Research The impact of cerebrovascular disease in Panama Fernando Gracia1*, Aron Benzadon2, Marco Gonzalez-Castellon1, and Blas Armien3 Background In Latin America, the cerebrovascular disease is considered a catastrophic public health problem. The objective of this publication is to describe the demographic characteristics and risk factors of cerebrovascular disease in Panama. Methods A hospital-based stroke registry was carried out between 2005 and 2006 to record all patients with cerebrovascular disease admitted to the two major teaching public hospital in Panama City. A comparative analysis was realized of the risk factor of two regional survey studies in Panamá and Colón province on 2007 and 2010. Results Sixty-three percent of the stroke was ischemic, and high blood pressure was the most common risk factor with 73%; the intrahospital mortality was 28·4%. In a National Health and Quality of Life Survey carried out in 2007, the crude prevalence of cerebrovascular disease was 0·7%. High blood pressure (22%), smoking (9·1%), alcoholism (10·8%), dyslipidemia (8·7%), and diabetes mellitus (5·4%) were the most common risk factors. In 2010, a survey to find out the Prevalence of Risk Factor Associated to Cardiovascular disease in the province of Panama and Colon found that crude prevalence of cerebrovascular disease was 1·6%. High blood pressure (28·4%), dyslipidemia (20·8%), and alcoholism (17·0%) were the most common risk factors. Conclusion Since 2013, both hospitals’ intravenous thrombolytic therapy program has been successfully applied as public health policy. A successful campaign on healthy lifestyle must be strengthened through a comprehensive approach with other public sectors in order to have an impact on the population, particularly in children and adolescents. Key words: cerebrovascular, Latin America, Panama, policy, registry, stroke
Cerebrovascular disease (CVD) is the second cause of death and the leading cause of disability in the world (1), and in Latin America is considered a catastrophic public health problem (2). In Panama, a pilot study in 1986 showed the prevalence rate of CVD to be 7·5 per 1000 inhabitants (3). By 2005, CVD represented the fourth cause of death (4). The Panamanian health system has made interventions to control and prevent this disease, but it was not until 2005 that three studies analyze the disease. The objective of this publication is to describe the demographic characteristics and risk factors of CVD in Panama. Correspondence: Fernando Gracia*, Health Sciences School, Universidad Latinoamericana de Ciencia y Tecnología, Hospital Santo Tomas, Sección de Neurología, Ave. Balboa y Calle 34 Este, Ciudad de Panamá, República de Panamá. E-mail: [email protected] 1 Neurology Section, Hospital Santo Tomás, Panama City, Panama 2 Complejo Hospitalario Metropolitano de la Caja de Seguro Social, Neurology Service, Panama City, Panama 3 Research Division and Technology Development, Instituto Conmemorativo Gorgas de Estudios de la Salud, Panama City, Panama Received: 9 June 2013; Accepted: 8 September 2013; Published online 21 November 2013 Conflict of interest: The authors declare no potential conflict of interest. DOI: 10.1111/ijs.12210
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Table 1 Demographic characteristics, stroke type, and modifiable risk factors in a hospital-based stroke registry in Panama, June 2005 to June 2006 Characteristics
Total
Patients with stroke (%) Age (mean ± SD) Male % Education (mean ± SD (n)) Race ethnicity%(n) Afrodescendent Hispanic Native Americans* Other Socioeconomic status %(n) Low Low medium Medium High medium High House type % (n) Urban Type stroke % (n) Transient ischemic attack Intracerebral hemorrhage Subarachnoid hemorrhagic Cerebral infarction Mixed Risk factor % (n) Hypertension Heart disease† Smoking‡ Previous stroke Diabetes Dyslipidemia Alcohol§ Intrahospital mortality % (n) Elegible IV thrombolysis %(n)
297 67·4 ± 15·7 144 (48·5) 7·1 ± 4·2 (211) 285 4·9 (14) 85·9 (244) 7·7 (22) 1·4 (4) 264 41·7 (110) 29·9 (79) 19·7 (52) 4·9 (13) 3·8 (10) 238 85·5 (201) 6·4 (19) 24·2 (72) 4·0 (12) 63·3 (188) 2·0 (6) 73·1 (217) 36·0 (107) 35·3 (105) 24·6 (73) 22·2 (66) 10·4 (31) 15·2 (45) 28·4 (75) 3·0 (7)
*Panamanians. † Coronary artery disease, arrhythmias, valve disease, or Chagas cardiomyopathy. ‡ Current and former smokers. § Two or more days per week. IV, intravenous; SD, standard deviation.
