https://doi.org/10.

1590/0004-282X-ANP-2020-0310
ARTICLE

What can be expected to be seen in a

Neurology ward? Eleven-year experience in a
Brazilian university hospital
O que se espera encontrar em uma enfermaria de Neurologia? A experiência de 11 anos
em um hospital universitário brasileiro
Daniel Gabay MOREIRA1, Enedina Maria Lobato de OLIVEIRA1, Fernando Morgadinho dos Santos COELHO1,
Henrique Ballalai FERRAZ1, Silvio FRANCISCO1, Vanderci BORGES1, Denis Bernardi BICHUETTI1

ABSTRACT
Background: Neurological disorders are significant causes of morbidity and mortality worldwide. However, data about general neurological
inpatient admissions in Brazil is limited. Objective: To investigate the prevalence of neurological disorders according to disease group and
lesion site among patients admitted to a general Neurology ward. Methods: This was an observational and descriptive study. The hospital
discharge database for the Neurology ward was surveyed in accordance with the International Classification of Diseases, 10 th edition (ICD-10),
from September 2008 to October 2019. The final diagnosis was classified into neurological disorder groups and site. Results: Overall, 2,606
clinical neurological patient files were included, with mean length of hospitalization of 16.7 days and a total of 325 readmissions (12.5%).
The overall mortality rate in the ward was 3.8% (100 patients). Among all the diagnoses, cerebrovascular disease was the most prevalent
(45.8%), followed by inflammatory disorders (22.2%). The brain was the most common lesion site (66.0%), followed by peripheral nerves
(10.0%) and meninges and cerebrospinal fluid (7.7%). Conclusions: The disease pattern upon admission showed that a majority of the cases
consisted of cerebrovascular disorders and that the brain was the most frequently affected structure, although we observed that a wide
variety of cases were admitted, encompassing all neurological disorders.
Keywords: Neurology; Patients’ Rooms; Prevalence; Disease.

RESUMO
Introdução: As doenças neurológicas representam importante causa de morbidade e mortalidade globalmente, mas informações
acerca de internações hospitalares em neurologia no Brasil são limitadas. Objetivo: Investigar a prevalência de admissões neurológicas
por grupo de doenças e pela topografia atendidas em uma enfermaria de neurologia geral. Métodos: Estudo observacional e descritivo.
Avaliados diagnósticos de saída de acordo com o Código Internacional de Doenças-10 (CID-10) no período de setembro de 2008 a outubro
de 2019. Os diagnósticos foram classificados em grupos de doença e por topografia. Resultados: Foram incluídos 2,606 pacientes, com
tempo médio de internação de 16,7 dias e um total de 325 (12,5%) readmissões. A mortalidade geral na enfermaria foi de 100 (3,8%)
pacientes. A doença cerebrovascular foi mais prevalente (45,8%), seguida das doenças inflamatórias (22,2%). A topografia encefálica foi a
mais comum (66,0%), seguida de nervos periféricos (10,0%), meninges e líquido cefalorraquidiano (7,7%). Conclusões: O perfil de doenças
observado neste estudo demonstrou maior prevalência das doenças cerebrovasculares e da topografia encefálica, embora uma grande
variedade de doenças tenha sido admitida dentro do espectro de doenças neurológicas.
Palavras-chave: Neurologia; Enfermaria; Prevalência; Doença.

Universidade Federal de São Paulo, Escola Paulista de Medicina, Disciplina de Neurologia, São Paulo SP, Brazil.
1

Daniel Gabay MOREIRA https://orcid.org/0000-0002-5918-185X; Enedina Maria Lobato de OLIVEIRA https://orcid.org/0000-0002-4939-7200;

Fernando Morgadinho dos Santos COELHO https://orcid.org/0000-0002-8482-3754; Henrique Ballalai FERRAZ https://orcid.org/0000-0002-3821-1407;
Silvio FRANCISCO https://orcid.org/0000-0001-9179-8764; Vanderci BORGES https://orcid.org/0000-0002-8723-2757;
Denis Bernardi BICHUETTI https://orcid.org/0000-0002-4011-3734
Correspondence: Denis Bernardi Bichuetti; Email: [email protected].
Conflict of interest: There is no conflict of interest to declare.
Authors’ contributions: DBB: contributed to study conception and design, acquisition of data, analysis and interpretation and critical review of the manuscript
for important intellectual content. DGM: contributed to study conception and design, acquisition of data, analysis and interpretation and critical review of
the manuscript for important intellectual content. EMLO, FMSC, VB, SF and HBF contributed to critical review of the manuscript for important intellectual
content. Statistical analysis was performed by DGM and DBB.
Received on June 28, 2020; Received in its final form on September 16, 2020; Accepted on September 20, 2020.

