Relationship between admission serum C-reactive protein and short term outcome following acute ischaemic stroke at a tertiary health institution in Nigeria.

BACKGROUND: There is evidence of an association between mediators of inflammation, particularly C-reactive protein (CRP), and outcome of acute ischaemic stroke. This provides a potential opportunity for interventions aimed at improving outcome. There is sparse data exploring the role of inflammatory markers such as CRP and stroke outcome in Africans. The study objective was to determine the association between admission serum CRP levels and short-term outcome in the Nigerian patient presenting with acute ischaemic stroke. MATERIALS AND METHODS: Consecutive patients hospitalized for first-ever acute ischaemic stroke at the Lagos University Teaching Hospital, Lagos, Nigeria, were prospectively enrolled between October 2007 and June 2008. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Serum CRP was determined on samples obtained within 7 days of stroke onset. All stroke patients were followed up till day 30 post-stroke. Outcome measures were 30 day Glasgow outcome scale score and functional impairment on the modified Rankin Scale (mRS). An age- and gender-matched healthy control group had serum CRP determined at inclusion. Elevated CRP was defined as any level above the cutoff (mean +2 x standard deviation of CRP level of controls). RESULTS: Eighty patients with acute ischaemic stroke (47 men and 33 women) and 40 controls (27 male and 13 female) (P = 0.47) were studied. Mean age in cases was 59.1 ± 15.0 years. Mean CRP was significantly higher in stroke cases than controls (17.7 ± 14.4 mg/L versus 1.1 ± 1.7 mg/L respectively) (P < 0.00001). The frequency of elevated CRP (>4.5 mg/L) was 76.3% in stroke (N = 61) and 5% (N = 2) in controls (P < 0.0001). The case fatality rate in stroke with elevated CRP (32.8%) was significantly higher than stroke with normal admission CRP (0%; P = 0.015). The association of higher admission CRP with fatality () was statistically significant (P < 0.0001). Amongst survivors, mean CRP levels were markedly higher in the patients with unfavorable motor outcome (moderate/severe disability; n = 22; 21.5 ± 11.1) compared to those with favorable outcome (mild disability; n = 38; 6.5 ± 6.2) (P < 0.00001). In multivariate regression analysis, only high NIHSS score (P = 0.004) and admission CRP (P = 0.008) were independently associated with case fatality. CONCLUSIONS: Elevated admission CRP and high NIHSS score are independent predictors of short-term case fatality and adverse functional outcome following acute ischaemic stroke in Nigerians.

Oro-dental and maxillofacial trauma in epilepsy at a tertiary hospital in Lagos.

BACKGROUND: Seizure-related injuries are common and are a major cause of morbidity in subjects with epilepsy. OBJECTIVE: To determine the frequency and types of oro-facial injuries in epileptic patients attending a tertiary hospital. METHODS: A structured questionnaire was used to obtain information about injuries to the oral and maxillofacial region in epileptic patients at the Neurology Clinic of the Lagos University Teaching Hospital over a period of two years. Information sought included patient's sociodemographics, type of seizure, self-management of seizures, and history of injuries during seizures. RESULTS: Of the 138 epileptic patients seen, 87 (63.0%) reported the occurrence of oral and maxillofacial injuries. Mean age of these patients (29.6±12.1 years) was not significantly different from that of those who had no injuries (33.5±15.6 years). Prevalence of seizure-related injuries was not significantly different in males and females (50 [58.8%] vs 37 [71.2%]). Injuries were more likely in those who had convulsive seizures than in those who had non-convulsive seizures. Patients who had hard objects forced between their clenched teeth during seizure episodes were more likely to sustain injuries. Soft tissue injuries were more common than injuries to the facial bones and teeth. Of these, the tongue was the most commonly injured. Majority of those with soft tissue injuries did not receive treatment in hospital. Although fractures of the cheek and jaw bones were not so common, all such cases received surgical treatment in hospital. CONCLUSION: A high proportion of epileptic patients in Lagos appear to suffer seizure-related oro-facial injuries. Measures for the prevention and management of these injuries are needed to help reduce the morbidity caused by such injuries.

Plasma homocysteine level and its relationship to clinical profile in Parkinson's disease patients at the Lagos University Teaching Hospital.

BACKGROUND: Hyperhomocysteinaemia (HHcy) is as a long-term sequelum of levodopa therapy in Parkinson's disease (PD). Information on its frequency and effects in Africans with PD is sparse. OBJECTIVE: To determine the frequency of HHcy and its relationship to clinical features of PD in African patients. METHODS: Using a case-control design, 40 consecutively attending PD patients and 40 age- and gender-matched healthy volunteering controls were studied. Parkinson's disease cases were evaluated for disease and treatment characteristics, using the Unified Parkinson Disease Rating Scale (UPDRS) motor and activities of daily living scores and disease stage (Hoehn and Yahr scale). Fasting total plasma homocysteine (Hcy) was determined in all subjects. Hyperhomocysteinaemia was defined as a Hcy level above the 90th percentile for the controls. RESULTS: Mean Hcy was 13.8 ± 5.4mmol/L in PD and 12.4±3mmol/L in controls (P>0.05). Hyperhomocysteinaemia (Hcy > 16.26umol/L) occurred in nine (22.5%) PD patients (all on levodopa) and 6 (15%) controls (P>0.05). Mean duration of levodopa use was 92 ± 105.3 months in PD with HHcy compared to PD patients with normal Hcy 33.9 ± 33.2 (p < 0.05). Disease severity and disability were similar regardless of Hcy levels. None of current age, disease duration, Hoehn and Yahr stage, UPDRS scores, total levodopa dose and duration was independent predictor of homocysteine level. CONCLUSION: There is increased occurrence of hyper-homocysteinaemia in Nigerian subjects with Parkinson's disease, receiving Levodopa. This hyperhomocysteinaemia is more common with prolonged use but appears to have no relationship with disease severity or disability.

Management of ischaemic stroke: the role of the neurosurgeon.

BACKGROUND: Neurosurgeons are often not involved in the management of patients with stroke in Nigeria. OBJECTIVE: To discuss the role of neurosurgeons in the management of ischaemic stroke. METHODS: We looked at the contributions that a neurosurgeon may be able to make in the care of the patient with an ischaemic stroke. The emphasis was on preventive and curative interventions in the surgical armamentarium of the neurosurgeon that could be of benefit to the patient. RESULTS: We presented some scenarios in patients with ischemic stroke that may require the assistance of a neurosurgeon. The article explored the role of preventive and definitive surgery in reducing morbidity and mortality in ischaemic stroke patients. CONCLUSION: There is a role for the neurosurgeon in the management of patients with ischaemic stroke. It is important that patients who might benefit from neurosurgical intervention are referred early for neurosurgical evaluation.

Prevalence and clinical characteristics of headache in medical students of the University of Lagos, Nigeria.

We investigated the 1-year prevalence, clinical features and mode of treatment of headache in medical students of the University of Lagos, Nigeria, using a self-administered headache questionnaire. Headache prevalence was 46.0% and was significantly higher in women than in men (62.8% vs. 34.1%). Prevalence of tension-type headache was higher than that of migraine (18.1% vs. 6.4%). Although tension-type headache had a similar prevalence in both sexes (male 17.3%, female 19.2%), migraine was three times more common in women (10.9% vs. 3.2%). A family history of headache was present in 22.0%. Only 4.6% sought medical assistance, whereas 68.2% took non-prescription drugs, mainly simple analgesics. Specific drugs for migraine and tension-type headache were rarely used. In conclusion, 1-year headache prevalence is high among medical students at this university. The low consultation rate and the rarity of usage of specific anti-headache drugs probably reflect inadequacies in the management of primary headaches in this population.

Recent developments in neurology.

OBJECTIVE: This review aims to highlight the significant developments in neuroscience and clinical neurology that have been recorded in the past few years. METHODS: Original research and reviews were identified by searching PubMed for articles published from January 1995 using the following search terms: recent, developments, advances, progress, neurology, and neuroscience. RESULTS: Notable strides have been made in the management of neurological conditions like stroke and epilepsy. There is also greater understanding of the pathogenesis of the neurodegenerative diseases, and some form of treatment is now available for previously 'untreatable' conditions like motor neuron disease and Alzheimer's disease. The application of the techniques of molecular genetics and molecular cell biology has advanced the understanding and diagnosis of several neurological disorders, such as Huntington's disease and myotonic dystrophy. Clinical neurology has also profited from the huge advances in structural and functional brain imaging that have taken place in recent years. Areas of current research include the potential use of stem cells to treat a wide variety of neurological disorders, and the use of nerve growth factors to promote regeneration of neurons in the central nervous system. CONCLUSION: Current advances in neurology and neuroscience hold the promise of new approaches to the understanding and management of neurological diseases.

Prospective case-control study of interictal depression and suicidal ideation in Nigerians with epilepsy.

BACKGROUND: Co-morbid depression and suicidal ideation in people with epilepsy (PWE) in developing countries are under-recognised, and so may be consequently undertreated. This study was designed to determine the frequency and clinical correlates of interictal depression and suicidal ideation in PWE. PATIENTS AND METHODS: Using a prospective design, we evaluated 96 PWE and two groups of controls (103 age- and sex-matched population controls and 13 persons with DSM - IV diagnosis of major depression (controls with depression - CWD) without epilepsy. Depression was assessed using Zung Self-rating depression scale (scores =40 indicating depression). RESULTS: Depression was more prevalent in PWE (25/96 i.e. 26.0%) than normal controls (10/103 i.e. 9.7%) (P = 0.004). Suicidal ideation scores were similar for depressed PWE and depressed normal controls (1.7 +/-1.0 v. 1.5 +/- 1.0; P>0.05), but significantly higher in CWD (2.61.3; P=0.04). Among PWE, mean duration of epilepsy (years) was the only variable significantly related to depression (i.e. 12.7 8.8 in depressed PWE v. 8.3 6.6 in non-depressed PWE (P=0.01). CONCLUSION: Depressive symptomatology is a frequent co-morbidity in our tertiary care population of PWE. However, suicidal ideation is less common in contrast to persons with major depression.

Comparative study of the effect of tocotrienols and -tocopherol on fasting serum lipid profiles in patients with mild hypercholesterolaemia: a preliminary report.

OBJECTIVES: Hypercholesterolaemia is a risk factor for cardiovascular diseases. Tocotrienols reportedly possess hypocholesterolaemic activity. This study examined the effect of tocotrienols (T3) in TOCOVIDTM Suprabio TM on serum lipids. Patients and Methods :A randomised (2:1), open-label study of patients with mild hypercholesterolaemia (= 5.18mmol/L to <7.77mmol/L) and one additional cardiovascular risk factor was carried out. Subjects received either tocotrienols (as TOCOVIDTM Suprabio TM ) (n=28) or vitamin E (a-tocopherol) 500mg daily (n=16). Fasting lipids were compared at baseline and after 4 weeks therapy. RESULTS: Following 4 weeks therapy, mean +/- SD total cholesterol declined significantly in the tocotrienol group (from 6.10+/-0.66 to 5.47+/-1.16; P=0.02) compared to the a-tocopherol group (from 5.92+/-0.52 to 5.47+/-0.76; P>0.05). Mean LDL-C levels (mmol/L) were also significantly reduced in the tocotrienol group (3.82+/-0.85 to 3.24+/-1.26; P=0.04), but not in those on a-tocopherol (3.84+/-0.75 to 3.28+/-0.94; P>0.05). There were no significant changes in HDL-C and triglycerides in both groups. The tocotrienol group experienced a net decline in TG (7.1+/-31.4 %; P>0.05) while the a-tocopherol group had a net increase at week 4 (38.6+/-61.7%; P>0.05). CONCLUSION: The study adds to existing evidence of the favourable effect of tocotrienols on total cholesterol and LDL-C. However, the results need further evaluation.

Stroke in young adults: report of three cases and review of literature.

OBJECTIVE: To highlight the occurrence, and review the literature on stroke in young adults. METHODS: This paper reports three cases of young strokes. Brain imaging was done for two cases. The two were haemorrhagic stroke; one from an identified arteriovenous malformation and the other from a suspected vascular malformation or intracranial aneurysm. The third case was a young man with nephrotic syndrome who presented with clinical features of a thrombotic stroke. A review of the literature on stroke in young adults was done via Medline search for relevant publications. RESULTS: The literature review shows that a thorough diagnostic work up is required in young adults with stroke if one is to identify the diverse, but often treatable, causes of stroke in this age group. CONCLUSION: Stroke is a significant, albeit uncommon, cause of mortality and morbidity in young adults.

Stroke in south west Nigeria: a 10-year review.

BACKGROUND AND PURPOSE: Stroke is a significant economic, social, and medical problem worldwide. This retrospective follow-up study aimed to review the pattern, types, and case fatality of stroke in Nigeria. METHODS: Records of all stroke patients admitted into Ogun State University Teaching Hospital (OSUTH), Sagamu, from December 1993 to November 2003 were reviewed. Patients were classified into hemorrhage or infarct using the World Health Organization criteria. Information was obtained as to the time of death in those who died and case fatality at 24 hours, 7 days, 30 days, and 6 months recorded. Autopsy records were also reviewed. RESULTS: A total of 708 stroke patients were reviewed and this constituted 2.4% of all emergency admissions. On clinical grounds, 49% of the patients had cerebral infarction (CI) and 45% had intracerebral hemorrhage (ICH), whereas 6% had subarachnoid hemorrhage. Stroke constituted 1.8% of all deaths at the emergency unit and the case fatality was 9% at 24 hours, 28% at 7 days, 40% at 30 days, and 46% at 6 months. CONCLUSIONS: Stroke constitutes a significant cause of mortality and the need for prompt institution of intensive treatment is emphasized. A changing pattern with an increasing frequency of hemorrhagic stroke in our population is suspected. However, because this was a retrospective study based on clinical examination in a highly selected stroke population, neuroimaging confirmation would be needed for any future prospective hospital or population-based studies.