A hospital-based stroke registry was carried out from June 2005 to June 2006 to record all patients with CVD admitted to the two major teaching public hospital in Panama City. In the screened 297 patients, with a mean age 67·4 ± 5·7 years, the male to female ratio was 1:1·1. One hundred eighty-eight (63·3%) had an ischemic stroke, and high blood pressure was the most common risk factor with 73·1%; the intrahospital mortality was 28·4% (Table 1) (5). In a National Health and Quality of Life survey (ENSCAVI) carried out in 2007, the crude prevalence of CVD was 0·7% (range 0·2–4·1%). High blood pressure (22%), smoking (9·1%), alcoholism (10·8%), dyslipidemia (8·7%), and diabetes © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Research
F. Gracia et al.
Table 2 Comparison of two population-based studies to establish the prevalence of risk factor associated to cardiovascular disease in Panama
Characteristics Patients with stroke (%) Age (mean ± SD) Male % (n) House type % (n) Urban Race ethnicity‡ % (n) Afrodescendent Hispanic Native Americans§ Other Risk factor % (n) Hypertension Heart Disease† Smoking** Previous stroke Diabetes Dyslipidemia Alcohol††
ENSCAVI-2007* nationwide
ENSCAVI-2007 Panama and Colon provinces
PREFREC-2010†
25 748 42·6 ± 29·4 39·9 (10 287)
11 513 42·2 ± 33·9 37·8 (4357)
3590 45·4 ± 16·4 29·9 (1074)
54·6 (14 072)
74·3 (8550)
47·0 (1688)
– – – – – 22·0 (5666) 3·7 (959) 9·1 (2347) 0·7 (187) 5·4 (1378) 8·7 (2251) 10·8 (2776)
– – – – – 23·8 (2740) 3·9 (453) 8·7 (997) 0·8 (94) 6·0 (693) 9·4 (1083) 13·7 (1579)
21·1 (757) 66·0 (2368) 10·9 (391) 2·0 (71) 28·4 (1021)‡‡ 2·5 (90)¶ 6·4 (228)‡‡ 1·6 (57)‡‡ 7·3 (262)§§ 20·8 (746)‡‡ 17·0 (501)
*National Health and Quality of Life Survey, 2007. † Prevalence of Risk Factors Associated to Cardiovascular Disease, 2010 (PREFREC). Coronary artery disease, arrhythmias, valve disease, or Chagas cardiomyopathy. ‡ Race ethnicity: No information in ENSCAVI. § Panamanians. ¶ Only coronary disease. **Current and former smokers. †† Two or more days per week. ‡‡ P value < 0·001 (comparing the results between provinces of Panama and Colon in ENSCAVI-PREFREC). §§ P value = 0·007. SD, standard deviation.
mellitus (5·4%) were the most common chronic diseases in the population (6). When we analyze the results of the provinces of Panama and Colon in ENSCAVI, they were similar to the general population (Table 2). In 2010, a survey to find out the Prevalence of Risk Factors Associated to Cardiovascular disease in the provinces of Panama and Colon (PREFREC) found that crude prevalence of CVD was 1·6%. High blood pressure (28·4%), dyslipidemia (20·8%), and alcoholism (17·0%) were the most common risk factors in the population (Table 2) (7). The impact of CVD in Panama is reflected in the results of these studies. The study designs of both surveys are comparable, although they are based in the interview of disease medical history; there are some differences in the structure of the questionnaire, observing that PREFREC survey was more specific. Nevertheless, the prevalence of CVD shows a mild increment from 8·0 to 16 per 1000 habitants in Panama and Colon provinces (P < 0·001). The high blood pressure was the most important risk factor (P < 0·001), followed by dyslipidemia (P < 0·001) and alcoholism. Smoking shows a decrement from 2007 to 2010, suggesting that the anti-smoking laws implementation has been successful (P < 0·001). Perhaps the differences in the results in both studies may be related with the sample. In fact, the authors are analyzing this information. Nevertheless, it stills remains as an important risk factor. The results of both studies may explain the consequences (morbidity, mortality, and disability) observed in our hospital© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
based registry, and are similar as in other countries (8). Hypertension was the most important risk factor, present in more than half of all patients with stroke, as seen in other Latin American studies (9). The high mortality rate stresses the need for acute stroke units. Recent publications show a reduction in morbidity and mortality by half when care is provided in stroke units (10). Most of our patients were from urban areas, with low socioeconomic and low educational levels, making it more difficult to access health care, following a healthy lifestyle and compliance with treatment. Only 3% of our patients were eligible for treatment with intravenous (IV) thrombolysis (Table 1), although was not provided because of unavailability of the drug. Poor knowledge of stroke symptoms, lack of sense of urgency, and an inefficient prehospital emergency system are the probable reasons for such low proportions of patients that could benefit from thrombolysis (11,12), contrasting with other series in which 30% to 50% arrive in a timely manner (13,14). Additional studies with appropriate designs are necessary to determine the incidence, cause of death, and disability for designing a prevention and control strategy for this disease in an efficient and sustainable manner. National guidelines and campaigns with effective strategies aimed to the scientific community, health care workers, and civil society at large must be prepared by national experts with international assistance in order to recognize this pathology in a timely manner and to dispel stigma Vol 9, October 2014, 28–30
