| Goulart et al., 20101919. Goulart AC, Bustos IR, Abe IM, et al. A stepwise approach to stroke surveillance in Brazil: the EMMA (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral) study. Int J Stroke. 2010;5(4):284-9.
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To evaluate stroke epidemiology based on WHO STEPS stroke surveillance in São Paulo, Brazil: STEP 1: hospitalized fatal and non-fatal events STEP 2: fatal events in the community STEP 3: stroke survivors in the community. |
Design/population: cross-sectional evaluation based on the WHO Stepwise Approach to Stroke Surveillance: STEP 1: hospital-based data comprising fatal and nonfatal stroke cases. STEP 2: stroke-related mortality data in the community using WHO questionnaires. STEP 3: questionnaire determining stroke prevalence, applied door-to-door within a family-health program in the neighborhood. Exclusion criteria: people who did not belong to the reference area. Statistics: frequencies, prevalence (95% CI), case-fatality rates according to CBV. |
STEP 1: 682 CBV cases ≥ 18 years: 472 incident cases, presented with CBV (84.3% with IS and 85.2% with first-ever stroke) from April 2006 to May 2009. STEP 2: 256 deaths from stroke were identified during 2006-2007. 44% of the deaths were unspecified stroke, 1/3 were IS, and 1/4 were HS. STEP 3: 577 subjects ≥ 35 years were screened at home, and 243 cases of stroke survival were diagnosed via a questionnaire, validated by a board-certified neurologist. |
| Abe et al., 20102424. Abe IM, Goulart AC, Santos Júnior WR, Lotufo PA, Benseñor IM. Validation of a stroke symptom questionnaire for epidemiological surveys. Sao Paulo Med J. 2010;128(4):225-31.
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To validate a questionnaire for evaluating individuals with stroke symptoms in the EMMA study, São Paulo, Brazil. |
Design/population: cross-sectional evaluation in a sample from all households in the coverage area of a primary healthcare unit in Butantan. Household members ≥ 35 years answered a stroke symptom questionnaire addressing limb weakness, facial weakness, speech problems, sensory disorders and impaired vision and 36 participants were randomly selected for a complete neurological examination (gold standard). Exclusion criteria: people who did not belong to the reference area and were not able to give responses to survey. Statistics: frequencies, sensitivity, specificity, PPV, NPV, positive and negative LH. |
Questionnaire properties: sensitivity 72.2%, specificity 94.4%, PPV 92.9% and NPV 77.3%. LR+ was 12.9, LR- was 0.29. Limb weakness was the most sensitive symptom, and speech problems were the most specific. The stroke symptom questionnaire is a useful tool and can be applied by trained interviewers with the aim of identifying community-dwelling stroke patients, through the structure of the Family Health Program. |
| Abe et al., 20112323. Abe IM, Lotufo PA, Goulart AC, Benseñor IM. Stroke prevalence in a poor neighbourhood of São Paulo, Brazil: applying a stroke symptom questionnaire. Int J Stroke. 2011;6(1):33-9.
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To verify the prevalence of stroke in a deprived neighborhood in São Paulo, Brazil and compared it with other surveys worldwide. |
Design/population: cross-sectional evaluation using questionnaire with six questions concerning limb and facial weakness, articulation, sensory disturbances, impaired vision and past diagnosis of stroke was completed door-to-door in a well-defined area of 15,000 people. Questionnaires were considered positive when a participant answered two or more questions about stroke symptoms or when the presence of stroke was confirmed by a physician, or when at least three questions had positive findings, even if not confirmed by a doctor. Exclusion criteria: people who did not belong to the reference area and were not able to give responses to survey. Statistics: prevalence rates (95% CI). |
A total of 243 people initially screened positive for stroke. Age-adjusted prevalence rate for men was 4.6% (95% CI: 3.5-5.7). For women, the prevalence rate was 6.5% (95% CI: 5.5-7.5); when considering only one question, the rate was 4.8% (95% CI: 3.9-5.7). Most commonly reported symptoms were limb weakness and sensory disorders. |
| Goulart et al., 20122525. Goulart AC, Bensenor IM, Fernandes TG, et al. Early and one-year stroke case fatality in Sao Paulo, Brazil: applying the World Health Organization's stroke STEPS. J Stroke Cerebrovasc Dis. 2012;21(8):832-8.
