Factors delaying hospital arrival of patients with acute stroke

Background:

Low rates of thrombolysis for ischemic stroke in India and other developing countries have been attributed to delays in presentation to the hospital.

Materials and Methods:

A prospective study was carried out during a 12-month period ending December 2012 in the department of Neurology, Malabar Institute of Medical Sciences, Kerala, India, to look for the factors contributing to delay in hospital arrival of patients with acute stroke. Patients and or their relatives were interviewed within 48 hours of admission using a structured questionnaire.

Results:

A total of 264 patients attending the emergency department were included. There were 170 men and 94 women. The mean age was 61.5 ± 12.4 years. A total of 67 (25%) patients presented within 4 hours of stroke onset. Factors associated with early arrival (multivariate logistic regression analysis) were distance 15 km or less from hospital (P 0.03, odds ratio (OR) 2.7), directly reaching the stroke department (P < 0.001, OR 9.7), history of coronary artery disease (P 0.001, OR 3.84), higher educational status (P 0.001, OR 3.7), and presence of hemiplegia (P 0.001, OR 5.5).

Conclusions:

We found a considerable delay in the early arrival of patients to our stroke department. Health promotion strategies to improve community awareness of early symptoms of stroke, education of local physicians about the importance of early referrals to the stroke centers, and wider availability and use of ambulance services are promising methods to help expedite presentation to hospital post stroke and thereby improve the management of stroke in India.

Primary Sjögren's syndrome manifesting as multiple cranial neuropathies: MRI findings

We report a case of primary Sjögren's syndrome presenting with multiple cranial nerve palsies and radiological evidence of cranial pachymeningitis and hypophysitis. A 47-year-old woman developed right sensory neural hearing loss followed, 2 months later, by right facial palsy. Cranial magnetic resonance imaging showed features of pachymeningitis and pituitary gland infiltration. The diagnosis of primary Sjögren's syndrome was confirmed by demonstrating positive SS-A and SS-B antibodies and histological evidence of lymphocytic infiltration of the sublabial salivary gland. During the 2-year follow-up, the patient had transient VI^th, IX^th, X^th, and XII^th cranial nerve palsies. Sjögren's syndrome should be considered in the differential diagnosis of patients presenting with multiple recurrent cranial nerve palsies, even if prominent sicca symptoms are absent.

Low cholesterol as a risk factor for primary intracerebral hemorrhage: A case-control study

Introduction:

An inverse association between serum cholesterol and the risk of hemorrhagic stroke has been noted in epidemiological studies. We performed a case–control study to assess the relationship between primary intracerebral hemorrhage (ICH) and low serum cholesterol.

Materials and Methods:

Prospectively recruited fully evaluated patients with ICH were compared with a control group based in a primary care practice, i.e. age- and sex-matched individuals attending the routine preventive health check-up. Low cholesterol was defined by the sex-specific lowest quintile of the population.

Results:

The proportion of ICH patients with low cholesterol was significantly higher than the controls (68% vs. 43%). Mean total cholesterol was also signficantly low in ICH patients compared with controls (177 mg/dL vs. 200 mg/dl; P-value = 0.0006). Low-density lipoprotein cholesterol (LDL-c) and triglycerides were also significantly low in ICH patients compared with controls. Mean LDL-C in the ICH patient group was 114 mg/dL, whereas it was 128.5 mg/dL in the control group (P-value = 0.016). There was no significant difference in the high-density lipoprotein (HDL) levels in both groups. In a subgroup analysis, both men and women in the ICH group had a significantly low mean cholesterol compared with the control group. Although lower mean cholesterol was seen in both young and older individuals in the ICH group than in controls, the difference was significant only in the older group (age >45 years). In multivariate analysis, presence of low cholesterol remained a significant predictor of hemorrhage. The odds ratio of low cholesterol in the hemorrhage cases was 2.75 (95% CI = 1.44–5.49) unadjusted and 2.15 (1.13–4.70) adjusted for age and hypertension.

Conclusions:

This study confirms an increased risk of primary ICH associated with low cholesterol both in men and women, especially in older individuals.

Genetic association analysis of KCNQ3 and juvenile myoclonic epilepsy in a South Indian population

Juvenile myoclonic epilepsy (JME) is a common subtype of idiopathic generalized epilepsy that shows a complex pattern of inheritance. We have tested the association between JME phenotype and an intragenic marker in KCNQ3 by using the transmission disequilibrium test in 119 probands and their parents. Mutations in KCNQ3 are known to cause benign familial neonatal convulsions and are involved in the physiologically important M current in neurons. Our results provide suggestive evidence of allelic association between JME and KCNQ3 ( P-value=0.008) and raise an interesting possibility of a genetic contribution to JME, viz., of a gene that causes a monogenic form of human epilepsy.

Spectrophotometric and fluorometric detection of DNA/BSA interaction, antimicrobial, anticancer, antioxidant and catalytic activities of biologically active methoxy substituted pyrimidine-ligand capped copper nanoparticles

New Schiff base ligand (DPMN) was synthesized from the condensation of 2-hydroxy-5-nitrobenzaldehyde and 2-amino-4,6-dimethoxypyrimidine which was confirmed by spectroscopic and analytical methods. Solid air stable copper nanoparticles (DPMN-CuNPs) were synthesized from its copper chloride salt and it is stabilized by the prepared Schiff base ligand by phase transfer assisted synthesis which is a modified Brust-Schiffrin technique. The formation of ligand stabilized copper nanoparticles was confirmed by UV-Visible and FT-IR spectroscopic techniques. The size, surface morphology and quality of DPMN-CuNPs were analyzed by SEM and TEM techniques. Antioxidant activities of DPMN and DPMN-CuNPs with DPPH, SOD, peroxide and nitrous oxide were analyzed by electronic absorption spectroscopy. DNA interaction between DPMN and DPMN-CuNPs with CT-DNA was carried out using electronic absorption, fluorescence, viscometric measurements and cyclic voltammetric techniques. Interaction between BSA and the synthesized compounds analyzed by electronic absorption spectroscopy, Antimicrobial studies confirmed that the synthesized DPMN-CuNPs possess significant biological activities than DPMN. Anticancer results suggest that prepared DPMN-CuNPs have significant anticancer activity against different cancer cell lines and least toxic effect against the normal (NHDF) cell line. Other than the positive response in biological evaluation, our DPMN-CuNPs possess good catalytic activity in methyl orange reduction, methylene blue degradation and nitro phenol reduction.

Reversible cerebral vasoconstriction syndrome in a patient with systemic lupus erythematosus

A 42-year-old woman, a diagnosed case of systemic lupus erythematosus (SLE), developed severe headache followed by left hemiparesis and cortical blindness. Magnetic resonance imaging (MRI) of brain demonstrated right parieto-occipital infarct and the patient was initiated on high-dose steroids and antiplatelet agents with which the patient had clinical and radiological deterioration. Magnetic Resonance angiography showed severe narrowing of bilateral anterior, middle, and posterior cerebral arteries (PCA) suggestive of reversible cerebral vasoconstriction syndrome (RCVS). Patient was treated with IV nimodipine and she recovered over a period of 2 weeks. Repeat MR-angiography done on day-30 was normal. The diagnosis of RCVS in patients with SLE is of practical importance, because treatment and prognosis for SLE-associated cerebral vasculitis differ strongly from the treatment of RCVS. Empirical high-dose glucocorticoid therapy should be avoided in patients with typical features of RCVS.

Childhood acute disseminated encephalomyelitis presenting as Foix-Chavany-Marie syndrome

A 10-year-old boy presented with anarthria and bilateral central faciolinguovelopharyngeomasticatory paralysis with "automatic voluntary dissociation" suggestive of Foix-Chavany-Marie syndrome or anterior opercular syndrome following a nonspecific upper respiratory infection. Brain magnetic resonance imaging revealed bilateral subcortical perisylvian demyelination in addition to multiple subcortical white-matter demyelination. The clinicoradiologic picture suggested acute disseminated encephalomyelitis. The child recovered completely following intravenous methylprednisolone and intravenous immunoglobulin therapy. This is the first report of anterior opercular syndrome in childhood acute disseminated encephalomyelitis.

Neuromuscular junctional disorders

Neuromuscular junctional disorders (NMJ) in children are distinct entity. They may be acquired or hereditary. They pose problem in diagnosis because of the higher occurrence of sero negative Myasthenia Gravis (MG) cases in children. The identity of MusK antibody positivity in a good percentage of sero negative cases further adds to problems in diagnosis. The Congenital Myasthenic Syndrome (CMS) which are rare disorders of hereditary neuromuscular transmission (NMT) has to be differentiated because immunotherapy has no benefit in this group. Molecular genetic studies of these diseases helps to identify specific type of CMS which is important as other drugs like Fluoxetine, Quinidine are found to be effective in some. In infancy, all can manifest as floppy infant syndrome. The important key to diagnosis is by detailed electrophysiological studies including repetitive nerve stimulation at slow and high rates and its response to anticholinesterases and estimation of Acetyl choline receptor antibodies. Other causes of neuromuscular transmission defects viz. snake venom poisoning and that due to drugs are discussed.