29
Research associated to stroke. Healthy lifestyle promotion campaigns and prevention of risk factors associated with stroke, particularly hypertension, must be strained and followed through in health policies. Multidisciplinary units for managing acute stroke must be established in hospitals with appropriate technologies and at strategic geographic areas at the national level and provide emergency care to these patients to improve their recovery and prognosis. It has been estimated that nearly 50 patients with acute ischemic stroke have been treated with IV thrombolytic therapy in the private sector in the last decade in Panama (unpublished data). Since 2013, IV thrombolytic therapy program has been successfully applied as a public health policy in at least three hospitals, and nearly 20 patients have been included. This is only possible if there is strong support from health authorities and private sector input. In addition, it is imperative that a comprehensive approach with other public sectors such as education and social welfare must be strengthened in order to have an impact on the population, particularly in children and adolescents.
Acknowledgements We thank the Hospital Santo Tomás, Complejo Hospitalario Metropolitano de la Caja de Seguro Social and the Instituto Conmemorativo Gorgas de Estudios de la Salud.
References 1 Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F. The global stroke initiative. Lancet Neurol 2004; 3:391–3. 2 Larracoechea J. Stroke is a catastrophic disease in Latin America. Int Newsl Neurol 2005; 64:25A–6A. 3 Gracia FJ, Bayard V, Triana E, et al. Prevalence of neurologic diseases in Belisario Porras Municipality, district of San Miguelito, Panama. Rev Med Panama 1988; 13:40–5.
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F. Gracia et al. 4 Panama CGotlRd. Defunciones certificadas por médico en la República de Panamá, según las diez principales causas de muerte: año 2008, en comparación con esas mismas causas para los años 2004– 2007. Panama en Cifras 2008. 5 Gracia F, Benzadon A, Gonzalez-Castrejon M et al. Registro hospitalario de la enfermedad cerebro-vascular en Panamá: estudio prospectivo en dos hospitales de referencia en la Ciudad de Panamá y programa de terapia trombolítica endovenosa como política de salud pública Rev Med Panama 2013 (In press). 6 Rivera AL, Roa R, McDonald A, Luque H, Gonzalez B, Gomez B. Encuesta nacional de salud y calidad de vida – ENSCAVI – 2007. Panama 2009. 7 Macdonald A, Motta J, Roa R et al. Prevalencia de factores de riesgos asociados a enfermedad cardiovascular (PREFREC) en la población adulta de 18 años y más. Provincias de Panamá y Colón 2012. 8 Ferri CP, Schoenborn C, Kalra L et al. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurg Psychiatry 2011; 82:1074–82. 9 Lavados PM, Sacks C, Prina L et al. Incidence, 30-day case-fatality rate, and prognosis of stroke in Iquique, Chile: a 2-year community-based prospective study (PISCIS project). Lancet 2005; 365:2206–15. 10 Indredavik B, Rohweder G, Naalsund E, Lydersen S. Medical complications in a comprehensive stroke unit and an early supported discharge service. Stroke 2008; 39:414–20. 11 Sposato LA, Esnaola MM, Zamora R et al. Quality of ischemic stroke care in emerging countries: the Argentinian National Stroke Registry (ReNACer). Stroke 2008; 39:3036–41. 12 Furlan AJ, Katzan IL, Caplan LR. Thrombolytic therapy in acute ischemic stroke. Curr Treat Options Cardiovasc Med 2003; 5:171– 80. 13 Lopez-Hernandez N, Garcia-Escriva A, Sanchez-Paya J et al. Delays before and after arrival at the hospital in the treatment of strokes. Rev Neurol 2005; 40:531–6. Retraso extrahospitalario e intrahospitalario en el tratamiento del ictus. spa. 14 Castillo J, Davalos A, Martinez-Vila E. Latent periods in attending patients with acute cerebrovascular disease. A multicenter study. Rev Neurol 1996; 24:427–30. Tiempos de latencia en la atencion de los pacientes con enfermedades cerebrovasculares agudas. Estudio multicentrico. Grupo de Estudio de las Enfermedades Cerebrovasculares de la Sociedad Espanola de Neurologia. spa.
© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Cerebrovascular disease (CVD) is the second cause of death and the leading cause of disability in the world (1), and in Latin America is considered a catastrophic public health problem (2). In Panama, a pilot study in 1986 showed the prevalence rate of CVD to be 7·5 per 1000 inhabitants (3). By 2005, CVD represented the fourth cause of death (4). The Panamanian health system has made interventions to control and prevent this disease, but it was not until 2005 that three studies analyze the disease. The objective of this publication is to describe the demographic characteristics and risk factors of CVD in Panama. Correspondence: Fernando Gracia*, Health Sciences School, Universidad Latinoamericana de Ciencia y Tecnología, Hospital Santo Tomas, Sección de Neurología, Ave. Balboa y Calle 34 Este, Ciudad de Panamá, República de Panamá. E-mail: [email protected] 1 Neurology Section, Hospital Santo Tomás, Panama City, Panama 2 Complejo Hospitalario Metropolitano de la Caja de Seguro Social, Neurology Service, Panama City, Panama 3 Research Division and Technology Development, Instituto Conmemorativo Gorgas de Estudios de la Salud, Panama City, Panama Received: 9 June 2013; Accepted: 8 September 2013; Published online 21 November 2013 Conflict of interest: The authors declare no potential conflict of interest. DOI: 10.1111/ijs.12210
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Vol 9, October 2014, 28–30
Table 1 Demographic characteristics, stroke type, and modifiable risk factors in a hospital-based stroke registry in Panama, June 2005 to June 2006 Characteristics
Total
Patients with stroke (%) Age (mean ± SD) Male % Education (mean ± SD (n)) Race ethnicity%(n) Afrodescendent Hispanic Native Americans* Other Socioeconomic status %(n) Low Low medium Medium High medium High House type % (n) Urban Type stroke % (n) Transient ischemic attack Intracerebral hemorrhage Subarachnoid hemorrhagic Cerebral infarction Mixed Risk factor % (n) Hypertension Heart disease† Smoking‡ Previous stroke Diabetes Dyslipidemia Alcohol§ Intrahospital mortality % (n) Elegible IV thrombolysis %(n)
297 67·4 ± 15·7 144 (48·5) 7·1 ± 4·2 (211) 285 4·9 (14) 85·9 (244) 7·7 (22) 1·4 (4) 264 41·7 (110) 29·9 (79) 19·7 (52) 4·9 (13) 3·8 (10) 238 85·5 (201) 6·4 (19) 24·2 (72) 4·0 (12) 63·3 (188) 2·0 (6) 73·1 (217) 36·0 (107) 35·3 (105) 24·6 (73) 22·2 (66) 10·4 (31) 15·2 (45) 28·4 (75) 3·0 (7)
*Panamanians. † Coronary artery disease, arrhythmias, valve disease, or Chagas cardiomyopathy. ‡ Current and former smokers. § Two or more days per week. IV, intravenous; SD, standard deviation.
