Thrombolysis in ischaemic stroke in rural North East Thailand by neurologist and non-neurologists

Background & Objective: Acute ischemic stroke (AIS) has been shown to be effectively treated with thrombolytic therapy. Thailand and other developing countries have limited stroke specialists to prescribe this treatment. Data regarding stroke outcomes in AIS patients who received thrombolytic therapy prescribed by neurologists compared with non-neurologists are limited. Methods: This was a large, multicenter, retrospective study conducted in 9 hospitals across the northeastern part of Thailand. The inclusion criteria were AIS patients who were admitted and treated with thrombolytic therapy between January 2010 and December 2012. Patients were categorized into two groups by physician specialty; neurologist and non-neurologist. Clinical outcomes and in-hospital mortality were compared between the groups. Results: There were 915 AIS patients who participated in the study; 175 patients were treated by the non-neurologists (19.1%). The mean age of all patients was 64 years and 55.1% were men. The median onset to needle time in both groups were similar at 180 minutes. The National Institutes of Health Stroke Scale (NIHSS) at discharge were significantly higher in neurologist group than non-neurologist group (NIHSS 6 vs 3, p value 0.03). The in-hospital mortality was also higher in neurologist group (9.5% vs 4.0%; p value 0.02). Conclusions: Non-neurologists may be able to thrombolyze AIS patients safely and effectively.

Clinical Manifestations of Eosinophilic Meningitis Due to Infection with Angiostrongylus cantonensis in Children

Eosinophilic meningitis, caused by the nematode Angiostrongylus cantonensis, is prevalent in northeastern Thailand, most commonly in adults. Data regarding clinical manifestations of this condition in children is limited and may be different those in adults. A chart review was done on 19 eosinophilic meningitis patients aged less than 15 years in Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand. Clinical manifestations and outcomes were reported using descriptive statistics. All patients had presented with severe headache. Most patients were males, had fever, nausea or vomiting, stiffness of the neck, and a history of snail ingestion. Six patients had papilledema or cranial nerve palsies. It was shown that the clinical manifestations of eosinophilic meningitis due to A. cantonensis in children are different from those in adult patients. Fever, nausea, vomiting, hepatomegaly, neck stiffness, and cranial nerve palsies were all more common in children than in adults.

Status Epilepticus in Srinagarind Hospital

Background : Status  epilepticus  (SE)  is  an  emergency  condition  and  contributes  to  high  mortality  rate  if  patients  were  misdiagnosed  and  improperly  managedObjective: To  describe  characteristics  and  management  of  patients  with  SE  in  Srinagarind  Hospital.Setting : Medical  ward,  Srinagarind  Hospital,  Faculty  of  Medicine,  Khon  Kaen  University.Patients:  Patients  diagnosed  as  SE,  between  1990-1996.Design : Descriptive  study.Results : Thirty  cases  were  diagnosed  as  SE,  18  male,  and 12 female.  Types  of  seizures  were  generalized  tonic – clonic  sezure  (GTC)  in  25 cases  and  epilepsia  partialis  continua  in  5  cases. Seven  cases  were  diagnosed  as  having  epilepsy  in the  past.  Causes  of  SE  (GTC)  were  CNS  infection in 7 cases,  antiepileptic  drug  withdrawal  in  6  cases,  post  arrest  in  3  cases,  antiepileptic drug  withdrawal  in  6 cases,  post  arrest  in  3 cases,  hyperglycemia  in 1 case,  hypertensive  encep-halopathy  in 1 case  and  unknown  in  4 cases.  Eighteen  GTC  patients  were  improperly   managed (72.00%) ,the common  causes  were  too  low  phenytoin  for  loading  dose  and  incorrect  diagnosis.  Mortality  rate  was 56.00% ,  cause  of  death  were  sepsis  and  brain  herniationh.Conclusion : SE  is  an  emergency  condition,  common causes  were  CNS  infection  and  antiepileptic  drug  withdrawal  and  contributed  to  high  mortality  rate  of  56.00%.  Eighteen  patients  (72.00%) were  improperly  managed. 

Cardiogenic Cerebral Embolism in Srinagarind Hospital

Background  : Rheumatic heart disease is the most common of valvular heart disease in Thailand and contributes to cerebrovascular disease.Objective : To study clinical features and recurrent rate of  cardiogenic cerebral embolism in Srinagarind HospitalDesign : Descriptive studySetting :  Srinagarind Hospital, Faculty of Medicine, Khon Kaen UniversityOne hundred and ten patients who were diagnosed cardiogenic cerebral embolism in department of internal Medicine service between 1983 and 1989.Measurement : Clinical features, history of previous stroke, underlying disease, atrial  fibrillation, left atrial colt  and recurrent rate by percentage.Results : There were 110 cases, 48 male and 62 cases were female. The patients’ mean age at diagnosis was 48.36 years (20-89 years). The main symptoms were hemi paresis (97.27%), aphasia (35.45%), alternation of conscious (32.73%), seizure (11.82%) and hemi anesthesia (10.00%). Underlying diseases were rheumatic heart disease (79.10%), non-valvular AF (11.82%), ischemic heart disease (4.55%), congenital heart disease (2.73%), prosthetic valve (0.90%) and endocarditic (0.90%). Sixty-five patients had echocardiogram, left atrial thrombus was found in 13 cases (20.00%). The most common abnormal valve was mitral valve. A trial fibrillation was found in 54 cases(62.00%). Three patients developed recurrent stroke within 2 weeks. Mortality rate was 15.45%, the most common cause of death was brain herniation (64.70%).Conclusion : Cardiogenic cerebral embolism was the most common cause of stroke in the young. The most common cause was mitral valve stenosis with atrial fibrillation. Recurrent rate within 2 weeks was 3.45%. The cause of death was brain herniation.

Cavernous Sinus Syndrome : A clinical comparison between mucormycosis and Non-mucormycosis

Introduction :  Cavernous  sinus  syndrome  is  a  disorder  characterized  by  paralysis  of  cranial  nerve  3, 4 6, and 5.  Causes  of  this  syndrome  are  infectious  and  non – infectious  source,  such  as  mucormycosis,  bacteria  and  malignancy.  Delay  in  diagnosis  and  improper  management  contributed  to  high  mortality  rate.  We  report  cavernous  sinus  syndrome  patients  at  Srinagarind  hospital  for  recognition  and  clinical  comparison  between  mucormycosis  and non – mucormycosis. Patient  and  Method :  Review  of  patient  charts  from  1985  to  1994  at  Srinagarind  Hospital,  Department  of  medicine,  Faculty  of  Medicine,  Khon  Kaen  university  with  sinus  thrombosis.Result :  There  were  25  patients, 9 male, 16  female,  male  to  female  ratio  was  1:1.7,  age  range  form  30-79  years,  mean  was  55.08  years.  Common  presenting  symptoms  were  headache  96%,  eye  pain  76%,  visual  impairment  56%  ptosis  52%  . Physical  examination  showed  paralysis  of  CN  3,4,6 100%,  visual  impairment  90%,  chemosis  72%, proptosis  64%,  black  crust  28%  weakness  20%  and  associated  with  sinusiis  80% .  Underlying  diseases  were  diabetes  mellitus  48%  and  chronic  renal  failure  20%.  Mortality  rate  was  54% .  The  common   causes   of  cavernous  sinus  syndrome  were  mucormycosis  60% ,  bacteria  36%  and  lymphoma  4%.  Clinical  comparison  between  mucormycosis  and  non-mucormycosis, visual  impairment,  weakness,  black  crust  were  more  common  in  mucormycosis  group,  high  level  of  BS,  BUN  and  CSF  sugar  to  BS  ratio  were  more  common  in  mucormycosis  group  too,  but  fever  was  more  common  in  non-mucormycosis  group  (P

Prevalence and Clinical Features of Myasthenia Gravis only and Myasthenia Gravis with hyperthyroidism

