Keywords:
stroke - mechanical thrombolysis - thrombectomy - intracranial hemorrhages - thrombolytic
therapy - fibrinolysis
Palavras-chaves:
acidente vascular cerebral - trombólise mecânica - trombectomia - hemorragias intracranianas
- terapia fibrinolítica - fibrinólise
Stroke is the major cause of death and sequelae in the world. The World Health Organization
recommends the adoption of urgent measures for its prevention and treatment. In Brazil,
there are about 68,000 deaths from stroke annually with significant economic and social
impact. Efforts to improve the acute treatment have included educational campaigns
to the population to recognize the signs and symptoms, and quick access to an emergency
ambulance[1]. Recently, positive trials of mechanical thrombectomy associated with intravenous
rtPA have been published[2] and new concepts about acute stroke treatment are being be considered. Until the
end of 2015, five positive randomized controlled trials confirmed that the use of
thrombectomy in cases of proximal occlusions to the middle cerebral artery is a better
approach than isolated intravenous therapy. The American Heart Association/American
Stroke Association published an update of the guideline with recommendations for endovascular
treatment in acute stroke as a class I level A recommendation[3]. The number needed to treat in these studies ranged from 3 to 5 ([Figure]). Despite several published studies having shown that much of the population cannot
identify the symptoms of stroke, resulting in a delay reaching the hospital[4],[5],[6],[7],[8], we aimed to quantify the current knowledge of physicians regarding the ‘state-of-the-art'
treatment for acute stroke.
Figure Rate of recanalization in the principal trials comparing mechanical endovascular
thrombectomy alone versus in combination with intravenous thrombolysis with rtPA infusion.
METHODS
An online questionnaire with a total of 10 questions was prepared by our interventional
neuroradiology team. The questions 1 to 6 contained epidemiological data and 7 to
10 inquired about current management of the stroke acute phase. The questionnaire
was built on the Survey Monkey® platform and the responses were collected 60 days after sharing with the press office
of the Department of Regional Council of Medicine (CRM-PR)[9]. Informed consent was obtained in the first part of the submission and was approved
by the ethical committee. The questionnaires were sent to all doctors with an active
membership to the CRM-PR. The data were analyzed by statistical frequency analysis.
RESULTS
The questionnaires were answered by 456 doctors. About 20% replied that they never
treated patients with acute stroke, a little more than 26% rarely attended to this
kind of population and almost 43% answered that they ‘sometimes' treated acute stroke
patients. Just over 10% of the respondents reported that they cared for stroke patients
daily. Experts in other areas accounted for 290 (63.6%) of all respondents, 101 (22.15%)
had no medical specialty, 35 (7.67%) were residents in internal medicine, 15 (3.3%)
were neurologists, 10 (2.2%) neurosurgeons, three (0.65%) neuroradiologists and two
(0.43%) interventional radiologists. We separated these into two groups: Neurogroup
(NG) and Nonneurogroup (NoNG) according to our expectation of their knowledge. The
NG included specialties related to stroke. In both groups, gender was classified as
male, time since graduation in medicine was more than 15 years and private office
preference were the principal answers. The [Table] shows the main questions and answers in the questionnaire, specifically comparing
the knowledge about mechanical thrombectomy between both groups. More than 258 (50%)
of the NoNG had ‘no idea' about the new evidence for mechanical thrombectomy. Six
(21%) of the NG also answered ‘no idea'. A question about stroke units had a slight
difference in favor of the NG, but critical points had the greatest mistakes for all.
The barrier to treatment revealed a misconception by most physicians in all areas.
A total of 216 (47.36%) believed that structural problems in hospitals were the greatest
obstacle for the treatment of acute stroke. The delay in seeking hospital treatment
was answered by 155 (34%) as the main barrier to treatment.