A hospital-based stroke registry was carried out from June 2005 to June 2006 to record all patients with CVD admitted to the two major teaching public hospital in Panama City. In the screened 297 patients, with a mean age 67·4 ± 5·7 years, the male to female ratio was 1:1·1. One hundred eighty-eight (63·3%) had an ischemic stroke, and high blood pressure was the most common risk factor with 73·1%; the intrahospital mortality was 28·4% (Table 1) (5). In a National Health and Quality of Life survey (ENSCAVI) carried out in 2007, the crude prevalence of CVD was 0·7% (range 0·2–4·1%). High blood pressure (22%), smoking (9·1%), alcoholism (10·8%), dyslipidemia (8·7%), and diabetes © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Research
F. Gracia et al.
Table 2 Comparison of two population-based studies to establish the prevalence of risk factor associated to cardiovascular disease in Panama
Characteristics Patients with stroke (%) Age (mean ± SD) Male % (n) House type % (n) Urban Race ethnicity‡ % (n) Afrodescendent Hispanic Native Americans§ Other Risk factor % (n) Hypertension Heart Disease† Smoking** Previous stroke Diabetes Dyslipidemia Alcohol††
ENSCAVI-2007* nationwide
ENSCAVI-2007 Panama and Colon provinces
PREFREC-2010†
25 748 42·6 ± 29·4 39·9 (10 287)
11 513 42·2 ± 33·9 37·8 (4357)
3590 45·4 ± 16·4 29·9 (1074)
54·6 (14 072)
74·3 (8550)
47·0 (1688)
– – – – – 22·0 (5666) 3·7 (959) 9·1 (2347) 0·7 (187) 5·4 (1378) 8·7 (2251) 10·8 (2776)
– – – – – 23·8 (2740) 3·9 (453) 8·7 (997) 0·8 (94) 6·0 (693) 9·4 (1083) 13·7 (1579)
21·1 (757) 66·0 (2368) 10·9 (391) 2·0 (71) 28·4 (1021)‡‡ 2·5 (90)¶ 6·4 (228)‡‡ 1·6 (57)‡‡ 7·3 (262)§§ 20·8 (746)‡‡ 17·0 (501)
*National Health and Quality of Life Survey, 2007. † Prevalence of Risk Factors Associated to Cardiovascular Disease, 2010 (PREFREC). Coronary artery disease, arrhythmias, valve disease, or Chagas cardiomyopathy. ‡ Race ethnicity: No information in ENSCAVI. § Panamanians. ¶ Only coronary disease. **Current and former smokers. †† Two or more days per week. ‡‡ P value < 0·001 (comparing the results between provinces of Panama and Colon in ENSCAVI-PREFREC). §§ P value = 0·007. SD, standard deviation.
mellitus (5·4%) were the most common chronic diseases in the population (6). When we analyze the results of the provinces of Panama and Colon in ENSCAVI, they were similar to the general population (Table 2). In 2010, a survey to find out the Prevalence of Risk Factors Associated to Cardiovascular disease in the provinces of Panama and Colon (PREFREC) found that crude prevalence of CVD was 1·6%. High blood pressure (28·4%), dyslipidemia (20·8%), and alcoholism (17·0%) were the most common risk factors in the population (Table 2) (7). The impact of CVD in Panama is reflected in the results of these studies. The study designs of both surveys are comparable, although they are based in the interview of disease medical history; there are some differences in the structure of the questionnaire, observing that PREFREC survey was more specific. Nevertheless, the prevalence of CVD shows a mild increment from 8·0 to 16 per 1000 habitants in Panama and Colon provinces (P < 0·001). The high blood pressure was the most important risk factor (P < 0·001), followed by dyslipidemia (P < 0·001) and alcoholism. Smoking shows a decrement from 2007 to 2010, suggesting that the anti-smoking laws implementation has been successful (P < 0·001). Perhaps the differences in the results in both studies may be related with the sample. In fact, the authors are analyzing this information. Nevertheless, it stills remains as an important risk factor. The results of both studies may explain the consequences (morbidity, mortality, and disability) observed in our hospital© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
based registry, and are similar as in other countries (8). Hypertension was the most important risk factor, present in more than half of all patients with stroke, as seen in other Latin American studies (9). The high mortality rate stresses the need for acute stroke units. Recent publications show a reduction in morbidity and mortality by half when care is provided in stroke units (10). Most of our patients were from urban areas, with low socioeconomic and low educational levels, making it more difficult to access health care, following a healthy lifestyle and compliance with treatment. Only 3% of our patients were eligible for treatment with intravenous (IV) thrombolysis (Table 1), although was not provided because of unavailability of the drug. Poor knowledge of stroke symptoms, lack of sense of urgency, and an inefficient prehospital emergency system are the probable reasons for such low proportions of patients that could benefit from thrombolysis (11,12), contrasting with other series in which 30% to 50% arrive in a timely manner (13,14). Additional studies with appropriate designs are necessary to determine the incidence, cause of death, and disability for designing a prevention and control strategy for this disease in an efficient and sustainable manner. National guidelines and campaigns with effective strategies aimed to the scientific community, health care workers, and civil society at large must be prepared by national experts with international assistance in order to recognize this pathology in a timely manner and to dispel stigma Vol 9, October 2014, 28–30
29
Research associated to stroke. Healthy lifestyle promotion campaigns and prevention of risk factors associated with stroke, particularly hypertension, must be strained and followed through in health policies. Multidisciplinary units for managing acute stroke must be established in hospitals with appropriate technologies and at strategic geographic areas at the national level and provide emergency care to these patients to improve their recovery and prognosis. It has been estimated that nearly 50 patients with acute ischemic stroke have been treated with IV thrombolytic therapy in the private sector in the last decade in Panama (unpublished data). Since 2013, IV thrombolytic therapy program has been successfully applied as a public health policy in at least three hospitals, and nearly 20 patients have been included. This is only possible if there is strong support from health authorities and private sector input. In addition, it is imperative that a comprehensive approach with other public sectors such as education and social welfare must be strengthened in order to have an impact on the population, particularly in children and adolescents.
Acknowledgements We thank the Hospital Santo Tomás, Complejo Hospitalario Metropolitano de la Caja de Seguro Social and the Instituto Conmemorativo Gorgas de Estudios de la Salud.
References 1 Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F. The global stroke initiative. Lancet Neurol 2004; 3:391–3. 2 Larracoechea J. Stroke is a catastrophic disease in Latin America. Int Newsl Neurol 2005; 64:25A–6A. 3 Gracia FJ, Bayard V, Triana E, et al. Prevalence of neurologic diseases in Belisario Porras Municipality, district of San Miguelito, Panama. Rev Med Panama 1988; 13:40–5.
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F. Gracia et al. 4 Panama CGotlRd. Defunciones certificadas por médico en la República de Panamá, según las diez principales causas de muerte: año 2008, en comparación con esas mismas causas para los años 2004– 2007. Panama en Cifras 2008. 5 Gracia F, Benzadon A, Gonzalez-Castrejon M et al. Registro hospitalario de la enfermedad cerebro-vascular en Panamá: estudio prospectivo en dos hospitales de referencia en la Ciudad de Panamá y programa de terapia trombolítica endovenosa como política de salud pública Rev Med Panama 2013 (In press). 6 Rivera AL, Roa R, McDonald A, Luque H, Gonzalez B, Gomez B. Encuesta nacional de salud y calidad de vida – ENSCAVI – 2007. Panama 2009. 7 Macdonald A, Motta J, Roa R et al. Prevalencia de factores de riesgos asociados a enfermedad cardiovascular (PREFREC) en la población adulta de 18 años y más. Provincias de Panamá y Colón 2012. 8 Ferri CP, Schoenborn C, Kalra L et al. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurg Psychiatry 2011; 82:1074–82. 9 Lavados PM, Sacks C, Prina L et al. Incidence, 30-day case-fatality rate, and prognosis of stroke in Iquique, Chile: a 2-year community-based prospective study (PISCIS project). Lancet 2005; 365:2206–15. 10 Indredavik B, Rohweder G, Naalsund E, Lydersen S. Medical complications in a comprehensive stroke unit and an early supported discharge service. Stroke 2008; 39:414–20. 11 Sposato LA, Esnaola MM, Zamora R et al. Quality of ischemic stroke care in emerging countries: the Argentinian National Stroke Registry (ReNACer). Stroke 2008; 39:3036–41. 12 Furlan AJ, Katzan IL, Caplan LR. Thrombolytic therapy in acute ischemic stroke. Curr Treat Options Cardiovasc Med 2003; 5:171– 80. 13 Lopez-Hernandez N, Garcia-Escriva A, Sanchez-Paya J et al. Delays before and after arrival at the hospital in the treatment of strokes. Rev Neurol 2005; 40:531–6. Retraso extrahospitalario e intrahospitalario en el tratamiento del ictus. spa. 14 Castillo J, Davalos A, Martinez-Vila E. Latent periods in attending patients with acute cerebrovascular disease. A multicenter study. Rev Neurol 1996; 24:427–30. Tiempos de latencia en la atencion de los pacientes con enfermedades cerebrovasculares agudas. Estudio multicentrico. Grupo de Estudio de las Enfermedades Cerebrovasculares de la Sociedad Espanola de Neurologia. spa.
© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
