Stroke care conditions in Brazil: can it still get worse?

As condições para atendimento do acidente vascular cerebral no Brasil: ainda pode ficar pior?

Dear Editors,

We read, with special interest, the article Medical perception of stroke care conditions in Brazil by Gagliardi et al.¹, published in the January issue of Arquivos de Neuro-Psiquiatria. As neuroradiologists with a special interest in this area, we definitely agree with the major concerns of the study's neurologists.

Unfortunately, we can assume that future conditions may get worse. With the results of the new trials^2,3,4,5,6 published over the past few years, public services will need to restructure their already scarce infrastructure. Currently, it is imperative to provide a neurointerventional treatment when an obstruction in the proximal middle cerebral artery has been demonstrated. In this setting, a careful selection of patients with adequate neuroimaging techniques is even more essential.

Brain non-contrast computed tomography (CT) is no longer enough. Angiographic CT (ACT) studies, which require powerful scanners and intravenous contrast administration, in addition to a careful interpretation, have been increasing diagnostic complexity. Providing an efficient emergency admission, with an available neurointerventional team and infrastructure (24 hours a day, seven days a week), is an additional challenge.

We also agree that it is well established that diffusion weighted-images better define the ischemic core in a hyperacute stroke setting. However, for practical purposes, until six hours after the ischemic ictus, these patients may reliably be identified by CT, as already demonstrated in previous trials. Therefore, considering costs, expertize and availability of an already-trained team and fast imaging acquisition, brain CT with ACT remains the more acceptable tool to provide fundamental data to make the best decision in this scenario.

Furthermore, some stroke teams have already considered other requirements. The current literature^7,8 has assessed the use of brain perfusion to select patients with relevant clinical deficit and imaging mismatch, in order to provide endovascular treatment beyond the classic window (> 6 hours). However, perfusion software remains expensive and relatively complex in its use. Despite that, it emerges as an option to increase the number of treated patients, including those currently neglected. New advances, increased costs. How to deal with this?

Definitively, primary stroke centers of the past must move on to become more balanced. While our centers need to be updated in their infrastructure, properly-trained, multiprofessional teams must be nimble and efficient when attending to patients. Besides that, costs must be acceptable to the health system. In other words, there is a long way to go, particularly in underdeveloped countries.

References

• ¹
  Gagliardi VD, Simis M, Cabeça HL, Gagliardi RJ. Medical perception of stroke care conditions in Brazil. Arq Neuropsiquiatr. 2018 Jan;76(1):13-21. https://doi.org/10.1590/0004-282x20170178
  » https://doi.org/10.1590/0004-282x20170178
• ²
  Assis Z, Menon BK, Goyal M, Demchuk AM, Shankar J, Rempel JL et al. Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial. J Neurointerv Surg. 2018 May;10(5):429-33. https://doi.org/10.1136/neurintsurg-2017-013316
  » https://doi.org/10.1136/neurintsurg-2017-013316
• ³
  Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM et al. Solitaire™ with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (Swift Prime) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke. Int J Stroke. 2015 Apr;10(3):439-48. https://doi.org/10.1111/ijs.12459
  » https://doi.org/10.1111/ijs.12459
• ⁴
  Broderick JP, Berkhemer OA, Palesch YY, Dippel DW, Foster LD, Roos YB et al. Endovascular therapy is effective and safe for patients with severe ischemic stroke: pooled analysis of interventional management of stroke III and multicenter randomized clinical trial of endovascular therapy for acute ischemic stroke in the netherlands data. Stroke. 2015 Dec;46(12):3416-22. https://doi.org/10.1161/STROKEAHA.115.011397
  » https://doi.org/10.1161/STROKEAHA.115.011397
• ⁵
  Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015 Mar;372(11):1009-18. https://doi.org/10.1056/NEJMoa1414792
  » https://doi.org/10.1056/NEJMoa1414792
• ⁶
  Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015 Jun;372(24):2296-306. https://doi.org/10.1056/NEJMoa1503780
  » https://doi.org/10.1056/NEJMoa1503780
• ⁷
  Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018 Feb;378(8):708-18. https://doi.org/10.1056/NEJMoa1713973
  » https://doi.org/10.1056/NEJMoa1713973
• ⁸
  Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018 Jan;378(1):11-21. https://doi.org/10.1056/NEJMoa1706442
  » https://doi.org/10.1056/NEJMoa1706442

Publication Dates

• Publication in this collection
  Jan 2019

History

• Received
  27 Feb 2018
• Accepted
  28 Sept 2018