Comprehensive portrait of stroke fellowship training in Brazil: A national survey study

BACKGROUND AND OBJECTIVES

The field of vascular neurology has undergone significant advances over the last decade, and care has become more complex. However, vascular neurology training programs remain underdeveloped in many countries, despite stroke impact on health care. There are efforts towards building a nationally regulated curricula in some countries. Still, comprehensive planning and implementation of these programs may be needed on a global scale, especially in countries where stroke treatment is not fully implemented. We aim to comprehensively analyze vascular neurology trainees' profiles in Brazil to describe training program contents from trainees and program directors' perspectives.

METHODS

We performed an observational, cross-sectional, web-based survey study to describe trainee and program-specific characteristics at vascular neurology fellowship training programs in Brazil. The study was conducted from June to September 2023 using a secure web-based survey sent to active fellows and program directors from all known vascular neurology fellowship programs in the country. All respondents were required to provide informed consent.

RESULTS

We obtained a 100 % response rate of a total of 12 programs distributed in 7 federal states. Notably, 57 % of the 28 surveyed fellows were women, 60 % were aged 25-30, and 70 % self-identified as White. All fellows had prior neurology training, and 60 % engaged in the program just following residency. Exposure to various training experiences was favorable, except for simulation-based learning and telestroke training. Program directors perceived exposure to be sufficient for most components but similarly found deficiencies in telestroke and simulation-based learning. Scientific productivity was low, with about two-thirds of fellows having no publications or abstracts. Most fellows (92.6 %) reported performing non-fellowship medical activities to supplement their incomes.

DISCUSSION

In conclusion, the number of vascular neurology training programs and trainees in Brazil is currently insufficient and exhibits an uneven geographic distribution. Despite this, the clinical training provided is extensive, and there is generally some funding available for fellows. These insights highlight the need for strategic improvements in Brazil's stroke education and could inform similar developments in other nations.

Barriers to patient recruitment in a poststroke neurorehabilitation multicenter trial in Brazil

There is a high demand for stroke rehabilitation in the Brazilian public health system, but most studies that have addressed rehabilitation for unilateral spatial neglect (USN) after stroke have been performed in high-income countries. Therefore, the aim of this study was to analyze USN patient recruitment in a multicenter noninvasive brain stimulation clinical trial performed in Brazil and to provide study design recommendations for future studies. We evaluated the reasons for exclusion of patients from a multicenter, randomized, double-blinded clinical trial of rehabilitation of USN patients after stroke. Clinical and demographic variables were compared between the included and excluded patients. A descriptive statistical analysis was performed. Only 173 of the 1953 potential neglect patients (8.8%) passed the initial screening. After screening evaluation, 87/173 patients (50.3%) were excluded for clinical reasons. Cognitive impairment led to the exclusion of 21/87 patients (24.1%). Low socioeconomic status led to the exclusion of 37/173 patients (21.4%). Difficulty obtaining transportation to access treatment was the most common reason for their exclusion (16/37 patients, 43.3%). The analyzed Brazilian institutions have potential for conducting studies of USN. The recruitment of stroke survivors with USN was restricted by the study design and limited financial support. A history of cognitive impairment, intracranial stenting or craniectomy, and lack of transportation were the most common barriers to participating in a multicenter noninvasive brain stimulation trial among patients with USN after stroke.

Brain stimulation can reduce unilateral spatial neglect after stroke: ELETRON trial

BACKGROUND

Rehabilitation top-down techniques based on brain stimulation present variable outcomes in unilateral spatial neglect (USN) after stroke. This study aimed to examine the effects of physical therapy after anodal and cathodal direct current stimulation (A-tDCS and C-tDCS, respectively) to improve visuospatial and functional impairments in individuals with USN after stroke.

METHODS

This double-blinded, pilot randomized clinical trial enrolled patients with USN after ischemic stroke. Randomization was stratified according to Behavior Inattention Test Conventional (BIT-C) and Catherine Bergego Scale (CBS). Outpatient physical therapy was conducted for 7.5 weeks after 20 min of tDCS. The primary outcome was the USN degree evaluated by the BIT-C. Secondary outcomes were the difference in CBS score, stroke severity [National Institutes of Health Stroke Scale (NIHSS)], disability [modified Rankin Scale (mRS)], autonomy [Barthel Index (BI), functional independence measure (FIM)], and quality of life (EQ-5D). Outcomes were analyzed using ANCOVA model corrected by age, baseline NIHSS and baseline BIT-C. Pairwise posthoc comparisons were performed using Bonferroni correction.