 Objective  : To  study  prevalence  and  clinical  features  of  myasthenia  gravis  (MG) and  myasthenia  gravis  with  hyperthyroidism  (MGHT)  Design  :  Case  review  study   Setting  :  Srinagarind  hospital,  Faculty  of  Medicine,  Khon  Kaen  University   Patienes :  One  hundred  and  four  patients  who  were  diagnosed  as  MG  and  MGHT  in  Department  of  Internal  Medicine  service  between  Januay  1891  and  May  1992.   Measurement :  Prevalence  of  MGHT,  history  of  fatigability,  fluctuation,  staging,  symptoms  and  signs,  prostigmine  test and  treatment  by  thymectomy  in  MG  and MGHT  by  percentage  and  Z – test  ( P  =  0.05)    Results  :  One  hundred  and  four  records  were  available  for  review,  there  were  85  cases  of  MG  and  19  cases  of  MGHT  that  made  the  prevalence  of  MGHT  of  18.3%.  Regarding  the  staging  of  disease,  in  MG  group  of  patients  only  8.2%  were  in  stage  I  compared  to  31.6%  in  MGHT  group( P =  0.003).  Ninty  four  percent  of  MGHT  patients  seeked  medical  attention  within  1  year  after  having  MG,  but  there  were  only  77.2%  in  MG  patients ( P = 0.048).  Concerning  thymectomy,  in  the  patients  who  had  stage  IIA  and  above,  58 / 78 (74.4%)  were  thymectized  in MG  group.  There  were  only  5/13  (38.5%)  in  MGHT  group  went  for  thymectomy  (p = 0.048).  The  other  clinlical  features  were  comparable.  The  pathological  findings  of  50  patients  in  MG  group  were  thymic  hyperplasia  34  cases  (68%)  ,  htymoma  2  cases,  malignant  thymoma  1  case  atrophic  change  5  cases  and normal  8  cases.  In  MGHT  goup  were  thymic  hyperplasia  4  cases  and  involuted    1   case.   Concludions :  The  prevalence  of  myasthenia  gravis  with  hyperthyroidism  in  our  study  is  18.3%,  which  probably  is  the  highest   among  all  series.  There  were  differences  in  some  clinical  features  between  MG  and  MGHT.  MGHT  patients  were  in  stage  1  more  frequent, seeked  medical  aedical  altention  earlier  and   MGHT  patients  went  for  thymectomy  less  frequent.

Paralytic rabies

 Three cases of paralytic rabies are reported. The important presenting symptoms were generalized muscle weakness and hyporeflexia without history of dog bites.  Clinical progression resembling myelitis with low sugar profile in CSF is presented in one case.  Percussion myoedema and fasciculation are useful physical signs for differentiation the paralytic rabies from Guillain-Barre-Syndrome and ascending myelitis.

Albendazole for neurocysticercosis

 Twelve cases of cerebral bysticercosis, treated with albendazole, were reviewed.  The results of treatment were excellent.  All of them were improved during treatment with minimal side effect.  On follow-up almost of them were in a good condition.

Thoracic cord compression by solitary osteochondroma

 The most common form of primary extradural spinal cord tumor in adults are chordomas and sarcomas(1).  Involvement of the spinal cord from vertebral osteochondroma is indeed rare(2,4) Ladpli reported 90 cases of spinal cord tumors and osteochondroma was not found(5).  The serious neurological manifestation of vertebral osteochondroma is spinal cord compression and usually presents with slow progression of motor and/or sensory deficits(3,4,6,7) (Table 1).  We report a patient with thoracic osteochondroma who presented with sudden onset of paraplegia.

Successful treatment of Wilson’s disease with zinc acetate solution

 A case of Wilson’s disease, presented with neurological disorders, was reported.  Her symptoms were deteriorated during D-penicillamine therapy and recovered with zinc acetate solution treatment. Key words : Wilson’s disease, zinc acetate solution.

Amyotrophic Lateral Sclerosis in Srinagarind Hospital

\ Retrospective study of 30 cases with amyotrophic lateral sclerosis who were admitted in Department of Medicine, Srinagarind Hospital during September 1981 to May 1989 was performed.\  Age incidence was range from 34 years to 75 years.\  (mean 53.2  11.9 years), male to female ratio was 2.75:1. The majority of them were farmer.\  The main presenting symptoms were muscle weakness (63.3%), dysarthria (60.0%) and dysphargia (56.6%). Duration of symptoms prior to admission was range from 1 month to 12 months.\  (mean 7.5  4.0 months)

