Browsing by Author "Hoppe, Arnold"
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Item Accuracy of diffusion-weighted imaging in the diagnosis of stroke in patients with suspected cerebral infarct(American Heart Association, 2013) Brunser, Alejandro; Hoppe, Arnold; Illanes, Sergio; Díaz, Violeta; Muñoz, Paula; Cárcamo, Daniel; Olavarría, Verónica; Valenzuela, Marcela; Lavados, PabloBACKGROUND AND PURPOSE: The accuracy of diffusion-weighted imaging (DWI) for the diagnosis of acute cerebral ischemia among patients with suspected ischemic stroke arriving to an emergency room has not been studied in depth. METHODS: DWI was performed in 712 patients with acute or subacute focal symptoms that suggested an acute ischemic stroke (AIS), 609 of them with AIS. RESULTS: DWI demonstrated a sensitivity of 90% and specificity of 97%, a positive likelihood ratio of 31 and a negative likelihood ratio of 0.1 for detecting AIS. The overall accuracy was 95%. Of those patients who demonstrated abnormal DWI studies, 99.5% were AIS patients, and of those patients with normal DWI studies 63% were stroke mimics. CONCLUSIONS: DWI is accurate in detecting AIS in unselected patients with suspected AIS; a negative study should alert for nonischemic conditions.Item Accuracy of Power Mode TranscranialDoppler in the Diagnosis of Brain Death(2015) Brunser, Alejandro; Lavados, Pablo; Cárcamo, Daniel; Hoppe, Arnold; Olavarría, Verónica; López, Javiera; Muñoz, Paula; Rivas, RodrigoBackground:The diagnosis of brain death (BD) is complex. For this reason, we aimed toevaluate the accuracy of power mode transcranial Doppler (PMD-TCD) in diagnosing BD.Patients and methods:Patients admitted to an intensive care unit between December 2003and January 2012 were included in this study if they were in a structural coma, had nocraniectomy, and were evaluated blind by a neurologist using PMD-TCD. The diagnosis of BDwas based on an evaluation that took into consideration the absence of sedative drugs, amedian blood pressure>60 mmHg, a body temperature>35 C, and the absence of brainstemreflexes. A neurosonologist followed a protocol using PMD-TCD that considered the examina-tion as positive for brain circulatory arrest given the presence of reverberating, small systolicpeaks or the disappearance of a previous signal present in both middle cerebral arteries andintracranial vertebral arteries.Results:A total of 74 patients were evaluated. In 61 (82.4%) patients the interval betweenboth evaluations was less than 1 hour. The sensitivity and specificity for the diagnosis of BD with PMD-TCD were 100% and 98%, respectively. The positive and negative likelihood ratios forBD were 45 and 0, respectively.Conclusion:PMD-TCD is accurate for the diagnosis of BD.Item Additional Information Given to a Multimodal Imaging Stroke Protocol by Transcranial Doppler Ultrasound in the Emergency Room: A Prospective Observational Study(2010) Brunser, Alejandro M.; Lavados, Pablo; Cárcamo, Daniel A.; Hoppe, Arnold; Olavarría, Verónica; Diaz, Violeta; Rivas, RodrigoBackground: Transcranial Doppler (TCD) ultrasound can demonstrate dynamic information. We aimed to evaluate whether TCD generates useful additional information in the emergency room after a multimodal stroke imaging protocol and also whether this modified the management of patients with cerebral infarction. Methods: Patients admitted between April 2006 and June 2007 with ischemic stroke of less than 24 h were subjected to a protocol consisting of non-contrast brain CT, computed tomography angiography, diffusion-weighted magnetic resonance imaging and then TCD within the following 6 h by an observer blinded to the results of imaging studies. Results: Seventy-nine patients were included. The imaging protocol was performed 457 (+/-346) min after stroke symptoms and TCD after 572 (+/-376) min. TCD provided additional information in 28 cases (35.4%, 95% CI 25.7-46.4). More that one piece of additional information was obtained in 6 patients. The most frequent additional information was collateral pathways. Multivariate analysis demonstrated that intracranial vessel occlusion was the variable most associated with additional information. In 7 patients (8.8%, 95% CI 4.3-17.1), additional information changed management: in 4 an additional angiography was performed, in 2 patients angiography was suspended and in 1 aggressive neurocritical care was indicated. Patients with NIHSS >10 were significantly more likely to have their initial treatment changed (p = 0.004). Conclusions: TCD can provide additional information to a multimodal acute ischemic stroke imaging protocol in a third of patients. This can result in changes in the management in some of these patients.Item Determinantes del tiempo puerta-aguja en trombolisis endovenosa en el infarto cerebral, experiencia de un centro(2020) Brunser, Alejandro; Mazzon, Enrico; Muñoz, Paula; Hoppe, Arnold; Lavados, Pablo; Rojo, Alexis; Navia, Víctor; Cavada, Gabriel; Olavarría, Verónica; Mansilla, EloyBackground: Intravenous thrombolysis (IT) in acute ischemic stroke (AIS) is time dependent. The time elapsed from hospital admission to the thrombolytic bolus is named door to needle time (DNT) and is recommend to be of less than 60 min. Aim: To describe the DNT in our center and determine those factors associated with a DNT longer than 60 min. Material and Methods: Prospective analysis of patients treated with IT at a private hospital between June 2016 and June 2019. The percentage of patients with DNT exceeding 60 min, and the causes for this delay were evaluated. Results: IT was used in 205 patients. DNT was 43.6 ± 23.8 min. Forty patients (19.5% (95% CI, 14.4-25.7), had a DNT longer than 60 min. Uni-varied analysis demonstrated that AIS with infratentorial symptomatology (ITS), was significantly associated with DNTs exceeding 60 min. A history of hypertension, a higher NIH Stroke Scale score, the presence of an hyperdense sign in brain tomography (p = 0.001) and the need for endovascular therapy (p = 0.019), were associated with DNT shorter than 60 min. Multivariate analysis ratified the relationship between ITS and DNT longer than 60 min (Odds ratio: 3.19, 95% confidence intervals 1.26-8). Conclusions: The individual elements that correlated with a DNT longer than 60 min were the failure to detect the AIS during triage and doubts about its diagnosisPublication Developing clinical decision making in stroke through virtual online simulation: automated asynchronous or instructor-led synchronous feedback? A randomized controlled trial(2023) Fuentes, Valentina; Palominos, Javier; Pettersen, María; Caro, Patricio; Navia, Víctor; Hoppe, Arnold; Armijo, Soledad; Machuca, FelipeAim: to determine whether asynchronous virtual simulation with automatic feedback enhances learning about clinical decision-making in stroke compared with synchronous simulation with instructor-guided feedback in 4th-year medical students. We hypothesize that instructor-guided feedback drives better learning than automatic feedback. Methodology: a quantitative randomized controlled parallel study was designed using the CONSORT extension to simulation studies. Twenty 4th year undergraduate medical students were divided into two groups. One group performed virtual simulations with instructor-guided feedback, and the other worked autonomously with automatic feedback. We administered a knowledge score test survey before and after applying the intervention bundle and a usefulness perception survey. Two-way repeated measures analysis of variance (ANOVA) was used to compare changes in performance. Results: the results of the two-way ANOVA on the performance level showed no significant changes between groups and between the first and third scenarios (p=0,428). Analysis of the simple main effect showed no significant difference between groups in the post-test (p =0,086) and no significant difference after the third scenario in the Synchronous (p = 0,001) and Asynchronous (p = 0,009) groups. The most remarkable improvement was the International Normalized Ratio that contraindicates thrombolysis (70 % improvement), followed by the first-line drug for hypertension and the platelet value that contraindicates thrombolysis (25 % improvement for both). Conclusion: we did not identify differences in student stroke knowledge gained via virtual simulation with automated v/s instructor-guided feedback. The students learned specific elements linked to the safety of administering thrombolytics in patients with stroke. Objetivo: determinar si la simulación virtual asíncrona con retroalimentación automática mejora el aprendizaje sobre la toma de decisiones clínicas en el ictus en comparación con la simulación síncrona con retroalimentación guiada por el instructor en estudiantes de medicina de 4º curso. Nuestra hipótesis es que la retroalimentación guiada por el instructor conduce a un mejor aprendizaje que la retroalimentación automática. Métodos: se diseñó un estudio cuantitativo aleatorizado controlado paralelo utilizando la extensión CONSORT para estudios de simulación. Veinte estudiantes de medicina de 4º curso se dividieron en dos grupos. Un grupo realizó simulaciones virtuales con feedback guiado por el instructor y el otro trabajó de forma autónoma con feedback automático. Se administró una encuesta de puntuación de conocimientos antes y después de aplicar el paquete de intervención y una encuesta de percepción de utilidad. Se utilizó un análisis de varianza (ANOVA) de medidas repetidas de dos vías para comparar los cambios en el rendimiento. Resultados: los resultados del ANOVA de dos vías sobre el nivel de rendimiento no mostraron cambios significativos entre los grupos ni entre el primer y el tercer escenario (p = 0,428). El análisis del efecto principal simple no mostró diferencias significativas entre los grupos en la prueba posterior (p = 0,086) ni diferencias significativas después del tercer escenario en los grupos Síncrono (p = 0,001) y Asíncrono (p = 0,009). La mejora más destacable fue la de la razón normalizada internacional que contraindica la trombólisis (mejora del 70 %), seguida del fármaco de primera línea para la hipertensión y el valor de plaquetas que