RESULTS

In the primary outcomes, A-tDCS led to greater improvement in BIT-C after intervention (MD: 18.4; 95%CI: 3.9-32.8; p=0.008) compared to sham. However, no significant differences were observed between A-tDCS and C-tDCS (MD: 13.9; 95%CI: -0.3-28.1; p=0.057), or C-tDCS and sham (MD: 4.5; 95%CI: -9.7-18.8; p=0.99). There were no significant differences between groups in terms of secondary outcomes.

CONCLUSIONS

A-tDCS associated with physical therapy can decrease the severity of USN after stroke. However, these preliminary findings must be confirmed by collecting additional evidence in a larger phase III trial.

REGISTRATION

URL: https://ensaiosclinicos.gov.br/; Unique Identifier RBR-78jvzx This article is protected by copyright. All rights reserved.

Abstract WP50: Cost-Effectiveness of Mechanical Thrombectomy for Acute Ischemic Stroke: An Analysis From RESILIENT Trial

Background and purpose: RESILIENT Trial was the first study in a developing country to demonstrate the benefit of mechanical thrombectomy (MT) in acute stroke patients. This economic evaluation aimed to access the cost-utility of MT under the perspective of the Brazilian Public Healthcare System.

Methods: Analysis was based on a subset sample of the original study (151 of 221 patients) from 4 hospitals. We compared costs and utilities between MT plus standard care (n=78) vs. standard care alone (n=73). Direct medical costs were considered, and utilities were inputted according to each patient’s Utility-Weighted modified Rankin Score (UW-mRS). First-year survival was obtained from trial follow-up and modelled for a life-time horizon adjusted by National Mortality Data. Direct medical costs were converted to I$ using Purchasing Power Parity (PPP). A discount rate of 5% was used. Incremental cost-effectiveness ratio (ICER) is expressed in cost (I$) per Quality-Adjusted Life Year (QALY).

Results: RESILIENT trial was stopped on its first interim analysis because of early efficacy. The incremental costs and QALYs gained with MT were estimated at I$ 8,369 and 0.75, respectively, compared with standard medical care, yielding an incremental cost-effectiveness ratio (ICER) of I$ 7,256 per QALY.

Conclusion: The initially higher costs of MT were offset by the clear benefit of the intervention. RESILIENT trial demonstrated that such therapy is likely to be cost-effective despite the economical constraints in the Brazilian healthcare system.

Interaction of Blood Pressure Lowering and Alteplase Dose in Acute Ischemic Stroke: Results of the Enhanced Control of Hypertension and Thrombolysis Stroke Study

OBJECTIVE

To determine the extent to which the effects of intensive blood pressure (BP) lowering are modified by doses of alteplase in thrombolysis-eligible acute ischemic stroke (AIS) patients.

METHODS

Prespecified analyses of the Enhanced Control of Hypertension and Thrombolysis Stroke Study for patients enrolled in both arms: (i) low-dose (0.6 mg/kg body weight) or standard-dose (0.9 mg/kg) alteplase and (ii) intensive (target systolic BP [SBP] 130-140 mm Hg) or guideline-recommended (target SBP <180 mm Hg) BP management. The primary outcome was functional recovery, measured by a shift in scores on modified Rankin scale at 90 days. The safety outcome was any intracranial hemorrhage (ICH).

RESULTS

There were 925 participants (mean age 67 years, 39% female, 77% Asian) randomized to both arms: 242 randomly assigned to guideline/standard-dose (GS); 234 to guideline/low-dose (GL); 227 to intensive/standard-dose (IS); and 222 to intensive/low-dose (IL). Overall, average SBP levels within 24 h were lower in the low-dose compared to standard-dose alteplase group (146 and 144 vs. 151 and 150 mm Hg, for GS and GL vs. IS and IL, respectively, p < 0.0001). There was no heterogeneity of the effects of BP lowering (intensive vs. guideline) on functional recovery between standard-dose (OR 0.81, 95% CI 0.59-1.12) and low-dose alteplase (1.06, 0.77-1.47; p = 0.25 for interaction). Similar results were observed for ICH (p = 0.50 for interaction).

CONCLUSIONS

In thrombolysis-treated patients with predominantly mild-to-moderate severity AIS, intensive BP lowering neither improve functional recovery, either with low- or standard-dose intravenous alteplase, nor beneficially interact with low-dose alteplase in reducing ICH.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov (NCT01422616).

Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage

IMPORTANCE

Hematoma expansion is a potentially modifiable predictor of poor outcome following an acute intracerebral hemorrhage (ICH). The ability to identify patients with ICH who are likeliest to experience hematoma expansion and therefore likeliest to benefit from expansion-targeted treatments remains an unmet need. Hypodensities within an ICH detected by noncontrast computed tomography (NCCT) have been suggested as a predictor of hematoma expansion.

OBJECTIVE

To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated our findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016.

MAIN OUTCOMES AND MEASURES

Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10.

RESULTS

A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001).

CONCLUSION AND RELEVANCE

Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion.