Comparison of Siriraj Stroke Score and the WHO criteria in the clinical classification of stroke subtypes.

Clinical distinction between cerebral haemorrhage (CH) and cerebral infarction (CI) is important in the management of stroke patients in areas where CT scan facility is lacking or access limited by cost and distance. This distinction is necessary in our environment where an increasing proportion of patients are suspected to have haemorrhagic stroke. This study compares Siriraj stroke score (SSS) and the WHO criteria for the acute stroke syndrome as simple tools for this purpose. The computerised tomography (CT) brain scans of all patients referred with clinical diagnosis of stroke at the University College Hospital (UCH), Ibadan, and RADMED diagnostic centre. Lagos were retrieved and reviewed as well as the case notes of these patients at the referral hospitals. Relevant clinical data were extracted from the case records. The patients were classified into either CI or CH using the WHO criteria for acute stroke syndrome and the SSS. This classification was compared with the CT scan diagnosis using the latter as the gold standard. Data analysis was performed with Epi-info software, and Kappa statistics (k value) for comparability test with 95% confidence interval was used to compare the two clinical criteria with the gold standard. Ninety-six patients had complete clinical records and CT scan features consistent with the diagnosis of stroke, of which 52 were diagnosed as CI and 44 as CH. SSS had sensitivity of 50% for haemorrhage and 58% for infarction with an overall accuracy of 54.2%. The WHO criteria for the acute stroke syndrome had sensitivity of 73% for haemorrhage and 69% for infarction with an overall accuracy of 71%. The kappa coefficient was 0.18 for the SSS and 0.41 for the WHO criteria. The diagnostic accuracy of the WHO criteria for the acute stroke syndrome is higher than that of the Siriraj stroke score. The WHO criteria showed moderate agreement (k=0.41) with the CT scan, while the SSS showed no agreement (k=0.18). When CT scan is not affordable or its use is limited by distance, the WHO criteria for acute stroke syndrome could be more useful. A prospective study with a larger sample size is suggested for definitive conclusion.

Effectiveness of high dose dexamethasone in the treatment of acute stroke.

A prospective double-blind placebo-controlled, randomised clinical trial was carried out to determine the effectiveness of short-course of high dose dexamethasone therapy on mortality and neurological recovery in stroke patients. During a sixteen month period of study, 230 patients with clinical diagnosis of stroke were seen. Of these, 40 were eligible for the study (27 were presumed to have had haemorrhagic stroke; and 13 were presumed to have had cerebral infarction). The commonest cause of exclusion was presentation after 24 hours of the ictus. Patients were sequentially paired and randomised into high dose dexamethasone and placebo groups in a double-blind fashion. There were twenty patients in either group. Of the 27 patients with haemorrhagic stroke, 15 were in the dexamethasone group and 12 in the placebo group. Of the 13 patients with cerebral infarction, 5 were in the dexamethasone group and 8 in the placebo group. Each patient received 100 mg of dexamethasone stat, and 16 mg every 6 hours for a period of 48 hours or equivalent volumes of placebo. Assessment of each patient was done using a neurological score. Sequential analysis by Armitage was employed, using survival at 1 month as the primary criterion of effectiveness. Survivors were followed-up for 6 months. At the end of one month, 16 patients (80%) had died in the dexamethasone group and 17 (85%) in the placebo group. The average day of death was six days in the dexamethasone group and 15 days in the placebo group, but this was not statistically significant. Of the seven survivors at one month, four were in the dexamethasone group and 3 in the placebo group. Five of them had cerebral infarction and two had haemorrhagic stroke. The two in the haemorrhagic subgroup who survived the first month died at the 2nd and 4th month respectively. At the end of six months, only the five patients with cerebral infarction were alive. Of these, 2 in the dexamethasone group were back at work while the third was chair-bound. The 2 survivors in the placebo group were chair and bed bound respectively. In conclusion, this study failed to demonstrate any benefit of a short-course of high dose steroid in improving the mortality of stroke patients and its use should be discouraged. However, possible benefit in the morbidity of survivors in the patients with cerebral infarction requires further studies.