Aberrations in SMAD family of genes among HNSCC patients

Head and neck cancer is a debilitating disease with several etiological factors. One of the main etiologies to be noticed is the alteration, which is either caused by genetic or environmental factors. Therefore, it is of interest to assess the effect of genetic alterations, especially the non-synonymous mutations of the SMAD gene family and its possible association with HNSCC. Data shows a significant novel mutation in the SMAD gene family in association with head and neck squamous cell carcinoma (HNSCC), which would aid in better diagnosis and treatment planning for cancer.

Seizures in hyperglycemic patients

AIM OF STUDY

To study the pattern of seizures in hyperglycemic patients and its correlation with serum osmolality, blood sugar and serum sodium.

MATERIALS AND METHODS

(Study period June 1999-June 2000) Forty patients who presented with first time seizures and who were detected to be diabetic were included in the study. All patients had detailed history, clinical examination blood sugar, BUN, serum electrolytes, serum osmolality, serum calcium estimation. EEG and CT head scan was also done. The seizures were classified as per ILAE classification (1981). The study group was further divided into Group A--those with normal CT (n 24) and Group B-- those showing infarcts in CT scan (n 16). The control group (n 40) were matched for age and had first occurrence of seizures and CT showed infarct and were euglycemic. All the investigations were done for the control group as well. Statistical analysis was done using ANOVA.

RESULTS

None of the patient had diabetic ketoacidosis. Patients in study group had statistically significant incidence of (1) Focal seizures with or without generalisation (100%); (2) Visual hallucination (25%); (3) Epilepsia partialis continua (20%). Comparing the subgroups (A and B) complex partial seizures and visual hallucination was significant at 5% level in the group A (NKH with normal CT). Ninety percent in the study group had increased serum osmolality (Vs 22.5% in the control group). Duration (eight days Vs 1) and frequency (15 per day vs 1.45) were positively correlated with RBS > S.osmolality > S.sodium.

CONCLUSION

1. Long duration and frequent focal motor seizures with or without secondary generalisation occurs in NKH which at times may be the first manifestation of DM. 2. Complex partial seizures, visual hallucination and epilepsia partialis continua are more common in NKH patients than in euglycemic patients. 3. There is positive correlation of blood sugar, S.osmolality and S.sodium with frequency and duration of seizures. RBS > S.osmolality > S.Na. 4. Correction of hyperglycemia is the main stay of management of seizures. 5. Movement induced seizures which is specific for NKH is a rarity.

Plasmapheresis in childhood acute disseminated encephalomyelitis

Accepted modes of therapy in acute disseminated encephalomyelitis include intravenous methylprednisolone, intravenous immunoglobulin or a combination of both. Effectiveness of plasmapheresis has been demonstrated by many case reports. We used plasmapheresis to treat steroid non-responsive acute disseminated encephalomyelitis in two children. There was complete clinical and radiological recovery in both the cases.

Anterior inferior cerebellar artery infarct with unilateral deafness

We report the case of a young man with anterior inferior cerebellar artery infarct causing unilateral deafness. Clinical features and audiometry suggested cochlear localization for deafness. MRI brain showed an infarct in the right AICA territory with involvement of pons. Involvement of the internal auditory artery explains the cochlear deafness.

Social factors and psychopathology in epilepsy

One hundred and six epilepsy patients were assessed over a period of 6 months for psychiatric morbidity, social support, stressful life events in previous year and disability. 45 patients (42.45%) had a psychiatric diagnosis. Organic depressive disorder headed the list (16.98%) followed by mild cognitive disorder (11.32%) and tobacco dependence (8.49%). There was no significant difference in the mean age, sex, mean education, age at onset of epilepsy, duration of epilepsy, psychiatric diagnosis, mean scores on social support scale, presumptive stressful life event scale and disability assessment schedule between different types of epilepsy. The difference in mean scores of presumptive stressful life events scale and disability assessment schedule between epileptics with and without psychiatric diagnosis was not statistically significant.

Acute disseminated encephalomyelitis treated with plasmapheresis

Accepted modes of therapy in acute disseminated encephalomyelitis include intravenous methyl prednisolone, intravenous immunoglobulin or a combination of both. Effectiveness of plasmapheresis has been demonstrated by previous case reports. We report two patients with steroid non-responsive acute disseminated encephalomyelitis in which plasmapheresis resulted in complete clinical and radiological recovery, though the therapy was initiated in the fifth week of illness. A total of 45-50 ml/kg body weight of plasma was removed in six equal exchanges over a period of two weeks. This report highlights that plasmapheresis could be of use even in the early second month of illness.