478
INTRODUCTION We reviewed all 6,717 entries from patients admitted
from 2008 to 2019. The patients were assembled in a data-
Neurological disorders account for nearly 12% of total base of diagnoses that was created in accordance with the
deaths globally and are the main cause of overall disease International Classification of Diseases, 10th edition (ICD-10),
burden, which is represented by the number of years of upon medical discharge. Since the hospital system combines
healthy life lost as the result of disability. The World Health clinical and surgical patients, we excluded from the analysis
Organization (WHO) has estimated that morbidity due to all non-clinical neurological patients, i.e. cases of nervous
neurological diseases has overtaken diseases consequent system tumors, traumatic brain and spine injury, Parkinson
to HIV/AIDS and malignant neoplasm1. In the United disease admitted for implantation of deep brain stimulation,
Kingdom National Health Service, one in every six people central vascular malformations (such as intracranial aneu-
has a neurological condition and deaths due to neurologi- rysm and arteriovenous malformation) and, hydrocepha-
cal causes increased by 39% between 2001 and 2014, while lus. Also, any records with incomplete data were excluded.
all other causes of death decreased by 6% over the same Only patients older than 12 years were included, since this is
period2. It has been is estimated that this impact is even an adult-only ward.
greater in developing countries than in higher-income The following variables were collected: age, sex, length
nations3. In Brazil, data relating to the distribution of neu- of stay, readmission, clinical outcome (death or discharge)
rological disorders is scant. Most of the studies investigat- and ICD-10 diagnosis. We subsequently classified the ICD-10
ing this have drawn a profile of these diseases in outpatient diagnoses into neurological disease groups and lesion
care settings4,5,6. sites, in order to understand whether residents and stu-
Hospital São Paulo is a major tertiary care hospital dents were encountering different diseases, with an oppor-
located in the southern district of São Paulo, a megalopolis tunity to evaluate patients within the entire spectrum of
with a population greater than 21 million inhabitants7. It is neurological symptoms, thus fulfilling the academic pur-
the major teaching hospital for Escola Paulista de Medicina, pose of the unit. The neurological diseases were grouped
the medical school of the Universidade Federal de São Paulo. as degenerative, metabolic, seizures, infectious, inflam-
The Neurology ward of Hospital São Paulo is responsible for matory, cerebrovascular and unclassified. The lesion site
medical assistance for all neurological admissions from the groups were the brain (comprising brain, midbrain and
Neurology and Neurosurgery Department, one of most tra- cerebellar lesions), cerebrospinal fluid, spine, peripheral
ditional centers for Neurology training across the country. nerves, neuromuscular junction or muscle, multiple site
This unit has 18 beds: eight dedicated to clinical Neurology and unclassified.
and ten to Neurosurgery. A multidisciplinary team that The analysis was performed using Microsoft Excel® and
includes residents from Neurology, Nursing, Physiotherapy, Epi-InfoTM 7. Quantitative variables were presented as means
Psychology and Speech and Language Pathology, all of them and standard deviations, while qualitative variables were
supervised by skilled tutors, is responsible for the medical presented as absolute numbers and percentages.
assistance8.
To better understand the prevalence of major inpatient
neurological disorders that are being cared for in the scenario RESULTS
of the 21st century, we designed a retrospective study with
prospectively acquired data on all admissions to the general Overall, 2,606 patients with clinical neurological diag-
Neurology ward over a period of 11 continuous years. noses were included for analysis. Table 1 describes the
demographic and general characteristics of the admis-
sions included during the study period. The largest group
METHODS was of cerebrovascular diseases (45.8%), followed by
inflammatory (22.2%) and unclassified (13.8%) (Figure 1)
This was a retrospective, descriptive and observational (Table 2). The group with unclassified diagnoses encom-
study that used prospectively acquired data. It evaluated passed patients discharged due to headache and single
all patients admitted to the Neurology ward of Hospital nerve impairments. The rest of the groups had each a per-
São Paulo, which is part of the public healthcare system centage incidence inferior to 10%.
of Brazil, over the period from September 2008 to October The most common lesion site was the brain (66.00%), fol-
2019. The study was approved by the ethics committee of lowed by peripheral nerves (10.0%), meninges and cerebro-
the Federal University of São Paulo. The patients’ medical spinal fluid (7.7%) and spinal cord (6.6%) (Figure 2) (Table 2).
records were obtained from the hospital system database, The  other anatomical lesion sites each had proportions
which collects information at the time of patient discharge. smaller than 5%. It is important to note that the multiple
Thus, the study was exempted from obtaining individual site group only included diagnoses of encephalomyelitis.
consent through a statement. The unclassified group represented general ICD-10 codes, for

