Cerebral venous thrombosis At high altitude

Cerebral Venous Thrombosis (CVT) is one of the rarest causes of stroke. It is described as complete or partial occlusion of the sinuses or cortical veins of the brain. A relationship between high altitude (HA) and cerebral venous thrombosis has been long suspected due to various case reports and studies, however, the exact underlying mechanisms and etiologies are highly complex and debatable. In this article review we discuss the incidence etiologies, risk factors, clinical presentations and management of CVT at high altitude. CVT majorly affects young people [2]. It presents with a wide variety of clinical presentations due to the complexity of cerebral venous architecture and a combination of edema, increased intracranial pressure and venous infarct. Numerous etiologies have been suggested for the incidence of CVT; varying from dehydration, increased blood viscosity leading to endothelial injury, immobility, inflammation, genetic expression of certain prothrombotic entities, triggering of the coagulation cascade, platelet dysfunction and underlying coagulation disorders. Individuals with history of coagulation abnormalities should be screened for underlying thrombophilias and cautiously ascend to higher altitudes. CVT should be considered in all neurological clinical presentations at high altitude. High altitude trekkers should be educated on how to keep hydrated and avoid immobility, exposure to extreme cold and seeking immediate help for symptoms like headache and disturbed mental status

Comparison of the International Crowding Measure in Emergency Departments (ICMED) and the National Emergency Department Overcrowding Study (NEDOCS) in Tertiary Care Hospital to Measure Emergency Department Crowding

Objective: To compare NEDOCS with ICMED in predicting clinicians' concerns regarding crowding in the Emergency Department of a tertiary care hospital in Pakistan. Study Design: Prospective comparative study. Place and Duration of Study: Accident & Emergency Department, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Dec 2021 to Jan 2022. Methodology: This study was conducted at the Accident and Emergency Department over 14 different days, 30 data sets of 3-hour intervals each were collected using the NEDOCS and ICMED proforma. NEDOCS Scores and ICMED scores were calculated. In addition, perceptions of the staff regarding crowding and danger to the patient's status were recorded on Visual Analogue scales. Results: The mean recorded NEDOCS score was 577.94±251.57, with 29 'extremely overcrowded' and 1 'overcrowded' data set.The mean ICMED score was 2.86±0.83. Twenty-four (80%) sets did not have crowding, with only six (20%) sets being categorized as 'crowded'. The NEDOCS score had a moderately positive correlation with the crowding perception of the staff (Correlation coefficient (r)=0.593). Conclusion: NEDOCS was a more suitable measure for recording ED crowding in Pakistan, as it recorded the quantitative component of waiting time. ICMED, on the other hand, only recorded waiting time on a binary scale, with the waiting time impact not translated fully on the total score

The NMT Scalp EEG Dataset: An Open-Source Annotated Dataset of Healthy and Pathological EEG Recordings for Predictive Modeling

Electroencephalogram (EEG) is widely used for the diagnosis of neurological conditions like epilepsy, neurodegenerative illnesses and sleep related disorders. Proper interpretation of EEG recordings requires the expertise of trained neurologists, a resource which is scarce in the developing world. Neurologists spend a significant portion of their time sifting through EEG recordings looking for abnormalities. Most recordings turn out to be completely normal, owing to the low yield of EEG tests. To minimize such wastage of time and effort, automatic algorithms could be used to provide pre-diagnostic screening to separate normal from abnormal EEG. Data driven machine learning offers a way forward however, design and verification of modern machine learning algorithms require properly curated labeled datasets. To avoid bias, deep learning based methods must be trained on large datasets from diverse sources. This work presents a new open-source dataset, named the NMT Scalp EEG Dataset, consisting of 2,417 recordings from unique participants spanning almost 625 h. Each recording is labeled as normal or abnormal by a team of qualified neurologists. Demographic information such as gender and age of the patient are also included. Our dataset focuses on the South Asian population. Several existing state-of-the-art deep learning architectures developed for pre-diagnostic screening of EEG are implemented and evaluated on the NMT, and referenced against baseline performance on the well-known Temple University Hospital EEG Abnormal Corpus. Generalization of deep learning based architectures across the NMT and the reference datasets is also investigated. The NMT dataset is being released to increase the diversity of EEG datasets and to overcome the scarcity of accurately annotated publicly available datasets for EEG research

Stroke at moderate and high altitude

Background: Stroke at high altitude is an understudied area in stroke research. With improvements in road infrastructure, access to high-altitude areas for recreation and living purposes has risen. Subsequently, it has been anticipated that due to normal physiological changes to high altitude the incidence of stroke is also likely to increase in these regions. Methods: We searched PubMed for available literature about stroke at high altitude. Cross-referencing was done from available articles and through other scientific search engines. Relevant case series and case reports were included in this review of the topic. Results: Only one review article, eight case series (including review of literature), and seven case reports were identified that could be included in this review. Most of the available data come from moderate and high altitude.Conclusions: There is limited available literature about stroke at high and extreme altitudes. Stroke at high altitude is likely to become an important subset of stroke population. Currently, there is inadequate knowledge about the incidence and prevalence, mechanisms, and stroke outcomes. Cerebral venous thrombosis is more common than arterial stroke. Stroke is probably secondary to conventional risk factors, polycythemia, and other coagulopathies. A case-control study may identify the at-risk population for stroke at moderate and high altitudes

Cerebral venous thrombosis at high altitude: Analysis of 28 cases

Objective: An association between cerebral venous sinus thrombosis (CVST) and high altitude has been previously proposed, but limited published data exist to support this association. We investigated 28 cases of CVST occurring at high altitude and sought to describe patient demographics, altitude and acclimatization, hematological laboratory findings, neuroimaging, treatment, and prognosis in these cases.Methods: Twenty-eight cases of symptomatic CVST occurring at high altitude were identified between the months of August 2017 and December 2018, in collaboration with Military Hospital, Rawalpindi and Combined Military Hospital, Skardu (Pakistan). Follow-up visits were performed at 1 and 6 months.Results: Twenty-seven (96%) of the patients were males, and the mean age was 33 years. In total, 32.1% were smokers. The mean NIHSS score on presentation was 5.5. 85.7% of the cases occurred at altitude higher than 8,000 feet. On average 107.8 days were spent at a high altitude prior to CVST. Totally, 71.4% had acclimatized for \u3e2 weeks. The mean hemoglobin (Hb) value was 16.7 g/dL and 50% had d-dimer levels higher than 1,000 ng/mL. On MRI, 25% showed signs of hemorrhage and 14.3% showed infarcts. Treatments provided include low-molecular-weight heparin and Rivaroxaban and were associated with good outcomes.Conclusion: CVST is not uncommon at high altitude (\u3e8,000 feet). It is predominantly a male disease. Most patients have high Hb and high D-dimer levels. The overall outcome was good

Cerebral venous thrombosis associated with COVID-19 infection: An observational, multicenter study

Background and purpose: Coronavirus disease 2019 (CO-VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients.Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged \u3e18 years) with symptomatic CVT and recent COVID-19 infection.Results: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0-1 at discharge.Conclusion: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors

Therapeutic plasma exchange for coronavirus disease-2019 triggered cytokine release syndrome; a retrospective propensity matched control study.

BackgroundCytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS.ObjectiveTo evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care.MethodologyRetrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing.ResultsAfter PS-matching, the selected cohort had a median age of 60 years (range 32-73 in TPE, 37-75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3-22 days' TPE and 3-20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33-97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29-78.76 (log rank 0.002), pConclusionAn earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan