Viviane Flumignan ZÉtola - Academia.edu (original) (raw)

Papers by Viviane Flumignan ZÉtola

Research paper thumbnail of Exclusive bed for thrombolysis. A simple measure that allows 85% of ischemic stroke patients to be treated in the first hour

Arquivos de Neuro-Psiquiatria, 2016

The door-to-needle time is an important goal to reduce the time to treatment in intravenous throm... more The door-to-needle time is an important goal to reduce the time to treatment in intravenous thrombolysis. Objective Analyze if the inclusion of an exclusive thrombolytic bed reduces the door-to-needle time. Method One hundred and fifty patients admitted for neurological evaluation with ischemic stroke were separated in two groups: in the first, patients were admitted in the Emergency Room for intravenous thrombolysis (ER Group); in the second, patients were admitted in an exclusive thrombolytic bed in the general neurology ward (TB Group). Results Sixty-eight (86.0%) patients from TB Group were treated in the first 60 minutes of arrival as compared to 48 (67.6%) in the ER Group (p = 0.011). Conclusion The introduction of a thrombolytic bed in a general hospital setting can markedly reduce the door-to-needle time, allowing more than 85% of patients to be treated within the first hour of admission.

Research paper thumbnail of Physicians are not well informed about the new guidelines for the treatment of acute stroke

Arquivos de Neuro-Psiquiatria

Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data ha... more Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data has added challenges to the treatment of ischemic stroke in the acute phase. Objective: To evaluate the knowledge of physicians about the treatment of ischemic stroke in the acute phase. Methods: An online questionnaire was submitted to all physicians enrolled in the Regional Council of Medicine in Brazil. Results: 456 physicians from different specialties answered the questions. Most of them did not know that mechanical endovascular thrombectomy is often considered as the gold standard treatment in cases of ischemic stroke in the acute phase; and 85% of them did not realize that thrombectomy together with intravenous thrombolysis was possible. The maximum time to act in an acute event also presented many divergences, even with regard to the infusion of rtPA. The lack of structure, medication and absence of a neurologist were considered the main barriers to treatment. Conclusion: Physician...

Research paper thumbnail of Intra-arterial Thrombectomy with Stent Retriever for Acute Ischemic Stroke – a Retrospective, Single-centered Study from Brazil

Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery, 2017

Objective To report our initial experience with intra-arterial thrombectomy (IAT) with stent retr... more Objective To report our initial experience with intra-arterial thrombectomy (IAT) with stent retriever for acute ischemic stroke. Methods We conducted a retrospective review of patients with acute ischemic stroke who underwent IAT from September 2010 to August 2016. Results Forty-one patients were included; mean age was 57 years (range: 29–85), and 54% were women. There were 32 anterior circulation occlusions, and 11 posterior circulation occlusions. The mean value of the National Institutes of Health Stroke Scale (NIHSS) upon admission (available in 9/41 patients) was 14 (range: 6–20). Nineteen patients had favorable outcomes (modified Rankin Scale [mRS]: 0–2 at 6 months), and 22 had unfavorable outcomes (mRS: 3–6 at 6 months). The mortality rate was 37% (15/41). Favorable outcomes were associated with revascularization within the first 360 minutes of the onset of symptoms (p = 0.000001), and satisfactory revascularization (thrombolysis in cerebral infarction [TICI] scale: 2b or 3)...

Research paper thumbnail of Efeito dos inibidores de recaptação da serotonina na plasticidade neural após Acidente Vascular Cerebral

Revista Neurociências, 2015

RESUMO Introdução. O uso de inibidores seletivos da recaptação da serotonina (ISRs) tem sido dest... more RESUMO Introdução. O uso de inibidores seletivos da recaptação da serotonina (ISRs) tem sido destacado como agentes de neuroplasticidade para recuperação motora e funcional em pacientes após acidente vascular cerebral (AVC). Objetivo. Considerando a disponibilidade desses fármacos em nosso meio, mesmo no sistema de atendimento público, objetivamos realizar revisão de literatura com intuito de melhor tomada de decisão. Método. Realizada revisão nas bases de dados até fevereiro de 2013, foram incluídos estudos que levassem em consideração as propriedades neuroprotetoras, anti-fadiga e efeito na capacidade de recuperação motora após AVC. Resultados. Dentre os estudos randomizados e controlados (RCT), observou-se melhora da recuperação motora com uso de Fluoxetina avaliada por meio da Fugl-Meyer Motor Scale após 90 dias de tratamento, melhora da independência funcional por meio da escala modificada de Rankin e Índice de Barthel com uso de Nortriptilina, maior ativação no córtex sensório-motor contralateral com uso de paroxetina e nenhum efeito positivo no controle da fadiga após AVC. Conclusão. Os estudos sugerem melhor recuperação motora e funcional com o uso dos SSRI. Não foi possível determinar diferença entre os agentes, pois os estudos disponíveis são heterogêneos em diferentes comparações, sendo que essas e outras lacunas estão sendo abordadas com estudos em andamento.

Research paper thumbnail of The use of neurovascular ultrasound versus digital subtraction angiography in acute ischemic stroke

Arquivos de neuro-psiquiatria, 2015

Cervical and intracranial arterial evaluation is an important issue for acute ischemic stroke (IS... more Cervical and intracranial arterial evaluation is an important issue for acute ischemic stroke (IS). Objective Compare the use of the neurovascular ultrasound examination (NVUE) to digital subtraction angiography (DSA) in acute IS patients for diagnosing significant extracranial and intracranial arteriopathy. Method Nonconsecutive patients with IS or transient ischemic attack admitted within 12 hours of the onset of symptoms were evaluated retrospectively. Standardized NVUE and DSA were done in all patients within the first 120 hours of hospital admission. Results Twenty-four patients were included in the study. Compared to DSA, the NVUE demonstrated 94.7% sensitivity and 100% specificity for identifying symptomatic extracranial and/or intracranial arteriopathy. Conclusion The standardized NVUE technique demonstrated high sensitivity and specificity compared to DSA for diagnosing arterial abnormalities in acute IS patients.

Research paper thumbnail of Role of TCD in sickle cell disease: A review

Perspectives in Medicine, 2012

Stroke is an important complication of sickle cell disease. Approximately twentyfour percent of p... more Stroke is an important complication of sickle cell disease. Approximately twentyfour percent of patients have a stroke by the age of 45. Blood transfusions decrease stroke risk in patients deemed at high risk by transcranial Doppler (TCD) by evidence of elevated intracranial internal carotid or middle cerebral artery velocity. This review describes the practical procedure of patient evaluation and illustrates, through Brazilian guidelines, the importance of uniform methodology in a setting with high prevalence of this disease.

Research paper thumbnail of Clinical utility of carotid and transcranial ultrasound in cerebrovascular diseases

Journal of Vascular Diagnostics, 2014

Carotid and transcranial (CTU) ultrasound is a useful tool in a number of clinical settings, part... more Carotid and transcranial (CTU) ultrasound is a useful tool in a number of clinical settings, particularly in cerebrovascular diseases. CTU is the only method that provides real-time determination of velocity and the spectral waveform of blood flow in the extracranial and basal intracranial arteries, and is effective in the detection of stenosis and occlusion. When transcranial ultrasound is considered, CTU is the only method that allows visualization of microembolic signals in the intracranial arteries. CTU makes a rapid differential diagnosis possible, improving therapeutic decision-making in acute stroke and determining the risk of recurrence and prognosis based on its findings. It is also the standard of care in children with sickle cell disease, when selecting patients for chronic blood transfusion, and for reducing the risk of ischemic stroke in these patients. CTU has some advantages, ie, relative simplicity in terms of interpretation and performance, and affordability, noninvasiveness, and portability. The main concern with ultrasound is that it is an operator-dependent tool and requires a high level of expertise and knowledge of three-dimensional cerebrovascular anatomy for correct interpretation of sonograms. The most significant limitation of intracranial evaluation by transcranial ultrasound is the absence of a suitable bone window in approximately 10% of patients. This paper gives an overview of the current utility and importance of CTU in the prevention and evaluation of ischemic cerebrovascular disease.

Research paper thumbnail of Is point-of-care accurate for indicating thrombolysis in anticoagulated patients on oral anticoagulation treatments?

Arquivos de Neuro-Psiquiatria, 2014

The use of oral anticoagulation treatment (OAT) in patients with an international normalized rati... more The use of oral anticoagulation treatment (OAT) in patients with an international normalized ratio (INR) higher than 1.7 is a contraindication to thrombolysis in acute ischemic stroke. The aim of the present study is to compare the use of point-of-care (POC) coagulometers to the standard coagulation analysis (SCA) procedure of the INR as a decision-making test for use with patients taking OAT. Method: Eighty patients on chronic OAT underwent a POC and an SCA during a regular outpatient evaluation. Results: When comparing the abilities of the POC test and the SCA test to identify adequate levels for thrombolysis (≤1.7), the POC had a sensitivity of 96.6% (95%CI 88.4-99.1) and a specificity of 60.0% (95%CI 38.6-78). POC overestimated INR levels by 0.51 points compared to the SCA test. Conclusion: POC has a high sensitivity compared to the SCA test for the identification of patients within the cut-off point for thrombolysis.

Research paper thumbnail of Warfarin as a therapeutic option in the control of chronic cluster headache: a report of three cases

The journal of headache and pain, 2005

Chronic cluster headache remains refractory to medical therapy in at least 30% of those who suffe... more Chronic cluster headache remains refractory to medical therapy in at least 30% of those who suffer from this condition. The lack of alternative medical therapies that are as effective as, or more effective than, lithium carbonate makes new therapies necessary for this highly disabling condition. Based on a previous report, we gave oral anticoagulants to three patients with chronic cluster headache. Two of them remained cluster headache-free while taking warfarin. In the third patient, the use of warfarin for three weeks initially increased the frequency and intensity of cluster headache attacks but subsequently induced a prolonged remission. In spite of the paucity of data available, oral anticoagulation appears to be a promising therapy for chronic cluster headache.

Research paper thumbnail of Intracranial embolism characteristics in PFO patients: A comparison between positive and negative PFO by transesophageal echocardiography

Journal of the Neurological Sciences, 2010

Patent foramen ovale (PFO) can be diagnosed by contrast-enhanced transcranial Doppler (cTCD), but... more Patent foramen ovale (PFO) can be diagnosed by contrast-enhanced transcranial Doppler (cTCD), but no definitive criteria exist to correlate the results obtained from cTCD with diagnoses of PFO obtained by contrast-enhanced transesophageal echocardiography (cTEE). The aim of the present study was to analyze markers in the positive RLS by cTCD that confirm the PFO by cTEE. Twenty-six stroke patients who had previously submitted to cTEE, 16 with PFO (PFO group) and 10 without PFO (no-PFO group), were evaluated for three markers based on a positive cTCD test. The number of microembolic signs (MES), the latency time (LT) to the first MES and the duration time (DT) of MES were evaluated to look for a difference between the PFO and no-PFO group. The PFO group had higher MES (80.9+/-124.5 vs. 10.2+/-25.6, p<0.001), shorter LT (12.5+/-6.6 vs. 16.2+/-5.1, p=0.02) and longer DT (21.4+/-17.4 vs. 11.7+/-12.5, p=0.013) compared with the no-PFO group. Considering only MCA tests with more than 9 MES and LT shorter than 9s, 30% of patients from the PFO group had positive tests compared with no patients from the no-PFO group. This cutoff demonstrates a specificity and positive predictive value of 100%. The rule of nine (>9 MES and LT <9s) for cTCD can be considered a marker for PFO diagnosis by cTEE.

Research paper thumbnail of Saline versus Saline with Blood as a Contrast Agent for Right-to-left Shunt Diagnosis by Transcranial Doppler: Is There a Significant Difference?

Journal of Neuroimaging, 2010

Research paper thumbnail of Neurofibromatosis, stroke and basilar impression: case report

Arquivos de Neuro-Psiquiatria, 1999

Neurofibromatosis type 1 (NF1) can virtually affect any organ, presenting most frequently with &q... more Neurofibromatosis type 1 (NF1) can virtually affect any organ, presenting most frequently with "cafe au lait" spots and neurofibromas. Vasculopathy is a known complication of NF1, but cerebrovascular disease is rare. We report the case of a 51-year-old man admitted to the hospital with a history of stroke four months before admission. On physical examination, he presented various "cafe au lait" spots and cutaneous neurofibromas. Neurologic examination demonstrated right-sided facial paralysis, right-sided hemiplegia, and aphasia. Computed tomography scan of head showed hypodense areas in the basal ganglia and centrum semiovale. Radiographs of cranium and cervical spine showed basilar impression. Angiography revealed complete occlusion of both vertebral and left internal carotid arteries, and partial stenosis of the right internal carotid artery. A large network of collateral vessels was present (moyamoya syndrome). It is an uncommon case of occlusive cerebrovascu...

Research paper thumbnail of Acidente vascular cerebral em pacientes jovens: análise de 164 casos

Arquivos de Neuro-Psiquiatria, 2001

Realizamos análise epidemiológica de 164 pacientes com AVC, cujo primeiro episódio ocorreu entre ... more Realizamos análise epidemiológica de 164 pacientes com AVC, cujo primeiro episódio ocorreu entre 15 e 49 anos de idade através de um estudo retrospectivo de pacientes ambulatoriais. O principal tipo de apresentação foi AVC isquêmico (AVCI) em 141 pacientes, ocorrendo AVC hemorrágico (AVCH) em16 casos e 7 pacientes com trombose venosa. A presença de fatores de risco aterotrombóticos foi prevalente, em 48,22% dos pacientes com AVCI sendo que a hipertensão arterial sistêmica (HAS), nos casos de AVCH, foi a etiologia mais frequente. Em 32% dos casos não se pode determinar a sua causa. Embora a população jovem possua determinantes diferentes e geralmente deva ter uma investigação etiológica mais abrangente, no grupo estudado foram prevalentes os fatores de risco conhecidos e potencialmente controláveis, sugerindo que campanhas de prevenção e detecção precoce devam ser incentivados.

Research paper thumbnail of Transcranial Doppler for patent foramen ovale screening: is there a good correlation with transesophageal echocardiography?

Arquivos de Neuro-Psiquiatria, 2008

Right-to-left shunt (RLS) can be identified by contrast-enhanced transcranial Doppler (cTCD) in p... more Right-to-left shunt (RLS) can be identified by contrast-enhanced transcranial Doppler (cTCD) in patent foramen ovale (PFO) patients. AIM: To evaluate cTCD for PFO screening comparing it to cTEE. METHOD: 45 previous cTCD performed for PFO diagnosis and correlated its findings with cTEE. Patients were submitted to a cTCD standardized technique and were divided in two groups according to RLS: Group 1, patients with a positive RLS and Group 2 when RLS was negative. RESULTS: 29 (65%) patients were included in group 1 and 16 (35%) in group 2. PFO confirmation by cTEE was performed in 28 (62%) patients. cTCD had a 92.85% sensitivity, 82.35% specificity, 89.65% positive predictive value and 87.5% negative predictive value when compared to cTEE for PFO diagnosis. CONCLUSION: Standardized technique cTCD allows for RLS visualization in PFO patients with a good correlation with cTEE and can be used as a screening test before cTEE.

Research paper thumbnail of Cerebrotendinous xanthomatosis: report of two Brazilian brothers

Arquivos de Neuro-Psiquiatria, 2004

Cerebrotendinous xanthomatosis is a treatable rare autossomal recessive disease characterized by ... more Cerebrotendinous xanthomatosis is a treatable rare autossomal recessive disease characterized by lipid storage secondary to a sterol 27-hydroxylase deficiency in the formation of cholic and chenodeoxycholic acids. We describe two Brazilian brothers with cognitive impairement and chronic diarrhea. One of them also presents bilateral cataracts. Neurological findings were progressive walking deficit, limb ataxia and pyramidal signs. Both patients had bilateral Achilles tendon xanthomata. Magnetic resonance image showed signal alterations in cerebellar hemispheres. We describe these cases with molecular genetic analysis confirming diagnosis and comparing with previous literature. The CYP27A1 gene study showed a C1187T mutation on exon 6.

Research paper thumbnail of Doppler transcraniano na prática neurológica

Arquivos de Neuro-Psiquiatria, 2006

O Doppler transcraniano (DTC) é um método relativamente novo, descrito em 1982 por Rune Aaslid e ... more O Doppler transcraniano (DTC) é um método relativamente novo, descrito em 1982 por Rune Aaslid e introduzido no Brasil em 1992 por Roberto Hirsch, na Universidade de São Paulo. O serviço de Neurologia do Hospital de Clínicas da Universidade Federal do Paraná (HC-UFPR) disponibilizou esse exame em 2001, com divulgação das principais vantagens do método no diagnóstico, seguimento e manejo terapêutico de pacientes com suspeita ou portadores de doença cerebrovascular. O objetivo deste trabalho é demonstrar como o DTC vem sendo utilizado em nosso meio e quais são as especialidades médicas que vêm absorvendo o auxílio do método. Embora diretrizes como a publicada pela Academia Americana de Neurologia em 2004 validem as indicações do DTC, estabelecendo especificidade e sensibilidade do método, verificamos que a solicitação do exame em nosso meio depende da divulgação do serviço, da implementação de linhas de pesquisa e, finalmente, do reconhecimento de sua utilidade na prática diária.

Research paper thumbnail of Rigid spine syndrome: case report

Arquivos de Neuro-Psiquiatria, 1998

We describe a patient who had difficulty in walking since toddling stage and presented proximal u... more We describe a patient who had difficulty in walking since toddling stage and presented proximal upper and lower member weakness which have evolved to a progressive limitation of neck and trunk flexure, compatible with rigid spine syndrome. The serum muscle enzymes were somewhat elevated and the electromyography showed a myopatic change. The muscle biopsy demonstrated an active and chronic myopathy. The DNA analysis through PCR did not display any abnormality for dystrophin gene. The dystrophin by immnofluorescence was present in all fibers, but some interruptions were found in the plasma membrane giving it the appearance of a rosary. The test for merosin was normal.

Research paper thumbnail of Incidência de cefaléia em uma comunidade hospitalar

Arquivos de Neuro-Psiquiatria, 1998

O objetivo foi determinar em um grupo de pessoas de uma comunidade hospitalar a incidência de cef... more O objetivo foi determinar em um grupo de pessoas de uma comunidade hospitalar a incidência de cefaléia e para esta a frequência, principais características e investigações médicas mais solicitadas. Utilizamos a combinação de questionário e entrevista. Do total de 1006 fichas aleatoriamente preenchidas, 987 pessoas responderam corretamente aos quesitos e destas 380 (38,5%) eram portadoras de cefaléia. Baseados na Classificação Internacional de Cefaléia dividimos os portadores em dois principais grupos, a migrânea e a cefaléia do tipo tensional. As demais foram agrupadas num terceiro grupo. A idade média foi 31,18 anos, com predomínio do sexo feminino em todos os tipos de cefaléia. A presença de história familiar foi positiva em 76,8% dos entrevistados. As características mais frequentes foram: localização frontal, tipo pulsátil e intensidade moderada. O principal fator desencadeante foi o estresse. A procura de acompanhamento médico deu-se em 41,3% dos portadores. Destes, aproximadam...

Research paper thumbnail of Investigação de neuropatia periférica durante o período recente do transplante de medula óssea

Arquivos de Neuro-Psiquiatria, 1998

Investigamos prospectivamente a incidência de neuropatia periférica em 43 pacientes através do es... more Investigamos prospectivamente a incidência de neuropatia periférica em 43 pacientes através do estudo da velocidade de condução nervosa e do teste de limiar de sensibilidade vibratória (palestesiômetro) realizados antes e após o transplante de medula óssea. Nesse período as principais drogas utilizadas para o condicionamento e imunossupressão foram o bussulfan, ciclofosfamida, ciclosporina A, methotrexate e corticoesteróides. Foram estudadas as velocidades de condução nervosa nos nervos mediano motor, fibular, tibial, mediano sensitivo e sural. Obtivemos alterações estatisticamente significativas na duração do potencial composto proximal do nervo mediano motor, na amplitude distal do nervo tibial posterior e na amplitude proximal do nervo sural. As diferenças observadas não se correlacionaram com alterações clínicas, e não foram suficientes para o diagnóstico de neuropatia periférica. Acreditamos que o esquema terapêutico utilizado não provoca toxicidade neurológica periférica no pe...

Research paper thumbnail of Curitiba acute ischemic stroke protocol: a university hospital and EMS initiative in a large Brazilian city

Arquivos de Neuro-Psiquiatria, 2011

Few healthcare centers in Brazil perform thrombolytic therapy for acute ischemic stroke (AIS) pat... more Few healthcare centers in Brazil perform thrombolytic therapy for acute ischemic stroke (AIS) patients. OBJECTIVE: The aim of this study was to describe an interinstitutional protocol for the rapid identification and thrombolytic treatment of AIS patients at a public health hospital in a large Brazilian city. METHOD: Emergency medical services (EMS) personnel evaluated 433 patients with possible stroke during a six-month period. After a standard checklist, patients with suspected AIS and symptoms onset of less than two hours were evaluated at our University Hospital (UH). RESULTS: Sixty-five (15%) patients met the checklist criteria and had a symptom onset of less than two hours, but only 50 (11%) patients were evaluated at the UH. Among them, 35 (70%) patients had ischemic stroke, 10 (20%) had hemorrhagic stroke, and 5 (10%) had other diagnoses. Of the 35 ischemic stroke patients, 15 (43%) underwent IV thrombolysis. CONCLUSION: The present study demonstrated that trained EMS worker...

Research paper thumbnail of Exclusive bed for thrombolysis. A simple measure that allows 85% of ischemic stroke patients to be treated in the first hour

Arquivos de Neuro-Psiquiatria, 2016

The door-to-needle time is an important goal to reduce the time to treatment in intravenous throm... more The door-to-needle time is an important goal to reduce the time to treatment in intravenous thrombolysis. Objective Analyze if the inclusion of an exclusive thrombolytic bed reduces the door-to-needle time. Method One hundred and fifty patients admitted for neurological evaluation with ischemic stroke were separated in two groups: in the first, patients were admitted in the Emergency Room for intravenous thrombolysis (ER Group); in the second, patients were admitted in an exclusive thrombolytic bed in the general neurology ward (TB Group). Results Sixty-eight (86.0%) patients from TB Group were treated in the first 60 minutes of arrival as compared to 48 (67.6%) in the ER Group (p = 0.011). Conclusion The introduction of a thrombolytic bed in a general hospital setting can markedly reduce the door-to-needle time, allowing more than 85% of patients to be treated within the first hour of admission.

Research paper thumbnail of Physicians are not well informed about the new guidelines for the treatment of acute stroke

Arquivos de Neuro-Psiquiatria

Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data ha... more Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data has added challenges to the treatment of ischemic stroke in the acute phase. Objective: To evaluate the knowledge of physicians about the treatment of ischemic stroke in the acute phase. Methods: An online questionnaire was submitted to all physicians enrolled in the Regional Council of Medicine in Brazil. Results: 456 physicians from different specialties answered the questions. Most of them did not know that mechanical endovascular thrombectomy is often considered as the gold standard treatment in cases of ischemic stroke in the acute phase; and 85% of them did not realize that thrombectomy together with intravenous thrombolysis was possible. The maximum time to act in an acute event also presented many divergences, even with regard to the infusion of rtPA. The lack of structure, medication and absence of a neurologist were considered the main barriers to treatment. Conclusion: Physician...

Research paper thumbnail of Intra-arterial Thrombectomy with Stent Retriever for Acute Ischemic Stroke – a Retrospective, Single-centered Study from Brazil

Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery, 2017

Objective To report our initial experience with intra-arterial thrombectomy (IAT) with stent retr... more Objective To report our initial experience with intra-arterial thrombectomy (IAT) with stent retriever for acute ischemic stroke. Methods We conducted a retrospective review of patients with acute ischemic stroke who underwent IAT from September 2010 to August 2016. Results Forty-one patients were included; mean age was 57 years (range: 29–85), and 54% were women. There were 32 anterior circulation occlusions, and 11 posterior circulation occlusions. The mean value of the National Institutes of Health Stroke Scale (NIHSS) upon admission (available in 9/41 patients) was 14 (range: 6–20). Nineteen patients had favorable outcomes (modified Rankin Scale [mRS]: 0–2 at 6 months), and 22 had unfavorable outcomes (mRS: 3–6 at 6 months). The mortality rate was 37% (15/41). Favorable outcomes were associated with revascularization within the first 360 minutes of the onset of symptoms (p = 0.000001), and satisfactory revascularization (thrombolysis in cerebral infarction [TICI] scale: 2b or 3)...

Research paper thumbnail of Efeito dos inibidores de recaptação da serotonina na plasticidade neural após Acidente Vascular Cerebral

Revista Neurociências, 2015

RESUMO Introdução. O uso de inibidores seletivos da recaptação da serotonina (ISRs) tem sido dest... more RESUMO Introdução. O uso de inibidores seletivos da recaptação da serotonina (ISRs) tem sido destacado como agentes de neuroplasticidade para recuperação motora e funcional em pacientes após acidente vascular cerebral (AVC). Objetivo. Considerando a disponibilidade desses fármacos em nosso meio, mesmo no sistema de atendimento público, objetivamos realizar revisão de literatura com intuito de melhor tomada de decisão. Método. Realizada revisão nas bases de dados até fevereiro de 2013, foram incluídos estudos que levassem em consideração as propriedades neuroprotetoras, anti-fadiga e efeito na capacidade de recuperação motora após AVC. Resultados. Dentre os estudos randomizados e controlados (RCT), observou-se melhora da recuperação motora com uso de Fluoxetina avaliada por meio da Fugl-Meyer Motor Scale após 90 dias de tratamento, melhora da independência funcional por meio da escala modificada de Rankin e Índice de Barthel com uso de Nortriptilina, maior ativação no córtex sensório-motor contralateral com uso de paroxetina e nenhum efeito positivo no controle da fadiga após AVC. Conclusão. Os estudos sugerem melhor recuperação motora e funcional com o uso dos SSRI. Não foi possível determinar diferença entre os agentes, pois os estudos disponíveis são heterogêneos em diferentes comparações, sendo que essas e outras lacunas estão sendo abordadas com estudos em andamento.

Research paper thumbnail of The use of neurovascular ultrasound versus digital subtraction angiography in acute ischemic stroke

Arquivos de neuro-psiquiatria, 2015

Cervical and intracranial arterial evaluation is an important issue for acute ischemic stroke (IS... more Cervical and intracranial arterial evaluation is an important issue for acute ischemic stroke (IS). Objective Compare the use of the neurovascular ultrasound examination (NVUE) to digital subtraction angiography (DSA) in acute IS patients for diagnosing significant extracranial and intracranial arteriopathy. Method Nonconsecutive patients with IS or transient ischemic attack admitted within 12 hours of the onset of symptoms were evaluated retrospectively. Standardized NVUE and DSA were done in all patients within the first 120 hours of hospital admission. Results Twenty-four patients were included in the study. Compared to DSA, the NVUE demonstrated 94.7% sensitivity and 100% specificity for identifying symptomatic extracranial and/or intracranial arteriopathy. Conclusion The standardized NVUE technique demonstrated high sensitivity and specificity compared to DSA for diagnosing arterial abnormalities in acute IS patients.

