Prognostic indicators in patients with intracranial tuberculoma: a review of 102 cases

To see the characteristics, course and outcome of patients suffering from intracranial tuberculoma. Retrospective review of 102 patients diagnosed as intracranial tuberculoma at a tertiary care center over 10 years. A total of 102 cases were seen with an age range of 1 to 75 years [mean, 30 years]. Predisposing factors included Diabetes mellitus [8 patients] and pregnancy or puerperium [7 patients]. Five pediatric patients had tuberculoma despite documented BCG vaccination. Fever [59%], headache [57%], meningeal irritation [36%] were the commonest presenting features; one-third of patients were drowsy or comatosed at presentation. Cerebrospinal fluid analysis was performed in 63 patients, of whom 88% had elevated protein, 83% had low glucose, and 84% had pleocytosis [one-third with neutrophilia]. Forty-nine [50%] patients had clinical or laboratory evidence of concomitant tuberculous meningitis, Chest radiographs showed active or old tuberculous infection [25%], with a miliary pattern in 20%. Two-thirds of subjects had multiple tuberculomas [mean, 4.5 lesions per patient] on contrast CT or MRI scan. Hydrocephalus was present in 37 [37%] patients of which 21 required shunt surgery. Thirty-nine patients had > 9 months of follow up; 17 patients showed complete recovery, 20 patients had partial recovery, and 2 patients had no response. Coma at presentation and miliary pattern on chest X-ray were predictors of poor prognosis. The study demonstrate that fever, headache, signs of meningeal irritation and cranial nerve palsies are common presenting features. Complete recovery was seen in 40% patients. Coma and military TB are predictors of poor prognosis

Cost of acute stroke care at a tertiary care hospital in Karachi, Pakistan

To evaluate cost of acute stroke care and its determinants at a tertiary care hospital in Karachi and to find out predictors of high cost care. Acute stroke is a leading cause of morbidity and mortality. Cost of care is the single most important determinant in availability of acute stroke care at a tertiary care hospital in Pakistan. It is also an important factor in development of public health policies and medical insurance plans. Average annual income in Pakistan is 4881 rupees [U$ 85]. Medical and billing records of 443 patients with acute stroke were retrospectively reviewed from 1998-2001 at The Aga Khan University Hospital [AKUH], Karachi. Acute stroke care at AKUH usually includes routine laboratory investigation including Lipid profile, Magnetic resonance imaging/angiography [MRI/MRA], Echocardiogram, Carotid Doppler's ultrasound and medical management in the Stroke care unit. 443 patients were included in study. Age range was 25-98 years [Mean 58 years]. 269 [61%] were male. Length of hospital stay was 1 day; 67 patients, 2 days; 83 patients, 3 days; 70 patients, 4-5 days; 87 patients, 6-10 days; 75 patients, 11-30 days; 49 patients and more than 30 days; 12 patients. Average length of stay was five days and median length was three days. Average total cost was 70,714 rupees [U$1179] which included average radiology cost; 12,507 rupees [U$ 208], average laboratory cost; 8365 rupees [U$139], average pharmacy cost; 13,320 rupees [U$222] and average bed/room charges; 27, 552 rupees [U$459]. Length of hospital stay is the most important determinant of cost. Average total cost for patients who stayed for 1 day was 19,597 rupees [U$ 326], 2-3 days; 25,568 rupees [U$426], 4-7 days; 49,705 rupees [U$828], 8-30 days; 153,586 rupees [U$2559], more than 30 days; 588,239 rupees [U$9804]. Average cost for general ward was 60,574 rupees [U$1010], private ward was 74,880 rupees [U$1248] and intensive care unit was 155,010 rupees [U$2583]. Cost of acute stroke care is extremely high as compared to average national income at our hospital. Most important determinant of cost is length of hospital stay. Cost cutting measures and increased funding from state are necessary to increase the availability of acute stroke care

Spetrum of complications and mortality of bacterial meningitis: an experience from a developing country

