Brazilian Public Health System protocol for the diagnosis, treatment, and clinical monitoring of acute ischemic stroke

Abstract

The Brazilian Ministry of Health has issued new recommendations for the management of patients with acute ischemic stroke. The protocol covers aspects related to diagnosis, treatment, and patient monitoring, expanding the available treatment options for patients treated within the Brazilian Public Health System (Sistema Único de Saúde – SUS, in Portuguese). This article discusses some of the recommendations presented in the current Clinical Practice Protocol, aiming to spread awareness of the document's updates and assist healthcare professionals and services in implementing these recommendations.

Keywords

Ischemic Stroke - Clinical Protocols - Tissue Plasminogen Activator - Thrombectomy - Public Health

Authors' Contributions

Conceptualization: AR, ACPNP, CS, VC, MF, AA; Methodology: AR, ACPNP; Writing–original draft: AR, ACPNP, KB, SM; Writing–review & editing: AR, MF, SM; Supervision: CS, VC, DG, GD, KB, SP, MF, SM, AA; Visualization: SM, SP, GD, DG; Validation: AA, SM.

Editor-in-Chief: Ayrton Roberto Massaro.

Associate Editor: Octavio Pontes-Neto.

Publikationsverlauf

Eingereicht: 09. Dezember 2024

Angenommen: 30. Dezember 2024

Artikel online veröffentlicht:
20. Juni 2025

• References

• 1 Powers WJ, Rabinstein AA, Ackerson T. et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50 (12) e344-e418
• 2 Roth GA, Mensah GA, Johnson CO. et al; GBD-NHLBI-JACC Global Burden of Cardiovascular Diseases Writing Group. Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study. J Am Coll Cardiol 2020; 76 (25) 2982-3021
• 3 Organization WH. Stroke, Cerebrovascular accident. 2024 [cited 2024 january]; Available from: https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html
• 4 Collaborators GBDCD, GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390 (10100): 1151-1210
• 5 Cassella CR, Jagoda A. Ischemic Stroke: Advances in Diagnosis and Management. Emerg Med Clin North Am 2017; 35 (04) 911-930
• 6 Tyagi S, Luo N, Tan CS. et al. Support system diversity among family caregivers of stroke survivors: a qualitative study exploring Asian perspectives. BMC Geriatr 2021; 21 (01) 594
• 7 O'Donnell MJ, Chin SL, Rangarajan S. et al; INTERSTROKE investigators. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016; 388 (10046): 761-775
• 8 Estratégicas. B.M.d.S.S.d.A.à.S.D.d.A.P. Diretrizes de Atenção à Reabilitação da Pessoa com Acidente Vascular Cerebral. 2013 [cited 2024 January]; Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_atencao_reabilitacao_acidente_vascular_cerebral.pdf
• 9 Brasil. Ministério da Saúde. Secretaria de Ciência, T., Inovação e Complexo da Saúde. Departamento de Gestão and e.I.d.T.e. Saúde, DIRETRIZES METODOLÓGICAS: ELABORAÇÃO DE DIRETRIZES CLÍNICAS, ed. S.d.C. Ministério da Saúde, Tecnologia, Inovação e Complexo da Saúde, Departamento de Gestão e Incorporação de Tecnologias em Saúde. 2023, Brasília: Ministério da Saúde
• 10 Ministério da Saúde. S.d.C., Tecnologia, Inovação e Complexo da Saúde, Departamento de Gestão e Incorporação de Tecnologias em Saúde. Protocolo Clínico e Diretrizes Terapêuticas do Acidente Vascular Cerebral Isquêmico Agudo. 2023 [cited 2024 January]; Available from: https://www.gov.br/conitec/pt-br/midias/relatorios/2023/rr_pcdt-avci-agudo_722_final.pdf
• 11 Schünemann H. B.J., Guyatt G, Oxman A, GRADE Handbook. 2013
• 12 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
• 13 Brasil. Ministério da Saúde. Secretaria de Ciência, T., Inovação e Complexo da Saúde. Departamento de Gestão, DIRETRIZES METODOLÓGICAS: Sistema GRADE – manual de graduação da qualidade da evidência e força de recomendação para tomada de decisão em saúde, ed. T. Ministério da Saúde, Inovação e Complexo da Saúde, Departamento de Gestão e Incorporação de Tecnologias em Saúde. 2014, Brasília: Ministério da Saúde
• 14 O'Donnell MJ, Xavier D, Liu L. et al; INTERSTROKE investigators. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010; 376 (9735) 112-123
• 15 de Caneda MA, Fernandes JG, de Almeida AG, Mugnol FE. [Reliability of neurological assessment scales in patients with stroke]. Arq Neuropsiquiatr 2006; 64 (3A): 690-697
• 16 Kothari R, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med 1997; 4 (10) 986-990
• 17 Roberts HC, Dillon WP, Furlan AJ. et al. Computed tomographic findings in patients undergoing intra-arterial thrombolysis for acute ischemic stroke due to middle cerebral artery occlusion: results from the PROACT II trial. Stroke 2002; 33 (06) 1557-1565
• 18 Patel SC, Levine SR, Tilley BC. et al; National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Lack of clinical significance of early ischemic changes on computed tomography in acute stroke. JAMA 2001; 286 (22) 2830-2838
• 19 Yew KS, Cheng E. Acute stroke diagnosis. Am Fam Physician 2009; 80 (01) 33-40
• 20 Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet 2008; 371 (9624) 1612-1623
• 21 Cefaleia., C.d.C.d.C.d.S.I.d., The International Classification of Headache Disorders ed. K. F. 2018, São Paulo: Omnifarma
• 22 Adams Jr HP, Adams RJ, Brott T. et al; Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003; 34 (04) 1056-1083
• 23 Gilligan AK, Thrift AG, Sturm JW, Dewey HM, Macdonell RA, Donnan GA. Stroke units, tissue plasminogen activator, aspirin and neuroprotection: which stroke intervention could provide the greatest.
• 24 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333 (24) 1581-1587
• 25 Hacke W, Kaste M, Bluhmki E. et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359 (13) 1317-1329
• 26 Ministério da Saúde. PORTARIA N° 664, DE 12 DE ABRIL DE 2012: Aprova o Protocolo Clínico e Diretrizes Terapêuticas – Trombólise no Acidente Vascular Cerebral Isquêmico Agudo. 2012 [cited 2023 December]; Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/PRT0664_12_04_2012.html
• 27 Ministério da Saúde. Relatório de recomendação: Trombectomia mecânica para acidente vascular cerebral isquêmico agudo. 2021 [cited 2024 January]; Available from: http://antigo-conitec.saude.gov.br/images/Relatorios/2021/20210222_Relatorio_589_trombectomia.pdf
• 28 Martins SO, Mont'Alverne F, Rebello LC. et al; RESILIENT Investigators. Thrombectomy for Stroke in the Public Health Care System of Brazil. N Engl J Med 2020; 382 (24) 2316-2326
• 29 Ministério da Saúde. Relatório de Recomendação: Trombectomia mecânica para acidente vascular cerebral isquêmico agudo com janela de sintomas maior do que 8h e menor que 24h. 2021 [cited 2024 January]; Available from: https://www.gov.br/conitec/pt-br/midias/relatorios/2021/relatorio_trombectomia_avci_8h-24h_677_2021_final.pdf
• 30 Albers GW, Marks MP, Kemp S. et al; DEFUSE 3 Investigators. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med 2018; 378 (08) 708-718
• 31 Nogueira RG, Jadhav AP, Haussen DC. et al; DAWN Trial Investigators. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 2018; 378 (01) 11-21