Research paper thumbnail of Role of TCD in sickle cell disease: A review

Perspectives in Medicine, 2012

Stroke is an important complication of sickle cell disease. Approximately twentyfour percent of p... more Stroke is an important complication of sickle cell disease. Approximately twentyfour percent of patients have a stroke by the age of 45. Blood transfusions decrease stroke risk in patients deemed at high risk by transcranial Doppler (TCD) by evidence of elevated intracranial internal carotid or middle cerebral artery velocity. This review describes the practical procedure of patient evaluation and illustrates, through Brazilian guidelines, the importance of uniform methodology in a setting with high prevalence of this disease.

Research paper thumbnail of Clinical utility of carotid and transcranial ultrasound in cerebrovascular diseases

Journal of Vascular Diagnostics, 2014

Carotid and transcranial (CTU) ultrasound is a useful tool in a number of clinical settings, part... more Carotid and transcranial (CTU) ultrasound is a useful tool in a number of clinical settings, particularly in cerebrovascular diseases. CTU is the only method that provides real-time determination of velocity and the spectral waveform of blood flow in the extracranial and basal intracranial arteries, and is effective in the detection of stenosis and occlusion. When transcranial ultrasound is considered, CTU is the only method that allows visualization of microembolic signals in the intracranial arteries. CTU makes a rapid differential diagnosis possible, improving therapeutic decision-making in acute stroke and determining the risk of recurrence and prognosis based on its findings. It is also the standard of care in children with sickle cell disease, when selecting patients for chronic blood transfusion, and for reducing the risk of ischemic stroke in these patients. CTU has some advantages, ie, relative simplicity in terms of interpretation and performance, and affordability, noninvasiveness, and portability. The main concern with ultrasound is that it is an operator-dependent tool and requires a high level of expertise and knowledge of three-dimensional cerebrovascular anatomy for correct interpretation of sonograms. The most significant limitation of intracranial evaluation by transcranial ultrasound is the absence of a suitable bone window in approximately 10% of patients. This paper gives an overview of the current utility and importance of CTU in the prevention and evaluation of ischemic cerebrovascular disease.

Research paper thumbnail of Is point-of-care accurate for indicating thrombolysis in anticoagulated patients on oral anticoagulation treatments?

Arquivos de Neuro-Psiquiatria, 2014

The use of oral anticoagulation treatment (OAT) in patients with an international normalized rati... more The use of oral anticoagulation treatment (OAT) in patients with an international normalized ratio (INR) higher than 1.7 is a contraindication to thrombolysis in acute ischemic stroke. The aim of the present study is to compare the use of point-of-care (POC) coagulometers to the standard coagulation analysis (SCA) procedure of the INR as a decision-making test for use with patients taking OAT. Method: Eighty patients on chronic OAT underwent a POC and an SCA during a regular outpatient evaluation. Results: When comparing the abilities of the POC test and the SCA test to identify adequate levels for thrombolysis (≤1.7), the POC had a sensitivity of 96.6% (95%CI 88.4-99.1) and a specificity of 60.0% (95%CI 38.6-78). POC overestimated INR levels by 0.51 points compared to the SCA test. Conclusion: POC has a high sensitivity compared to the SCA test for the identification of patients within the cut-off point for thrombolysis.

Research paper thumbnail of Warfarin as a therapeutic option in the control of chronic cluster headache: a report of three cases

The journal of headache and pain, 2005

Chronic cluster headache remains refractory to medical therapy in at least 30% of those who suffe... more Chronic cluster headache remains refractory to medical therapy in at least 30% of those who suffer from this condition. The lack of alternative medical therapies that are as effective as, or more effective than, lithium carbonate makes new therapies necessary for this highly disabling condition. Based on a previous report, we gave oral anticoagulants to three patients with chronic cluster headache. Two of them remained cluster headache-free while taking warfarin. In the third patient, the use of warfarin for three weeks initially increased the frequency and intensity of cluster headache attacks but subsequently induced a prolonged remission. In spite of the paucity of data available, oral anticoagulation appears to be a promising therapy for chronic cluster headache.

Research paper thumbnail of Intracranial embolism characteristics in PFO patients: A comparison between positive and negative PFO by transesophageal echocardiography

Journal of the Neurological Sciences, 2010

Patent foramen ovale (PFO) can be diagnosed by contrast-enhanced transcranial Doppler (cTCD), but... more Patent foramen ovale (PFO) can be diagnosed by contrast-enhanced transcranial Doppler (cTCD), but no definitive criteria exist to correlate the results obtained from cTCD with diagnoses of PFO obtained by contrast-enhanced transesophageal echocardiography (cTEE). The aim of the present study was to analyze markers in the positive RLS by cTCD that confirm the PFO by cTEE. Twenty-six stroke patients who had previously submitted to cTEE, 16 with PFO (PFO group) and 10 without PFO (no-PFO group), were evaluated for three markers based on a positive cTCD test. The number of microembolic signs (MES), the latency time (LT) to the first MES and the duration time (DT) of MES were evaluated to look for a difference between the PFO and no-PFO group. The PFO group had higher MES (80.9+/-124.5 vs. 10.2+/-25.6, p<0.001), shorter LT (12.5+/-6.6 vs. 16.2+/-5.1, p=0.02) and longer DT (21.4+/-17.4 vs. 11.7+/-12.5, p=0.013) compared with the no-PFO group. Considering only MCA tests with more than 9 MES and LT shorter than 9s, 30% of patients from the PFO group had positive tests compared with no patients from the no-PFO group. This cutoff demonstrates a specificity and positive predictive value of 100%. The rule of nine (>9 MES and LT <9s) for cTCD can be considered a marker for PFO diagnosis by cTEE.

