Thrombolysis in the treatment of acute stroke: is there a role for streptokinase when tissue plasminogen activator is not available?

Every year 350,000 people suffer an acute stroke in Pakistan. Treatment of acute stroke has not improved significantly despite the availability of intravenous thrombolysis with tissue plasminogen activator [tPA].The drug is expensive and is offered to a selected few. Streptokinase [SK], a low cost alternative thrombolytic agent, is widely available in Pakistan and is utilized to treat patients with acute coronary syndromes. Streptokinase was tested in acute stroke in the 1980's and found to be ineffective in ischemic stroke. This is likely due to trial design flaws, rather than the drug itself. Factors that may have contributed to poor outcomes include a prolonged treatment window, inclusion of patients with established infarction on CT scan, failure to treat excessive arterial pressures, a fixed dose of streptokinase and concomitant use of antithrombotic medications. Given the lack of therapeutic alternatives we believe that a properly designed trial in appropriate patient population utilizing stricter inclusion criteria, including early treatment with a lower dose of SK is warranted

Comparability and validity of siriraj stroke score and allen stroke score in differentiation of acute ischemic and haemorrhagic stroke

To compare and validate Alien stroke score [ASS] and Siriraj stroke scores [SSS] in differentiating acute cerebral hemorrhage [CH] and cerebral infarction [CI]. This comparative, analytical study was conducted at Khyber Teaching Hospital Peshawar, Pakistan from July 2000 to February 2002. Study included 100 patients of acute ishemic or hemorrhagic stroke confirmed on CT scan brain after clinically evaluation. ASS and SSS were calculated for each patient and compared with the results of CT scan for comparability [Kappa Statistics] and validity by using SPSS 10. Out of 100 patients, 69 had CI and 31 had CH. The overall comparability of ASS and SSS was fair [Kappa=0.51]. ASS and SSS were uncertain in 27 and 18 cases respectively; with Kappa showing worst comparability in term of certain results [K= 0.23]. In 64 cases with both scores in the diagnostic range, the Kappa showing excellent comparability [K=0.91].The sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] of ASS was 38.70%, 91.30%, 66.67%, 76.82% respectively for CH and 71.1%, 80.64%, 89.09% and 55.56% respectively for CI, with overall predictive accuracy of 61%. The sensitivity, specificity, PPV and NPV of SSS was 67.74%, 94.2%, 84% and 86.67% respectively for CH and 78.26%, 90.32%, 94.73% and 65.11% respectively for CI, with overall predictive accuracy of 75%. Although, SSS being simple with more accuracy is better than ASS, both these scores lack sufficient validity to be used for exclusion of cerebral haemorrhage before offering antithrombotic or thrombolytic therapy

Frequency of seizures and epilepsy after ischaemic stroke

To evaluate the frequency and risk factors of seizures and epilepsy after ischemic stroke. This prospective observational study was conducted on patients with Ischemic Stroke in the Department of Neurology; Postgraduate Medical Institute, Lady Reading Hospital, Peshawar. These stroke patients were followed up for a total period of 2 years. Initially 210 patients were enlisted in the study. Out of these, 10 patients died or lost to follow up so they were excluded from the final analysis leaving a figure of 200. The main outcome measures were the occurrence of single or recurrent seizures as well as the occurrence of both early [within 2 weeks] and late [after 2 weeks] seizures were recorded. Patients who already had history of seizures, those with intra-cerebral bleed and sub-arachnoid hemorrhage were excluded from the study. Out of 200 patients [130 males and 70 female], 6 [3%] patients had early seizures while 10 [5%] patients presented for the first time with late onset seizures. So a total of 16 [8%] patients had post stroke seizures. Early seizures were mostly generalized tonic clonic seizures, while late seizures were mostly partial with or without secondary generalization. Epilepsy characterized by recurrent seizures occured in 3 patient's [1.5%]. Stroke patients have overall 8% risk of seizures and 1.5% risk of epilepsy in the first 2 years after an ischemic stroke. Majority of these seizures occurred after 2 weeks of onset of stroke

Intracerebral hemorrhage: presentation, early morbidity and mortality

To study the mode of presentation, risk factors, early morbidity and mortality of patients presenting with intracerebral hemorrhage [ICH] to a General Neurology Unit This study was conducted at Lady Reading Hospital from January 2001 up to December 2001 on patients with confirmed ICH. Traumatic bleed was excluded from the study. After initial clinical assessment Glasgow coma scouring was done in all patients and the morbidity was assessed by modified ranking scale [MRS]. Patient's MRS was recorded at the time of discharge and at one month follows up. Out 74 patients [46 male and 25 female] 33 patients presented with headache and 30 patients had vomiting. Twenty patients had GCS /= 10. Five patient developed obstructive hydrocephalus which needed surgical intervention. Thirty nine patients had severe disability at the time of discharge. After a follow up of one month, 32 patients had improved, 17 patients were in status queue while two patients had deteriorated. Six patients died in the hospital and 04 patients died at home while 13 patients were lost to follow-up. High mortality was seen in patients with GCS

