Browsing by Author "Martins, H"
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- Early EEG Predicts Poststroke EpilepsyPublication . Bentes, C; Martins, H; Peralta, AR; Morgado, C; Casimiro, C; Franco, AC; Fonseca, AC; Geraldes, R; Canhão, P; Pinho e Melo, T; Paiva, T; Ferro, JObjective: Electroencephalography (EEG) can identify biomarkers of epileptogenesis and ictogenesis. However, few studies have used EEG in the prediction of poststroke seizures. Our primary aim was to evaluate whether early EEG abnormalities can predict poststroke epilepsy. Methods: A prospective study of consecutive acute anterior circulation ischemic stroke patients, without previous epileptic seizures, who were admitted to a stroke unit over 24 months and followed for 1 year. All patients underwent standardized clinical and diagnostic assessment during the hospital stay and after discharge. Video-EEG was performed in the first 72 h (first EEG), daily for the first 7 days, in case of neurological deterioration, at discharge, and at 12 months after stroke. The occurrence of epileptic seizures in the first year after stroke (primary outcome) was evaluated clinically and neurophysiologically during the hospital stay and at 12 months. A telephone interview was also performed at 6 months. The primary outcome was the occurrence of at least one unprovoked seizure (poststroke epilepsy). Secondary outcomes were the occurrence of at least one acute symptomatic seizure and (interictal and/or ictal) epileptiform activity on at least one EEG during the hospital stay for acute stroke. The first EEG variables were defined using international criteria/terminology. Bivariate and multivariate analyses with adjustment for age, admission National Institutes of Health Stroke Scale (NIHSS) score, and Alberta Stroke Program Early CT Score (ASPECTS) were performed. Results: A total of 151 patients were included; 38 patients (25.2%) had an acute symptomatic seizure and 23 (16%) had an unprovoked seizure.The first EEG background activity asymmetry and first EEG with interictal epileptiform activity were independent predictors of poststroke epilepsy during the first year after stroke (P = 0.043 and P = 0.043, respectively). No EEG abnormality independently predicted acute symptomatic seizures. However, the presence of periodic discharges on the first EEG was an independent predictor of epileptiform activity (p = 0.009) during the hospital stay. Significance: An early poststroke EEG can predict epilepsy in the first year after stroke, independently from clinical and imaging-based infarct severity.
- Epilepsia Partialis Continua After an Anterior Circulation Ischaemic StrokePublication . Bentes, C; Franco, AC; Peralta, A; Viana, P; Martins, H; Morgado, C; Casimiro, C; Fonseca, C; Geraldes, R; Canhão, P; Pinho e Melo, T; Paiva, T; Ferro, JMBackground and purpose: Although cerebrovascular disorders are the main cause of epilepsia partialis continua (EPC) in adulthood, the frequency of EPC after stroke is unknown. The aim was to prospectively ascertain its frequency 1 year after an ischaemic stroke. Methods: This was a prospective study of consecutive acute anterior circulation ischaemic stroke patients, previously independent, with an admission National Institutes of Health Stroke Scale score ≥4, an acute ischaemic lesion on imaging and no previous epileptic seizures. During admission patients received standardized diagnostic and medical care and were submitted to a neurophysiological evaluation protocol. One year after stroke, patients were re-evaluated by an epilepsy expert neurologist and performed a video-electroencephalogram with electromyography co-registration whenever myoclonus was observed during neurological examination for jerk-locked back averaging analysis (JLBA). EPC was defined as continuously repeated fragments of epileptic seizures, with preserved consciousness, lasting at least 1 h, and representing locally restricted epileptic activity. Results: In all, 151 acute anterior circulation stroke patients were consecutively included and prospectively evaluated, but 23 died in the first year. One year after stroke, from 127 patients alive, 117 (92.1%) underwent clinical and neurophysiological evaluation. In two (1.7%) patients, EPC diagnosis was made both by clinical and electroencephalographic criteria, namely JLBA. Both patients had a history of remote symptomatic seizures and one of them acute symptomatic seizures and non-convulsive status epilepticus criteria during the first 7 days after stroke. Conclusions: Despite its low frequency, the high stroke incidence makes post-stroke EPC relevant. This study draws attention to this recognizable condition with therapeutic and eventually prognostic implications.