Adult Community-acquired Bacterial Meningitis in Srinagarind Hospital

 The total 19 cases of community-acquired bacterial meningitis who were admitted in Department of Medicine, Srinagarind Hospital during December 1983 to November 1988 were reviewed.  Age incidence was ranged from 16 years to 69 years, male to female ratio was 5.3:1.  The majority of them were farmer and lived in Khon Kaen and nearby provinces.  There was no seasonal variation.  The common presenting symptoms were headache (94.7%), fever (89.4%), alteration of consciousness (68.4%) and nausea/vomiting (57.8%).  Meningeal signs were found in 84.2%.  Complete blood count showed leukocytosis and shift to the left.  In almost all of them, cerebrospinal fluid revealed white blood cell more than 1,000 cells/cu.mm. with polymorphoneuclear cell predominated, high protein (100-500 mg./dl.) and low sugar profile.  Gram stain and culture of CSF were positive in 78.9% and 68.4% respectively.  The most common organism was Stretococus pneumoniae.  The symptoms improved after treatment within 1-4 days.  The mortality rate was 36.8%.

Cryptococcal meningitis in adults

 Retrospective studies of 22 cases with cryptococcal meaingitis who were admitted in Department of Medicine, Srinagarind Hospital during February 1984 to October 1988 were performed.  Age incidence was range from 23 years to 70 years, male to female retio was 1.75:1.  The majority of them were farmer and lived in the North-East of Thailand.  There was no seasonal variation.  Associated diseases were found in 27.2%. All of them had no history of closed contact with the pigeon.  The common presenting symptoms were headache (100%), fever (50.0%), nausea/vomiting (40.9%) and alteration of consciousness (40.9%).  Meningeal signs were found in 57.0%.  Abnormal finding of chest X-rays was 36.3%.  On admission, cerebrospinal fluid values revealed : high initial opening pressure 63.6%, white blood cell pleocytosis 91.0%, high protein 77.1% hypoglycorrhachia 86.2%, positive india ink stain 63.1%, positive culture 89.4% and positive cryptococcal antigen 85.7%.  After treatment, 59.0% of the patients were improved.  Relapsed rate was 15.3%.  Less than 20 leukocytes/cu.mm. in cerebrospinal fluid was the poor prognostic factor.

Cerbral Cysticercosis : Clinical Manifestation and The Result of Treatment

 Twelve cases of cerebral cysticercosis who were admitted in Department of Internal Medicine, Srinagarind Hospital during September 1986 to April 1988 were reviewed.  Age incidence was ranged from 16 years to 70 years, male to female ratio was 2:1.  All of them were presented with epilepsy.  Duration from the first attack of epilepsy prior to the admission was ranged from 1 day to 5 years.  Neurological examination were entirely normal in almost of them.  Soft tissue calcification were positive in 2 cases.  Abnormalities in cerebrospinal fluid were mild pleocytosis and mild elevation of protein.  Computed tomography of brain showed focal low density area with increased enhancement in 11 cases and multiple cystic lesions in 1 case.  All were treated with praziquantel 2,400 mg./day for 15 days and other supportive treatments.  Result of computed tomography of the brain at the last day of treatment devided into three patterns; (1) the lesions were disappeared completely, (2) markedly improved and (3) similar to the previous treatment.  However, the latter were returned to normal within 3 months later.  The complications during treatment were mild headache (3 cases), hyperthermia (2 cases) and generalized maculo-papular rash (1 case).  On follow up, without any anticonvulsant drugs, all of them had no epileptic attack.

Tuberculous Meningitis in Adults

 Retrospective studies of 60 cases with tuberculous meningitis who were admitted in Department of Internal Medicine, Srinagarind Hospital during September 1983 to December 1987 were performed. Age incidence was ranged from 18 years to 91 years , male to female ratio was 1.22: 1. The majority of them were farmer and lived in Khonkaen and nearby provinces. There was no seasonal variation. Significannt addociated diseases were not found. Famillial history of tuberculosis was 13.3% The common presenting symptoms were headache (78.3%) fever (70.0%) and alteration of consciousness (58.3%) . Meningeal signs were found in 76.6%. Abnormal finding of chest X-rays was 55% On admission in almost of them, cerebrospinal fluid values revealed white blood cell up to 500 cells/cu.mm.and protein 100-500 mg/dl.Results of culture for M.tuberculosis in cerebrospinal fluid were positive in 2/21 cases. The symptoms were improved after treatment within 1-3 weeks. Severe change of consciousness was the poor prognostic sign.

