Stroke management in a university hospital in the largest South American city

Arq Neuropsiquiatr 2008;66(2-B):308-311 Stroke management in a university hospital in the largest South American city Adriana Bastos Conforto1, Rodrigo Bomeny de Paulo2, Cristiane Borges Patroclo3, Samira Luísa dos Apóstolos Pereira3, Helder de Souza Miyahara2, Camila Barião da Fonseca2, Fabio Iuji Yamamoto3, Paulo ������ Eurípides ������������������� Marchiori4, Eli ���������� Faria Evaristo ��������5, Milberto Scaff6 Abstract – Objective: To describe characteristics and provision of care for patients admitted with cerebrovascular disorders (CVD), focusing on ischemic stroke (IS), in a large, public, academic hospital in São Paulo, Brazil.   Method: We retrieved information about 357 patients with CVD admitted to the Neurology Emergency Department (NED) and Neurology Ward (NW) of our institution. We described patient characteristics and management of IS in NED and in NW.   Results: IS was diagnosed in 79.6% of CVD patients admitted to NED; 2.7% were submitted to thrombolysis. Extent of IS investigation and management were significantly different in NED and NW.   Conclusion: IS patients in our center were younger than in developed countries. IS management was significantly influenced by patient characteristics. This information can aid in planning strategies to decrease stroke burden. Key words: stroke, diagnosis, thrombolytic therapy, emergency treatment. Manejo do acidente vascular cerebral em um hospital universitário na maior cidade da América do Sul Resumo – Objetivo: Descrever características e manejo de pacientes internados com diagnóstico de doença cerebrovascular (DCV), enfocando principalmente o acidente vascular cerebral isquêmico (AVCI), em um hospital público universitário em São Paulo.   Método: Coletamos informações de 357 pacientes com DCV internados no Pronto-Socorro de Neurologia (PSN) e na Enfermaria de Neurologia (EN) de nossa instituição. Descrevemos características dos pacientes e manejo do AVCI no PSN e na EN.   Resultados: O AVCI foi diagnosticado em 79,6% dos pacientes com DCV admitidos no PSN; 2,7% foram submetidos a trombólise. A extensão da investigação e o manejo da doença foram significativamente diferentes no PSN e na EN.   Conclusão: Os pacientes com AVCI em nosso centro foram mais jovens que em países desenvolvidos. O manejo do AVCI foi influenciado significativamente pelas características dos pacientes. Estas informações podem auxiliar no planejamento de estratégias para diminuir as conseqüências das DCV em nosso meio. Palavras-chave: acidente cerebrovascular, diagnóstico, terapia trombolítica, tratamento de emergência. It has been estimated that two thirds of stroke patients live in low-income and middle-income countries1. Stroke will be an epidemic in South America over the next decades in association with demographic changes of the population, progressive urbanization and changes in lifestyle. In order to implement effective health policies, it is crucial to know how stroke care is currently provided but there is a gap in information about stroke management in the continent2,3. Stroke is a leading cause of mortality in Brazil and ageadjusted mortality rates for stroke are higher than in other South American countries4-6. São Paulo is the largest city in South America. In 2004, it was estimated that 19,128,164 people lived in the urban São Paulo metropolitan area7. Cerebrovascular disease was a common cause of overall mortality, second only to ischemic heart disease4. Our goals were to describe characteristics and provision of care for patients admitted with cerebrovascular This study was performed in the Neurology Department, Clinics Hospital/São Paulo University, São Paulo SP, Brazil: 1MD, PhD. Neurology Division, Clinics Hospital/São Paulo University and Instituto do Cérebro, Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo SP, Brazil; 2 MD, São Paulo University Medical School; 3MD, Neurology Division, Clinics Hospital/São Paulo University; 4MD, PhD, Associate Professor, Neurology Department, Clinics Hospital/ São Paulo University; 5MD, PhD, Neurology Division, Clinics Hospital/São Paulo University; 6MD, PhD, Chief Professor, Neurology Department, Clinics Hospital/São Paulo University. Financial support: Rodrigo Bomeny de Paulo received a scholarship for medical students provided by Programa Institucional de Bolsas de Iniciação Científica/Conselho Nacional de Desenvolvimento Científico e Tecnológico (PIBIC – Institucional Usp), grant Usp 2006.1.36948.1.0. Received 30 January 2008, received in final form 12 April 2008. Accepted 26 April 2008. Dra. Adriana Bastos Conforto – Neurology Division / Clinics Hospital / São Paulo University - Avenida Dr. Enéas C. Aguiar 255/5084 - 05403-000 São Paulo SP - Brasil. E-mail: , 308 Stroke management: university hospital Conforto et al. Arq Neuropsiquiatr 2008;66(2-B) diseases (CVD), focusing on ischemic stroke (IS), in a large public, academic hospital in São Paulo. Method We retrospectively evaluated hospital records of 357 patients aged >15 years, consecutively admitted with a diagnosis of acute stroke event or transient ischemic attack (TIA) in the Neurology Emergency Department (NED) between September 1st and December 1st, 2004, and in the Neurology Ward (NW), between November 1st, 2003 and November 1st, 2005. The local Ethics Committee approved the study and the procedures followed were in accordance with institutional guidelines. Neurologists and a CT scanner were available on-site in the Neurology Emergency Department (NED), 24-hours a day, 365 days per year. The entire hospital had 3000 beds, 20 of them dedicated to Neurology patients. Patients with a diagnosis of IS were typically either discharged home from the NED, or were referred to ICUs or the general Neurology Ward (NW). Discharge home, from NED, was made at the discretion of the neurologist in charge; usually, patients were discharged if there were no need of intensive care, and no decrease in level of consciousness (LOC), in the presence of a stable neurological status. If these criteria were fulfilled and beds were available, patients were admitted to NW. Patients admitted to the NW, but not patients admitted exclusively to the NED, were routinely referred to outpatient followup in our institution. A total of 186 patients were admitted within the threemonth period and the diagnosis was IS in 148 (79.6%) patients. We also reviewed information from 191 patients admitted with a diagnosis of acute IS or TIA in the NW in the two-year period. Identical standardized forms were used to abstract data from medical files of all patients: demographic characteristics, history of arterial hypertension, history of previous stroke or TIA, performance of thrombolysis, source of referral of patients, interval between time of symptom onset (or last time the patient was seen well) and NED admission, and performance of diagnostic procedures. Scales of stroke severity, such as the NIH Stroke Scale, were not app (...truncated)