Research paper thumbnail of Saline versus Saline with Blood as a Contrast Agent for Right-to-left Shunt Diagnosis by Transcranial Doppler: Is There a Significant Difference?

Journal of Neuroimaging, 2010

Research paper thumbnail of Neurofibromatosis, stroke and basilar impression: case report

Arquivos de Neuro-Psiquiatria, 1999

Neurofibromatosis type 1 (NF1) can virtually affect any organ, presenting most frequently with &q... more Neurofibromatosis type 1 (NF1) can virtually affect any organ, presenting most frequently with "cafe au lait" spots and neurofibromas. Vasculopathy is a known complication of NF1, but cerebrovascular disease is rare. We report the case of a 51-year-old man admitted to the hospital with a history of stroke four months before admission. On physical examination, he presented various "cafe au lait" spots and cutaneous neurofibromas. Neurologic examination demonstrated right-sided facial paralysis, right-sided hemiplegia, and aphasia. Computed tomography scan of head showed hypodense areas in the basal ganglia and centrum semiovale. Radiographs of cranium and cervical spine showed basilar impression. Angiography revealed complete occlusion of both vertebral and left internal carotid arteries, and partial stenosis of the right internal carotid artery. A large network of collateral vessels was present (moyamoya syndrome). It is an uncommon case of occlusive cerebrovascu...

Research paper thumbnail of Acidente vascular cerebral em pacientes jovens: análise de 164 casos

Arquivos de Neuro-Psiquiatria, 2001

Realizamos análise epidemiológica de 164 pacientes com AVC, cujo primeiro episódio ocorreu entre ... more Realizamos análise epidemiológica de 164 pacientes com AVC, cujo primeiro episódio ocorreu entre 15 e 49 anos de idade através de um estudo retrospectivo de pacientes ambulatoriais. O principal tipo de apresentação foi AVC isquêmico (AVCI) em 141 pacientes, ocorrendo AVC hemorrágico (AVCH) em16 casos e 7 pacientes com trombose venosa. A presença de fatores de risco aterotrombóticos foi prevalente, em 48,22% dos pacientes com AVCI sendo que a hipertensão arterial sistêmica (HAS), nos casos de AVCH, foi a etiologia mais frequente. Em 32% dos casos não se pode determinar a sua causa. Embora a população jovem possua determinantes diferentes e geralmente deva ter uma investigação etiológica mais abrangente, no grupo estudado foram prevalentes os fatores de risco conhecidos e potencialmente controláveis, sugerindo que campanhas de prevenção e detecção precoce devam ser incentivados.

Research paper thumbnail of Transcranial Doppler for patent foramen ovale screening: is there a good correlation with transesophageal echocardiography?

Arquivos de Neuro-Psiquiatria, 2008

Right-to-left shunt (RLS) can be identified by contrast-enhanced transcranial Doppler (cTCD) in p... more Right-to-left shunt (RLS) can be identified by contrast-enhanced transcranial Doppler (cTCD) in patent foramen ovale (PFO) patients. AIM: To evaluate cTCD for PFO screening comparing it to cTEE. METHOD: 45 previous cTCD performed for PFO diagnosis and correlated its findings with cTEE. Patients were submitted to a cTCD standardized technique and were divided in two groups according to RLS: Group 1, patients with a positive RLS and Group 2 when RLS was negative. RESULTS: 29 (65%) patients were included in group 1 and 16 (35%) in group 2. PFO confirmation by cTEE was performed in 28 (62%) patients. cTCD had a 92.85% sensitivity, 82.35% specificity, 89.65% positive predictive value and 87.5% negative predictive value when compared to cTEE for PFO diagnosis. CONCLUSION: Standardized technique cTCD allows for RLS visualization in PFO patients with a good correlation with cTEE and can be used as a screening test before cTEE.

Research paper thumbnail of Cerebrotendinous xanthomatosis: report of two Brazilian brothers

Arquivos de Neuro-Psiquiatria, 2004

Cerebrotendinous xanthomatosis is a treatable rare autossomal recessive disease characterized by ... more Cerebrotendinous xanthomatosis is a treatable rare autossomal recessive disease characterized by lipid storage secondary to a sterol 27-hydroxylase deficiency in the formation of cholic and chenodeoxycholic acids. We describe two Brazilian brothers with cognitive impairement and chronic diarrhea. One of them also presents bilateral cataracts. Neurological findings were progressive walking deficit, limb ataxia and pyramidal signs. Both patients had bilateral Achilles tendon xanthomata. Magnetic resonance image showed signal alterations in cerebellar hemispheres. We describe these cases with molecular genetic analysis confirming diagnosis and comparing with previous literature. The CYP27A1 gene study showed a C1187T mutation on exon 6.