- Morphological Changes of the Internal Carotid Artery: Prevalence and Characteristics. A Clinical and Ultrasonographic Study in a Series of 19 804 Patients Over 25 Years OldPublication . Martins, H; Mayer, A; Batista, P; Soares, F; Almeida, V; Pedro, AJ; Oliveira, VBackground and purpose: Morphological changes of the internal carotid arteries (McICA) are frequently found during cervical ultrasound studies. However, the etiology of McICA remains controversial. During this study, the prevalence and demographic characteristics of McICA, such as kinking, coiling or looping identified by Doppler ultrasound, were analysed and its relationship with vascular risk factors and stroke was assessed. Methods: A retrospective study was performed by analysing 19 804 patients who were subjected to cervical ultrasonographic study between January 2000 and June 2012. The data were statistically analysed with SPSS® 20 and a multivariate logistic regression was performed. Statistical significance was accepted for P < 0.05 and 95% confidence intervals (CIs) were used. Results: Morphological changes of the internal carotid arteries were present in 2678 patients (13.5%) and were unilateral in 61.6% of these cases. Carotid kinking was found in 80% of the patients, coiling in 16% and looping in 1%. In multivariate analysis, the presence of McICA was related to older groups (1.04; 95% CI, 1.04-1.05; P < 0.01), female gender (1.78; 95% CI, 1.64-1.94; P < 0.01), patients with hyperlipidemia (1.28; 95% CI, 1.17-1.40; P < 0.01), carotid thickness (1.22; 95% CI, 1.13-1.33; P < 0.01) and cardiac or cardioembolic disease (1.11; 95% CI, 1.01-1.21; P = 0.02). The results of this study indicate that kinking in the carotid artery was associated with ipsilateral cerebral ischemic events (1.43; 95% CI, 1.040-1.958; P < 0.05). Conclusion: Morphological changes of the internal carotid arteries were associated with aging, female gender and patients with hyperlipidemia, hypertension, diabetes and heart disease. Kinking was associated with ipsilateral cerebral ischemia.
- Post-Stroke Seizures Are Clinically UnderestimatedPublication . Bentes, C; Martins, H; Peralta, AR; Casimiro, C; Morgado, C; Franco, AC; Fonseca, AC; Geraldes, R; Canhão, P; Pinho e Melo, T; Paiva, T; Ferro, JMCerebrovascular disease is the leading cause of epilepsy in adults, although post-stroke seizures reported frequency is variable and few studies used EEG in their identification. To describe and compare EEG and clinical epileptic manifestations frequency in patients with an anterior circulation ischaemic stroke. Prospective study of acute anterior circulation ischaemic stroke patients, consecutively admitted to a Stroke Unit over 24 months and followed-up for 1 year. All patients underwent standardized clinical and diagnostic assessment. Seizure occurrence was clinically evaluated during hospitalization and by a telephone interview at 6 months and a clinical appointment at 12 months after stroke. Video-EEG was performed in the first 72 h (1st EEG), daily after the 1st EEG for the first 7 days after the stroke, or later if neurological worsening, at discharge, and at 12 months. 151 patients were included (112 men) with a mean age of 67.4 (11.9) years. In the 1st year after stroke, 38 patients (25.2%) had an epileptic seizure. During hospitalization, 27 patients (17.9%) had epileptiform activity (interictal or ictal) in the EEG, 7 (25.9%) of them electrographic seizures. During the first week after stroke, 22 (14.6%) patients had a seizure and 4 (2.6%) non-convulsive status epilepticus criteria. Five (22.7%) acute symptomatic seizures were exclusively electrographic. At least one remote symptomatic seizure occurred in 23 (16%) patients. In the first 7 days after stroke, more than one-fifth of patients with seizures had exclusively electrographic seizures. Without a systematic neurophysiological evaluation the frequency of post-stroke seizures are clinically underestimated.