Frequency of congenital heart diseases in patients under the age of twelve years at lady reading hospital Peshawar

To find out the frequency of various congenital heart diseases [CHI]] in patients less than 12 years of age at Lady Reading hospital, Peshawar. This retrospective study was conducted at Department of Cardiology, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar. Patients referred for echocardiography were reviewed. Trans-thoracic two dimensional echocardiography and Doppler studies were done on all cases. The results were analyzed from the data retrieved from the computerized data base of Cardiology department from July 1998 to December 2005 covering almost seven years and six months. Records of patient aged twelve and below and labeled as congenital heart disease were analyzed on SPSS windows version 10. Out of 3072 patients with CHD, 83.7% were acyanotic heart diseases. Ventricular septal defect was present in 1248 patients [40.6%], atrial septal defects [ASD] were 493 [16%] comprising of ASD secundum in 397 [12.9%] and ASD primum in 96 [3.1%] patients. PDA was present in 394 patients [12.8%]. A total of 473 patients [15.4%] had the tetrology of Fallot and 236 patients [7.7%] had pulmonic stenosis. Complex congenital heart diseases were present in 198 [6.4%] patients and coarctation of aorta was found in 0.9%. Majority of the congenital cardiac anomalies in patients less than 12 years of age are acyanotic. VSD and ASD are the major acyanotic and TOF is the major cyanotic congenital heart disease

Hypertension in acute ischemic and haemorrhagic stroke

To know the pattern of systolic and diastolic blood pressure in hypertensive patients with acute ischemic and hemorrhagic stroke. Material and This study was conducted on 100 patients with acute stroke, admitted in Khyber Teaching Hospital from July 2000 onward. Hypertensive patients were finally selected for analysis. BP was recorded at arrival and 24 hours after admission. Out of 100 patients with stroke, hypertension was present in 72 cases. Out of these 72 patients, 44 cases [61.1%] had cerebral infarction [CI] and 28 cases [38.9%] had cerebral haemorrhage [CH]. Overall mean systolic BP at arrival [SBP-A] was 163 [ +/- 35.606] mm Hg. Mean SBP-A in patients with CI was 152.3 [ +/- 34.397] mm Hg and in patients with CH was 181.25 [ +/- 30.357] mm Hg. Overall 68% of hypertensive stroke patients had uncontrolled systolic BP at arrival. Overall mean diastolic BP at arrival [DBP-A] was 95. 97 [ +/- 20.733] mm Hg. Mean DBP-A in CI was 88.75[ +/- 17.854] mm Hg and in CH was 107.32[ +/- 20.115] mm Hg. The mean difference of DBP-A in CH and CI was 18.57mm Hg. Mean systolic BP and Mean diastolic BP, 24 hours after admission were 157.85 mm Hg and 92.08 mm Hg respectively. Majority of hypertensive stroke patients have uncontrolled blood pressure. Hypertension is a risk factor for both ischemic and hemorrhagic stroke. More elevation of blood pressure is more frequently associated with cerebral hemorrhage than cerebral infarction

Renal tubular acidosis: a case report

This case report describes a 19 years old boy presenting with bilateral lumbar pain, abdominal cramps and generalized bodyaches. Systemic examination was unremarkable. Patient was diagnosed as Type I Renal Tubular Acidosis on the basis of alkaline urine, nephrocalcinosis, hypokalemic hyperchloremic metabolic acidosis with normal serum anion gap and positive amrnonium chloride challenge test

Neurological manifestations of Wilson's disease

To study the frequency of various neurological manifestations in patients with Wilson's Disease.Patients suspected of having Wilson's disease were admitted to the Neurology unit of Postgraduate Medical Institute, Lady Reading hospital, Peshawar, for a full work up for Wilson's disease. Only those patients who had neurological signs or symptoms of Wilson's disease were included in this study. Out of 15 patients 9 were female and 6 were male, ranging in age from 8 to 26 years, with mean age of 15.6 years [SD +/- 5.82]. Most common neurological features were tremors followed by rigidity, dysphagia/drooling, speech or gait problems. All patients had low serum ceruloplasmin level and Kayser-Fleischer corneal rings. Liver involvement in the form of cirrhosis was found in 13 [86.7%] patients on ultrasonography, since no liver biopsy was done it could not be determined whether the remaining two patients had liver involvement or not. Neurological manifestations are not uncommon in Wilson's disease. It should be considered in patients of any age presenting with unusual liver, neurologic or psychiatric abnormalities. It should especially be looked for in children and other young patients with extrapyramidal signs or symptoms