Cerebral cysticercosis : Recent advances in the diagnosis and treatment of Cerebral cysticercosis

 Cerebral cysticercosis is one of the neurological diseases that can be commonly found in developing countries. In the past , the main treatment was only symptomatic care such as anticonvulsant therapy. Recently, two major medical advances have a review of cerebral cysticercosis.The first is the increased availability of CAT scanning , which has contributed both to a more accurate diagnosis and to a better understanding of the pathophyiology of cerebral cysticercosis. Investigators can now easily assess changes in lesions or their disappearance during treatment. The second advance is the development and experimental use of chemotherapeutic agents, such as praziquantel, in the treatment of cerebral cysticercosis. Both will be discussed in detail.

Heat stroke

 Heat stroke is a serious clinical  entity that commonly occurs in millitary, sports , occupational and the elderly debillitated persons after exposure to  a hot environment. Disturbances in central nervous system are the major presenting symptoms accompanied with abnormalities in other systems. It is a medical emergency, requiring rapid cooling and intensive care, even with optimum treatment, deaths and permanent damage still occur, therefore prevention is the best strategy.

Aseptic cerebral sinovenous occlusion: a case report

 Asptic intracranial sinovenous occlusion is an uncommon clinical entity.  The typical symptoms are severe headache, vomiting, convulsion, progressive drowsiness, papilledema and focal neurological signs.  It is commonly found in young women taking oral contraceptive pills.  A 29-year-old woman who presented with typical symptoms of cerebral sinovenous occlusion and had history of using oral contraceptive pills was reported.  Computed tomography scan and cerebral angiography showed sagittal sinus thrombosis.  The symptoms were fully recovered by supportive treatment without anticoagulant therapy.

Unusual Manifestation In Cryptococcal Meningitis : A Case Report

 The common symptoms in cryptococcal meningitis are chronic headache and nausea/vomiting respectively.  Impairment of visual acuity and hearing loss are less common finding, both of which can be found in the late stage of the disease.  Lymphocytic pleocytosis in cerebrospinal fluid analysis is a common laboratory finding.  A 42 year-old, farmer, male patient whose diagnosis was cryptococcal meningitis presented with acute headache, rapidly followed by visual and hearing loss and eosinophilic pleocytosis in CSF is reported.  Diagnostic approach will be discussed in details.

Cardiogenic Cerebral Embolism in Srinagarind Hospital

Background: Rheumatic heart disease is the most common valvular heart disease in Thailand and contributes to cerebrovascular disease.Objective:To study underlying diseases , recurrent rate and complication of anticoagulant therapy of cardiogenic cerebral embolism in Srinagarind Hospital.Design: Descriptive studySetting: Srinagarind Hospital, Faculty of Medicine, Khon Kaen University.Subjects: One hundred and eighty four patients who were diagnosed cardiogenic cerebral embolism in department of internal medicine service between 1985 and 1996.Measurement: Underlying diseases, atrial fibrillation, long term follow up, recurrent rate and complication of anticoagulant therapy by percentage.Results: There were 184 cases, 81 males and 103 females. The patients’ mean age at diagnosis was 47.50 years (15-89 years). Underlying diseases were rheumatic heart disease (70.10%), non-valvular AF (9.23%), dilated cardiomyopathy (6.20%), bacterial endocarditis (3.80%) , ischemic heart disease (3.26%) , mitral valve prolapse ( 2.10%) , hyperthyroidism ( 2.10%) , prosthetic valve ( 1.63%) , hypertrophic cardiomyopathy ( 1.05%)  and ventricular septal defect with pulmonic stenosis ( 0.53%). Atrial  fibrillation was found in 124 cases ( 67.39%). Thirty nine patients (30.24%) were rheumatic heart disease without atrial fibrillation.  Recurrent rate within first year was 19.04%.  Intracerebral hemorrhage caused by anticoagulant therapy was 4.34%.Conclusion: Cardiogenic cerebral embolism was the most common cause of stroke in the young. Although the most common cause was rheumatic heart disease with atrial fibrillation but there were about 30% of rheumatic heart disease patients that still have normal sinus rhythm. Recurrent rate within one year was 19.04% while intracerebral hemorrhage caused by anticoagulant therapy was only 4.34%.Key words : Cardiogenic cerebral embolism, rheumatic heart disease, atrial fibrillation