39 (26.2%), 70 (47.0%), and 40 (26.8%) were treated with a NOAC, AC, and AP, respectively. More patients with severe stenosis or occlusion were treated with NOAC than with AC or AP (61.8 vs. 60.0 vs. 22.5%, p = 0.002). Other baseline clinical and radiographic findings, including the presence of acute infarction and hematoma, did not differ between the 3 treatment groups. One hundred and thirty-five (90.6%) patients had clinical follow-up (median time 7.5 months) and 125 (83.9%) had radiographic follow-up (median time 5 months) information. There were 2 recurrent strokes in the NOAC group and 1 in each of the AC and AP groups (p = 0.822). There were more major hemorrhagic events in the AC group (11.4%) compared to the NOAC (0.0%) and AP (2.5%) groups (p = 0.034). Three patients treated with NOAC and none treated with AC or AP had a worsened degree of stenosis on follow-up imaging (8.6 vs. 0.0 vs. 0.0%, p = 0.019).
Conclusion: Compared to traditional anticoagulants for CAD, treatment with NOACs is associated with similar rates of recurrent stroke, fewer hemorrhagic complications, but greater rates of radiographic worsening. These data suggest that NOACs may be a reasonable alternative in the management of CAD. Prospective validation of these findings is needed.
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Depois comento.
Primeiro foi o MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands), cujos dados foram apresentados no Congresso Mundial de AVC em Istambul. Trial interrompido pelos resultados bons do braço de endovascular.
Agora outros dois trials, que comparam grupos de tratamento com embolectomia versus rTPA, também foram interrompidos pela eficácia da terapia intervencionista.
O ESCAPE (Endovascular Treatment for Small Core and Proxim al Occlusion Ischemic Stroke), estudo canadense, e o EXTEND IA (Extending the Time for Thrombolysis in Emergency Neurological Deficits – Intra-Arterial) — pararam suas randomizações após análises interidas desmonstrarem benefício da terapia endovascular.
Detalhe: todos estes trials usam devices de segunda e terceira geração (exemplos: TREVO, SOLITAIRE), diferentemente dos anteriores, IMS III, MR RESCUE e SYNTHESIS, que tinham dispositivos antigos e inclusive possibilidade de terapia IA (usando rTPA local).
Neurorradio intervencionista: They are back!!!!!!!
E agora? Será que as fontes pagadoras continuarão a não reembolsar os materiais…?!?!?!
Notícia boa para nossos queridos amigos intervencionistas!!!!!
Foram apresentados no Congresso Mundial de AVC, em Istambul, novos dados do estudo IMS III, que avaliou rTPA endovenoso (sistêmico) versus rTPA e terapia endovascular combinada no AVCi agudo, e os resultados iniciais do estudo MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands).
Em relação ao IMS-III, os pesquisadores observaram que, na análise de follow-up de 12 meses, embora os pacientes com AVCi mais leves ficaram melhores do que os mais graves, a evidência foi de que, ao contrário do grupo mais leve, a terapia endovascular fez diferença (favoravelmente) no subgrupo de pacientes com AVCi mais severo, quando comparados com a terapia de primeira linha – rTPA EV sozinho. Lembro aqui que AVCi moderado foi definido pelo trial como NIH de 8-19, e severo > ou igual a 20.
Até então, os dados do IMS-III que tínhamos eram os publicados na NEJM em 2013, que tinha jogado 5476 baldes de água fria na terapia endovascular –> este paper mostrou similaridade dos tratamentos quando medidos desfechos em 90 dias, motivo inclusive de sua interrupção por futilidade.
A melhora ao longo do tempo até a visita de 12m foi de 8% no grupo de AVCi mais grave, versus 2% no grupo moderado.
O “odds ratio” para o efeito do tratamento chegar ao escore de mRS de 0 a 2 foi de 0,95 no subgrupo de AVCi moderado, e 2,37 no grupo severo, isso já ajustadas variáveis como escala de NIH, tempo de início dos sintomas e idade.
Tabela. Desfechos favoráveis em 12 meses (mRS de 0 a 2)
| Grupo/Tratamento | Endovascular + rTPA EV (%) | rTPA EV sozinho (%) | P |
| AVCi moderado (NIH 8-19)(n=452) | 55.6 | 57.7 | – |
| AVCi severo (NIH >20)(n=204) | 32.5 | 18.6 | .037 |
Ou seja, aparentemente, parece haver uma maior diferença, uma melhora maior, mais “tardia”, em relação aos AVCis mais graves que recebem rTPA e terapia endovascular??? Seria isso?! Fiquei algo confusa com estes números. Preciso “digerir” melhor…
Depois volto com os dados do MR CLEAN…
Neurorradiologia ressurgindo das cinzas!!!!!
Vamos chamar mais os caras!!!!!
Pra treinar seu ouvido em alemão, e curtir também :). Super Sommer – Luttenberger Klug
Música boa (Allen Stone). E a última música, uma voz power do ex-vocal do The Calling.
Allen Stone – Unaware (live from his mother’s living room)
Alex Band (vocal/The Calling) – Holding on
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