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Browsing by Author "Mansilla, Eloy"

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A Chilean Experience of Telestroke in a COVID-19 Pandemic Year
(2022) Delfino, Carlos; Mazzon, Enrico; Cavada, Gabriel; Muñoz Venturelli, Paula; Brunser, Alejandro; Jurado, Felipe; Lara, Lorena; Rocha, Diego; Arévalo, Mirya; Rojas, Diego; Mansilla, Eloy
Background and purpose: Telemedicine for stroke patients' care (telestroke [TS]) has grown notably in recent decades and may offer advantages during health crisis. Hospital admissions related to stroke have decreased globally during the COVID-19 pandemic, but scarce information is available regarding the effect of COVID-19 in TS. Using a population-based TS registry, we investigated the impact of the first year of the COVID-19 pandemic throughout our TS network in Santiago, Chile. Methods: Stroke codes evaluated after the onset of COVID-19 restrictions in Chile (defined as March 15, 2020) were compared with those evaluated in 2019. We analyzed differences between number of stroke codes, thrombolysis rate, stroke severity, and time from the stroke onset to hospital admission. Results: We observed that the number of stroke codes and the number of patients undergoing reperfusion therapy did not change significantly (p = 0.669 and 0.415, respectively). No differences were found with respect to the median time from the stroke onset to admission (p = 0.581) or in National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.055). The decision-making-to-needle time was significantly shorter in the COVID-19 period (median 5 min [IQR 3-8], p < 0.016), but no significant changes were found at the other times. Conclusions: This study demonstrates the potential of adapting TS to extreme situations such as the COVID-19 pandemic, as well as the importance of establishing networks that facilitate patient access to quality treatments.
Breaking Down Barriers: Easter Island's First Telestroke Thrombolysis Experience and Case Report
(2022) Mazzon, Enrico; Arévalo, Mirya; Mirelis, Samuel; Delfino, Carlos; Rojas, Diego; Lara, Luis; Cárcamo, Daniel; Jurado, Felipe; Rocha, Diego; Muñoz, Paula; Mansilla, Eloy
Easter Island (Rapa Nui), Chile, is remote, located in the Polynesian Triangle in Oceania. The closest continental point is Chile, 3,512 km east. It has a population of 7,750 inhabitants, who are Chilean citizens, and receives more than 60,000 tourists a year. For this entire population, there is a medium complexity hospital without a neurology specialist. In 2019, local professionals were trained in a Telestroke program with remote clinical support conducted by neurologists located on mainland Chile. We present a 50-year-old native male, with unknown medical history, who suddenly presented right-half-body weakness and aphasia. He was evaluated via Telestroke consultation, and thrombolysis with tenecteplase was indicated. The patient improved rapidly and 45 min later the NIHSS score was 0 points. To our knowledge, this is the first reported case of Telestroke treatment in such a remote area, highlighting the importance of telemedicine to overcome geographical and technological stroke care barriers and to improve patients' outcome, no matter where they live.
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, Eloy
Background: 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 diagnosis
Diffusion-weighted imaging as predictor of acute ischemic stroke etiology
(2021) Brunser, Alejandro; Mansilla, Eloy; Navia, Victor; Mazzon, Enrico; Rojo, Alexis; Cavada, Gabriel; Olavarría, Verónica; Muñoz Venturelli, Paula; Manuel, Pablo
Background: Topographic patterns may correlate with causes of ischemic stroke. Objective: To investigate the association between diffusionweighted imaging (DWI) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Methods: We included 1019 ischemic stroke patients. DWI were classified as: i) negative; ii) DWI single lesion (cortico-subcortical, cortical, subcortical ≥20 mm, or subcortical <20 mm); iii) scattered lesions in one territory (small scattered lesions or confluent with additional lesions); and iv) multiple lesions (multiple unilateral anterior circulation [MAC], multiple posterior circulation [MPC], multiple bilateral anterior circulation [MBAC], and multiple anterior and posterior circulations [MAP]). Results: There was a relationship between DWI patterns and TOAST classification (p<0.001). Large artery atherosclerosis was associated with small, scattered lesions in one vascular territory (Odds Ratio [OR] 4.22, 95% confidence interval [95%CI] 2.61–6.8), MPC (OR 3.52; 95%CI 1.54–8.03), and subcortical lesions <20 mm (OR 3.47; 95%CI 1.76–6.85). Cardioembolic strokes correlated with MAP (OR 4.3; 95%CI 1.64–11.2), cortico-subcortical lesions (OR 3.24; 95%CI 1.9–5.5) and negative DWI (OR 2.46; 95%CI 1.1–5.49). Cryptogenic strokes correlated with negative DWI (OR 4.1; 95%CI 1,84–8.69), cortical strokes (OR 3.3; 95%CI 1.25–8.8), MAP (OR 3.33; 95%CI 1.25–8.81) and subcortical lesion ≥20 mm (OR 2.44; 95%CI 1,04–5.73). Lacunar strokes correlated with subcortical lesions diameter <20 mm (OR 42.9; 95%CI 22.7–81.1) and negative DWI (OR 8.87; 95%CI 4.03–19.5). Finally, MBAC (OR 9.25; 95%CI 1.12–76.2), MAP(OR 5.54; 95%CI 1.94–15.1), and MPC (OR 3.61; 95%CI 1.5–8.7) correlated with stroke of other etiologies. Conclusions: A relationship exists between DWI and stroke subtype.