Moreira DG et al. Neurology ward in a Brazilian university hospital 479

 Table 1. Demographics of the 2,606 admissions over an 11- situations in which it was not possible to be certain of the
year period. correct lesion site, such as when the discharge diagnosis was
n % filled out as “unspecified demyelinating disease of the central
Age (n=2,606) nervous system” or “other degenerative specified diseases of
Mean±SD 48.8±18.0 - the nervous system”.
12–20 136 5.2
21–30 361 13.8
31–40 431 16.5
Table 2. Groups according to neurological disorders and lesion
41–50 393 15.1 site admitted to the neurology ward.
51–60 521 20.0 n %
61–70 438 16.8 Neurological disorders (n=2,606)
71–80 241 9.3 Cerebrovascular 1192 45.7
81–90 75 2.9 Inflammatory 579 22.2
91–99 10 0.4 Seizures 201 7.7
Sex (n=2,606) Infectious 183 7.0
Female 1,361 52.2 Degenerative/metabolic 91 3.5
Male 1,245 47.8 Unclassified 360 13.8
Length of stay (days) Lesion site (n=2,606)
Mean 16.6 - Brain 1720 66.0
Admissions (n=2,606) Peripheral nerve 261 10.0
1 admission
st
2,281 87.5 Meninges and cerebrospinal fluid 200 7.7
Readmission 325 12.5 Spine 163 6.3
Clinical outcome (n=2,606) Muscle 126 4.8
Discharge 2,506 96.2 Multiple sites 63 2.4
Death 100 3.8 Unclassified 73 2.8
Total 2,606 100.0 Total 2,606 100.0

Figure 1. Groups of neurological disorders admitted to the Neurology ward (n=2,606).

480 Arq Neuropsiquiatr 2021;79(6):478-482

Figure 2. Groups according to lesion sites, admitted to the Neurology ward (n=2,606).

DISCUSSION headache, seizures, cerebrovascular diseases and demen-

tia syndrome4,5. We categorized headache diagnoses in the
Inpatient care is clinically challenging, demands multi- unclassified group, as they most likely represent a symptom
disciplinary coordinated care and is potentially high-priced, of inpatients’ final diagnoses, rather than a separate disease.
especially in academic hospitals9. Comprehending a unit’s Nonetheless, headache was included in the third most preva-
profile of patient admissions and disease prevalence is a first lent group among neurological admissions.
step towards organizing this care and shaping educational The diagnostic process varies among diseases and dis-
programs in university hospitals. tinct specialties. There are three major spectra: clinical-dom-
Cerebrovascular diseases are the largest cause of neuro- inant, laboratory-dominant and neuroimaging-dominant15.
logical admissions worldwide, with frequencies ranging from The role of neuroanatomy in understanding and determin-
47.5 to 62%. Infectious diseases and seizures alternate in the ing possible lesion sites has long been established within the
second and third position, ranging from 3.9 to 21.8% and 4.8 approached to neurological disorders. This is vital for guiding
to 9.8%, respectively10,11,12,13. In one of the few Brazilian inpa- investigation and neurological rationale, especially in aca-
tient series available, the cerebrovascular group was the most demic centers16. In our series, the brain was the site predom-
prevalent, with a frequency of 51%14. In our ward too, cerebro- inantly affected, which was not surprising considering that
vascular diseases were the most prevalent group, followed by nearly half of our admissions were due to cerebrovascular dis-
inflammatory diseases, mainly composed of multiple sclero- ease, followed by inflammatory diseases mainly encompass-
sis, neuromyelitis optica, myasthenia gravis, Guillain-Barré ing relapses of multiple sclerosis and central nervous system
syndrome and optic neuritis alone. This might be explained demyelinating and inflammatory diseases. Nevertheless, we
by the fact that Hospital São Paulo has specialized Neurology found that all areas of Neurology and neurological clinical
outpatient clinics that care for demyelinating and neuromus- sites were being seen, which was in keeping with the purpose
cular disease. Besides  being the hospital’s main provider of of an academic unit.
acute care, our emergency unit is also an open walk-in clinic, This study was not intended to be a complete review
so many patients with inflammatory diseases without diag- of clinical admissions or treatment results, which would
noses come to our hospital seeking care. require a complete chart review of all admitted patients.
The outpatient scenario in Brazil differs from the hospi- The fact that we excluded all possible surgical patients might
talization profile, given that the most common complaints have reduced the number of patients cared for by clini-
or diseases seen in neurological consultation offices are cal Neurology residents that we evaluated, given that some

Moreira DG et al. Neurology ward in a Brazilian university hospital 481

 neurosurgical patients might first have been admitted to admitted to the ward. This biases the inpatient population
clinical care and investigation, and were then moved to surgi- towards those with more complex diseases and longer stays.
cal care. Moreover, this study embraces a common limitation In conclusion, in this Brazilian general Neurology ward,
of database studies, i.e. situations of incomplete or incorrect lesions to the brain and cerebrovascular diseases accounted
input of data. To surmount this, a complete review of all med- for the major causes of neurological admissions. The present
ical records would need to be conducted, which was beyond findings contribute to a better understanding of hospital-
the objectives of this report. Furthermore, it is worth men- ized neurological patients and can help in future planning of
tioning that patients seeking care in Hospital São Paulo are allocation of effort and medical assistance priorities, as well
first assisted in the neurological emergency service and many as guiding academic centers in organizing their rotations to
receive their complete medical treatment there and are not cover the full spectrum of neurological care.

References

1. Aarli JA, Dua T, Janca A, Muscetta A. Neurological disorders: public 10. Ezeala-Adikaibe BA, Aneke E, Orjioke C, Okafor HU, Ezeala-
health challenges. Geneva: WHO Press; 2007. Adikaibe NP, Mbadiwe N, Chime P, et al. Neurological admissions
2. The Neurological Alliance. Neuro numbers 2019: a report by at Enugu State University Teaching Hospital: a 5-year
Neurological Alliance. London: The Neurological Alliance; 2019. retrospective review. J Exp Res. 2018;6(2):1-10. https://doi.
org/10.4103/2141-9248.133472
3. Pandey S. Challenges in neurological practice in developing
countries. Indian J Public Health. 2012; 56(3):227-30. https://doi. 11. O Eze C, A Kalu U. Pattern of neurological admissions in the tropics:
org/10.4103/0019-557x.104253 experience at Abakaliki South-Eastern Nigeria. Niger J Med.
2014;23(4):302-5.
4. Antonio TJO, Ribeiro CP, Santos DT, Henriques VM, Silva LCL, Vieira
FG. The main neurologic diagnoses from a neurology outpatiente 12. Chowdhury RN, Hasan HATM, Rhaman YU, Khan SI, Hussain AR,
clinic in Rio de Janeiro, Brazil. Neurol Int. 2019;11(2):33-6. https:// Ahsan S. Pattern of neurological disease seen among patients
doi.org/10.4081/ni.2019.8129 admitted in tertiary care hospital. BMC Res Notes. 2014;7(202):1-5.
5. De Marchi Assuncao C, Taques CH. Profile of neurological disorders https://doi.org/10.1186/1756-0500-7-202
in an adult neurology clinic in Araucária Brazil. J Neurol Sci. 13. Gajurel BP, Parajuli P, Nepali R, Oli KK. Spectrum of neurological
2017;381:433-4. https://doi.org/10.1016/j.jns.2017.08.3437 disorders admitted in Tribhuvan University Teaching Hospital
6. Ferri-de-Barros JE, Nitrini R. Que pacientes atende um Maharajgunj. JIOM Nepal. 2012; 34(3):50-3. https://doi.org/10.3126/
neurologista? Alicerce de um currículo em neurologia. Arq jiom.v34i3.8918
Neuro-Psiquiatr. 1996;54:637-44. https://doi.org/10.1590/s0004- 14. Bacellar A, Pedreira BB, Costa G, Assis T. Frequency, associated
282x1996000400013 features, and burden of neurological disorders in older adult
7. EMPLASA. Sobre a região metropolitana de São Paulo. São Paulo: inpatients in Brazil: a retrospective cross-sectional study. BMC
EMPLASA. 2019. [accessed on Mar 28, 2020]. Available at: https:// Health Serv Res. 2017;17(504):1-8. https://doi.org/10.1186/s12913-
emplasa.sp.gov.br/RMSP 017-2260-x

8. Ferraz HB, Neves AC. Neurology at Escola Paulista de Medicina 15. Dhand A, Bucelli R, Varadhachary A, Tsiaklides M, De Bruin G,
(1933-1995): from Fausto Guerner to José Geraldo Camargo Dhaliwal G. Monitoring the diagnostic process on an inpatient
Lima. Arq. Neuro-Psiquiatr. 2015;73(2):166-9. https://doi. neurology service. Neurohospitalist. 2017;7(3):132-6. https://doi.
org/10.1590/0004-282x20140211 org/10.1177/1941874416677681
9. Josephson SA, Engstrom JW, Wachter RM. Neurohospitalists: 16. Vogt C, Vogt O. Importance of neuroanatomy in the field of
an emerging model for inpatient neurological care. Ann Neurol. neuropathology. Neurology. 1951;1(5). https://doi.org/10.1212/
2008;63(2):135-40. https://doi.org/10.1002/ana.21355 wnl.1.5.205

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