Misdiagnosis of stroke--a computerised tomography scan study.

Misdiagnosis of stroke has significant implication for definitive therapy. This study assessed the frequency of misdiagnosis of stroke using computerised tomography (CT) scan of the brain. One hundred and fifty-six patients admitted over a five year period (1991-1996) with clinical features suggestive of stroke had their CT brain scan reviewed. Only 89 (57%) had neuroradiological features consistent with stroke, of which 59 (66%) had cerebral infarction while 30 (34%) had cerebral haemorrhage. In 67 (43%) of the cases, there were no features of cerebro-vascular accident (CVA) on the CT scan. In this group, cerebral atrophy was the commonest radiological abnormality (21/67), followed by brain tumor (10/67) and subdural haematoma (9/67). The CT scan was normal in 25 patients. The misdiagnosis of surgically treatable conditions in as many as 21 (13.5%) of the 156 patients calls for better neurological evaluation of patients admitted for stroke in tertiary and non-tertiary hospitals. Where available, patients with clinical diagnosis of stroke should have CT scan evaluation to ensure that patients who can be helped surgically are identified early and appropriately treated.

Human resources development for the prevention of blindness in Anglophone West Africa.

As recent as 1986, acute shortage of qualified manpower was one of the major difficulties in the prevention of blindness in Africa. Following the WHO sub-regional workshop on Manpower development for Prevention of Blindness, the West African Health Community in collaboration with the National Prevention of Blindness programmes in Anglophone West Africa made concerted efforts at developing appropriate manpower at all levels of eye care. Eight categories of eye care workers were identified and personnel to population ratios adopted for each. Curriculum was developed and training begun for two new cadres-Primary Eye care Trainers and Diplomate Ophthalmologist. These are expected to boost the training of Integrated Eye Care workers for primary eye care and increase surgical services, especially cataract surgery rates, at secondary eye care level respectively. There are constraints and difficulties but the support provided by two non-government organisations (Sight Savers International and Christoffel Blindenmission) had been helpful in overcoming some of these. Significant progress has been made in the last decade in developing the required manpower but large deficits still remain. The political will, commitment and co-operation of all stakeholders would be required to achieve the desired targets for the next decade.

The effects of induced hypoxia on the cardiovascular system in dogs poisoned with tetanus toxin.

Tetanus toxicity was induced in dogs by injecting the toxin subcutaneously in the groin. On developing generalised toxic symptoms, these dogs were characterised by signs of increased sympathetic discharge to the cardiovascular system as evidenced by high basal values of blood pressure, heart rate and LV dP/dt max. Mild to moderate hypoxia induced by ventilation with 10% O2 in N2 had no appreciable effect on the cardiovascular variables. However, moderate to severe hypoxia induced by ventilation with 7% O2 in N2 further increased the sympathetic discharge to the heart and blood vessels resulting in increases in heart rate, LV dP/dt max and blood pressure. These responses were abolished by adrenergic blockers. The responses in the tetanus dogs were identical to those seen in dogs without tetanus toxicity. Atropine or moderate lactic acidaemia did not alter the responses to hypoxia. Beta-adrenergic blockers appear to be useful drugs in the control of tetanus patients who show evidence of increased sympathetic activity or who develop hypoxaemia.

Social problems of adolescent and adult epileptics in a developing country, as seen in Lagos, Nigeria.

