Current patterns in the management of adult stroke by Filipino neurologists: A nationwide cross-sectional survey among fellows of the Philippine Neurological Association

BACKGROUND: Despite the availability of clinical guidelines for stroke, variation exists in the management patterns of stroke among neurologists.OBJECTIVE: To determine the current practice patterns of Filipino adult neurologists in stroke and their adherence to the current clinical guidelines of the Stroke Society of the Philippines (SSP).METHODS: Cross-sectional survey using a 3-page, 17-item questionnaire reviewed by the Stroke Council of the Philippine Neurological Association (PNA).RESULTS AND OBSERVATIONS: From November 2013 to July 2014, 136 of 277 (49%) locally practicing board certified adult neurologists of the PNA were surveyed. Some important findings from the survey include: (1) 70% of respondents underestimated the benefit of warfarin in stroke prevention in nonvalvular atrial fibrillation (NVAF); (2) for acute ischemic stroke, although the recommended systolic blood pressure (SBP) threshold is >220 mm Hg, 43% would initiate antihypertensive therapy at SBP >180 mm Hg; (3) for acute primary intracerebral hemorrhage (ICH), 42% would start antihypertensives at SBP >140 mm Hg; (4) despite the absence of guidelines recommending the use of neuroprotectant drugs for acute stroke, 75% and 56% of neurologists have prescribed it to >80% of their patients with infarcts and ICH respectively; (5) 46% of neurologists have not experienced giving thrombolytic therapy to any of their patients with acute ischemic stroke; (6) among patients with clinically stable hemorrhagic strokes, 77% of neurologists would give antithrombotics, while 28% of them would start it 30 days after the onset of stroke; (7) only 21% of respondents have ordered carotid studies as part of their work up in >80% of their patients with ischemic strokes; and (8) 64% of respondents have requested carotid revascularization procedures for patients with significant carotid stenosis, and about 38% of these patients underwent the procedure.CONCLUSION: The management patterns in stroke remain varied among Filipino neurologists, although the patterns show increasing adherence toward guideline recommendations. The following practices are noted: underestimation of the benefits of oral anticoagulation for stroke prevention among patients with NVAF; use of pharmacologic control of blood pressure below the recommended threshold for acute ischemic stroke; widespread use of neuroprotectant drugs despite lack of definite evidence for its use; low utilization of carotid studies in the work-up of patients with ischemic stroke and the low rate of revascularization procedures in confirmed cases of carotid stenosis; and a relative increase in experience with thrombolysis.

Hemichorea and myoclonus in Filipino patients with cerebral toxoplasmosis: A report of two cases

BACKGROUND: This paper synthesizes two unique cases of an adult Filipino patient presenting with involuntary unilateral extremity movements which upon further workup revealed cerebral toxoplasmosis as their primary etiology, further revealing their immunocompromised states. To our best knowledge there is limited available data on cerebral toxoplasmosis in our local setting. RATIONALE AND OBJECTIVES: The Filipino population is not spared from the pervasive global upsurge of AIDS cases as well as HIV-related infections. The aim of this report is to document the clinical features and diagnostics of two patients with cerebral toxoplasmosis presenting with unilateral involuntary extremity movements to heighten the level of awareness of Filipino physicians on the need to further explore possible etiologies of common neurological signs and symptoms as well as document additional cases of HIV-related infection in our country. CASE DESCRIPTION: The first case is a 30 year old male with no comorbidities who presented with fever and sudden onset of choreoathetoid movements of the left extremities. MRI revealed a rim enhancing nodule in the left supraorbital frontal lobe and in the middle cerebral peduncle. The second case is a 40 year old male, known hypertensive, initially diagnosed to have pulmonary tuberculosis, who presented with sudden onset of focal left arm myoclonic jerks. MRI revealed a rim enhancing cortical nodule on the right precentral gyrus. Both lesions were consistent with characteristics of toxoplasmosis. Both patients also showed positive serological titers for toxoplasmosis and had low CD4 T-cell count on flow cytometry. Both patients were treated with high dose trimethoprim-sulfamethoxazole and were further worked up for HIV-related infections. CONCLUSION: Majority of Filipino patients are still not provided with the opportunity to be diagnosed and treated for HIV-related infections, with one reason being the low index of suspicion for such cases. There is still limited amount of data available locally regarding patients presenting with Cerebral Toxoplasmosis, and that common neurological signs and symptoms as presented in this report should provide the much needed enlightenment in a physician's clinical eye to entertain such etiologies.

Safety, tolerability and recovery assessment of using sulodexide in acute ischemic stroke (STRAUSS): A pilot study

Sulodexide was evaluated in an investigator-initiated, multi-center, randomized, controlled, open-labeled study to determine its safety and tolerability profile, and effect on the neurological recovery and functional outcome of patients with acute ischemic stroke. Sixty-five (65) patients were randomized to Standard care group and 46 to Standard care plus Sulodexide Treatment group. Sulodexide was observed to be safe and well-tolerated among patients included in this study. Although not statistically significant, Modified Rankin Scale Responder Analysis consistently showed higher proportions of functionally improved patients in the Sulodexide group than in the Standard Care group on treatment days 10, 30, and 90 respectively.