contraindica la trombólisis (mejora del 25 % para ambos). Conclusiones: no identificamos diferencias en los conocimientos sobre ictus adquiridos por los estudiantes mediante simulación virtual con feedback automatizado v/s guiado por el instructor. Los alumnos aprendieron elementos específicos relacionados con la seguridad de la administración de trombolíticos en pacientes con ictus.Item Diffusion-weighted imaging determinants for acute ischemic stroke diagnosis in the emergency room(2018) Brunser, Alejandro M.; Cavada, Gabriel; Muñoz Venturelli, Paula; Olavarría, Verónica; Rojo, Alexis; Almeida, Juan; Díaz, Violeta; Hoppe, Arnold; Lavados, PabloPurpose The aim of this study was to investigate the clinical-radiological determinants of diffusion-weighted image (DWI) abnormalities in patients with suspected acute ischemic stroke (AIS) seen at the emergency room (ER). Methods During the study period, 882 consecutive patients were screened at Clínica Alemana de Santiago, Chile; 786 had AIS and 711 (90.4%) were included. Results DWI demonstrated 87.3% sensitivity and 99.0% specificity, with a positive likelihood ratio of 79 and a negative likelihood ratio of 0.13 for the detection of AIS. In the univariate analysis, a positive DWI in AIS was associated with admission National Institute of Health Stroke Scale (NIHSS) score (OR 1.09, 95% CI 1.04–1.1%), time from symptom onset to DWI (OR 1.03, 95% CI 1.01–1.05), presence of a relevant intracranial artery occlusion (OR 3.18, 95% CI 1.75–5.76), posterior circulation ischemia (OR 0.44, 95% CI 0.28–0.7), brainstem location of the AIS (OR 0.16, 95% CI 0.093–0.27), infratentorial location of AIS (OR 0.44, 95% CI 0.28–0.70), and lacunar (OR 0.27, 95% CI 0.11–0.68) or undetermined stroke etiology (OR 0.12, 95% CI 0.3–0.31). In multivariate analysis, only admission NIHSS score (OR 1.07, 95% CI 1.01–1.13), time from symptom onset to DWI (OR 1.04, 95% CI 1.01–1.13), brainstem location (OR 0.13, 95% CI 0.051–0.37), and lacunar (OR: 0.4, 95% CI 0.21–0.78) or undetermined etiology (OR: 0.4, 95% CI 0.22–0.78) remained independently associated. Conclusion DWI detects AIS accurately; the positivity of these evaluations in the ER is associated only with NIHSS on admission, time to DWI, brainstem location, and AIS etiology.Item Exclusion Criteria for Intravenous Thrombolysis in Stroke Mimics: An Observational Study(2013) Brunser, Alejandro M.; Illanes, Sergio; Lavados, Pablo; Muñoz, Paula; Carcamo, Daniel; Hoppe, Arnold; Olavarria, Verónica; Delgado, Iris; Dıaz, VioletaBackground: Stroke mimics (SMs) are frequent in emergency departments (EDs), but are treated infrequently with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis. We aimed at identifying the factors that lead to the exclusion of SMs from thrombolytic therapy.Methods: Consecutive patients presenting to the ED between December 2004 and March 2011 with symptoms that suggested acute ischemic stroke were included.Results: Eight hundred forty-two patients were included in this study; 113 (13.4%) were considered SMs; these patients were younger (P = .01), more frequently diabetic (P = .001), arrived later to the ED (P = .03), had lower National Institutes of Health Stroke Scale scores (P < .001), and higher frequencies of negative diffusion-weighted imaging studies (P = .002). The most common causes of cases of SM were toxic metabolic disorders (n = 34 [30.1%]) and seizures (n = 22 [19.5%]). The most frequent cause of consultation was aphasia (n = 43 [37.6%]). SM patients had a total of 152 contraindications for rt-PA, with 34 (30%) patients having >1 contraindication. The most frequent of these were being beyond the therapeutic window for thrombolysis (n = 96) and having deficits not measurable by the National Institutes of Health Stroke Scale or very mild symptoms before the start of rt-PA (n = 37). Twenty-four (21.2%) patients had both contraindications simultaneously. Two patients (1.76%) in the SM group were candidates for rt-PA but did not receive this treatment because they or their family rejected it. Of 729 stroke patients, 87 (11.9%) did receive rt-PA.Conclusions: SM patients frequently had exclusion criteria for systemic thrombolysis, the most frequent being presenting beyond the established thrombolytic windowItem Exclusion criteria for intravenous thrombolysis in stroke mimics: an observational study(Elsevier, 2013) Brunser, Alejandro; Illanes, Sergio; Lavados, Pablo; Muñoz, Paula; Carcamo, Daniel; Hoppe, Arnold; Olavarría, Verónica; Delgado, Iris; Diaz, VioletaBACKGROUND: Stroke mimics (SMs) are frequent in emergency departments (EDs), but are treated infrequently with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis. We aimed at identifying the factors that lead to the exclusion of SMs from thrombolytic therapy. METHODS: Consecutive patients presenting to the ED between December 2004 and March 2011 with symptoms that suggested acute ischemic stroke were included. RESULTS: Eight hundred forty-two patients were included in this study; 113 (13.4%) were considered SMs; these patients were younger (P = .01), more frequently diabetic (P = .001), arrived later to the ED (P = .03), had lower National Institutes of Health Stroke Scale scores (P < .001), and higher frequencies of negative diffusion-weighted imaging studies (P = .002). The most common causes of cases of SM were toxic metabolic disorders (n = 34 [30.1%]) and seizures (n = 22 [19.5%]). The most frequent cause of consultation was aphasia (n = 43 [37.6%]). SM patients had a total of 152 contraindications for rt-PA, with 34 (30%) patients having >1 contraindication. The most frequent of these were being beyond the therapeutic window for thrombolysis (n = 96) and having deficits not measurable by the National Institutes of Health Stroke Scale or very mild symptoms before the start of rt-PA (n = 37). Twenty-four (21.2%) patients had both contraindications simultaneously. Two patients (1.76%) in the SM group were candidates for rt-PA but did not receive this treatment because they or their family rejected it. Of 729 stroke patients, 87 (11.9%) did receive rt-PA. CONCLUSIONS: SM patients frequently had exclusion criteria for systemic thrombolysis, the most frequent being presenting beyond the established thrombolytic window.Item Fighting Against Stroke in Latin America: A Joint Effort of Medical Professional Societies and Governments(2021) Ouriques Martins, Sheila Cristina; Lavados, Pablo; Secchi, Thaís Leite; Brainin, Michael; Ameriso, Sebastián; Gongora-Rivera, Fernando; Sacks, Claudio; Cantú-Brito, Carlos; Álvarez Guzmán, Tony Fabián; Pérez-Romero, Germán Enrique; Muñoz Collazos, Mario; Barboza, Miguel A.; Arauz, Antonio; Abanto Argomedo, Carlos; Novarro-Escudero, Nelson; Amorin Costabile, Héctor Ignacio; Crosa, Roberto; Camejo, Claudia; Mernes, Ricardo; Maldonado, Nelson; Mora Cuervo, Daissy Liliana; Pontes Neto, Octávio Marques; Sampaio Silva, Gisele; Carbonera, Leonardo Augusto,; Souza, Ana Claudia; Gomes de Sousa, Eduardo David; Flores, Alan; Melgarejo, Donoban; Santos Carquín, Irving R.; Hoppe, Arnold; Freitas de Carvalho, João José; Mont'Alverne, Francisco; Amaya, Pablo; Bayona, Hernán; Navia, Víctor; Duran, Juan Carlos; Urrutia, Víctor C.; Vianna Araujo, Denizar; Feigin, Valery L.; Nogueira, Raúl G.Introduction: Stroke is one of the leading causes of death in Latin America, a region with countless gaps to be addressed to decrease its burden. In 2018, at the first Latin American Stroke Ministerial Meeting, stroke physician and healthcare manager representatives from 13 countries signed the Declaration of Gramado with the priorities to improve the region, with the commitment to implement all evidence-based strategies for stroke care. The second meeting in March 2020 reviewed the achievements in 2 years and discussed new objectives. This paper will review the 2-year advances and future plans of the Latin American alliance for stroke. Method: In March 2020, a survey based on the Declaration of Gramado items was sent to the neurologists participants of the Stroke Ministerial Meetings. The results were confirmed with representatives of the Ministries of Health and leaders from the countries at the second Latin American Stroke Ministerial Meeting. Results: In 2 years, public stroke awareness initiatives increased from 25 to 75% of countries. All countries have started programs to encourage physical activity, and there has been an increase in the number of countries that implement, at least partially, strategies to identify and treat hypertension, diabetes, and lifestyle risk factors. Programs to identify and treat dyslipidemia and atrial fibrillation still remained poor. The number of stroke centers increased from 322 to 448, all of them providing intravenous thrombolysis, with an increase in countries with stroke units. All countries have mechanical thrombectomy, but mostly restricted to a few private hospitals. Pre-hospital organization remains limited. The utilization of telemedicine has increased but is restricted to a few hospitals and is not widely available throughout the country. Patients have late, if any, access to rehabilitation after hospital discharge. Conclusion: The initiative to collaborate, exchange experiences, and unite societies and governments to improve stroke care in Latin America has yielded good results. Important advances have been made in the region in terms of increasing the number of acute stroke care services, implementing reperfusion treatments and creating programs for the detection and treatment of risk factors. We hope that this approach can reduce inequalities in stroke care in Latin America and serves as a model for other under-resourced environments.Item Incidence, risk factors, prognosis, and health-related quality of life after stroke in a low-resource community in Chile (ÑANDU): a prospective population-based study(2021) Lavados, Pablo; Hoffmeister, Lorena; Moraga, Ana M.; Vejar, Angélica; Vidal, Carolina; Gajardo, Constanza; Portales, María Bernardita; San Martín, Daniela; López, Eduardo; Rojo, Alexis; Olavarría, Verónica V.; Almeida, Juan; Brunser, Alejandro M.; Muñoz Venturelli, Paula; Hoppe, Arnold; Díaz, Violeta; Sacks, ClaudioBackground Stroke is a