Table
Main questions and answers of the questionnaire. The absolute numbers refer to the
number of doctors who chose the respective alternative.
|
Questions and answers
|
Neuro
|
Non-neuro group
|
|
In 2015, five large well-conducted trials have been published in journals with a high
impact factor. Do you know the level of evidence for mechanical thrombectomy indication
(removal of endovascular thrombus) according to the latest guidelines of the American
Heart Association/American Stroke Association?
|
|
A
|
67.86%
|
13%
|
|
B
|
3.57%
|
12.85%
|
|
C
|
7.14%
|
4%
|
|
D
|
0%
|
0.90%
|
|
I have no Idea
|
21.43%
|
58.50%
|
|
Not even knew it existed
|
0%
|
10%
|
|
Treatment of stroke in the acute phase: incorrect statement that the doctor must identify.
|
|
A The main recent trials of the subject studied only the anterior circulation stroke.
|
8
|
159
|
|
B Intra-arterial thrombolysis is contraindicated if intravenous thrombolysis has been
started.
|
4
|
61
|
|
C Mechanical thrombectomy can be performed with the same stent that is commonly used
for cerebral aneurysm embolization.
|
11
|
95
|
|
D The window for mechanical thrombectomy is classically up to 6 hours, with some exceptions.
|
5
|
113
|
|
Regarding the availability of spaces exclusively intended for patient care of acute
stroke (stroke units) of the Brazilian public health system. Which is the incorrect
statement that the doctor must identify:
|
|
A They must give patient care for the stroke within 24 hours of the ictus.
|
9
|
87
|
|
B They must offer thrombolytic intravenous treatment for ischemic stroke.
|
2
|
50
|
|
C They don't offer endovascular treatment for mechanical recovery of the thrombus.
|
15
|
228
|
|
D Currently, stroke treatment is entitled to at least 5 beds.
|
2
|
63
|
|
What is the main barrier to emergency treatment in medium and high complexity hospitals
in cases of ischemic stroke reported in the Brazilian and world literature?
|
|
A Insecurity of the physician in the emergency room to perform thrombolysis
|
1
|
69
|
|
B The delay in reaching the hospital after the onset of symptoms.
|
21
|
134
|
|
C Lack of assessment by a neurologist in a timely manner.
|
0
|
15
|
|
D Structural, inputs and logistics problems.
|
6
|
21
|
DISCUSSION
Emerging therapies in the treatment of stroke continue to be published and recent
multicenter studies have brought news that change the guidelines yet again.
However, in many countries, the implementation of all these treatments requires great
logistical effort, government support and medical knowledge.
Publications about the lay knowledge still show that, in spite of the public campaigns
and Stroke International Day, many people cannot recognize the signs and symptoms
of a stroke and consequently cause delays in medical care. On the other hand, it is
important to remember that there are few neurologists in an emergency room, primary
care or possibly even inside the hospital. Medical education on the new trends of
acute stroke treatment needs to be disseminated among all medical specialties and
beyond. We did not find studies with these characteristics in the literature to evaluate
this.
We found a lack of knowledge in most physicians, including neurologists, neurosurgeons
and neuroradiologists away from acute stroke care. Even some basic concepts were not
known. Perhaps one of the barriers to achieving real improvement in stroke treatment
may be the lack of a task force in the entire medical community dealing with emergencies.
In Brazil, and possibly in many other countries, the major limiting factor remains
the doctors' lack of information about stroke. Correcting this deficiency is a fundamental
factor that must precede any other measures.
Developing countries like Brazil can aspire to follow all the scientific improvements
but they also need to add education resources for physicians. Almost all the achievements
in stroke care, since the first thrombolysis in our country, came through the task
force of the Brazilian Academy of Neurology, represented by the Brazilian Society
of Cerebrovascular Diseases. The stroke units with intravenous thrombolysis were only
implemented and supported by government in 2012, in other words, 17 years after the
first publication of this[1]. We need go forward, where the science goes, and do it faster. Today, there are
only four stroke units in the state of Paraná, three in the capital Curitiba and one
in the metropolitan region.
We suggest including all physicians in a serious continuing medical education program.
If the treatment requires a neurologist, personally or by telemedicine, this knowledge
should be available for all.
We conclude that physicians are not well informed about the new guidelines for the
treatment of acute stroke. Most physicians incorrectly answered most of the questions
on the questionnaire. This is critical, because endovascular mechanical thrombectomy
is a procedure with an evidence level 1A that, together with intravenous thrombolysis,
has completely changed the neurological outcome of these patients. This knowledge
needs to be more widely disseminated with all its details, from the clinical findings
of stroke to the criteria of indications and exclusions for endovascular rescue.