- Quantitative EEG and Functional Outcome Following Acute Ischemic StrokePublication . Bentes, C; Peralta, AR; Viana, P; Martins, H; Morgado, C; Casimiro, C; Franco, AC; Fonseca, AC; Geraldes, R; Canhão, P; Pinho e Melo, T; Paiva, T; Ferro, JMObjective: To identify the most accurate quantitative electroencephalographic (qEEG) predictor(s) of unfavorable post-ischemic stroke outcome, and its discriminative capacity compared to already known demographic, clinical and imaging prognostic markers. Methods: Prospective cohort of 151 consecutive anterior circulation ischemic stroke patients followed for 12 months. EEG was recorded within 72 h and at discharge or 7 days post-stroke. QEEG (global band power, symmetry, affected/unaffected hemisphere and time changes) indices were calculated from mean Fast Fourier Transform and analyzed as predictors of unfavorable outcome (mRS ≥ 3), at discharge and 12 months poststroke, before and after adjustment for age, admission NIHSS and ASPECTS. Results: Higher delta, lower alpha and beta relative powers (RP) predicted outcome. Indices with higher discriminative capacity were delta-theta to alpha-beta ratio (DTABR) and alpha RP. Outcome models including either of these and other clinical/imaging stroke outcome predictors were superior to models without qEEG data. In models with qEEG indices, infarct size was not a significant outcome predictor. Conclusions: DTAABR and alpha RP are the best qEEG indices and superior to ASPECTS in post-stroke outcome prediction. They improve the discriminative capacity of already known clinical and imaging stroke outcome predictors, both at discharge and 12 months after stroke. Significance: qEEG indices are independent predictors of stroke outcome.
- Seizures, Electroencephalographic Abnormalities, and Outcome of Ischemic Stroke PatientsPublication . Bentes, C; Peralta, AR; Martins, H; Casimiro, C; Morgado, C; Franco, AC; Viana, P; Fonseca, AC; Geraldes, R; Canhão, P; Pinho E Melo, T; Paiva, T; Ferro, JMOBJECTIVE: Seizures and electroencephalographic (EEG) abnormalities have been associated with unfavorable stroke functional outcome. However, this association may depend on clinical and imaging stroke severity. We set out to analyze whether epileptic seizures and early EEG abnormalities are predictors of stroke outcome after adjustment for age and clinical/imaging infarct severity. METHODS: A prospective study was made on consecutive and previously independent acute stroke patients with a National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 on admission and an acute anterior circulation ischemic lesion on brain imaging. All patients underwent standardized clinical and diagnostic assessment during admission and after discharge, and were followed for 12 months. Video-EEG (<60 min) was performed in the first 72 h. The Alberta Stroke Program Early CT Score quantified middle cerebral artery infarct size. The outcomes in this study were an unfavorable functional outcome (modified Rankin Scale [mRS] ≥ 3) and death (mRS = 6) at discharge and 12 months after stroke. RESULTS: Unfavorable outcome at discharge was independently associated with NIHSS score (p = 0.001), EEG background activity slowing (p < 0.001), and asymmetry (p < 0.001). Unfavorable outcome 1 year after stroke was independently associated with age (p = 0.001), NIHSS score (p < 0.001), remote symptomatic seizures (p = 0.046), EEG background activity slowing (p < 0.001), and asymmetry (p < 0.001). Death in the first year after stroke was independently associated with age (p = 0.028), NIHSS score (p = 0.001), acute symptomatic seizures (p = 0.015), and EEG suppression (p = 0.019). SIGNIFICANCE: Acute symptomatic seizures were independent predictors of vital outcome and remote symptomatic seizures of functional outcome in the first year after stroke. Therefore, their recognition and prevention strategies may be clinically relevant. Early EEG abnormalities were independent predictors and comparable to age and early clinical/imaging infarct severity in stroke functional outcome discrimination, reflecting the concept that EEG is a sensitive and robust method in the functional assessment of the brain.
- sFlt-1/PlGF Ratio for the Predictive Diagnosis of Preeclampsia: Budget Impact Analysis from the Public Healthcare Perspective in PortugalPublication . Campos, A; Machado, AP; Martins, H; José Pais, MS; Érsek, K; Lopes, NOverview and Aims: The last decade brought relevant insights into the pathophysiology of preeclampsia (PE), namely the role of the circulating levels of placental growth factor (PlGF) and soluble Fms-like tyrosine kinase-1 (sFlt-1). The purpose of this study is to estimate the financial impact of introducing the sFlt-1/PlGF ratio for the evaluation of women with suspicion of PE in the Portuguese National Healthcare System (SNS). Study Design: budget impact study evaluating short-term costs associated with the introduction of the sFlt-1/PlGF ratio from the SNS payer’s perspective. The time horizon for the study is 1 year. Population: The target population consists of women presenting to the healthcare system with signs or symptoms su ggestive of preeclampsia (estimated in 8500 subjects). Methods: A decision-tree model was used to estimate the budget impact of the introduction of the sFlt-1/PlGF ratio in the SNS. The model compares the management costs in the current clinical practice (“no test” scenario) vs. current diagnostic procedures plus the sFlt-1/PlGF ratio (“test” scenario). Clinical inputs have been derived primarily from literature review and, where data was unavailable, expert opinion. Resources and unit costs have been obtained from Portugal-specific sources. Results: In the current standard practice (no test), total costs were estimated to be €9 863 264 (€1160 per patient), with unnecessary admissions representing about €3,5 million. Total costs in the test scenario sum up to €9 781 194 (€1150 per patient), representing a cost saving to the system of €82 070 (€10 per patient), mainly due to a reduction of false positives and related unnecessary hospitalizations of women not developing PE. Conclusions: There is favorable economic evidence about the introduction of the sFlt- 1/PlGF ratio in the SNS. The generated savings appear to offset the costs related to the test.
- The Influence of Women's Attachment Style on the Chronobiology of Labour Pain, Analgesic Consumption and Pharmacological EffectPublication . Costa-Martins, JM; Pereira, M; Martins, H; Moura-Ramos, M; Coelho, R; Tavares, JCircadian variation in biological rhythms has been identified as affecting both labour pain and the pharmacological properties of analgesics. In the context of pain, there is also a growing body of evidence suggesting the importance of adult attachment. The purpose of this study was to examine whether labour pain, analgesic consumption and pharmacological effect are significantly affected by the time of day and to analyse whether this circadian variation is influenced by women's attachment style. This prospective observational study included a sample of 81 pregnant women receiving patient-controlled epidural analgesia (PCEA). Attachment was assessed with the Adult Attachment Scale - Revised. The perceived intensity of labour pain in the early stage of labour (3 cm of cervical dilatation and before the administration of PCEA) was measured using a visual analogue scale (VAS). Pain was also indirectly assessed by measuring the consumption of anaesthetics. The latency period and the duration of effect were recorded for a chronopharmacology characterisation. Pain, as assessed with the VAS, was significantly higher in the night-time group than in the daytime group. An insecure attachment style was significantly associated with greater labour pain at 3 cm of cervical dilatation (p < 0.001) and before the beginning of analgesia (p < 0.001) as well as with higher analgesic consumption and lower pharmacological efficacy (p < 0.05). The time of day was significantly associated with the pharmacological effect: the latency period was longer at night, and the duration of the pharmacological effect was longer during the daytime. The interaction between time of day and attachment style was not significant for any of the study variables. Our results provide evidence of the importance of circadian variation in studying labour pain and the pharmacological effect of labour analgesia involving epidural blockage with a PCEA regimen. Moreover, although there was no evidence that attachment style influenced the circadian variation, these data emphasise that insecure attachment patterns are a risk factor for greater labour pain and analgesic consumption, which should be considered in pain management approaches.
- Women's Attachment as a Predictor of Pain During Labour and Post-Delivery: a Prospective Observational StudyPublication . Costa Martins, JM; Fernandes da Silva, C; Pereira, M; Martins, H; Oliveira, C; Puga, A; Coelho, R; Tavares, JINTRODUCTION: Labour is considered to be one of the most painful and significant experiences in a woman's life. The aim of this study was to examine whether women's attachment style is a predictor of the pain experienced throughout labour and post-delivery. MATERIAL AND METHODS:Thirty-two pregnant women were assessed during the third trimester of pregnancy and during labour. Adult attachment was assessed with the Adult Attachment Scale ' Revised. The perceived intensity of labour pain was measured using a visual analogue scale for pain in the early stage of labour, throughout labour and post-delivery. RESULTS:Women with an insecure attachment style reported more pain at 3 cm of cervical dilatation (p < 0.05), before the administration of analgesia (p < 0.01) and post-delivery (p < 0.05) than those securely attached. In multivariate models, attachment style was a significant predictor of labour pain at 3 cm of cervical dilatation and before the first administration of analgesia but not of the perceived pain post-delivery. DISCUSSION: These findings confirm that labour pain is influenced by relevant psychological factors and suggest that a woman's attachment style may be a risk factor for greater pain during labour. CONCLUSION:Future studies in the context of obstetric pain may consider the attachment style as an indicator of individual differences in the pain response during labour. This may have important implications in anaesthesiology and to promote a relevant shift in institutional practices and therapeutic procedures.