The aim of this study was to obtain data on predisposing factors, causative organisms and their associated mortality and complications related to acute bacterial meningitis. The chart review of all patients in whom acute bacterial meningitis was diagnosed at The Aga Khan University Hospital from January 1995 through December 2001. One hundred ninety-four patients were included in study. There were 146 males and 48 females. The mean age of our study population was 41 +/- 12.3 years. One hundred and ninety [97.9%] patients had communityacquired meningitis-, only 4 [2.0%] patients developed meningitis nosocomially. The two most common predisposing factors were diabetes mellitus [13.9%] and otitis media [7.7%] among all 194 patients. A significant proportion of patients with complications had diabetes mellitus [24.6%, p<0.001]. CSF and blood cultures were positive in 53 [27.3%] and 42 [21.6%] patients respectively-, there was no statistical difference found. The most common organisms isolated were Streptococcus pneumoniae in 35 [36.8%] patients followed by Neisseria meningitides in -30 [31.5%] -patients. Approximately 68% of -positive cultures -yielded S. pneumoniae and N. meningitides [p<0.0001]. The overall mortality rate was 22.1%. The mortality rate for Streptococcus pneumoniae was 17.1%. The highest mortality was observed in patients with Pseudomonal meningitis where all four patients expired followed by mortality rate of 85.7% in Escherichia coli afflicted patients [p<0.001]. Complications occurred in 73 [37.6%] patients with persistent complications in 31 [42.4%] patients. Complications resolved in 34 [46.5%] patients. The most common complications were seizures [12.8%] and cranial nerve palsies [11.3%]. Seizures were more likely to occur in older patients [p<0.05] whereas hydrocephalus was more common in younger patients [p<0.05]. Bacterial Meningitis remains a serious disease associated with substantial morbidity and mortality. Most cases are community acquired with S. Pneumoniae being the most common pathogen. Old age, diabetes mellitus, a positive culture, seizures as a complication and late stage in the disease are the important predictors of a poor outcome

Ischemic stroke subtypes in Pakistan: the Age Khan University stroke data bank

Frequency of ischemic stroke subtypes is influenced by ethnic and geographic variables. Our objective was to identify various stroke subtypes and its determinants at a tertiary care hospital. We prospectively collected data on ischemic stroke subtypes admitted to The Aga Khan University Hospital in Karachi. A total of 596 patients were enrolled in 22 months in the Aga Khan Universtiy Stroke Registry. These included 393 patients with Ischemic stroke, 126 patients with intracerebral hemorrhage, 50 patients with subarachnoid hemorrhage and others. The ischemic stroke group was classified according to the TOAST criteria and comprised of lacunar 168/393 [42.7%]; large artery atherosclerosis 106/393 [26.9%]; cardioembolic 24/393 [6.1%]; undetermined 80/393 [20.3%]; and other determined types 15/393 [3.8%]. The high proportion of lacunar strokes in our population may be due to high burden of inadequately treated hypertension and diabetes. Clear cut cardioembolic stroke was relatively infrequent in our population. Lacunar stroke is the most common subtype of stroke in our patient population. This is most likely secondary to uncontrolled hypertension

Should carotid endarterectomy be performed for symptomatic carotid stenosis in Pakistan?

The risk of stroke and death associated with carotid endarterctomy is operator dependant. Data regarding risks of this procedure are not available in Pakistan and therefore it is difficult to make accurate risk benefit analysis for individual patients. Our objective was to determine safety of carotid endarterectomy at an academic tertiary care center in Pakistan. Patients who underwent carotid endarterectomy [CEA] at our hospital during a ten-year period were identified through ICD-9 coding system of the hospital medical records. Demographic features, associated medical problems and immediate postoperative complications were recorded and analyzed. Sixty-three carotid endarterectomies were performed on 59 patients. Ages range from 43 to 80 [mean 61 +/- 8] years; 53 were male and 10 were female. Common associated diseases among these patients were hypertension; 38 [64.4%], ischemic heart disease; 26 [44%], diabetes mellitus; 24 [40.7%], dyslipidemia; 19 [32.2%] and renal insufficiency; 13 [22%]. Most common complication was neuropraxia [transient neuropathy]; 5 [7.9%], followed by pneumonia and stroke; each in 3 [4.8%] patients. None of the strokes related to the surgical procedure were disabling. Two of the patients who had stroke, recovered fully within 17 weeks and one recovered partly but was independent in all daily activities of living [ADLs]. One patient died following simultaneous coronary artery bypass graft [CABG] and CEA. The risk of stroke or death for patients undergoing CEA was high with simultaneous CABG [3/11, 27%] and low for patients undergoing CEA alone [1/52, 2%]. Carotid endarterectomy is a safe procedure in patients with symptomatic carotid stenosis at our hospital and should be performed, when indicated