Risk Factors for Stroke in Rural Population of Telangana State of India, an Unmatched Case Control Study.

Context Stroke tops the list of causes for acquired disability among adults and is the second leading cause of death worldwide. Evidence from developed countries indicate significant decline in stroke incidence and mortality, attributable to prevention of risk factors in general population. There is limited evidence on risk factors for stroke in rural India. Aims This study aims to ascertain the risk factors for stroke in rural Telangana and provide a guide to health care providers in adopting treatment and prevention strategies. Settings and Design The study was conducted in the Moinabad mandal of Ranga Reddy District, Telangana state of India. This is a population based unmatched case-control study. Methods and Materials All the houses of Moinabad were approached by a door-to-door survey to identify cases. A total of 288 persons were enrolled in the study which included 144 cases and 144 controls. Statistical Analysis To derive age and gender adjusted odds ratios of various risk factors, binary logistic regression analysis was performed. Results The estimated crude prevalence of stroke in Moinabad mandal is 257 per lakh population. Modifiable risk factors identified were, total cholesterol, systolic blood pressure, alcohol consumption, smoking, diastolic blood pressure, low high-density lipoprotein cholesterol, and central obesity as measured by waist circumference. Nonmodifiable risk factors identified were male gender and higher age group. Conclusion The high prevalence of stroke in rural Telangana makes it an important public health challenge for the state. The identified risk factors need to be addressed at population level.

A study on the clinical outcomes and management of meningitis at a tertiary care centre.

BACKGROUND: Meningitis is a life threatening central nervous system infection that is prevalent worldwide. Many studies have been conducted on bacterial meningitis, but the information is inadequate on the other types of meningitis, especially prevalent in India. Regional information regarding trends, in terms of etiology and microbiological susceptibility, are essential for timely and adequate management of meningitis. AIMS: The present study was undertaken to evaluate the changing epidemiology of meningitis by reviewing the causative agents, the available laboratory methods for making the etiological diagnosis, the risk factors and the clinical outcomes, and the management of meningitis in our patient population. MATERIALS AND METHODS: It is an observational study conducted at a tertiary care centre. A structured data form was designed to collect the information from the medical records and charts of medical investigations of the patients. Details regarding etiological agents, prevalence of clinical features and management were recorded and interpreted. RESULTS: A total of 147 patients suspected to be having meningitis were included. The common types of meningitis in our study were aseptic (39%), tuberculous (28%), pyogenic (28%), fungal (3%) and others (2%). The classical triad of headache with fever, neck stiffness, and altered mental sensorium was seen in 26% patients, and 83% had at least 2 out of these 4 symptoms. The incidence of seizures was found to be 63% in the presence of aseptic meningitis. Significant clinical improvement was seen in 89% of the patients suffering from aseptic meningitis. CONCLUSIONS: Aseptic meningitis was found to be the predominant type among all different varieties of meningitis. An increased incidence of meningitis was seen in patients with diabetes mellitus. The incidence of seizures was high in viral/aseptic meningitis. The empirical treatment given in most of the cases was ceftriaxone. Isolation of the culpable organisms was possible in a very few cases due to the usage of empirical antibiotics prior to the performance of the lumbar puncture for the diagnostic analysis of the cerebrospinal fluid.

Bilateral putaminal necrosis in a comatose patient with metabolic acidosis.

We present a case of acute-onset coma in a young woman, associated with metabolic acidosis, respiratory distress, and hypotension. Magnetic resonance imaging of the brain done on day 2 of admission showed features of bilateral putaminal necrosis. History of methanol ingestion, though not forthcoming at admission, was confirmed later after the patient regained consciousness. A final diagnosis of methyl alcohol toxicity resulting in severe metabolic acidosis, coma, and bilateral blindness was made. This case is reported to emphasize the point that the finding of bilateral putaminal necrosis in a patient with coma and metabolic acidosis is virtually diagnostic of methyl alcohol toxicity even in the absence of any positive history.

Striatal toe.

We report a case of striatal toe in an adolescent with an infarct in lentiform nucleus and briefly discuss its differential diagnoses.

Raman spectroscopy provides a powerful, rapid diagnostic tool for the detection of tuberculous meningitis in ex vivo cerebrospinal fluid samples.

In this letter, we propose a novel method for diagnosis of tuberculous meningitis using Raman spectroscopy. The silicate Raman signature obtained from Mycobacterium tuberculosis positive cases enables specific and sensitive detection of tuberculous meningitis from acquired cerebrospinal fluid samples. The association of silicates with the tuberculosis mycobacterium is discussed. We envision that this new method will facilitate rapid diagnosis of tuberculous meningitis without application of exogenous reagents or dyes and can be aptly used as a complementary screening tool to the existing gold standard methods.

Decompressive surgery for severe cerebral venous sinus thrombosis.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is one of the common causes of stroke in young people. Mortality in CVST, in addition to progressive thrombosis, is related to elevated intracranial pressure causing transtentorial herniation. The role of decompressive surgery in CVST is not well established. AIMS: We report our experience with decompressive surgery in CVST and review the literature. SETTINGS AND DESIGN: This is a retrospective study carried out in the Stroke Unit of a multispeciality tertiary care hospital in south India. MATERIALS AND METHODS: The medical records of patients admitted with the diagnosis of CVST between December 2003 and July 2009 were reviewed. The clinical presentation, etiology, medical management, indications for surgery and outcomes were assessed for patients undergoing decompressive surgery. The sensorium was assessed using the Glasgow Coma Scale (GCS), while the outcome was assessed using the modified Rankin scale (mRS). Descriptive statistics were used as appropriate. RESULTS: One hundred and six patients were admitted with the diagnosis of CVST during the study period. Eleven patients (10%) underwent decompressive surgical procedure. Indications for surgery included a low GCS at admission with large infarct on the computed tomography scan, mass effect and midline shift, clinical and radiological signs of transtentorial herniation, deterioration in the sensorium in spite of anti-edema measures and postthrombolysis hematoma. Eight patients (73%) had a good outcome while three patients (27%) died. Of the patients who died, two had a low GCS and bilaterally nonreactive pupils before the surgery while one had thrombosis of the deep venous system. CONCLUSION: Decompressive surgery for patients with large cerebral venous infarcts is a life-saving procedure. Patients with CVST who develop clinical and radiological features of transtentorial herniation either at presentation or during the course of medical management may benefit from decompressive surgery.

Intrasinus thrombolysis in cerebral venous sinus thrombosis: single-center experience in 19 patients.

BACKGROUND: Evidence from small case series suggests that the intrasinus thrombolysis (IST) is relatively safe and effective in rapid recanalization of thrombosed sinuses and reversal of neurological deficits in patients with cerebral venous and sinus thrombosis (CVST) However, in the absence of randomized controlled trials, the exact role of IST in the management of CVST is unclear, AIM: To study the safety and efficacy of IST in patients with CVST. MATERIALS AND METHODS: Adult patients with CVST who received IST during a two-year period (January 2003-December 2004) were included. Data regarding demographic, clinical and radiological features were collected. Follow-up data were obtained at 3-6 months. Magnetic resonance venography (MRV) was repeated to assess the recanalisation of venous sinuses. RESULTS: Nineteen patients (11 women) with a mean age of 32 years (range 17-46 years) received IST during the study period. Common clinical features at presentation included headache, altered consciousness and seizures. Indications for thrombolysis included clinical deterioration despite adequate anticoagulation and rapid worsening of consciousness or neurological deficits. Thirteen patients (68%) had dural sinus thrombosis alone and six others had coexisting deep venous system involvement. Venous infarcts were present in 13 patients. At discharge, 15 patients (79%) had good outcome and were either asymptomatic or had only mild deficits and were independent for activities of daily living. Three patients died and one survived with severe neurological deficits. Angiographic improvement (as per digital subtraction angiography) was noted in 12 patients (complete in five and partial in seven) and seven patients had poor or no recanalization of the involved venous sinuses. At a median follow-up of 6.3 months, 14 (74%) patients had no or mild neurological deficits. CONCLUSION: IST is safe and effective in patients with CVST who fail to respond to conventional medical treatment. However, the subgroup of patients who are likely to benefit the most from this procedure is not clear from our data. Large randomized controlled trials are required to further clarify this issue.

Contralateral diaphragmatic palsy in acute stroke: an interesting observation.

