Impact of "Stroke Code"-Rapid Response Team: An Attempt to Improve Intravenous Thrombolysis Rate and to Shorten Door-to-Needle Time in Acute Ischemic Stroke.

OBJECTIVE: "Stroke code" (SC) implementation in hospitals can improve the rate of thrombolysis and the timeline in care of stroke patient. MATERIALS AND METHODS: A prospective data of patients treated for acute ischemic stroke (AIS) after implementation of "SC" (post-SC era) were analyzed (2015-2016) and compared with the retrospective data of patients treated in the "pre-SC era." Parameters such as symptom-to-door, door-to-physician, door-to-imaging, door-to-needle (DTN), and symptom-to-needle time were calculated. The severity of stroke was calculated using the National Institutes of Health Stroke Score (NIHSS) before and after treatment. RESULTS: Patients presented with stroke symptoms in pre- and post-SC era (695 vs. 610) and, out of these, patients who came in window period constituted 148 (21%) and 210 (34%), respectively. Patients thrombolyzed in pre- and post-SC era were 44 (29.7%) and 65 (44.52%), respectively. Average DTN time was 104.95 min in pre-SC era and reduced to 67.28 min (P < 0.001) post-SC implementation. Percentage of patients thrombolyzed within DTN time ≤60 min in pre-SC era and SC era was 15.90% and 55.38%, respectively. CONCLUSION: Implementation of SC helped us to increase thrombolysis rate in AIS and decrease DTN time.

Problems and limitations in thrombolysis of acute stroke patients at a tertiary care center.

AIM: (1) To evaluate the number of patients thrombolysed within 1 h of arrival to emergency room (ER) (2) To identify reasons for delay in thrombolysis of acute stroke patients. MATERIALS AND METHODS: All patients admitted to ER with symptoms suggestive of stroke from January 2011 to November 2013 were studied. Retrospective data were collected to evaluate ER to needle (door to needle time [DTNt]) time and reasons for delay in thrombolysis. The parameters studied (1) onset of symptoms to ER time, (2) ER to imaging time (door to imaging time [DTIt]), (4) ER to needle time (door to needle) and (5) contraindications for thrombolysis. RESULTS: A total of 695 patients with suspected stroke were admitted during study period. 547 (78%) patients were out of window period. 148 patients (21%, M = 104, F = 44) arrived within window period (<4.5 h.). 104 (70.27%) were contraindicated for thrombolysis. Majority were intracerebral bleeds. 44 (29.7%) were eligible for thrombolysis. 7 (15.9%) were thrombolysed within 1 h. The mean time for arrival of patients from onset of symptoms to hospital (symptom to door) 83 min (median - 47). The mean door to neuro-physician time (DTPt) was 32 min (median - 15 min). The mean DTIt was 58 min (median - 50 min). The mean DTNt 104 (median - 100 min). CONCLUSION: Reasons for delay in thrombolysis are: Absence of stroke education program for common people. Lack of priority for triage and imaging for stroke patients.

Pre- and posttreatment MR imaging findings in lead encephalopathy.

A 41-year-old man suspected of having lead poisoning was evaluated with MR imaging before and after British antilewisite therapy. The MR imaging findings showed bilateral symmetric involvement of the occipital lobe, affecting predominantly the gray-white matter junction and the subcortical white matter. A right cerebellar lesion was noted, with focal hyperintensities involving the gray-white matter. Similar lesions were seen in the temporal, parietal, and frontal regions. These lesions resolved after chelation therapy.

Overlap myasthenic syndrome.

This is a report of a case of overlap myasthenic syndrome i.e. one which has the feature of both myasthenia gravis and lambert Eaton myasthenic syndrome (LEMS). The patient had first thyrotoxicosis and then was seen with bulbar and limb weakness andEMG showed decrement on repetitive tests at 3Hz. A second admission was for what appeared to be an axonal degeneration neuropathy with respiratory embarrassment. This was based on nerve conduction studies showing low muscle action potentials in all muscles with normal conduction velocities. There was a good response to steroids and relapse on stopping steroids and on the third admission all the electrophysiologic features of LEMS were noted. At his time the patient had bulbar and facial weakness and an excellent response to Prostigmine suggesting associated myasthenia gravis. This is the first overlap myasthenic syndrome reported from India.

Superficial siderosis of the nervous system.

A male patient had been operated in 1990 at a different hospital for a suprasellar mass lesion causing progressive blindness. At exploration, the mass was felt to be inflammatory in nature with arachnoiditis and hydrocephalus. Deep yellow staining of tissues round the mass was recorded at the time of first surgery. The patient was readmitted in 1996 for progressive visual failure, ataxia, mental changes and deafness. MRI confirmed persistence of suprasellar mass and showed the characteristic findings of superficial siderosis of CNS. On reexploration, the mass had multiple vessels over the walls and contained xanthochromic fluid. It was excised and histologically examined to be an epidermoid with a cyst. The patient developed chest infection, became drowsy and died. The MRI picture, the CSF finding and the yellow staining of tissue confirmed the diagnosis of superficial siderosis of the CNS, which was first thought of after seeing the diagnostic MRI. The cause of the superficial siderosis was recurrent bleeding from the tumour.

Renal cell carcinoma as significant manifestation of tuberous sclerosis complex.

We present a case of renal cell carcinoma diagnosed in 1982; aged 20 years. Regular follow up of the abdomen by USG noted first the presence of 2 nodules in the remaining kidney in 1994, age 30 and more lesions in 1997, aged 35. These were suspected to be angiomyolipomas on USG. The radiologist on this basis raised the question of tuberous sclerosis. Subsequent evaluation by internist/neurologist showed few adenoma sebaceum lesions a single ash leaf macule, a shagreen patch on the back, and characteristic multiple subependymal calcifications diagnostic of tuberous sclerosis on CT scan brain. The mentation was normal, there was history of only a single fit in childhood. The renal cell carcinoma was thus the first significant manifestation of tuberous sclerosis complex (TSC).

Neurological manifestations of HIV disease.

We report the results of neurological evaluation of 1,527 HIV positive subjects. Neurological complications were seen in 457 patients (481 neurological events). The prevalence was 20.24% of patients attending the out-patient clinic and in 44.57% of in-patients. Involvement of all levels of neuraxes was documented. The commonest manifestations were neuropathies, including herpes zoster (28.27%), meningitis (17.88%) and mass lesions (16%). Cryptococcal meningitis was clearly commoner than tubercular meningitis (67.44% vs 18.60% of all cases of meningitis, respectivelv). Amongst mass lesions, 14/24 single lesions and 27/38 multiple lesions responded to anti-toxoplasma treatment and were diagnosed as CNS toxoplasmosis. In abscence of biopsy, it would be prudent to initiate empirical anti-toxoplasma treatment for all HIV patients with mass lesions and assess clinical and radiological response. To our knowledge this is the largest series of neurological manifestations of HIV disease documented in Indian literature.