Cerebral Venous Sinus Thrombosis in Children: A Multicenter Cohort From the United States

This study presents a large multicenter cohort of children with cerebral venous thrombosis from 5 centers in the United States and analyzes their clinical findings and risk factors. Seventy Patients were included in the study (25 neonates, 35%). The age ranged from 6 days to 12 years. Thirty-eight (55%) were younger than 6 months of age, and 28 (40%) were male. Presenting features included seizures (59%), coma (30%), headache (18%), and motor weakness (21%). Common neurological findings included decreased level of consciousness (50%), papilledema (18%), cranial nerve palsy (33%), hemiparesis (29%), and hypotonia (22%). Predisposing factors were identified in 63 (90%) Patients. These included infection (40%), perinatal complications (25%), hypercoagulable/hematological diseases (13%), and various other conditions (10%). Hemorrhagic infarcts occurred in 40% of the Patients and hydrocephalus in 10%. Transverse sinus thrombosis was more common (73%) than sagittal sinus thrombosis (35%). Three children underwent thrombolysis, 15 Patients received anticoagulation, and 49 (70%) were treated with antibiotics and hydration. Nine (13%) Patients (6 of them neonates) died. Twenty-nine Patients (41%) were normal, whereas 32 Patients (46%) had a neurological deficit at discharge. Seizures and coma at presentation were poor prognostic indicators. In conclusion, cerebral venous thrombosis predominantly affects children younger than age 6 months. Mortality is high (25%) in neonatal cerebral venous thrombosis. Only 18 (25%) Patients were treated with anticoagulation or thrombolysis

Should Carotid Endarterectomy be performed for Symptomatic Carotid Stenosis Pakistan?

Objective: The risk of stroke and death associated with carotid endarterctomy is operator dependant. Data regarding risks of this procedure are not available in Pakistan and therefore it is difficult to make accurate risk benefit analysis for individual patients. Our objective was to determine safety of carotid endarterectomy at an academic tertiary care center in Pakistan. Methods: Patients who underwent carotid endarterectomy (CEA) at our hospital during a ten-year period were identified through ICD-9 coding system of the hospital medical records. Demographic features. associated medical problems and immediate postoperative complications were recorded and analyzed. Results: Sixty-three carotid endarterectomies were performed on 59 patients. Ages range from 43 to 80 (mean 61±8) years; 53 were male and 10 were female. Common associated diseases among these patients were hypertension; 38 (64.4°/x), ischemic heart disease; 26 (44%), diabetes mellitus: 24 (40.7%); dyslipidemia; 19 (32.2%) and renal insufficiency; 13 (22%). Most common complication was neuropraxia (transient neuropathy) 5 (7.9%), followed by pneumonia and stroke; each in 3 (4.8%) patients. None of the strokes related to the surgical procedure were disabling. Two of the patients who had stroke, recovered fully within 17 weeks and one recovered partly but was independent in all daily activities of living (ADLs). One patient died following simultaneous coronary artery bypass graft (CABG) and CEA. The risk of stroke or death for patients undergoing CEA was high with simultaneous CABG (3/11, 27%) and low for patients undergoing CEA alone (1/52, 2%). Conclusion: Carotid endarterectomy is a safe procedure in patients with symptomatic carotid stenosis at our hospital and should be performed, when indicated. (JPMA 53:589;2003)

Prognostic indicators in patients with intracranial tuberculoma: a review of 102 cases

Objective: To see the characteristics, course and outcome of patients suffering from intracranial tuberculoma. Methods: Retrospective review of 102 patients diagnosed as intracranial tuberculoma at a tertiary care center over 10 years. Results: A total of 102 cases were seen with an age range of 1 to 75 years (mean, 30 years). Predisposing factors included Diabetes mellitus (8 patients) and pregnancy or puerperium (7 patients). Five pediatric patients had tuberculoma despite documented BCG vaccination. Fever (59%), headache (57%), meningeal irritation (36%) were the commonest presenting features; one-third of patients were drowsy or comatosed at presentation. Cerebrospinal fluid analysis was performed in 63 patients, of whom 88% had elevated protein, 83% had low glucose, and 84% had pleocytosis (one-third with neutrophilia). Forty-nine (50%) patients had clinical or laboratory evidence of concomitant tuberculous meningitis, Chest radiographs showed active or old tuberculous infection (25%), with a miliary pattern in 20%. Two-thirds of subjects had multiple tuberculomas (mean, 4.5 lesions per patient) on contrast CT or MRI scan. Hydrocephalus was present in 37 (37%) patients of which 21 required shunt surgery. Thirty-nine patients had \u3e 9 months of follow up; 17 patients showed complete recovery, 20 patients had partial recovery, and 2 patients had no response. Coma at presentation and miliary pattern on chest X-ray were predictors of poor prognosis. Conclusion: The study demonstrate that fever, headache, signs of meningeal irritation and cranial nerve palsies are common presenting features. Complete recovery was seen in 40% patients. Coma and military TB are predictors of poor prognosis (JPMA 54:83;2004)

Impact of Bacille Calmette-Guerin Vaccination on Neuroradiological Manifestations of Pediatric Tuberculous Meningitis

The authors conducted this study to identify whether bacille Calmette-Guerin (BCG) vaccination leads to an altered spectrum of neuroimaging findings outcome in pediatric Patients with tuberculous meningitis. This retrospective study was conducted through chart review and review of computed tomography (CT) scans and magnetic resonance imaging (MRI) of Patients with confirmed central nervous system tuberculosis from the year 1992 to 2005, at a large tertiary care hospital in Karachi, Pakistan. A total of 108 pediatric Patients with tuberculous meningitis were included in the analysis. Of the 108 Patients, 63 (58.3%) were male and 45 (41.7%) had received bacille Calmette-Guerin vaccination. There was no difference in terms of severity of clinical presentation and outcome between vaccinated and unvaccinated group. There were no significant differences in CT or MRI findings between the 2 groups except for tuberculomas on MRI, which were significantly higher in the non-bacille Calmette-Guerin vaccinated group (52.2% vs 22.7%, P = .042). Bacille Calmette-Guerin vaccination appears to translate into less tuberculoma formation on MRI

Neuroleptic malignant syndrome: need for early diagnosis and therapy

Background: Neuroleptic Malignant Syndrome (NMS) is a medical entity that has received little attention in the clinical settings in Pakistan. The aim of our study was to review the predisposing factors, outcomes and characteristics of in-patients diagnosed with NMS. Methods: We performed a retrospective chart review of all cases (age \u3e 15 years) at a tertiary care center in Karachi between January 01, 1990 and November 30, 2001, diagnosed using ICD 10 coding. Data was collected using a standardized data entry form and statistical analysis was performed using Epi Info 6, Version 6.02. Results: There were a total of 20 patients diagnosed with NMS (11 male and 9 female) in our study with a mean age of 46.6±15.9 years. Haloperidol was the most frequently responsible neuroleptic. Of the 18 patients on a neuroleptic, most developed NMS after 8 weeks of therapy. There were 5 mortalities all of which were associated with septic shock. Fourteen patients recovered completely from the episode and did not have any neurologic sequelae. Conclusions: NMS is an important preventable clinical entity. Early diagnosis and judicious use of antipsychotics is warranted to prevent mortality and heightened morbidity. Key Words: Neuroleptic malignant syndrome, antipsychotics, predisposing factor

Ischemic stroke subtypes in Pakistan: The Aga Khan University stroke data bank

Objective: Frequency of ischemic stroke subtypes is influenced by ethnic and geographic variables. Our objective was to identify various stroke subtypes and its determinants at a tertiary care hospital. Methods: We prospectively collected data on ischemic stroke subtypes admitted to The Aga Khan University Hospital in Karachi. Results: A total of 596 patients were enrolled in 22 months in the Aga Khan Universtiy Stroke Registry. These included 393 patients with Ischemic stroke, 126 patients with intracerebral hemorrhage, 50 patients with subarachnoid hemorrhage and others. The ischemic stroke group was classified according to the TOAST criteria and comprised of lacunar 168/393 (42.7%); large artery atherosclerosis 106/393 (26.9°/x); cardioembolic 24/393 (6.1%); undetermined 80/393 (20.3°!0); and other determined types 15/393 (3.8%). The high proportion of lacunar strokes in our population may be due to high burden of inadequately treated hypertension and diabetes. Clear cut cardioembolic stroke was relatively infrequent in our population. Conclusion: Lacunar stroke is the most common subtype of stroke in our patient population. This is most likely secondary to uncontrolled hypertension (JPMA 53:584;2003)

MS in Asian countries

This paper reviews all available English language literature on MS from Asian countries published between 1970 and 2005. Although limited data are available, the review reveals that western Asia--including the Middle East--has the highest prevalence of MS across the continent, and that MS in Asia largely resembles conventional MS in western countries. Opticospinal MS (a distinct clinical entity from conventional MS) is more common in eastern Asian regions. Larger epidemiological and genetic studies, with more complete ascertainment in various Asian populations, are needed so that we can understand the diversity of Asian MS

Radiologic features of Hallervorden Spatz Disease

Hallervorden Spatz Disease is a rare familial neurodegenerative disorder, which primarily affects children but also can occur in adults1 . Major clinical features are abnormal involuntary movements and cognitive impairment2 . Diagnosis is based on clinical and radiological features. The radiological features are hypointense signals in globus pallidus and substantia niagra on MR! of brain3 . Occasionally the pallidal hypointense signals surround hyperintense signals, this is known as “tigereye-sign”4 and is postulated to be specific for Hallervorden Spatz Disease. We report two brothers with such MRI findings