New Oral Anticoagulants versus Warfarin for Cerebral Venous Thrombosis: A Multi-Center, Observational Study / 대한뇌졸중학회지

No abstract available.

The Effect of Repetitive Arm Cycling Training Priming with Transcranial Direct Current Stimulation on Post-Stroke: Pilot Study

Transcranial direct current stimulation (tDCS) is a noninvasive method that may increase the rehabilitation effects in stroke. The objective of the study was to test whether tDCS priming with training on an arm ergometer boosts motor performance in chronic stroke patients. Three chronic subcortical stroke patients had continued a sole unilateral stroke 30–36 months formerly. They had some voluntary control of the arm in the affected side underwent a cycling training on an arm ergometer for 20 minutes a day, during 5 days a week priming with cathodal tDCS stimulation of unaffected hemisphere. They were tested during 4 sessions 1 week before, at the beginning, at the end, and 1 week after the end of the training priming with tDCS. We executed; 1) Rivermead Motorik Assessment (global function, arm and leg), 2) the Modified Ashworth Scale of the elbow flexors and extensors, 3) the minimum torque on the lesion side, 4) grip strength, and 5) pegboard performance at each time of testing the patients. All patients tolerated tDCS very well during experiment. Patients showed significant (p = 0.01) improved of force and spasticity (p = 0.03). The grip strength and pegboard performance improved significantly too after DCS priming with training. These results showed that cathodal tDCS is a useful device for rehabilitation when priming with motor training in stroke patients. These patients proved the clinical relevance of the results.

Diagnosis, treatment and follow-up in four children with biotinidase deficiency from Pakistan

Biotinidase deficiency is an inherited disorder in which the vitamin biotin is not recycled. If untreated, affected individuals develop neurological and cutaneous symptoms. Untreated individuals with biotinidase deficiency either succumb to disease or are left with significant morbidity. We describe clinical course and follow-up of 4 children from Pakistan. All 4 presented with classical symptoms of biotinidase deficiency and responded dramatically to oral biotin within days to weeks. Biotinidase deficiency is reported in Pakistani children from different part of world, however; there is no such report from Pakistan. This highlights lack of awareness of biotinidase deficiency among physicians in Pakistan.

Plant Root Hair in Tap Water: A Potential Cause for Diagnostic Confusion / 대한진단검사의학회지

Plant root hairs are commonly found artifacts in parasitology specimens and may be confused with helminthes by an untrained eye. We report a case of brain tuberculoma where the tissue sample was contaminated with root hair derived from tap water; the presence of this root hair, which mimicked a larva, led to diagnostic confusion. Therefore, tap water should be considered a source of root hair and vegetable matter.

Mechanism of neuronal injury in cerebral venous thrombosis

The impact of CVT on the brain is wide spectrum, ranging from completely normal parenchyma to brain oedema and/or haemorrhage. Multiple factors relate to neuronal injury in CVT including; dural sinus pressure, increased venous flow velocities, collateralization of venous channels, rate of occlusion, development of cytotoxic and vasogenic oedema, recanalization and accelerated myelination. It is suggested that recanalization of occluded vein, as well as, the presence or absence and the efficiency of intracranial venous collaterals, may have an impact on the extent of brain tissue damage and hence the prognosis of acute CVT

Heparin in the treatment of cerebral venous thrombosis

Cerebral venous thrombosis [CVT] is a potentially life-threatening condition requiring rapid diagnosis and urgent treatment. Heparin anticoagulation is the time-honoured treatment, and is advocated in all cases of CVT, irrespective of etiology or presence of haemorrhage. The supportive evidence is largely observational; data from randomized placebo-controlled trials shows a nonsignificant trend favouring heparin. Current practice is to begin heparin [unfractionated or low-molecular weight] immediately on confirmation of the diagnosis. Newer anti-thrombotic agents such as ximelagatran may offer advantages over heparin and need to be investigated in the treatment of CVT

Local thrombolytic treatment of cerebral venous thrombosis in three paediatric patients

There is increasing evidence that local thrombolysis can be used with relative safety and efficacy in adults with superior sagittal sinus thrombosis [SSST]. However, little data is available on the use of local thrombolysis in children with SSST. We report three patients who received local thrombolysis for dural sinus thrombosis. Two patients received urokinase and one patient received urokinase followed by local TPA infusion. Recanalization was achieved in two patients

Neuroleptic malignant syndrome: need for early diagnosis and therapy

Neuroleptic Malignant Syndrome [NMS] is a medical entity that has received little attention in the clinical settings in Pakistan. The aim of our study was to review the predisposing factors, outcomes and characteristics of in-patients diagnosed with NMS. We performed a retrospective chart review of all cases [age > 15 years] at a tertiary care center in Karachi between January 01, 1990 and November 30, 2001, diagnosed using ICD 10 coding. Data was collected using a standardized data entry form and statistical analysis was performed using Epi Info 6, Version 6.02. There were a total of 20 patients diagnosed with NMS [11 male and 9 female] in our study with a mean age of 46.6 +/- 15.9 years. Haloperidol was the most frequently responsible neuroleptic. Of the 18 patients on a neuroleptic, most developed NMS after 8 weeks of therapy. There were 5 mortalities all of which were associated with septic shock. Fourteen patients recovered completely from the episode and did not have any neurologic sequelae. NMS is an important preventable clinical entity. Early diagnosis and judicious use of antipsychotics is warranted to prevent mortality and heightened morbidity

Herpes simplex encephalitis: analysis of 68 cases from a tertiary care hospital in Karachi, Pakistan

To evaluate clinical presentation, radiological and cerebrospinal fluid findings and outcome of patients with Herpes simplex encephalitis [HSE]. The charts of all the patients [n=88], who were admitted to The Aga Khan University, Karachi with diagnosis of HSE, from 1990-2002, were retrospectively reviewed. Sixty eight patients were included in the study. The variables were identified [including demographic data, signs and symptoms at presentation and laboratory investigations such as CSF analysis including, PCR, serum IgM antibodies, EEG and neuroimaging]. The patients were included in the study if they had any three of the five criteria positive in addition to clinical features suggestive of herpes encephalitis. Sixty eight patients, that fulfilled the criteria, were included in the study. Clinical findings included fever, seizures, altered mental status, aphasia and hemiparesis. CSF, analysed in all the patients, was abnormal in 65 patients [96%] and EEG was abnormal in 82% patients. All patients underwent CT or MRI of the brain, 66% patients had abnormal scans. Temporal lobe involvement was seen in 34 patients [50%] and 11 patients had purely extra temporal lesions. All patients were treated with standard Acyclovir. Seven patients died. At the time of discharge, 17 patients showed normal neurological examination, 29 were ambulatory with assistance and 15 were bedridden. Our study suggests that large number of patients with HSE have extra temporal involvement on CT or MRI. Majority of patients had complete or good recovery after completion of therapy

Rapidly developing Optic Neuritis secondary to Ethambutol: possible mechanism of injury

Optic neuritis has been described among the toxic effects of Ethambutol. This side effect is dose related. The mean duration of Ethambutol induced optic neuritis [EON] is three months. We report a case of EON after few days of exposure to Ethambutol and the symptoms resolved after discontinuation of Ethambutol. This most likely represents an idiosyncratic reaction which is different as compared to dose related optic neuritis

Prognostic indicators in patients with primary intraventricular haemorrhage

Primary intraventricular haemorrhage [PIVH] is a rare clinical entity. We sought to evaluate risk factors, clinical and radiological features, and outcome of patients with PIVH. Cases of PIVH were identified from cohort of patients with non traumatic intracerebral haemorrhage [ICH] by reviewing the radiological data. Their charts were reviewed and demographic, clinical, radiological and laboratory data was recorded and analyzed. Chi square and t test were used to determine predictors of poor outcome. Fifteen of 677 [2%] patients with ICH had PIVH. Nine [60%] were men. Median age was 56 years. Predisposing factors included hypertension in twelve [80%], coagulopathy in five [33%] and vascular malformations in two [13%] patients. Eleven [73%] patients developed hydrocephalus. Two patients died. Univariate analysis identified diabetes mellitus, blood in all ventricles and coagulopathy as predictors of death during initial hospital stay and hydrocephalus as predictor of poor outcome [death and disability combined] [p<0.05]. Hypertension is most common associated risk factor for primary intraventricular haemorrhage followed by coagulopathy. Hydrocephalus is a common complication, associated with poor outcome. Diabetes mellitus, coagulopathy and panventricular blood predict early mortality

Chronic infections and risk of stroke: possible explanation for cryptogenic stroke

The association of certain infections as a potential cause of stroke has been known for some time. The complications of bacterial or fungal endocarditis resulting in emboli, mycotic aneurysm and subarachnoid hemorrhage; meningeal infiltration by spirochetes and inflammatory cells seen in neurosyphilis; strokes by direct invasion of cerebral blood vessels in tuberculous meningitis as well as other basilar meningitides; and cerebral vasculitis in association with varicella zoster infection are the few examples. More recent interest has been focused on chronic infections by common organisms such as Helicobacter Pylori and Chlamydia Pneumonie and their role in atherosclerosis processes. This article reviews the current literature highlighting the association of these infections to atherosclerotic processes which ultimately result in strokes. The pathophysiology of stroke is variable. Large artery atherosclerosis accounts for the main pathogenesis in myocardial infarction, whereas thrombo-embolism, lipohyalinosis, hypercoagulable states and arterial dissection are some of the pathogenetic-mechanisms involved in stroke. Still 30-40% of strokes have no apparent etiology [cryptogenic strokes]. This shows the diversity and variability of the cerebral vasculature when compared with the coronary vasculature. The risk factors for stroke therefore need to be investigated independently of those for atherosclerosis and MI. It would be also imperative to consider the temporal profile of the associated infective process. Acute infections, may cause or contribute to acute stroke by promoting a pro-inflammatory or pro-coagulant effect at the time of the infection for example acute bronchitis could alter inflammatory and coagulation parameters, leading to sudden atherosclerotic plaque rupture or thrombosis, precipitating a clinical event. Alternatively, chronic, subclinical infection with certain organisms may be one of several potential underlying causes of the chronic inflammatory process of atherosclerosis. Both acute and chronic processes could occur together in any one individual, as well. Similarly, it should be taken into consideration if the infective process is localized or systemic. The presence of a chronic infection anywhere in the body, for example, could promote systemic pro-inflammatory changes, including monocyte and macrophage activation, cytokine release, hypercoagulability, or systemic changes in other mechanisms of atherogenesis, such as lipid metabolism. Direct vessel invasion and infection, alternatively, may contribute to local changes in the vessel wall that lead to atherogenesis, progression of plaque growth, or plaque rupture. Thus, if infections were shown to play an important role in the initiation or progression of atherosclerosis, the implications for clinical practice and stroke prevention would be significant. Although much of the data on the role of infection in atherosclerosis is based on association of organisms with atherosclerosis, and thus does not clearly provide proof of causality, more experimental data is becoming available from in vitro work, animal studies, and even clinical trials