Diffusion-weighted imaging as predictor of acute ischemic stroke etiology
(2022) brunser, alejandro; Mansilla, Eloy; NAVIA, VICTOR; Mazzon, Enrico; Rojo, Alexis; Cavada, Gabriel; Olavarría, Verónica V.; Munoz Venturelli, Paula; Lavados, Pablo
Background: Topographic patterns may correlate with causes of ischemic stroke. Objective: To investigate the association between diffusion weighted imaging (DWI) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Methods: We included 1019 ischemic stroke patients. DWI were classified as: i) negative; ii) DWI single lesion (cortico-subcortical, cortical, subcortical ≥20 mm, or subcortical <20 mm); iii) scattered lesions in one territory (small scattered lesions or confluent with additional lesions); and iv) multiple lesions (multiple unilateral anterior circulation [MAC], multiple posterior circulation [MPC], multiple bilateral anterior circulation [MBAC], and multiple anterior and posterior circulations [MAP]). Results: There was a relationship between DWI patterns and TOAST classification (p<0.001). Large artery atherosclerosis was associated with small, scattered lesions in one vascular territory (Odds Ratio [OR] 4.22, 95% confidence interval [95%CI] 2.61–6.8), MPC (OR 3.52; 95%CI 1.54–8.03), and subcortical lesions <20 mm (OR 3.47; 95%CI 1.76–6.85). Cardioembolic strokes correlated with MAP (OR 4.3; 95%CI 1.64–11.2), cortico-subcortical lesions (OR 3.24; 95%CI 1.9–5.5) and negative DWI (OR 2.46; 95%CI 1.1–5.49). Cryptogenic strokes correlated with negative DWI (OR 4.1; 95%CI 1,84–8.69), cortical strokes (OR 3.3; 95%CI 1.25–8.8), MAP (OR 3.33; 95%CI 1.25–8.81) and subcortical lesion ≥20 mm (OR 2.44; 95%CI 1,04–5.73). Lacunar strokes correlated with subcortical lesions diameter <20 mm (OR 42.9; 95%CI 22.7–81.1) and negative DWI (OR 8.87; 95%CI 4.03–19.5). Finally, MBAC (OR 9.25; 95%CI 1.12–76.2), MAP (OR 5.54; 95%CI 1.94–15.1), and MPC (OR 3.61; 95%CI 1.5–8.7) correlated with stroke of other etiologies. Conclusions: A relationship exists between DWI and stroke subtype
Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience
(2020) Brunser, Alejandro; Mazzon, Enrico; Cavada, Gabriel; Mansilla, Eloy; Rojo, Alexis; Almeida, Juan; Olavarría, Verónica; Muñoz Venturelli, Paula; Lavados, Pablo
Background: Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. Objective: We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. Methods: Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. Results: 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient’s age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37–14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98–32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81–357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37–14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10–0.40) remained independently associated. Conclusions: Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.
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, Alejandro
Background: 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.
The role of TCD in the evaluation of acute stroke
(Wiley, 2016) Brunser, Alejandro; Mansilla, Eloy; Hoppe, Arnold; Olavarria, Veronica; Sujima, Emi; Lavados, Pablo
BACKGROUND: 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.
