Clinical practice guidelines for the management of ischemic stroke in Pakistan

Ischemic stroke represents a huge global burden, being the leading cause of physical disability and the third leading cause of death worldwide1. Although rigorous epidemiological data from Pakistan are lacking, stroke is certainly the commonest reason for admission to a neurology ward in our part of the world, as elsewhere. Recent years have seen a number of new developments in the clinical approach to stroke, including in the areas of diagnostic work-up, acute treatment and secondary prevention. These developments enable the formulation of clinical practice guidelines for achieving standardized management of ischemic stroke, with the overall aini of improving the care of stroke patients. This article presents a set of guidelines that may be useful to clinicians involved in the care of stroke patients in Pakistan. The term \u27stroke\u27 is used here to refer exclusively to ischemic brain infarction; this paper does not address intracerebral hemorrhage

Neurology in the 21st century: contemporary state of diagnostics and therapeutics

Although neurological disease has been recognized since antiquity, neurology as a systematic clinical discipline is less than 130 years old. Neurological practice has traditionally been constrained by the complexity of the human nervous system, which has been slow to yield its secrets. Over the last three decades, however, clinical neurology has been transformed in terms of both diagnostics and therapeutics and now marches in lockstep with the cutting edge of medicine. Efficacious treatments are now available for the majority of neurological diseases, including epilepsy, migraine, Guillain-Barre syndrome, Parkinson\u27s disease, multiple sclerosis, and ischemic stroke. This neurological revolution has been enabled by advances in neuroimaging and through the integrated application of basic research, drug development, biotechnology and clinical trial methodology. Neurology in the 21st century is a dynamic specialty offering relief and benefit to many patients, and holding the promise for one day conquering neurological disease in all its manifestations

Biopsy proven case of Creutzfeldt- Jacob disease from Pakistan

Creutzfeldt-Jakob disease (CJD) is a rare type of prion disease leading to a rapidly progressive dementia (RPD) and other associated neurological features specially startle myoclonus. The annual incidence of CJD has been reported to be 1 per million or 271 people in USA2, but from Asia especially from Pakistan, only few case reports have been published. The probable cause behind the rarity of this disease in our society is still unclear.The diagnosis of CJD requires a high level of suspicion and lack of the availability of specific markers like CSF 14-3-3 in our setup makes it more difficult. Similarly brain biopsy is not an acceptable option for families of the sufferers because of the unavailability of the specific treatment. To our knowledge this is the first biopsy proven case of Crutzfeld Jacob disease (CJD) from Pakistan

Pakistani physicians and the repatriation equation

In Pakistan, students who are accepted into medical school are congratulated — only half-jokingly — on three counts: that they will become doctors, that they will become certified by the American Board of Medical Specialties, and that they will soon be living in the United States

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 antithrombotic agents such as ximelagatran may offer advantages over heparin and need to be investigated in the treatment of CVT

Primary Angiitis of The Central Nervous System Presenting As Sudden Vision Loss In A Young Patient

Primary angiitis of the central nervous system is a rare disorder that primarily affects the cerebral vessels and can prove to be a diagnostic challenge to the clinicians. It can present with a variety of clinical manifestations and lacks the evidence of any systemic disease. Digital subtraction angiography is often necessary to confirm the diagnosis of cerebral vasculitis but in cases where it may fail to do so, brain biopsy is eventually required. Obliviousness to this condition may lead to false management strategies and hence it is imperative to make an accurate diagnosis to facilitate proper treatment that mainly includes a combination of steroids and immunosuppressive agents. We report a case of a 27-year-old male with sudden bilateral vision loss who underwent extensive workup and was ultimately diagnosed with primary angiitis of the central nervous system. He was treated with steroids and responded well to it

A unique MRI presentation of fungal infection in the brain

Fungal infections of CNS are common in certain geographic locations. MRI with or without contrast is a useful prediagnostic tool. However, the findings may sometimes be misleading. In this case report, the authors present unusual imaging findings in the MRI of fungal infection in an immunocompetent host, whereby hyper-intense signals were seen on T2-weighted images and patchy post-contrast enhancement was observed with surrounding edema. These findings were suggestive of a neoplastic lesion but it was identified as aspergillosis on subsequent histopathology. This unusual MRI finding of CNS highlights the need to consider fungal infection as a differential diagnosis of all mass lesions on MRI, irrespective of their signal characteristics

PO5.53 critical illness polyneuropathy and myopathy: experience at a tertiary care center in Pakistan

Background: Polyneuropathy and Myopathy are frequently encountere in the setting of Critical illness patients. Up to 50% of intensive care unit (ICU) patients show electrophysiological features of either or both conditions. These conditions interfere with functional recovery and delay weaning from mechanical ventilation, resulting in excess morbidity,mortality and cost of care. This study was to define the clinical spectrum of critical illness Polyneuropathy (CIP) and Myopathy (CIM) in a setting of developing country. Methods: Hospital records spanning the period 2000 through 2005 weresearched with ICD-9 codes to identify patients with CIP and CIM. Functional improvement was judged by (i) increment of at least 1grade on the Medical Research Council scale of motor strength: and (ii)reappearance of deep-tendon reflexes. Results: CIP or CIM was established in 47 patients of these, mean age was 54: mean length of stay in hospital 34 (range 8100) electrophysiological studiesrevealed CIP in 31 patients (66%) CIM in 12 (26%) and a mixedpicture in 4 (8%). Major co-morbid conditions included sepsis (39%) anddiabetes mellitus (17%), with an additional 28% having both and 17% having either. Neuromuscular blocking drugs were administered to 14 (30%) and steroids to 10 (21%) patients: an additional 11 (23%) patients received both agents while 12 (26%) patients received neither. In hospital mortality was 51%. At discharge and follow-up, motor improvement was seen in 11 (23%) while 12 (26%) remained neurologically unchanged. Conclusions: We conclude that CIP and CIM are frequent identifiable complications of critical illness in our setting. These observations need further prospective studies to delineate risk factors and out come predictors, to improve critical care patients