Frequency of Ischemic Stroke Subtypes Based on Toast Classification at a Tertiary Care Center in Pakistan.

BACKGROUND: The purpose of this study was to determine the frequency of ischemic stroke subtypes based on Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification at a tertiary care center in Pakistan. MATERIALS AND METHODS: A cross-sectional study was conducted in Stroke Unit of Shifa International Hospital, Islamabad. We included 145 patients who presented to us from November 2015 to February 2016 with radiological confirmed neurological deficits consistent with ischemic stroke. The causes of ischemic stroke were classified according to TOAST criteria. Regression analysis and Chi-square test were used to compute P value. RESULTS: Among the 145 patients diagnosed with ischemic stroke, there were 54.1% males and 45.9% females with a mean age of 65 ± 14 years. Nearly 62.7% patients had hypertension (HTN) as the most common risk factor, followed by 38.6% diabetes mellitus (DM), 27.5% heart failure, 19.3% valvular disease, 18.6% previous stroke, 16.4% smoking, 15.1% dyslipidemia, 13.7% ischemic heart disease, and 13.1% atrial fibrillation. HTN was significantly associated with large vessel disease (P = 0.028). DM was significantly associated with small vessel disease (P = 0.001). Smoking and atrial fibrillation both were associated with unknown etiology of stroke (P = 0.001 and P = 0.039, respectively). Most common etiology of stroke was cardioembolism (40%), and atrial fibrillation is found to be the most common cause of cardioembolic stroke with 30.6% incidence. CONCLUSION: Our study concludes that cardioembolic stroke is the most common cause of acute ischemic stroke in our stroke unit. Atrial fibrillation is found to be the most common cause of cardioembolic stroke.

Eosinophilic granulomatosis with polyangiitis presenting with multiple intracerebral haemorrhages - A case report.

Eosinophilic granulomatosis with polyangiitis also known as Churgg-Strauss syndrome is a systemic multi system vasculitis. Neurological involvement is mostly in the form of peripheral nervous system disease. Central nervous system involvement is relatively uncommon with most cases being secondary to ischaemic infarctions. Intra cerebral haemorrhage is rare and is usually in the form of solitary haemorrhagic lesions. Multiple intra cerebral haemorrhages are exceptionally rare with only one case documented in medical literature. Here, we present the case of a middle aged male who presented to us with multiple intra cerebral haemorrhages, mono neuritis multiplex, renal and respiratory tract involvement and peripheral blood eosinophilia. Upon fulfilling the American College of Rheumatology criteria, he was diagnosed as an exceptionally rare case of EGPA with multiple intra cerebral haemorrhages. He was treated with intra venous corticosteroids and immune suppressants, and made a good recovery.

Ventricular septal defect following disobliteration of right coronary artery.

Reperfusion injury is thought to occur during coronary recanalisation but rarely produces clinically significant effects other than arrhythmia. We report an unusual case of Ventricular Septal Defect (VSD) developing after successful disobliteration of the right coronary artery. In this case clinical, electrocardiographic and biochemical evidence of myocardial injury developed 6 hours after successful percutaneous recanalization of the infarct related artery. A rapidly developing VSD soon became apparent necessitating surgical intervention to repair the defect. Unfortunately the patient died soon after surgery.

Bilateral tension pneumothoraces following coronary artery bypass grafting.

It is an unusual case of bilateral tension pneumothoraces developing in the postoperative period in a patient who underwent total arterial revascularization for two vessel coronary artery disease. The patient had been a previous heavy smoker and at operation had been noted to have thin walled lung parenchyma with multiple small bullae mainly in the left upper lobe. He suddenly developed bilateral pneumothoraces following intermittent continuous positive airway pressure requiring initially bilateral needle decompression followed by chest drain insertion. He recovered well and the air leak sealed after 3 days.

Critical incident identification in common orthopaedic injury.

OBJECTIVE: To identify the occurrence of any critical incidents in the 50 consecutive patients with common orthopaedic injury (distal radius fractures) treated in a District General Hospital of United Kingdom. METHODS: All patients admitted with distal radius fracture and subjected to manipulation/closed reduction under anaesthesia or surgical interventions were included in this study. Patients who were manipulated in Accident and Emergency were excluded. RESULTS: Although a very common fracture to treat in orthopaedic practice, a radial fracture can be associated with significant critical incidents during its management. Nineteen critical incidences in 50 patients treated for their distal radius fracture were identified. Three occurred while consultants were operating, whereas 16 took place during surgery by trainees. CONCLUSION: A critical incident identification form has been formulated which can be incorporated in any procedure for training and evaluation purpose.

Foreign body in urinary bladder--early CT cystogram is investigation of choice.

Extra peritoneal bladder injuries are very difficult to diagnose on clinical examination alone. CT-scan with cystogram (Contrast: Ultavista300) is a reliable diagnostic tool to evaluate such injuries at an early stage. For accurate diagnosis of bladder injury, enhancement of bladder contents is necessary otherwise extravasated urine can be mistaken for haematoma or ascites. Retrograde filling of bladder with minimum 250 -300 ml of contrast material is necessary before performing abdominopelvic CT to rule out any form of bladder injury. Therefore in case of suspected bladder injury CT cystogram should be performed at the time of initial CT examination in the emergency room. We report a case of extraperitoneal bladder injury and foreign body in urinary bladder after a firework injury.

Massive bilateral pulmonary emboli complicating coronary artery bypass grafting: a case report.

We report an unusual case of massive bilateral pulmonary emboli following single coronary artery bypass grafting on cardiopulmonary bypass. The patient was admitted electively, received deep vein thrombosis prophylaxis, and had no clinical evidence of deep vein thrombosis in the perioperative period. On the tenth postoperative day he developed sudden dyspnea and a diagnosis of pulmonary embolus was made with computed tomography. Despite full anticoagulation he continued to deteriorate, and despite attempts at pulmonary embolectomy he died of right-sided heart failure. Post-mortem confirmed the diagnosis, but there was no evidence of thrombi in the pelvic and leg veins.