Mortality of tetanus at the Lagos University Teaching Hospital, Nigeria.

Records of 349 tetanus patients, aged 10 years and above, admitted to the Lagos University Teaching Hospital, Nigeria, between 1990 and 1999 were reviewed. The male:female ratio was 1.98:1, and the ages were between 10 and 88 years, with a mean age of 29.8 years. The overall case fatality rate (CFR) of tetanus was 36.96% (33.19% for men and 44.44% for women). The CFR is similar to that previously reported in the hospital, but higher than that reported from Europe and North America. The lowest CFR was in the 10-19-year age group, and there was a trend towards increasing CFR with increasing age. Tetanus patients in the intensive care unit (ICU) had a significantly higher CFR than those in the medical wards. Unlike in developed countries, where management of tetanus in ICU has resulted in a decrease in CFR, the CFR of tetanus at the Lagos University Teaching Hospital has not significantly reduced over the years.

Natural history of cerebral saccular aneurysms.

Cerebral saccular aneurysms are relatively common, and are most commonly located at the branching points of large arteries of the circle of Willis. Many are asymptomatic and only discovered incidentally. Available evidence suggests that these aneurysms develop as a result of a combination of congenital or inherited defects weakening the arterial wall, and acquired degenerative vascular disease. It appears that most untreated cerebral aneurysms will get larger, and that all aneurysms have the potential to rupture. The only consistent significant predictor of aneurysmal rupture in most studies is the size of an aneurysm. Aneurysms less than 5mm have a very low rupture rate while those greater than 10mm have a significant risk of subsequent rupture. There is no consensus on the influence of the other reported risk factors such as hypertension, cigarette smoking and aneurysm location, on aneurysmal rupture. Those who have suffered a ruptured aneurysm are at a high risk for a recurrent haemorrhage shortly after the initial one.

Longitudinal study of mortality predictors in Parkinson's disease in Nigerians.

Parkinson's disease (PD) has been associated with increased mortality. The mortality in Nigerians has not been described. This study was designed to assess mortality in PD and relate it to gender, age at onset of PD and at baseline, and duration of PD. A case-control study of 28 PD and 28 age- and sex-matched controls from similar geographic locality was conducted. Baseline clinical characteristics of the PD patients and controls were documented at study inception. Cases and controls selected between January and June 1997 were followed up after a 6-year interval (May 2002). The case fatality rate (CFR) in PD was 25% compared to 7.1% in controls (Mantel-Haenszel test, P=0.07). PD survivors (compared to PD patients who died) were significantly younger both at study onset (mean age 59.8 +/- 10.3 v. 72.3 +/- 6.8; P=0.002) and at onset of PD (mean age 57.3 +/- 10.3 v. 69.3 +/- 6.5; P=0.003), and had significantly less severe disease at baseline (mean Hoehn & Yahr stage 2.1 < or = 0.7 v. 2.9 +/- 1.1; P=0.04). CFR was significantly higher in PD cases aged =70 years at study onset (Mantel-Haenszel test, P=0.004) and at onset of PD (Mantel-Haenszel test, P=0.001), but not in age-matched controls. PD affecting Nigerians is associated with increased mortality as has been demonstrated in other geographic locations. Factors associated with increased mortality include advanced age, older age at onset of PD, and more severe disease.

Comparison of Siriraj Stroke Score and the WHO criteria in the clinical classification of stroke subtypes.