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To identify case-fatality rates up to one year in a community hospital in São Paulo, Brazil. |
Design/population: cross-sectional evaluation of all patients with first-ever stroke seeking acute care at the hospital's emergency ward between April 2006 and December 2008, to verify early and late case fatality according to stroke subtype. We used years of formal education as a surrogate for socioeconomic status. Exclusion criteria: people who did not belong to the reference area; those who did not receive first acute treatment at the community hospital; and cases of recurrent stroke. Statistics: frequencies, case-fatality rates and OR from 10 days to 1 year. |
Out of 430 first-ever stroke events, 365 (84.9%) were IS. After 1 year, we reported 108 deaths (86 of IS; 22 of HS). Age-adjusted case-fatality rates for IS and HS were: 6.0% versus 19.8% at 10 days, 10.6% versus 22.1% at 28 days, 17.6% versus 29.1% at 6 months and 21.0% versus 31.5% at 1 years. Low education was a predictor of death at 6 months (OR: 4.31; 95% CI: 1.34-13.91) and 1 years (OR: 4.21; 95% CI: 1.45-12.28) particularly in IS cases. |
| Fernandes et al., 20122121. Fernandes TG, Goulart AC, Santos-Junior WR, et al. Nível de escolaridade e dependência funcional em sobreviventes de acidente vascular cerebral isquêmico [Educational levels and the functional dependence of ischemic stroke survivors]. Cad Saúde Pública. 2012;28(8):1581-90.
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To evaluate the functional dependence of stroke survivors in the EMMA study. |
Design/population: cross-sectional evaluation of ischemic stroke individuals who survived after acute phase (after 28 days) in subsample from EMMA using the modified Rankin scale at 28 days and 6 months. Exclusion criteria: people who did not belong to the reference area; those who did not receive first acute treatment at the community hospital; HS; and recurrent stroke. Statistics: frequencies, case-fatality rates and OR from 10 days to 1 year. |
Among 355 survivors from first-ever IS (mean age: 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days, and these comprised low education (OR: 3.7; 95% CI: 1.60-8.54) and anatomical stroke location (total anterior circulation infarct; OR: 16.9; 95% CI: 2.93-97.49). |
| Fernandes et al., 20122626. Fernandes TG, Goulart AC, Campos TF, et al. Taxas de letalidade precoce por acidente vascular cerebral em três registros hospitalares no nordeste e sudeste do Brasil [Early stroke case-fatality rates in three hospital registries in the Northeast and Southeast of Brazil]. Arq Neuropsiquiatr. 2012;70(11):869-73.
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To evaluate early stroke case-fatality rates in three hospitals in three distinct cities located in two macroregions of Brazil. |
Design/population: cross-sectional evaluation of 10 and 28-day case-fatalities in stroke registries in São Paulo, João Pessoa and Natal. Exclusion criteria: people who did not belong to the reference area; those who did not receive first acute treatment at the hospitals; and cases of recurrent stroke. Statistics: frequencies and case-fatality rates at 10 days, 28 days and 6 months after acute event. |
Out of 962 first-ever events (mean age: 68.1 years; 53% men), 83.6% were classified as IS and 16.4% as HS. Overall, the case-fatality rates and 95% CI for HS were higher than for IS, both at 10 days [12.3%; (95% CI: 7.2-17.4) versus 7.0% (95% CI: 5.3-8.8) and at 28 days (19.8%; 95% CI: 13.6-26.0 versus 11.1%; (95% CI: 8.9-13.3)]. |
| Barros et al., 20132727. Barros JB, Goulart AC, Alencar AP, Lotufo PA, Bensenor IM. The influence of the day of the week of hospital admission on the prognosis of stroke patients. Cad Saude Publica. 2013;29(4):769-77.
