Implementation of the Protocol of Early Treatment of Acute Ischemic Stroke established for the first time at a public hospital in Rio de Janeiro

Introduction

Cerebrovascular diseases constitute an important chapter in medicine, and amongst them acute ischemic stroke (AIS) deserves special attention since it possesses few therapeutic options, which effectively reduce the high mortality and morbidity rates. Thrombolytic therapy appears an important option, despite the narrow therapeutic window, and its use is reinforced by the World Health Organization and Brazilian Society of Cerebrovascular diseases (2001) and by extensive scientific evidence. However, there are still few Brazilian public health units that have looked to adjusting their structure for the accomplishment of treatment.

Objective

To analyze the cases from the first 12 months after implementation of the protocol for early treatment of AIS at a large public hospital in Rio de Janeiro.

Methods

An observational series study was conducted including cases of all patients admitted to an ICU with signs of stroke in an interval of up to 3 hours after the start of the symptoms, with a multidisciplinary team specially trained at Albert Einstein Hospital and Mãe de Deus Hospital.

Results

During the period of study, 24 patients were admitted with signs of stroke inside the 3-hour period. Amongst them, four presented with signs of hemorrhagic stroke at computerized tomography, while the remaining 17 did not possess evidence of bleeding, suggesting AIS. Thrombolytic therapy, in accordance with the protocol, was implemented in 17 of the cases, leaving three excluded from the thrombolytic protocol – one of these three due to the family's refusal to go through with the protocol, another one for possessing a history of AIS in less than 3 months and the last one due to reversion of the symptoms. Amongst the patients that underwent thrombolysis, the mean Glasgow Coma Scale was 10.4 ± 1.5 and mean National Institute of Health Stroke Scale (NIHSS) was 12.6 ± 5. There were two casualties, including a patient that presented with hemorrhagic transformation. Three did not show significant clinical improvement; however, 12 presented with important improvement, with force restoration and aphasia involution according to the NIHSS, modified Ranking, and Barthel's Index.

Conclusion

Implementation of the protocol for early treatment of the AIS in a large public emergency hospital assumes a series of challenges, but constitutes the main entrance to patient who are victims of acute stroke. During implementation and training there was a need for greater consciousness and involvement of all sectors in order to make the process effective: starting at prehospital until ICU admittance, with an exclusive bed reserved for AIS. Facing the impressive number of stroke victims, there are few patients who could benefit from treatment. In spite of this small sample size, among the deceased patients one presented with an AIS located in the brainstem and the other suffered nonsurgical bleeding with complications due to severe prior coronary artery disease. With the consolidation and divulging of the protocol, the number of beneficiaries might be greater.