Diaphragmatic palsy in hemiparetic stroke is not well recognized. Further, its implications on stroke outcome have not been studied. Here, we report a patient with left-sided diaphragmatic palsy due to an acute right middle cerebral artery territory infarction. The diagnosis was suspected on finding an elevated dome of the diaphragm on the left side in a routine chest radiograph and was confirmed by finding decreased movements of the left hemidiaphragm on fluoroscopic examination. We hypothesize that this condition is probably under-recognized in clinical practice and its clinical importance not well known. The pathophysiological basis of diaphragmatic palsy in acute stroke and its possible clinical implications are discussed.

Reversible electrophysiological abnormalities in hypokalemic periodic paralysis.

Compound muscle action potential (CMAP) amplitude declines during a paralytic attack in patients with hypokalemic periodic paralysis (HPP). However, serial motor nerve conduction studies in HPP have not been commonly reported. We report a 9 year old girl with HPP, who had severely reduced CMAPs in all motor nerves at presentation during the episode of quadriparesis. However, the amplitude of CMAPs increased and reached normal levels as the serum potassium concentration and motor power returned to normal state.

Platelet glycoprotein IIb/IIIa inhibitors in acute ischemic stroke.

Acute ischemic stroke (AIS) is a common cause of morbidity and mortality worldwide. Thrombolytic therapy with tissue plasminogen activator, the only approved treatment for AIS, is received by less than 2% of patients. Moreover, there is a slight increase in hemorrhagic complications with thrombolysis. Therefore, there is a need for newer therapeutic modalities in AIS, which could be used in window periods beyond 3-6 h after stroke onset with fewer hemorrhagic complications. Glycoprotein IIb/IIIa inhibitors (GPI), after their initial success in patients with acute coronary syndromes, promised much in patients with AIS over the past decade or so. However, their exact role in patients with AIS, including the window periods and type of strokes, and the risk of symptomatic or asymptomatic hemorrhage are unclear at the moment. The current review focuses on the literature concerning the use of GPI in AIS and looks at the available evidence regarding their use. Abciximab thought to be safe and effective in initial case series and early trials, has not been shown to improve outcomes in AIS, and is associated with higher rates of hemorrhage. Tirofiban appears to be safe and effective in initial trials and there is a need to conduct further trials to establish its role in AIS.

Positron emission tomography in neurological diseases.

Positron emission tomography (PET) is the study of human physiology by electronic detection of positron-emitting radiopharmaceuticals. It is one of the noninvasive technologies that can measure the metabolic and functional activity of living tissue. Positron emission tomography finds its clinical applications in broadly three specialties--oncology, cardiology, and neurology. The current review focuses on its indications in neurological diseases. Recently published literature on the use of PET in neurology has been thoroughly analyzed. Several reports regarding the usage of PET in epilepsy, stroke, dementia, and movement disorders are available. Positron emission tomography does not appear to be useful as a primary or sole imaging technique in these conditions. On the other hand, it is useful in very specific situations, which have been elaborated in the review. It is also noteworthy that PET is complementary to the computed tomography/magnetic resonance imaging findings and data obtained from combining these modalities can be valuable in situations such as localization of the epileptogenic focus in cases of refractory epilepsy or for prediction of the outcome after thrombolysis in acute ischemic stroke. The major handicaps in widespread use of PET appear to be its lack of availability and its relatively high cost. Nevertheless, a review such as this would be helpful in judiciously selecting those patients who would benefit from undergoing a PET scan, at a time when PET imaging facility is likely to be available soon in the Indian private sector.

Patient's perspective on epilepsy: self-knowledge among Omanis.

Improving patients' knowledge has been suggested to improve their symptoms and prognosis. Very little is known about epileptic patient's knowledge of their illness in cross-cultural settings. This pilot study investigated what Omani patients know about their disorder. Patients attending a tertiary hospital completed a structured knowledge questionnaire to elicit information pertaining to aetiology, safety, compliance with medication regimes, legal and employment issues concerning epilepsy.Although correctly endorsing issues related to their medication, this cross-cultural sample was found to have limited knowledge about their condition. In particular, most patients were unable to give accurate indications of epilepsy, neither were they able to give correct responses to questions pertaining to safety and compliance. There is a need for improving patient's knowledge. As with other chronic disorders, people with epilepsy in Oman should receive systematic health education about how to manage the condition most effectively.