Stroke Characteristics as Predictors of New-onset Seizure in Patients with Acute Ischemic Stroke

Introduction: The current guidelines on diagnosis and management of new-onset seizures in stroke are not well defined, especially in the Indian setting. Our study aims at providing insight into the hospital prevalence risk of new-onset seizures following ischemic stroke and to correlate seizure risk with the characteristics of stroke and other clinical parameters. Methods: A total of 127 patients were analyzed for the study where we assessed the clinical severity and the imaging severity of stroke using the National Institute of Health Stroke Scale (NIHSS) score and Alberta Stroke Program Early CT (ASPECT) score, respectively. Seizure-related variables including semiology, timing, and details of antiepileptic drugs (AEDs) were assessed under the domain of early and late poststroke seizures (PSSs). All patients were followed for 6 months for the seizure recurrence and change in Barthel index. In statistical analysis, quantitative variables were compared using the independent t-test/Mann–Whitney U test, and qualitative variables were correlated using Chi-square test/Fisher’s exact test. Univariate and multivariate logistic regression was used to find out the significant risk factors of acute symptomatic seizure. Results: The mean age of the study population was 59.72 years (±14.77), with a male predominance (60.63%). About 78.74% of the cases had an NIHSS score more than or equal to 6.24% had posterior circulation strokes and the rest had anterior circulation strokes. A cortical location of infarct was observed in 62.2% of cases and a subcortical location in 61.4% of cases. The prevalence of early PSSs observed in our study was 10.6%. Of those, 80% had generalized seizures, 13.3% had focal seizures, and 6.67% had focal seizures with secondary generalizations. No patient in the study group had late-onset seizures. Total leukocyte count, serum protein levels, serum uric acid levels, and erythrocyte sedimentation rate (ESR) values were associated with early seizures (p<0.05). Patients with early seizures were found to have a longer hospital stay (8 vs 6 days with p<0.05). In the Trial of Org 10,172 in Acute Stroke Treatment (TOAST) etiological classification, an acute stroke of undetermined etiology was found to have a significant association with the occurrence of early seizure in both univariate and multivariate analysis [p = 0.030; odds ratio (OR) 4.735 (1.160–22.576)]. There was no difference in change in the Barthel index among the two groups. Conclusion: There was no recurrence of seizures in those who defaulted for AED and one patient had a seizure even on AED. Prophylactic AEDs in stroke patients based on stroke characteristics could not be ascertained, but the sample size was small. Knowing the fact that antiepileptics cause sedation and increase the chance of aspiration, continuing AEDs in patients who develop acute symptomatic seizures should be judged judiciously.

Assessment of EEG as a Diagnostic and Prognostic Indicator Tool in the Febrile Seizures.

Objective: To assess the sensitivity, specificity, and predictive value of EEG as a diagnostic and prognostic tool in the febrile seizures. Method: This study was conducted on 50 consecutive children with febrile seizures attending the pediatric OPD of a tertiary care hospital. The children were prospectively identified and EEG was carried out on two occasions. First EEG was done within one week of febrile seizure episode and second EEG was done after 03 months of first EEG. EEG records were obtained with the standard international protocols for duration of 35 minutes which included 25 minutes of sleep record in all the children. Photic stimulation, hyperventilation and sleep deprivation were used as activation procedures. Descriptive analysis of EEG tracings was done in terms of background activity and presence of abnormal waveforms. Result: Paroxysmal EEG abnormalities were present in 54% of children. Most common epileptiform discharges were of generalized epileptic discharge followed by focal polyspikes. Sleep deprivation was the most effective activation procedure in evaluating febrile seizure with abnormal epileptiform discharge patterns. Validity measures of EEG in febrile seizure were found to have 90% sensitivity, 70% specificity, 72% positive predictive value and 88% negative predictive value within 95% confidence interval. Conclusion: EEG is a sensitive method for identifying and quantifying electrical activity in febrile seizures. EEG is useful as a diagnostic and prognostic tool in febrile seizures and can provide information regarding presence of abnormalities, degree of encephalopathy and electrographic features but like all diagnostic tool it is not fully infallible and requires further alternative diagnostic and clinical support.

Gastrointestinal problems at high altitude.

Gastrointestinal (GI) problems at high altitude are commonplace. The manifestations differ considerably in short-term visitors, long-term residents and native highlanders. Ethnic food habits and social norms also play a role in causing GI dysfuntion. Symptoms like nausea and vomiting are common manifestations of acute mountain sickness and are seen in 81.4% short-term visitors like mountaineers. Anorexia is almost universal and has a mutifactorial causation including effect of hormones like leptin and cholecystokinin and also due to hypoxia itself. Dyspepsia and flatulence are other common symptoms. Diarrhoea, often related to poor hygiene and sanitation is also frequently seen especially among the short-term visitors. Peptic ulceration and upper gastro-intestinal haemorrhage are reported to be common in native highlanders in the' Peruvian Andes (9.6/10000 population per year) and also from Ladakh in India. A hig h incidence o f gastriccarcinoma is also reported, especially from Bolivia (138.2 cases per 10000 population per year). Megacolon and sigmoid volvulus are common lower GI disorders at high altitude. The latter accounted for 79% of all intestinal obstructions at a Bolivian hospital. Thrombosis of the portosystemic vascultature and splenic hematomas has been reported from India. Malnutrition is multifactorial and mainly due to hypoxia. Fat malabsorption is probably significant only at altitudes > 5000m. Neonatal hyperbilirubinemia was found to be four times more common in babies born at high altitude in Colorado than at sea level. Gall stones disease is common in Peruvian highlands. A high seroprevalence of antibodies to H pylori (95%) has been found in Ladakh but its correlation to the prevalence of upper gastro-intestinal disease has not been proven.

Vasovagal syncope: an enigma.

Syncope is a common clinical problem affecting 3.5% of the general population. About 40% of cases remain undiagnosed and 30% experience recurrent episodes. The article presents an update on the etiopathogenesis and theories of syncope. The pathophysiology of syncope remains elusive. Lewis introduced the term "vasovagal" implying therein that both vasodilatation and bradycardia were involved in the response. Individuals susceptible are unable to maintain adaptive neurocardiovascular responses to upright posture for prolonged periods of time. A complex hemodynamic response develops, with marked hypotension, bradycardia and a loss of consciousness. The "empty ventricle theory", first proposed by Sharpey - Schafer, widely accepted for several years, has been challenged and various other aspects of the vasovagal response have now been studied and implicated in contributing to the episode of unconsciousness. These include baroreflex dysfunction, neuro - endocrine responses, role of respiration and cerebrovascular dysfunction. An episode of syncope represents an episode of unconsciousness. Even a single episode of unconsciousness in the present day lifestyle is a source of distress to a patient, warranting a workup and diagnosis. The etiopathogenesis of the simple faint is complex and we may well be dealing with a constellation of responses and a more detailed classification than hitherto imagined.