Research paper thumbnail of Doppler transcraniano na prática neurológica

Arquivos de Neuro-Psiquiatria, 2006

O Doppler transcraniano (DTC) é um método relativamente novo, descrito em 1982 por Rune Aaslid e ... more O Doppler transcraniano (DTC) é um método relativamente novo, descrito em 1982 por Rune Aaslid e introduzido no Brasil em 1992 por Roberto Hirsch, na Universidade de São Paulo. O serviço de Neurologia do Hospital de Clínicas da Universidade Federal do Paraná (HC-UFPR) disponibilizou esse exame em 2001, com divulgação das principais vantagens do método no diagnóstico, seguimento e manejo terapêutico de pacientes com suspeita ou portadores de doença cerebrovascular. O objetivo deste trabalho é demonstrar como o DTC vem sendo utilizado em nosso meio e quais são as especialidades médicas que vêm absorvendo o auxílio do método. Embora diretrizes como a publicada pela Academia Americana de Neurologia em 2004 validem as indicações do DTC, estabelecendo especificidade e sensibilidade do método, verificamos que a solicitação do exame em nosso meio depende da divulgação do serviço, da implementação de linhas de pesquisa e, finalmente, do reconhecimento de sua utilidade na prática diária.

Research paper thumbnail of Rigid spine syndrome: case report

Arquivos de Neuro-Psiquiatria, 1998

We describe a patient who had difficulty in walking since toddling stage and presented proximal u... more We describe a patient who had difficulty in walking since toddling stage and presented proximal upper and lower member weakness which have evolved to a progressive limitation of neck and trunk flexure, compatible with rigid spine syndrome. The serum muscle enzymes were somewhat elevated and the electromyography showed a myopatic change. The muscle biopsy demonstrated an active and chronic myopathy. The DNA analysis through PCR did not display any abnormality for dystrophin gene. The dystrophin by immnofluorescence was present in all fibers, but some interruptions were found in the plasma membrane giving it the appearance of a rosary. The test for merosin was normal.

Research paper thumbnail of Incidência de cefaléia em uma comunidade hospitalar

Arquivos de Neuro-Psiquiatria, 1998

O objetivo foi determinar em um grupo de pessoas de uma comunidade hospitalar a incidência de cef... more O objetivo foi determinar em um grupo de pessoas de uma comunidade hospitalar a incidência de cefaléia e para esta a frequência, principais características e investigações médicas mais solicitadas. Utilizamos a combinação de questionário e entrevista. Do total de 1006 fichas aleatoriamente preenchidas, 987 pessoas responderam corretamente aos quesitos e destas 380 (38,5%) eram portadoras de cefaléia. Baseados na Classificação Internacional de Cefaléia dividimos os portadores em dois principais grupos, a migrânea e a cefaléia do tipo tensional. As demais foram agrupadas num terceiro grupo. A idade média foi 31,18 anos, com predomínio do sexo feminino em todos os tipos de cefaléia. A presença de história familiar foi positiva em 76,8% dos entrevistados. As características mais frequentes foram: localização frontal, tipo pulsátil e intensidade moderada. O principal fator desencadeante foi o estresse. A procura de acompanhamento médico deu-se em 41,3% dos portadores. Destes, aproximadam...

Research paper thumbnail of Investigação de neuropatia periférica durante o período recente do transplante de medula óssea

Arquivos de Neuro-Psiquiatria, 1998

Investigamos prospectivamente a incidência de neuropatia periférica em 43 pacientes através do es... more Investigamos prospectivamente a incidência de neuropatia periférica em 43 pacientes através do estudo da velocidade de condução nervosa e do teste de limiar de sensibilidade vibratória (palestesiômetro) realizados antes e após o transplante de medula óssea. Nesse período as principais drogas utilizadas para o condicionamento e imunossupressão foram o bussulfan, ciclofosfamida, ciclosporina A, methotrexate e corticoesteróides. Foram estudadas as velocidades de condução nervosa nos nervos mediano motor, fibular, tibial, mediano sensitivo e sural. Obtivemos alterações estatisticamente significativas na duração do potencial composto proximal do nervo mediano motor, na amplitude distal do nervo tibial posterior e na amplitude proximal do nervo sural. As diferenças observadas não se correlacionaram com alterações clínicas, e não foram suficientes para o diagnóstico de neuropatia periférica. Acreditamos que o esquema terapêutico utilizado não provoca toxicidade neurológica periférica no pe...

Research paper thumbnail of Curitiba acute ischemic stroke protocol: a university hospital and EMS initiative in a large Brazilian city

Arquivos de Neuro-Psiquiatria, 2011

Few healthcare centers in Brazil perform thrombolytic therapy for acute ischemic stroke (AIS) pat... more Few healthcare centers in Brazil perform thrombolytic therapy for acute ischemic stroke (AIS) patients. OBJECTIVE: The aim of this study was to describe an interinstitutional protocol for the rapid identification and thrombolytic treatment of AIS patients at a public health hospital in a large Brazilian city. METHOD: Emergency medical services (EMS) personnel evaluated 433 patients with possible stroke during a six-month period. After a standard checklist, patients with suspected AIS and symptoms onset of less than two hours were evaluated at our University Hospital (UH). RESULTS: Sixty-five (15%) patients met the checklist criteria and had a symptom onset of less than two hours, but only 50 (11%) patients were evaluated at the UH. Among them, 35 (70%) patients had ischemic stroke, 10 (20%) had hemorrhagic stroke, and 5 (10%) had other diagnoses. Of the 35 ischemic stroke patients, 15 (43%) underwent IV thrombolysis. CONCLUSION: The present study demonstrated that trained EMS worker...