Current practices in the management of patients with spontaneous intracerebral hemorrhage at the National Hospital of Sri Lanka - A clinical audit.

Background and Objectives: Spontaneous, non-traumatic intracerebral hemorrhages (ICH) is the second most common cause of stroke after acute ischemia. However, it causes significant mortality and morbidity and has comparatively worse outcomes. Most studies show that ICH when treated with good medical care has lower mortality. Our primary aim was to evaluate how ICH is currently managed at the National hospital of Sri Lanka (NHSL), the premier tertiary care hospital in the country, whilst identifying strengths, weaknesses and deficiencies. We plan to develop a comprehensive management protocol for ICH patients and to reevaluate the treatment practices after applying them. NHSL is a research centre for the international, multicenter INTERACT2 trial, which emphasizes intensive blood pressure, blood sugar and temperature control and managing coagulopathy in ICH leading to better outcomes. We are recruiting new ICH cases to this trial. Methodology: The prospective standard audit was conducted at NHSL for a period of 3 months and the study population consisted of 76 patients with spontaneous ICH. The 2015 AHA/ASA guideline for the management of spontaneous intracerebral hemorrhage was used as the standard guide for the management. Results: Of 76 patients with ICH 46 (60.5%) were males and mean age was 61.3+- 12.6 years. The blood pressure (BP) and blood sugar control was achieved only in 51.3% (39) and 15.8% (12) respectively. Although prophylactic anti-epileptics are not recommended in ICH almost 70% were started on them, in spite of only 15.8% having overt convulsions. Steroids though not recommended to lower intracranial pressure in ICH 51% were on them. Of those ICH admitted to medical and neurology wards 81% were referred to neurosurgery irrespective of the location and the nature of the bleed and when not indicated (based on AHA/ASA guidelines) delaying and interfering with optimal medical care. Conclusions: Several deficiencies were identified in the current management routines of ICH at NHSL including delayed, suboptimal medical care, unnecessary widespread use of AEDs and steroids. Large majority of neurosurgical referrals too were unnecessary and not indicated.

Familial Multiple Sclerosis in a Mother and Son Pair: A Sri Lankan and a South Asian First.

Multiple sclerosis (MS) is an immune-mediated demyelinating disorder involving the central nervous system (CNS). It is common amongst young females. Although the exact cause of MS is yet unknown, viral infections such as EBV, environmental factors, and autoimmune and genetic mechanisms involving HLA-DRB1 loci are implicated. Familial MS is reported from some geographic locations and ethnic groups but is thought to be rare in Asia. In this paper, we present both a Sri Lankan mother and her son, with clinically definite MS conforming to McDonald's 2017 clinical and MAGNIMS 2016 radiological criteria. Both had oligoclonal bands in their CSF (OCB-IEF) with no serum bands indicating intrathecal production and were negative for AQP4 and MOG IgG serology. Familial MS is more common among siblings, with sister-sister relationship having the highest rate. The lowest relation was amongst father-son and mother-son pairs. Amongst siblings, the risk of MS is between 3.5% and 4.7%. Inherited factors rather than common environmental exposure influence susceptibility in such cases. To the best of our knowledge, MS occurring in a mother-son pair has not been reported before either from Sri Lanka or South Asia.