Epidemiology of stroke: findings from a community-based survey in rural Bangladesh.

OBJECTIVES: This study was designed to determine the epidemiology of stroke in a rural population of Bangladesh. STUDY DESIGN: In a cross-sectional study, we surveyed stroke patients. METHODS: The survey was conducted in a rural community of Bangladesh from January 2016 to June 2016. All community members 15 years and older in a surveillance system were included in this study. The Questionnaire for Verifying Stroke-Free Status was used to screen stroke cases at household level which were again examined by the neurologist for confirmatory diagnosis. RESULTS: The prevalence of stroke was 1.96 (95% confidence interval [CI] 1.69-2.26) per 1000 population. The highest prevalence was 9.65 (95% CI 7.42-12.33) per 1000 population, identified among patients aged 65-79 years. Males had higher prevalence (2.38 per 1000 population) than females (1.55 per 1000 population). Of the 24% of patients who had radiological examination (magnetic resonance imaging and computed tomography scan) reports, 17.2% of stroke cases were ischemic, 4.8% were intracerebral, and about 1.1% were subarachnoid. The ratio of infarction to hemorrhage was 2.91. Approximately 67% of patients were diagnosed as hypertensive, and 37% of patients had elevated blood glucose level. While 15% of patients were found to be overweight or obese, 45% of patients had raised blood cholesterol level. More than 10% of patients reported that they had heart disease before the occurrence of stroke. About 40% of patients had the history of tobacco consumption. CONCLUSIONS: The prevalence of stroke is higher among elderly and male populations. A significant proportion of patients presented with hypertension and/or diabetes.

Digital Subtraction Angiography is Superior to Magnetic Resonance Angiography in Diagnosis of Cerebral Arteriovenous Malformation.

This study was carried out to compare MRA and DSA in diagnosis of cerebral AVM. It was a retrospective observational study conducted in the Department of Neurology Dhaka Medical College Hospital (DMCH), Dhaka during the period of January 2010 to December 2010. Thirty patients with haemorrhagic stroke age ranging from 13 to 65 years were selected on the basis of inclusion and exclusion criteria as the study sample. MRA and DSA were done in all the selected patients. The mean age of the patients of haemorrhagic stroke was 30.3 ± 14.3 years and male female ratio was 2.7:1. Regarding the venous drainage of AVM 13 and 12 were superficial and deep respectively, and evaluated 100% by MRA. In the diagnosis of cerebral AVM nidus size S1: <3 and S2: 3-6 cm sensitivity was 100% but accuracy was 100% and 73.3% respectively. DSA was 100% sensitive in the diagnosis of superficial and deep venous drainage AVM. Regarding the eloquence of brain area 15 had no eloquence by both MRA and DSA and identification of eloquence of brain area sensitivity was 73.3% and accuracy was 86.7%. The main feeding vessels was found (22, 73.3%) in both DSA and MRA findings. Distal vessels was seen (8, 26.7%) in DSA but not seen in MRA findings. Intranidal aneurysm and Angiopathic AVM were seen in 3(10.0%) and 4(13.3%) respectively in DSA. This study was carried out to diagnose the patients presented with cerebral AVM by MRA and DSA. MRA could not be evaluated flow status of AVM, distal feeding arteries, intranidal aneurysm and angiopathic AVM which could be detected by DSA. So, DSA is superior to MRA in diagnosis of cerebral AVM.

Socio-demographic characteristics, types and Slit Skin Smear (SSS) of the leprosy patients: a hospital based study.

This study was aimed to identify the socio-demographic profile, to know the types and to find out the Slit Skin Smear (SSS) result associated with leprosy. It was a descriptive type of cross sectional study. Total 62 patients having clinical features of leprosy, attending in Department of Neurology of Mymensingh Medical College Hospital (MMCH) and Mymensingh Tuberculosis and Leprosy Hospital, Mymensingh from January 2010 to December 2011 were included. Patients underwent a detailed clinical evaluation followed by laboratory investigations. Out of 62 cases, the results showed that the mean age of leprosy patients were 37.8±14.6 years with the age range 12-80 years and the peak incidence was between 20-40 years. The frequency of male and female was 70.9% and 29.1% respectively with M: F of 2.4:1. From rural area 74.2% leprosy patients and 25.8% patients were from urban area and mainly day-labours (25.8%) and housewife (24.2%) by occupation. Married was 87.1% of patients and 12.9% were unmarried. Twenty one percent (21%) leprosy patients were found contact with leprosy. It was observed in this study that, 35.5% patients were PB (Pauci Bacillary) group and 64.5% of the patients were in MB (Multi Bacillary) group. Lepromatous Leprosy (LL) patients were (17.7%) and Borderline Lepromatous (BL) patients were (11.3%). Patients with Tuberculoid Type (TT) were (3.2%) and patients with Borderline Tuberculoid (BT) were (61.3%). The result of Slit skin smear (SSS) examination was negative in 59.7% patients and positive in 40.3%.

Stroke in Bangladeshi patients and risk factor.

To evaluate comprehensively the distribution of established risk factors of stroke among Bangladeshi patients. This is an observational study. It involved 8400 stroke patients from different hospitals in Bangladesh over a period of sixteen years. Common established risk factors of stroke e.g. age, sex, family history, hypertension, diabetes, ischemic heart disease, smoking, obesity, dyslipidaemia, alcoholism, use of oral contraceptive pill, lack of fresh fruit consumption etc. were evaluated in these patients through a preformed questionnaire and data were analyzed. Majority of the stroke events occurred after the age of forty (82.3%) and the ischemic stroke (72%) is the most common. Apart from non modifiable risk factors (advancing age, sex, Family history of stroke) hypertension was the most common modifiable risk factor found in stroke patients (57.6%) followed by smoking (44.6%), tobacco use (24.3%), OCP use in female (40% of female stroke), diabetes (23%), ischemic heart disease (17.1%), obesity (10.6%) and dyslipidaemia (5.3%). Lack of fresh fruit consumption and alcoholism were found in some of the patients. Stroke is common after the age of forty. Ischemic events are commonest type of stroke. Hypertension, smoking, tobacco use, diabetes and ischemic heart disease were five most common risk factors of stroke. Outlining the common stroke risk factors in our settings, may help the physicians and care givers in managing this disabling disease properly.

Prevalence of stroke above forty years.

Number of elderly persons gradually increased in Bangladesh due to improved health awareness and health care. Age is the single most important risk factor for stroke. This study aims at finding the prevalence of stroke in a Bangladeshi population aged forty years and above. The cases of stroke were ascertained in two phases of door-to-door survey. In phase-I, trained interviewers performed face-to-face interview with subjects for the detection stroke cases using the World Health Organization (WHO) screening protocol for neurological diseases. In phase-II, subjects suspected to have a stroke underwent a clinical evaluation for diagnosis or exclusion of stroke by a neurological team. The study involved 15627 participants aged 40 years and above. A total of 47 participants found to have stroke, expressing an overall prevalence rate of 3.00 per 1000 (95% CI 0.95 to 2.45). Prevalence of stroke were 2.0, 3.0, 2.0, 10.0, and 10.0 per 1000 within age groups of 40-49 years, 50-59 years, 60-69 years, 70-79 years and 80 years and above age group respectively. Prevalence of stroke in people with age range 70-79 years compared to 40-49 years age range is 4.988 (95% CI 2.309 to 10.77) times and people with age range ≥80 years compared to 40-49 years age range is 4.798 (95% CI 1.597 to14.416) times. Prevalence was higher among men in comparison with women. The male: female ratio is 3.44:2.41 per 1000 respectively. Bangladeshi male populations in rural areas are found to have stroke more than urban people. A large community based study should be undertaken to further confirm the result of this present study.

Effect of dexamethasone on brain oedema following acute ischemic stroke.

A randomized clinical trial was conducted to asses the effects of dexamethasone on brain oedema following acute ischemic stroke in the departments of Medicine of different hospitals from July, 2003 to December, 2006. A total of 60 patients were included in the study. They were divided into two groups keeping the similarity regarding the age, sex and severity of the stroke between two groups. There were 30 patients in experimental group and 30 in control group. The level of consciousness was compared by Glasgow Coma Scale (GCS) on 3rd, 7th and 10th day of intervention and improvement was found in both the groups, but the improvement of level of consciousness was statistically significant in Dexamethasone treated group. The volume of hypodense area did not differ significantly in two groups in CT scans before and after treatment (p=0.74). The study results demonstrate that Dexamethasone improves the level of consciousness in acute ischemic stroke associated with brain oedema but did not reduce volume of hypodense area.

Endovascular embolization of life threatening intracranial arterio-venous malformation.

Haemorrhagic stroke from cerebral arteriovenous malformations (AVMs) represents 2% of all hemorrhagic strokes. A clear understanding of the diagnostic and treatment algorithms of cerebral AVM management is very important, because AVMs are a cause of hemorrhage in young adults. Surgery, endovascular therapy, and radiosurgery can be used alone or in combination to treat an AVM. We reported a 40 years old man of cerebral arteriovenous malformation (AVM), complicated with intracerebral hemorrhage (ICH). Digital subtraction angiogram was done for diagnosis and endovascular embolization for treatment of the case. This is the first successful cerebral arteriovenous malformations (AVMs) embolization in any government hospital of Bangladesh. The aim of this case report is to inform about this new technologies and emerging treatment strategies in these areas.

Epilepsy and abnormal electroencephalogram in children with autism spectrum disorder.

Epilepsy occurs in 30 to 40% of individuals with autism spectrum disorder (ASD). However the association of epilepsy or abnormal electroencephalogram is not known in our population. This study addresses the incidence of epilepsy and or abnormal electroencephalogram in Bangladeshi children with autism spectrum disorder. The clinical history and electroencephalogram of 18 children diagnosed with autism spectrum disorder were retrospectively reviewed. Forty four percent were diagnosed with epilepsy or abnormal electroencephalogram. This abnormal electroencephalogram or epilepsy occurred at significantly higher rates in children with more impaired range of autism spectrum disorder. These finding suggest that the use of neurological investigative technique such as electroencephalogram (EEG) should be considered routinely in children with autism spectrum disorder especially in more impaired individuals.

Tuberculosis of the central nervous system.

Tuberculosis can involve any organ system of the body. Although rare tuberculosis of nervous system (NS) is not uncommon in our country. In the nervous system tubercle bacilli can cause tuberculous meningitis, abscess , tuberculoma in brain & spinal cord. Untreated Central Nervous System (CNS) tuberculosis is devastating. Early diagnosis & prompt treatment of NS is essential to avoid morbidity & mortality. Tubercle bacilli causes chronic caseating granulomatous lesion. Tubercular meningitis presents with fever, headache, neck stiffness & cranial nerve palsy. Tuberculoma may present with headache, seizure and focal deficit. In the spinal cord tuberculoma or tubercular abscess may result in para paresis or quadri-paresis. For diagnosis of nervous system tuberculosis CSF analysis and neuroimaging are important. CSF cell count, Gram staining, Culture and Polymerase Chain Reaction (PCR) are helpful for diagnosis. Imaging helps in the diagnosis of tuberculoma and tubercular abscess. Computed tomography (CT) guided Fine Needle Aspiration for Cytology (FNAC) helps to establish the histopathological diagnosis. Use of combination antitubercular drugs for long period (12-18 months) is necessary to treat nervous system tuberculosis.

Axonal variant of Guillain-Barre syndrome associated with Campylobacter infection in Bangladesh.

BACKGROUND: Campylobacter jejuni enteritis is the predominant bacterial infection preceding Guillain-Barré syndrome (GBS), an acute postinfectious immune-mediated polyradiculoneuropathy. The purpose of this study was to define the clinical phenotype of GBS and the relation with preceding C jejuni infections in Bangladesh. METHODS: We performed a prospective matched case-control hospital surveillance including 100 patients fulfilling the National Institute of Neurological Disorders and Stroke criteria for GBS from 2006 to 2007 in the Dhaka area of Bangladesh. Detailed clinical, electrophysiologic, serologic, and microbiologic data were obtained with a follow-up of 6 months. RESULTS: GBS affected predominantly young adult males living in rural areas. Sixty-nine percent of the patients had clinical evidence of a preceding infection. The most frequent symptom was diarrhea (36%). The majority of patients had a pure motor variant of GBS (92%) with relatively infrequent cranial nerve involvement (30%). Twenty-five percent of patients required respiratory support. Electrophysiologic studies showed that 67% of patients had an axonal variant of GBS. Eleven patients (14%) died, and 23 (29%) remained severely disabled during the follow-up. Positive C jejuni serology was found in an unprecedented high frequency of 57% as compared with 8% in family controls and 3% in control patients with other neurologic diseases (p < 0.001). C jejuni infection was significantly associated with serum antibodies to the gangliosides GM1 and GD1a, axonal neuropathy, and greater disability. CONCLUSIONS: We report an unusually high frequency of the axonal variant of Guillain-Barré syndrome in Bangladesh, associated with preceding Campylobacter jejuni infection, severe residual disability, and high mortality.

Fahr's disease: a very rare cause of epilepsy.

Fahr's disease, first described by Karl Theodor Fahr in 1930, refers to sporadic or familial idiopathic basal ganglia calcification that is associated with many neurological and psychiatric abnormalities, but may also be secondary to other diseases. Most cases present with extrapyramidal symptoms. But here we describe a case of Fahr's disease, who presented with complex partial seizure and behavioral abnormalities. On screening, the cause of seizure was found to be bilateral calcification of cerebellum, basal ganglia and thalamus, due to abnormal calcium and phosphate metabolism. A clinical diagnosis of complex-partial seizure with secondary generalization due to secondary Fahr's disease was done on the basis of clinical features, investigations, and exclusion of other causes of intracranial calcification.