leading cause of disability and death worldwide. The best estimates of local, national, and global burden of stroke are derived from prospective population-based studies. We aimed to investigate the incidence, risk factors, long-term prognosis, care, and quality of life after stroke in the Ñuble region of Chile. Methods We did a prospective community-based study with use of multiple overlapping sources of hospitalised, ambulatory, and deceased cases. Standardised diagnostic criteria were used to identify and follow up all cases occurring in the resident population of the Ñuble region, Chile (in a low-income rural-urban population including predominantly people of Indigenous-European heritage), for 1 year. Participants were included if they had a clinical diagnosis of stroke confirmed according to the study criteria. All cases were adjudicated by vascular neurologists. Incidence rates of first-ever stroke were calculated from the population of Ñuble according to the 2017 national census. Findings From April 1, 2015, to March 31, 2016, we ascertained 1103 stroke cases, of which 890 (80·7%) were first-ever incident cases. The mean age of patients with first-ever stroke was 70·3 years (SD 14·1) and 443 (49·8%) were women. A CT scan was obtained in 801 (90%) of 890 patients (mean time from symptom onset to scan of 13·4 h (SD 29·8). The incidence of first-ever stroke age-adjusted to the world population was 121·7 (95% CI 113·7–130·1) per 100 000. The age-adjusted incidence rates, per 100000 inhabitants, by main pathological subtypes were as follows: ischaemic stroke (101·5 [95% CI 90·9–113·0]); intracerebral haemorrhage (17·9 [13·5–23·4]), and subarachnoid haemorrhage (4·2 [2·1–7·3]). The 30-day case-fatality rate was 24·6% (21·9–27·6). At 6 months after the stroke, 55·9% (432 of 773) of cases had died or were disabled, which increased to 61·0% (456 of 747) at 12 months. Health-related quality of life in survivors was low at 6 months, improving slightly at 12 months after the stroke. Interpretation The incidence of stroke in this low-resource population was higher than our previous finding in northern Chile and within the mid-range of most population-based stroke studies. This result was due mainly to a higher incidence of ischaemic stroke, probably associated with increasing age and a high prevalence of cardiometabolic risk factors in the population studied. Our findings suggest that more should be done for the prevention and care of stroke in communities like the Ñuble population. Funding The National Agency for Research and Development and the Technology-Health Research Fund, Clínica Alemana de Santiago, Boehringer Ingelheim, Bristol Meyers Squibb, The Herminda Martin Clinical Hospital of Chillán, Universidad Mayor, and Universidad de Concepción.Item Nasolaryngoscopic Validation of a Set of Clinical Predictors of Aspiration in a Critical Care Setting(2010) Caviedes, Ivan R.; Lavados, Pablo; Hoppe, Arnold; Lopez, Marıa AAntecedentes: la aspiración es frecuente en pacientes con trastornos neurológicos agudos y disfunción de la deglución. Su incidencia en accidentes cerebrovasculares, tan alta como 51%, aumenta la mortalidad hasta 3 veces. La neumonía, su principal complicación, aumenta aún más la morbilidad, la mortalidad y los costos de atención al paciente. El objetivo de este estudio fue evaluar un conjunto de predictores de aspiración al lado de la cama ["voz húmeda", prueba de deglución de agua de 3 onzas y auscultación cervical en una unidad de cuidados intensivos (UCI)] y compararlos con la nasolaringoscopia como estándar de oro. Métodos: Realizamos un estudio prospectivo, no ciego, de predictores de riesgo de aspiración al lado de la cama en 65 pacientes consecutivos de UCI con un trastorno neurológico agudo o una afección médica o quirúrgica grave con disminución del nivel de conciencia. Resultados: Se detectó aspiración endoscópica en 17 pacientes. Las sensibilidades para la voz húmeda, la prueba de deglución de agua de 3 onzas y la auscultación cervical fueron 58.82%, 88.23% y 82.35%; las especificidades fueron 78,26%, 62,50% y 80,43%. Los valores predictivos positivos fueron 50%, 45,45% y 60,86%, y los valores predictivos negativos fueron 83,72%, 93,75% y 92,50%, respectivamente. Las razones de probabilidad positivas fueron 2,70, 2,35 y 4,20, respectivamente. La asociación de 2 predictores clínicos positivos, voz húmeda y auscultación cervical o voz húmeda y prueba de deglución de agua de 3 onzas, mejoró la especificidad a 92,85% y 84,61%, valores predictivos positivos a 83,33% y 69,23%, y cocientes de probabilidad a 10,76 y 5,85 , respectivamente. Conclusiones: Los predictores clínicos de cabecera para los riesgos de aspiración son una herramienta de cribado útil para los pacientes de la UCI que presentan factores de riesgo para esta complicación.Item Sonotrombolisis en el ataque cerebrovascular isquémico: once años de experiencia en Clínica Alemana de Santiago(Sociedad Médica de Santiago, 2014) Brunser, Alejandro; Hoppe, Arnold; Muñoz, Paula; Cárcamo, Daniel; Lavados, Pablo; Gaete, Javier; Roldán, Andrés; Rivas, RodrigoBackground: Sonothrombolysis (ST) is an emerging modality for the treatment of stroke. Aim: To assess the feasibility to perform ST in a Chilean hospital. Material and Methods: Patients attended at a private clinic with an acute ischemic stroke, between September 2002 and May 2013 and eligible for endovenous thrombolysis, were studied with a transcranial Doppler (Spencer PMD 100 or 150®). Those with an adequate sonographic window and a demonstrated arterial occlusion were monitored continuously with transcranial Doppler at the site of worst residual flow following the CLOTBUST study protocol. Results: One thousand twenty six patients were studied, of whom 136 received intravenous thrombolysis (rt-PA) and 61, aged 66 ± 18 years (59% males), were subjected to ST (7% of total). Their median National Institutes of Health Stroke Scale score was 14, the lapse from symptom onset to rt-PA was 127 minutes (43-223). Middle cerebral artery (MCA) occlusion was found in 88.5% of patients. Complete recanalization was achieved in 44.3% of patients. Sixty percent had Modified Rankin Scale of 0 to 2 at 3 months (95% confidence intervals (CI) 48.1 to 72). Case fatality was 9.8% and asymptomatic intracranial hemorrhage occurred in 9.8% (95% CI: 4.3 to 20.2). Conclusions: ST can be carried out in a complex medical center and is safe.Item Stroke Care and Application of Thrombolysis in Ibero-America: Report From the SITS-SIECV Ibero-American Stroke Register(2019) Alonso de Leciñana, María; Mazya, Michael V.; Kostulas, Nikolaos; Del Brutto, Oscar H.; Abanto, Carlos; Massaro, Ayrton; Bastos, Mario de; Martins, Sheila; Ameriso, Sebastian F.; Gongora-Rivera, Fernando; Sacks, Claudio; Hoppe, Arnold; Abad, Patricio; Meza, Gloria; Arauz-Gongora, Antonio; Wahlgren, Nils; Díez-Tejedor, Exuperio; SITS-SIECV InvestigatorsBackground and Purpose— Standardized registries may provide valuable data to further improve stroke care. Our aim was to obtain updated information about characteristics of stroke patients and management of stroke across the Ibero-American countries, using a common in-hospital registry (Safe Implementation of Treatments in Stroke–Sociedad Iberoamericana de Enfermedades Cerebrovasculares) as a basis for further quality improvement. Methods— Data for this study were entered into the Safe Implementation of Treatments in Stroke registry from September 2009 to December 2013 by 58 centers in 14 countries. Data included demographics, risk factors, onset-to-door time, National Institutes of Health Stroke Scale score, stroke subtype, ischemic stroke etiology, treatments, 3-month mortality, and modified Rankin Scale score. Time to treatment was also recorded for patients treated with thrombolysis. Results— Five thousand four hundred one patients were registered; median age, 65 years; 46% women; 3915 (72.5%) ischemic strokes; 686 (13.7%) hemorrhagic strokes; 213 (4.3%) subarachnoid hemorrhages; 414 (8.3%) transient ischemic attacks; and 31 (0.6%) cerebral vein thrombosis. The most prevalent risk factors were hypertension (71.3%), dyslipidemia (35.2%), and diabetes mellitus (23.6%). Atrial fibrillation was present in 15.1%. Three hundred one ischemic strokes were treated with intravenous thrombolysis (IVT; 7.7%). Patients undergoing IVT were more severely affected (median baseline National Institutes of Health Stroke Scale score, 11 versus 6). The rate of symptomatic intracerebral hemorrhages after IVT was 5.7%. At 3 months, 60.3% of IVT-treated patients and 59.1% of untreated patients were independent (modified Rankin Scale score, 0–2). Mortality was 11.4% in treated and 12.8% in untreated patients. Conclusions— Safe Implementation of Treatments in Stroke–Sociedad Iberoamericana de Enfermedades Cerebrovasculares is the largest registry of a general stroke population and the first study to evaluate the level of IVT use in Ibero-America. It provides valuable information that may help to improve the quality of stroke care in the Ibero-American region.Item Telestroke in Chile: 1 year experience at 7 hospitals(2019) Mansilla, Eloy; Mazzon, Enrico; Jurado, Felipe; Lara, Lorena; Arévalo, Mirya; Rojas, Diego; Stephens, Gloria; Hoppe, Arnold; Brunser, AlejandroBackground: Acute ischemic stroke (AIS) is one of the leading causes of death in Chile. Intravenous thrombolysis (IVT) is an effective treatment. Geographical barriers and lack of specialists limit its application. Telemedicine can overcome some of these pitfalls. Aim: To describe the implementation and results of AIS treatment by telemedicine at the TeleStroke Unit (TeleACV) of the Southern Metropolitan Health Service, connected with seven hospitals in Chile. Material and methods: Descriptive analysis of a prospective tele-thrombolysis data-base that covers from 2016 to 2018, with an emphasis in the last year. Results: During the analyzed period, seven remote telemedicine centers were activated as far as 830 kilometers on a continental level from the reference center and up to 3,700 kilometers on an island level. There were 1,024 telemedicine consultations, 144 (14%) of them resulted in an IVT treatment. During 