Transcranial Doppler as a Predictor of Ischemic Events in Vertebral Artery Dissection
(2020) Brunser, Alejandro; Lavados, Pablo; Cavada, Gabriel; Muñoz Venturelli, Paula; Olavarría, Verónica; Navia, Víctor; Mansilla, Eloy; Díaz, Violeta
Background and purpose: Transcranial Doppler (TCD) helps identify patients with carotid dissections at risk of ischemic events (IEs). There is paucity of data identifying independent predictors of IE in vertebral arterial dissection (VAD). We sought to investigate the clinical and ultrasound predictors of IE. Methods: Patients with VAD admitted between June 2017 and February 2020 were evaluated clinically and with TCD; sonographic curves, microembolic signals (MES), and the breath-holding index (BHI) test were applied. Covariates found on univariate screen (P < .25) were included in a multivariable linear regression to identify independent predictors of IEs. Results: Of 88 patients with 100 VAD, 75 (85.2%) were females with a mean age 37.9 ± 7.5 years. All patients received antiplatelet treatment. TCD monitoring lasted an average of 21 ± 2.1 minutes. TCD was abnormal in 23 cases (26.1%); 21 patients had abnormal sonographic curves in the vertebral/basilar arteries, while in 4 cases, MES were present and in 5 (4.5%), BHI was abnormal. None of the patients with a normal TCD had an IE. Six strokes occurred during follow up. On univariate analysis, male sex, diabetes, dyslipidemia, a previous myocardial infarct, migraine, time of consultation to the ER, bilateral VAD, MES, BHI abnormalities, post stenotic flow in the basilar artery (PFB), and basilar/vertebral velocities were significantly associated with the risk of IEs. In the multivariate analysis, only the presence of PFB was a significant predictor of IE (OR: 68.6, 95% CI 5-937, <.001). Conclusions: TCD in VAD predicts patients at high risk of IE.
Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience
(2023) brunser, alejandro; Nuñez, Juan Cristobal; Mansilla, Eloy; Cavada, Gabriel; Olavarría, Verónica V.; Munoz Venturelli, Paula; Lavados, Pablo
Background: The efficacy of intravenous thrombolysis (IVT) is time-dependent. Objective: To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. Methods: Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. Results: A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p < 0.003) remained significant. Conclusion: Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.
Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience [Quien está en el servicio de emergencia importa al hablar de tiempo puerta-aguja: experiencia de un centro clínico]
(2023) brunser, alejandro; Nuñez; Juan; Mansilla, Eloy; Cavada, Gabriel; Olavarría, Verónica V.; Munoz Venturelli, Paula; Lavados, Pablo
Background: The efficacy of intravenous thrombolysis (IVT) is time-dependent. Objective: To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. Methods: Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. Results: A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66–11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN ( p = 0.002), coronavirus disease 2019 pandemic period ( p = 0.21), time to emergency room (ER) ( p = 0.21), presence of diabetes ( p = 0.142), hypercholesterolemia ( p = 0.007), atrial fibrillation ( p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) ( p = 0.001), lower systolic ( p = 0.143) and diastolic ( p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion ( p = 0.05), use of tenecteplase ( p = 0.18), thrombectomy ( p = 0.13), and years of experience of the physician ( p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44–10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02–1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96–0.99; p < 0.003) remained significant. Conclusion: Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.
Yield of Echocardiography in the Evaluation of Cerebral Ischemic Events: A Single Center Cohort Study
(2019) Brunser, Alejandro M.; Ibañez-Arenas, Rodrigo; Larico, Martín; Mansilla, Eloy; Almeida, Juan; Olavarría, Verónica; Muñoz Venturelli, Paula; Rojo, Alexis; Cavada, Gabriel; Lavados, Pablo
Background: Echocardiography (ECO) is frequently used as a screening test in patients with acute ischemic brain disease. We aimed to evaluate the additional information and therapeutic impact resulting from ECO in these patients. Methods: We conducted a prospective study performing ECO on consecutive patients with ischemic stroke or transient ischemic attacks, admitted to our centre between February 2013 and May 2017. Results: A total of 696 patients were included (female, 57.3%; mean age, 70 ± 15.3 years). Seven hundred thirty two echocardiographic examinations were performed (696 transthoracic and 36 transesophageal). Echocardiography yielded findings judged of clinical importance in 142 patients (20.4%, 95% CI 17.5-23.5). The most frequent of these were left atrial volume enlargement or a normal evaluation. Echocardiography findings resulted in changes in the management of 76 patients (10.7% 95% CI 8.8-13.4); initiation of anticoagulation therapy, administration of IV antibiotic therapy, cardiac surgeries, or other pharmacological therapies occurring in 42 cases (6%). The presence of coronary heart disease (OR: 2.64 95% CI 1.34-5.25), atrial fibrillation (OR: 0.24; 95% CI, 0.2-0.69), and admission NIHSS (OR: 1.04; 95% CI, 1.01-1.09), were the variables associated with changes in management. Conclusions: In unselected patients with acute ischemic stroke ECO had a low yield of additional information, and it changed management in a small percentage of patients.

Browsing by Author "Mansilla, Eloy"

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