Moyamoya disease presented as a case of hemiplegic migraine.

Moyamoya disease is a rare cerebral vasculopathy characterised by progressive narrowing of the major intracranial vessels and development of collateral vessels. Clinically, it presents with cerebral ischaemic or haemorrhagic events, with eventual severe morbidity and mortality. A 10-year-old girl presented with episodic vascular headache and transient left sided hemiparesis, which persisted for a few hours and was clinically labelled as sporadic hemiplegic migraine according to International Headache Society criteria. We investigated all possible causes of unusual headache. Cerebral digital subtraction angiogram was carried out and moyamoya disease was finally diagnosed.

Association of lipid profile with ischemic stroke.

This study is an observational case control study conducted in the Neurology department of Dhaka Medical college Hospital (DMCH) to see the relation of ischemic stroke with different components of serum lipids. Cases and controls were selected following certain inclusion and exclusion criteria. Result showed that ischemic stroke was more common after the age of 50 years with mean age of 63.58+/-10.22 years. Male suffered more than female from ischemic stroke (M:F=2.57:1). 80% of the stroke patients belong to middle class economic condition who avail free services of Govt. hospitals. Hypertension and diabetes mellitus (DM) were found to be significant risk factors for ischemic stroke (P<0.01 and P<0.05 respectively). High level of serum total cholesterol and low density lipoprotein (LDL) cholesterol showed significant risk in ischemic stroke (p<0.05). In contrast, low level of high density lipoprotein (HDL) cholesterol appeared as a significant risk factor (p<0.01) indicating beneficial effect of HDL cholesterol on atherosclerotic process. Serum triglyceride level showed no significant effect on ischemic stroke (p>0.05).

Diabetic neuropathy and zinc therapy.

This was a double blind study conducted on 60 subjects; 20 age and sex matched healthy controls (Group-I), 20 patients of diabetes mellitus with neuropathy who received placebo for 6 weeks (Group-IIA); and 20 patients of diabetes mellitus with neuropathy who were given oral 660 mg zinc sulphate for 6 weeks (Group-IIB). Serum zinc level, fasting blood sugar (FBS), blood sugar 2 hour after breakfast (2HABF) and motor nerve conduction velocity (MNCV) were estimated on day 0 and after 6 weeks in all subjects. Serum zinc levels were significantly low (p<0.001) in group II-A and II-B as compared to healthy controls (group-I) at base line. After 6 weeks the changes in pre and post therapy values of FBS, 2HABF and MNCV (median and common peroneal nerve) were highly significant (p<0.001) for group II-B alone with insignificant change (p>0.05) in group II-A. Therefore, zinc therapy helps in achieving better glycemic control and improvement in peripheral neuropathy as assessed by MNCV.

Risk factors & clinical presentations--a study of eighty-five hospital admitted stroke cases.

Stroke is the commonest neurological cause of morbidity and mortality. Changes in risk factors may influence stroke incidence. Definitive diagnosis of the type of stroke is necessary for management and it has a strong impact on stroke outcome. A total of eighty-five consecutive stroke patients irrespective of age and sex admitted during the period of August 2000 to June 2001 were studied. They were asked about occupation, area of habitat, smoking habit, family history of ischaemic heart disease and/or stroke, any febrile illness, recent history of productive cough, dysuria and diarrhoea. They were searched for hypertension, diabetes mellitus, ischaemic heart disease, valvular heart disease and dislipidaemia. In every patient complete blood count, urine examination, fasting blood glucose and serum lipids, ECG, x-ray chest were performed. CT scan of brain was performed in 68 cases. Male was found 81.18% of cases with age 62.54 +/- 13.08 (m +/- SD) years. Female were 18.82% of cases with age 58.81 +/- 12.77 (m +/- SD). 75.29% of patients were belongs to middle class family. 51.76% of patients came from rural area and 48.24% of patients came from urban area. 78.82% of patients were hypertensive. Infection was associated with 37.65% of cases. Hemiplegia was commonest presentation (88.24%). Though altered consciousness was found more in haemorrhagic stroke (54.84%) but it was not significantly. High from ischaemic cases (p > 0.10) Male suffer more from stroke. Hypertension is the commonest risk factor. Infection is a common association of stroke. Altered consciousness is not a reliable guide to differentiate between ischaemic and haemorrhagic stroke is hospitalized cases.