Stroke-Transient Cerebral Ischaemic Attacks (TIAs) A Medical Emergency-Preventable and Treatable.

TIA is a serious condition and a medical emergency requiring immediate evaluation and treatment to prevent a stroke. Confirmation of diagnosis is vital. Medical conditions like hypoglycaemia, migraine etc which mimic TIA should be identified. TIA syndrome in carotid territory needs special evaluation by Duplex sonography to detect significant stenosis (>70%) near bifurcation. Recurrent TIA in the same territory leaves neuro deficit and this needs prevention by appropriate therapy (platelet antiaggregants, anticoagulants, surgical intervention). An algorithm listing initial workup for TIA is shown in Figure 1. Associated risk factors (e.g. high blood pressure, tobacco use, uncontrolled diabetes mellitus, high cholesterol level and obesity etc) need special emphasis. Lifestyle modification and lack of physical exercise cannot be ignored. In high risk group where TIA lasts longer than 10 minutes with significant neuro deficit in elderly subjects having diabetes or hypertension will need special attention and treatment. Diagnostic tests should include cardiovascular evaluation and ultrasound scanning of carotid arteries. Special neuroimaging tests like CT/MRI and CTA/MRA to visualize cerebral vasculature and detect asymptomatic lesions are helpful in planning long term management and prevention of stroke.

Factors affecting burden on caregivers of stroke survivors: Population-based study in Mumbai (India).

BACKGROUND: Caring for stroke patients leads to caregiver (CG) strain. The aims of this study are to identify factors related to increased CG burden in stroke survivors in a census-defined population and to assess the relationship between patient characteristics and CG stress. MATERIALS AND METHODS: In a prospective population-based study, 223 first ever stroke (FES) were identified over a 1-year period. At 28 days, 127 (56.9%) were alive and 79 (35%) died, and 17 were lost to follow-up. One hundred and eleven CGs of 127 FES survivors agreed to participate. The level of stress was assessed by two scales: Oberst Caregiving Burden Scale (OCBS) and the Caregivers Strain Index (CSI) in CGs of survivors with mild stroke Modified Rankin Scale (MRS 1-2) and in those with significant disability (MRS 3-5). RESULTS: The mean age of CGs was 45.6 years, approximately 22 years younger than that of the patients (67.5 years). Eighty-nine (80%) of the CGs were females and only 22 (20%) were males. Urinary incontinence (P=0.000008), morbidity at 28 days by MRS (P=0.0051), female gender (P=0.0183) and moderate to severe neurological deficit by National Institute of Health Stroke Scale (NIHSS) on admission (P=0.0254) were factors in FES cases leading to major CGs stress. CG factors responsible for major stress were long caregiving hours (P≤0.000001), anxiety (P≤0.000001), disturbed night sleep (P≤0.000001), financial stress (P=0.0000108), younger age (P=0.0021) and CGs being daughter-in-laws (P=0.012). CONCLUSION: Similar studies using uniform methodologies would help to identify factors responsible for major CG stress. Integrated stroke rehabilitation services should address CG issues to local situations and include practical training in simple nursing skills and counseling sessions to help reduce CG burden.

Choroidal tubercles in neurotuberculosis: prevalence and significance.

PURPOSE: Neurotuberculosis is a relatively common form of tuberculosis and may be seen in 1-10% of patients of systemic tuberculosis and may present in several forms. Ocular lesions are frequently seen, most commonly optic nerve lesions. Limited data are available for choroidal tubercles. We conducted a prospective study 1) to determine the prevalence of choroidal tubercles in a cohort of patients of neurotuberculosis as well as its relative prevalence in the various morphological manifestations and 2) to study the role of co-existent systemic tuberculous infection. METHODS: IRB-approved prospective cross-sectional observational study. A hospital-based cohort of patients underwent a detailed physical, laboratory and ocular evaluation. RESULTS: A total of 52 (20 male, 32 female) patients were evaluated with tubercles being seen in 23 eyes (18 patients, 34.6%). Twenty four patients (46.12%, 16 female, 8 male) presented with intracranial granulomas and 28 (53.8%, 16 female, 12 male) presented with tuberculous meningitis. Tubercles were seen in 10 eyes of 8 (28.5%) patients with tuberculous meningitis and in 13 eyes of 10 patients (41.6%) with intracranial granulomas. This result is not statistically significant. Twenty seven patients (51.9%) had neurotuberculosis without systemic infection, whereas 25 (48.1%) patients had systemic foci. Tubercles were seen in 18 eyes (13 patients) with systemic foci and in 5 eyes (5 patients) of neurotuberculosis alone. The odds ratio for the presence of systemic tuberculosis when choroidal tubercles are present is 5.6 (95% confidence interval: 1.39-24.49, statistically significant [p = 0.005]). CONCLUSIONS: Tubercles were equally likely to occur in either manifestation of neurotuberculosis, and their presence was related to the presence of systemic focus of tuberculous infection. The presence of choroidal tubercles may serve as a diagnostic marker for the presence of an underlying systemic infection.