Clinical distinction between cerebral haemorrhage (CH) and cerebral infarction (CI) is important in the management of stroke patients in areas where CT scan facility is lacking or access limited by cost and distance. This distinction is necessary in our environment where an increasing proportion of patients are suspected to have haemorrhagic stroke. This study compares Siriraj stroke score (SSS) and the WHO criteria for the acute stroke syndrome as simple tools for this purpose. The computerised tomography (CT) brain scans of all patients referred with clinical diagnosis of stroke at the University College Hospital (UCH), Ibadan, and RADMED diagnostic centre. Lagos were retrieved and reviewed as well as the case notes of these patients at the referral hospitals. Relevant clinical data were extracted from the case records. The patients were classified into either CI or CH using the WHO criteria for acute stroke syndrome and the SSS. This classification was compared with the CT scan diagnosis using the latter as the gold standard. Data analysis was performed with Epi-info software, and Kappa statistics (k value) for comparability test with 95% confidence interval was used to compare the two clinical criteria with the gold standard. Ninety-six patients had complete clinical records and CT scan features consistent with the diagnosis of stroke, of which 52 were diagnosed as CI and 44 as CH. SSS had sensitivity of 50% for haemorrhage and 58% for infarction with an overall accuracy of 54.2%. The WHO criteria for the acute stroke syndrome had sensitivity of 73% for haemorrhage and 69% for infarction with an overall accuracy of 71%. The kappa coefficient was 0.18 for the SSS and 0.41 for the WHO criteria. The diagnostic accuracy of the WHO criteria for the acute stroke syndrome is higher than that of the Siriraj stroke score. The WHO criteria showed moderate agreement (k=0.41) with the CT scan, while the SSS showed no agreement (k=0.18). When CT scan is not affordable or its use is limited by distance, the WHO criteria for acute stroke syndrome could be more useful. A prospective study with a larger sample size is suggested for definitive conclusion.

Clinical manifestations of myasthenia gravis - review of cases seen at the Lagos University Teaching Hospital.

OBJECTIVE: to review cases of myasthenia gravis at the Lagos University Teaching Hospital. METHODS: features of 27 cases of myasthenia gravis seen at the Neurology outpatient clinic of the Lagos University Teaching Hospital between January 1995 and December 2000 were reviewed using a uniform protocol. RESULTS: peak age incidence was in the third decade, and the male to female ratio 1.7 to 1. The commonest presentation was ptosis (85.1% ), followed by diplopia (37% ) and limb weakness (37% ). Other features such as dysphonia, dysphagia and dysarthria, were relatively uncommon. Ocular myasthenia gravis was diagnosed in half of the patients and generalised myasthenia in the other half. All the patients except four responded satisfactorily to prednisolone and/or anti-cholinesterase. Azathioprine was added to the treatment of those that did not respond well, and replaced prednisolone in a patient who developed steroid-induced diabetes mellitus. One patient developed myasthenic crisis and required artificial ventilator support. One patient had thymectomy. CONCLUSION: cases of myasthenia gravis present infrequently at the neurology clinic of the Lagos University Teaching Hospital. Clinical presentation and response to treatment are similar to those described elsewhere.

A preliminary study of the frequency of focal neurological deficits in HIV/AIDS patients seropositive for Toxoplasma gondii IgG in Lagos, Nigeria.

BACKGROUND: Cerebral toxoplasmosis is a common cause of focal neurologic deficits in HIV/AIDS. Financial constraints and access to neuroradiological facilities limit definitive diagnosis and first-line treatments are largely expensive and cumbersome. OBJECTIVE: This study examined the frequency of focal neurological signs in HIV/AIDS patients with positive Toxoplasma gondii IgG antibodies (and thus at high risk of reactivation), and the relationship to CD4 count. METHODS: Using a case-control design, T. gondii IgG serology was determined in 83 HIV/AIDS patients on HAART and 42 HIV seronegative controls. Neurological evaluation and CD4 count (mm3) was conducted in all subjects. RESULTS: A total of 71 (85.5%) HIV/AIDS patients were seropositive for T. gondii IgG. The IgG seroprevalence was 84.8% for cases with CD4 count < 200 and 86.0% with CD4 < or = 200 (P = 0.46). Of the cases with positive Toxoplasma antibodies, the frequency of neurological lateralizing signs was higher in those with CD4 count < 200 (32.6%) compared to persons with CD4 count > or = 200 (7.1%) (chi2 = 4.90, Fisher exact P <0.01). The mean CD4 count of cases with lateralizing signs was 113.7 +/- 113.9 in contrast to 254.0 +/- 218.9 in those without lateralizing signs (P < 0.01). CONCLUSION: In our study, a higher frequency of focal neurological signs was found in the T. gondii seropositive HIV/AIDS patients with a higher degree of immune compromise (CD4 count < 200). We suggest the adoption of routine prophylactic anti-toxoplasma therapy in this subgroup given that cerebral toxoplasmosis is a leading cause of intracranial space occupying lesions in HIV/AIDS.