2018, 597 tele-consultations were made, thrombolysis was done in 115 (19%) patients aged 66+-13 years; 54 (46.6%) being female. The median admission National Institute of Health Stroke Scale was 8 (interquartile range (IQR) 5-14). The median door-to-needle time was 56.5 (IQR 44.8-73.3) minutes; 60% of patients were treated within 60 minutes. Eight patients (7%) were referred for a subsequent mechanical thrombectomy to a center of greater complexity. Symptomatic intra-cranial hemorrhages occurred in four treated patients (4%). One patient had a systemic bleeding. Conclusions: The Telestroke Unit achieved a high rate of IVT and good door-to-needle times. This may help to overcome some of the geographic barriers and the specialist availability gap in our country.Publication Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression(2022) Olavarría, Verónica; Hoffmeiste, Lorena; Vidal, Carolina; Brunser, Alejandro; Hoppe, Arnold; Lavados, PabloIntroduction: The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions. Methods: We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria. Results: A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4-15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1-10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window. Conclusions: The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.Item The role of TCD in the evaluation of acute stroke(Wiley, 2016) Brunser, Alejandro; Mansilla, Eloy; Hoppe, Arnold; Olavarria, Veronica; Sujima, Emi; Lavados, PabloBACKGROUND: The additional information that transcranial Doppler (TCD) can provide as part of a multimodal imaging stroke protocol in the setting of hyper acute strokes has not been evaluated. METHODS: Consecutive patients admitted between December 2012 and January 2015 with ischemic stroke of less than 4.5 hours of onset were studied as soon as possible with a protocol consisting of noncontrast brain computed tomography, computed tomography angiography of supra-aortic vessels, diffusion-weighted magnetic resonance imaging, and TCD. RESULTS: Eighty-six patients were included. The imaging protocol was performed 113.9 (±23) minutes after the stroke symptoms appeared and by TCD after 150.2 (±19) minutes. Sixty-six (76.7%) patients were treated with revascularization therapies. TCD provided additional information in 49 cases (56.9.4%, 95 CI 46.4-66.9). More than one piece of additional information was obtained in 17 patients. The most frequent additional information was collateral pathways, information related to patency of vessels, and active microembolization. Multivariate analysis demonstrated that, intracranial vessel occlusion (P <.001) and optimal sonographic windows (P <.004) were the variables associated with additional information. In 15 patients (17.4%; 95 CI 9.4-25.5) the additional information changed the management. In 8 patients endovascular rescue was applied after the failure of intravenous thrombolysis; in 5 patients angiography was suspended and in 2 other cases aggressive neurocritical care was indicated. CONCLUSIONS: TCD in the first 4.5 hours of acute ischemia can provide additional information to a multimodal acute ischemic stroke imaging protocol, and can induce changes in the management of a proportion of these patients.Item Transcranial doppler as a predictor of ischemic events in carotid artery dissection(Wiley, 2017) Brunser, Alejandro; Lavados, Pablo; Hoppe, Arnold; Muñoz Venturelli, Paula; Sujima, Emi; Lopez, Javiera; Eloy, Mansilla; Carcamo, Daniel; Diaz, VioletaAbstract BACKGROUND: We aim to evaluate clinical features and transcranial Doppler (TCD) elements, as predictors of the development of ischemic events (IEs) in patients suffering from spontaneous carotid arterial dissection without stroke (CCADW). METHODS: Consecutive patients with CCADW, seen in Clínica Alemana de Santiago between April 2004 and January 2015, were evaluated clinically, and with TCD, microembolic signals (MES) monitoring and breath hold Index (BHI) test were performed. RESULTS: Forty-one patients with 45 CCADW were included. Mean age 41.9 years, 31 male, and 12 (29.1%) patients present with multiple CCADW. At the moment of TCD evaluation, 17 (41.4%) patients were being treated with antiplatelets and the rest under Heparin. TCD monitoring lasted in average 53.3 minutes and demonstrated at the moment of evaluation, MES in four carotid arteries (11.1%) of 3 patients and 13 (28.8%) abnormal BHI in 11 patients. Six IEs occurred in 3 patients, 3 strokes, and 3 transient ischemic attacks. In the univariate analysis correlating IE with clinical and ultrasonographic findings, the degree of carotid stenosis, the presence of multiple CAD, and the presence of MES plus abnormalities of BHI were significantly associated with the risk of an IE. Multivariable analysis showed that only the presence of MES plus abnormal BHI were significant (P < .001). MES and abnormal BHI were present in the 3 patients and in four arterial territories that had IE. CONCLUSIONS: TCD can identify a subgroup of patients with CCADW who are at high risk of IE.Item Transcranial Doppler in a Hispanic-Mestizo population with neurological diseases: a study of sonographic window and its determinants(John Wiley & Sons, 2012) Brunser, Alejandro; Silva, Claudio; Carcamo, Daniel; Muñoz, Paula; Hoppe, Arnold; Olavarría, Verónica; Diaz, Violeta; Abarca, JuanBetween 5% and 37% of patients are not suitable for transtemporal insonation with transcranial Doppler (TCD). This unsuitability is particularly frequent in elderly females and non-Caucasians. We aim to evaluate TCD efficiency in a mixed Hispanic population in Santiago, Chile and to determine whether factors associated with the presence of optimal windows depend exclusively on patient-related elements. Seven hundred forty-nine patients were evaluated with power mode TCD. Optimal temporal windows (TWs) included detection of the middle, anterior, posterior cerebral arteries and terminal carotid. The patient's age and sex, the location of the examination, the time of day, whether the test was conducted on weekends and whether mechanical ventilation was used were recorded. Percentages of optimal windows were calculated. Examinations were deemed ideal if both TWs were optimal. TWs were obtained in 82% of cases. In univariate analyses, male sex (P < 0.001), an age below 60 years (P < 0.0001) and mechanical ventilation (P= 0.04) correlated with ideal TWs. Using logistic regression where dependent variable was a non-ideal window only male sex odds ratio (OR) 2.3 (1.51–3.45) and age below 60 OR 13.8 (7.8–24.6) were statistically significant. Our findings indicate that Hispanic populations have detection rates for TWs similar to Europeans and are affected by patient-related elements.Item Trombolisis intravenosa en cuadros imitadores de isquemia cerebral: experiencia de un centro(Sociedad Medica de Santiago, 2016) Brunser, Alejandro; Hoppe, Arnold; Muñoz, Paula; Lavados, Pablo; Illanes, Sergio; Diaz, Violeta; Olavarria, VeronicaBackground: The effectiveness of intravenous thrombolysis (IVT) in cerebral ischemia is time dependent. Stroke mimics (SM) are frequent in emergency rooms. The effort to reduce door to needle time, can lead to administer thrombolytics to SM. Aim: To describe the frequency and prognosis of SM treated with IVT. Material and Methods: Prospective analysis of all patients evaluated in a Chilean private clinic between December 2004 and July 2015 with a suspected acute ischemic stroke (AIS). We calculated the number of SM that were treated with IVT. In these patients, we analyzed the presence of symptomatic cerebral hemorrhage defined as the presence of a neurological deterioration of four points or more on the National Institute of Health Stroke Scale, the presence of extracranial bleeding according to Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries criteria and the patient’s functional status at three months by modified Rankin scale (MRS). Results: We evaluated 1,417 patients with suspected AIS, of which 240 (16.9%) were finally diagnosed as SM. A total of 197 patients were treated with IVT, of these 10 (5%) corresponded to SM. All SM patients treated with thrombolytic drugs were functionally independent at 3 months and showed no bleeding complications. Conclusions: Occasionally SM patients were treated with IVT. This treatment was not associated with bleeding complications and the prognosis of these patients at three months was favorable.Item Validez del Doppler transcraneal en el diagnóstico de muerte encefálica(2010) Brunser, Alejandro; Hoppe, Arnold; Cárcamo, Daniel; Lavados, Pablo; Roldán, AndrésS; Rivas, Rodrigo; Valenzuela, Marcela; Montes, José MiguelThe clinical diagnosis of brain death is complex. Aim: To evaluate the diagnostic accuracy of transcranial Doppler (TCD) for brain death. Patients and Methods: Patients seen on the intensive care unit of a private hospital between January 2004 to December 2008, were included if they were in structural coma, had no craniectomy and had a blind evaluation by a neurologist and TCD done in less than three hours. The diagnosis of brain death was based on a clinical evaluation that considered the absence of sedative drugs, median blood pressure >60 mmHg, body temperature over 35º Celsius and complete absence of brainstem reflexes. An expert neurosonologist, with a TCD-PMD-100, 2 Mhz transducer, used an institutional protocol that considers the examination as positive for brain circulatory arrest when there is presence of reverberating, small systolic peaks or the disappearance of a previous signal present on both middle cerebral arteries and intracranial vertebral arteries. Results: Fifty three patients were evaluated, 25 with clinical brain death. On 45 cases (84.9%), the interval between both evaluations was less than one hour. The sensitivity, specificity, positive and negative predictive values for the diagnosis of brain death with TCD were 100, 96, 96.1 and 100% respectively. Positive and negative likelihood ratios for brain death were 28 and 0, respectively. Conclusions: TCD is a valid and useful technique for the diagnosis of brain death and can be used on complicated cases.