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To evaluate the distribution of stroke hospital admissions (weekdays or weekend) and their respective prognosis based on a sample from the EMMA study. |
Design/population: prospective evaluation of all consecutive stroke cases between April 2006 and December 2008, with subsequent 1-year follow-up. Exclusion criteria: people who did not belong to the reference area; those who did not receive first acute treatment at the community hospital; and cases of recurrent stroke. Statistics: frequencies, case-fatality rates and OR from 10 and 28 days after acute event. |
Out of 430 first-ever stroke cases in people ≥ 35 years old, no associations between frequencies of hospital admissions due to IS and HS and the specific day of the week on which the admission occurred were found. However, 10 and 28-day case-fatality rates were higher in HS cases admitted at the weekend. It was found that HS admitted on weekends had a worse survival rate (50%) than those admitted during weekdays (25.6%; P log-rank = 0.03). Multivariate HR was 2.49 [95% CI: 1.10-5.81; P trend = 0.03] for risk of death at the weekend compared with weekdays for HS cases, but no difference in survival was observed for IS cases. |
| Goulart et al., 20131717. Goulart AC, Fernandes TG, Santos IS, et al. Predictors of long-term survival among first-ever ischemic and hemorrhagic stroke in a Brazilian stroke cohort. BMC Neurol. 2013;13:51.
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To identify prognostic factors associated with long-term stroke survival among IS and HS first-ever stroke cases in the EMMA study. |
Design/population: prospective evaluation on consecutive IS and HS stroke cases in a community hospital in São Paulo, Brazil. Cardiovascular risk factors and sociodemographic characteristics (age, gender, race and educational level) were evaluated as prognostic factors. Exclusion criteria: people who did not belong to the reference area; those who did not receive first acute treatment at the community hospital; and cases of recurrent stroke. Statistics: Kaplan-Meier survival and crude and multiple Cox proportional hazard models (with HR) were performed. |
Among 665 first-ever stroke cases, we found a lower survival rate among HS cases than among IS cases at the end of 4 years of follow-up (52% versus 44%; P = 0.04). The risk of death was highest among people with IS and without formal education (HR: 1.83; 95% CI: 1.26-2.68) and with diabetes (HR: 1.45; 95% CI: 1.07-1.97). Age had equal influence on the high risk of poor survival, regardless of stroke subtype. In addition, HS, low education and diabetes were significant independent predictors of poor long-term survival. |
| Fernandes et al., 20143131. Fernandes TG, Benseñor IM, Goulart AC, et al. Stroke in the rain forest: prevalence in a ribeirinha community and an urban population in the Brazilian Amazon. Neuroepidemiology. 2014;42(4):235-42.
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To determine the CBV prevalence in a town in the Brazilian Amazon region, comparing urban versus rural population in the same municipality. |
Design/population: cross-sectional evaluation of CBV to calculate prevalence rates among 6,216 residents ≥ 35 y old in the town of Coari, Amazonas, using a screening questionnaire, the Stroke Symptom Questionnaire. CBV prevalence rates (PRs) from the door-to-door survey were calculated according to the location of the home. Exclusion criteria: people who did not belong to the reference area and were not able to give responses to survey. Statistics: prevalence rates (95% CI). |
There were 4,897 respondents in the urban area and 1,028 in the rural area. The crude prevalence of stroke was 6.3% in the rural area and 3.7% in the urban area, regardless of age and sex. Among stroke cases, people in the rural area were those with less access to medical care in comparison with the urban area (32.1% versus 52.5%; P = 0.01), and there was a positive association between the rural area and no medical care (PR: 1.33; 95% CI: 1.03-1.71), independently of age, sex, education and functional impairment. |
| Baccaro et al., 20152828. Baccaro A, Segre A, Wang YP, et al. Validation of the Brazilian-Portuguese version of the Modified Telephone Interview for cognitive status among stroke patients. Geriatr Gerontol Int. 2015;15(9):1118-26.
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To examine the psychometric properties of the Brazilian version of the Modified Telephone Interview for Cognitive Status (TICS-M) for cognitive impairment in a post-stroke subsample from the EMMA study. |
Design/population: validation study. Original version of the TICS-M was translated and adapted into Brazilian-Portuguese language, and applied to 30 non-clinical subjects. After that, two trained researchers applied TICS-M to 61/73 EMMA participants who completed the follow-up: (i) personal interview 6 months after stroke; (ii) telephone interview 1 week after the first evaluation; and (iii) telephone interview 2 weeks after the first evaluation. Exclusion criteria: aphasia or other clinical conditions that made the interview impossible. Statistics: Reliability (test-retest) using Pearson's correlation, ICC and Cronbach's alpha coefficient. ROC analysis using the MMSE was used as a comparison. Structural validity of TICS-M was assessed through PCA in relation to 103 individuals (30 non-clinical and 73 stroke patients). |
Reliability and ICC ranged from 0.87 to 0.97 across the evaluations. Cronbach's alpha was 0.96. PCA analysis extracted three meaningful domains: working memory, recall memory and orientation. Best cutoff point for screen cognitive impairment was 14 out of 15 (91.5% sensitivity; 71.4% specificity). The area under the curve was 0.89. |
| de Mello et al., 20162929. de Mello RF, Santos Ide S, Alencar AP, et al. Major Depression as a Predictor of Poor Long-Term Survival in a Brazilian Stroke Cohort (Study of Stroke Mortality and Morbidity in Adults) EMMA study. J Stroke Cerebrovasc Dis. 2016;25(3):618-25.
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To evaluate the influence of major depression disorder (MDD) on long-term survival in a subsample of EMMA participants. |
Design/population: prospective evaluation of IS and HS cases. The Patient Health Questionnaire (PHQ-9) for MDD was applied 30 days after index event and periodically during 1-year follow-up. All participants were able to answer telephone interview. Exclusion criteria: aphasia or other clinical conditions that made the interview impossible. Statistics: Kaplan-Meier survival and crude and multiple Cox proportional hazard models. |
Among 164 (85.9%) subjects with IS and 27 (14.1%) with HS, overall incidence of MDD was 25.1% during 1 year of follow-up, regardless of stroke subtype or recurrence. The peak rate of MDD was more than 1 month post-acute event. Post-stroke MDD was associated with lower survival after 1 year of follow-up (85.4% with MDD versus 96.5% without MDD; log-rank P = 0 .006). A higher and independent risk of all-cause mortality among those who developed MDD compared with participants without MDD was also detected (HR: 4.60; 95% CI: 1.36-15.55; P = 0 .01). |
| Valiengo et al., 20163030. Valiengo L, Casati R, Bolognini N, et al. Transcranial direct current stimulation for the treatment of post-stroke depression in aphasic patients: a case series. Neurocase. 2016;22(2):225-8.
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To evaluate the safety and efficacy of tDCS for patients with post-stroke depression (PSD) and with aphasia post-stroke. |
Design/population: open-label study on PSD depression diagnosed by means of Aphasic Depression Questionnaire (SADQ) and the Aphasic Depression Rating Scale (ADRS), to evaluate the severity of PSD in four first-ever stroke cases from October 2012 to August 2014. Diagnoses of PSD and aphasia were confirmed by a psychiatrist and a speech-language pathologist, respectively. All eligible individuals (subsample from EMMA) received 10 sessions (once a day) of bilateral tDCS to the dorsolateral prefrontal cortex (DLPFC) and two additional sessions after two and four weeks (total of 12 sessions). Exclusion criteria: non-confirmed PSD and aphasia. Statistics: patients' scores from the ADRS and SADQ were subjected to one-way analysis of variance (ANOVA) with time (baseline, week 2, week 4, week 6) as the within-subject factors. Post-hoc comparisons were carried out using Bonferroni test. Additionally, the partial Eta squared (pη2) was calculated for each ANOVA. |
Among the four females evaluated, all exhibited improvement in depression after tDCS [decreases in SADQ (47.5%) and in ADRS (65.7%)]. This improvement was maintained four weeks after the treatment. In this preliminary open-label study conducted on four PSD patients with aphasia, bilateral tDCS over the DLPFC was shown to induce a substantial mood improvement; tDCS was safe and well tolerated by every patient. |