Adolescent and adult epileptics attending the Neurology Clinic were interviewed about their social problems. Forty-nine percent were attending normal school; a third of these believed that seizure disorder affected their school performance. Of 40% who had attended school but left, about half withdrew from school prematurely because of the frequency of their seizures. Ninety percent of those who could be employed had jobs. About a third of these had lost income because of the illness. Self-employed patients were most affected. Very few patients lost their jobs despite most employers' knowledge of their employees' epilepsy. About one-sixth had lost friends or spouses because of epilepsy and a few had withdrawn from social activities for fear of having a seizure in public. Others had no problems interacting with other members of the society. Most of the patients claimed they took antiepileptic drugs regularly. One third had difficulty paying for these drugs. One quarter denied being epileptics. In conclusion, the social difficulties of adolescent and adult epileptics in Nigeria are similar to those of epileptics elsewhere. Educational problems are most common and these are related to poor seizure control. This is partly due to financial difficulties in obtaining drugs regularly.

A simple, direct extraction method for gas-liquid chromatographic determination of valproic acid in plasma.

A single high-recovery extraction process is described for rapid gas-liquid chromatographic (GLC) determination of valproic acid (VPA). The drug is extracted from acidified plasma into an equal volume (0.2 ml) of chloroform. Evaporation is avoided by extraction into a chloroform bed, from which an aliquot is analysed by isothermal GLC employing a column packed with 10% DEGS. The reproducibility and accuracy of the method was good. In 100 plasma samples from patients, there was an excellent correlation (r = 0.98) between VPA levels determined concomitantly by this method and the technique for Kupferberg. Single plasma samples can be analysed in 20 min, and 40 samples can easily be analysed daily by a single technician. Ethosuximide concentrations can also be determined simultaneously. The method is suitable for emergency and routine use in drug monitoring laboratories.

Haemodynamic changes during experimental tetanus toxicity in dogs.

Haemodynamic variables were compared in control dogs, dogs with local tetanus toxicity and dogs with generalised tetanus toxicity. The results showed an increase in the inotropic and chronotropic activation of the heart in both groups of tetanus dogs, but there was no significant change in the mean systemic blood pressure and the common carotid occlusion reflex was unchanged. Spontaneous fluctuations in the systemic blood pressure were observed in some dogs with tetanus, and occurred more often in those with generalised tetanus. The modification of these fluctuations by beta-adrenergic blockade and diazepam, suggest that they are of autonomic neural origin. It is suggested that these changes in the cardiovascular system are the results of neurophysiological and biochemical changes in the sympathetic nervous system, which have been reported to occur in tetanus.

Favourable prognosis of prolonged coma associated with large doses of diazepam in severe tetanus.

A report is made of five tetanus patients who were treated with large repetitive doses of Diazepam and became comatose. The period of impaired consciousness varied from thirteen to twenty-one days. None had significant respiratory depression, and full recovery occurred in all. It is proposed that Diazepam-induced prolonged coma should be regarded as a side-effect rather than a toxic effect and should caution rather than contra-indicate further use of large doses of the drug in the management of tetanus.

Sympathetic cardiovascular effects of experimental strychnine poisoning in dogs.

The cardiovascular effects of intravenously administered strychnine were studied in anesthetized and paralyzed dogs. Administration of strychnine in cumulative doses of up to 0.1 to 0.2 mg/kg caused significant pressor, as well as positive inotropic and chronotropic, effects on the heart which were abolished by adrenergic blocking agents. The cardiovascular responses possibly were elicited by a central mechanism in contrast to the peripheral inhibitory action of strychnine on the sympathetic system. Diazepam caused a marked attenuation of the pressor response with only slight changes on the heart. A combination of diazepam and propranolol would appear to be a useful therapy in cases of strychnine poisoning showing marked cardiovascular excitation.

Value of determination of oxygen consumption in tetanus.

Oxygen consumption (VO2) was determined in 10 patients with moderate tetanus. The mean (+/- SE) VO2 of 425-2-2 +/- 50-3 ml/min on admission fell significantly to 249-9 +/- 13-1 ml/min standard temperature and pressure dry (STPD) after parenteral diazepam. There was also a significant fall in minute ventilation after administration of diazepam. The results suggest that the simple practical determination of VO2 will be of immense value in assessing the efficacy of muscle relaxants, assessing the severity of tetanus, and determining the calorie needs of patients.