24 research outputs found
‘Crescendo transient ischemic attack’—an uncommon presentation of a very common disease: a case report on capsular warning syndrome
Capsular warning syndrome is a rare presentation of transient ischaemic attack, which described as recurrent episodes of motor and/or sensory deficits which typically sparring the cortical function. It has a significant risk to progress into a massive stroke with permanent disability, thus important to be recognize early. Here, we report a middle-aged gentleman with no known medical illness presented with eight episodes of transient ischaemic attack within the span of 24 h. He was treated with double anti-platelet for 21 days and was not subjected to thrombolysis at time of presentation because it was outside the window period of 4.5 h and has fully recovered after each episode. The purpose of this case report is to share the uncommon clinical presentation of transient ischaemic attack, which is still not fully understood and warrant more studies especially on the treatment that can affect the progression of the disease
Risk factors and predictors of levodopa-induced dyskinesia among multiethnic Malaysians with Parkinson's disease
Chronic pulsatile levodopa therapy for Parkinson's disease (PD) leads to the development of motor fluctuations and dyskinesia. We studied the prevalence and predictors of levodopa-induced dyskinesia among multiethnic Malaysian patients with PD. Methods: This is a cross-sectional study involving 95 patients with PD on uninterrupted levodopa therapy for at least 6 months. The instrument used was the UPDRS questionnaires. The predictors of dyskinesia were determined using multivariate logistic regression analysis. Results: The mean age was 65.6 ± 8.5 years. The mean onset age was 58.5 ± 9.8 years. The median disease duration was 6 (7) years. Dyskinesia was present in 44% (n = 42) with median levodopa therapy of 3 years. There were 64.3% Chinese, 31% Malays, and 3.7% Indians and other ethnic groups. Eighty-one percent of patients with dyskinesia had clinical fluctuations. Patients with dyskinesia had lower onset age ( p < 0.001), longer duration of levodopa therapy ( p < 0.001), longer disease duration ( p < 0.001), higher total daily levodopa dose ( p < 0.001), and higher total UPDRS scores ( p = 0.005) than patients without dyskinesia. The three significant predictors of dyskinesia were duration of levodopa therapy, onset age, and total daily levodopa dose. Conclusions: The prevalence of levodopa-induced dyskinesia in our patients was 44%. The most significant predictors were duration of levodopa therapy, total daily levodopa dose, and onset age
Biochemical aspirin resistance in stroke patients: a cross-sectional single centre study
Background: Aspirin use is known to reduce the recurrence of stroke. However, the clinical response to aspirin has been mixed. The rate of stroke recurrence whilst on aspirin treatment is still unacceptably high. A plausible explanation for this may be resistance to the effects of
aspirin. The causes of aspirin resistance are manifold and multi-factorial. We conducted a study to investigate the prevalence rate of biochemical aspirin resistance in a cohort of aspirin-naïve stroke patients. We also sought to determine the inherent factors that may predispose towards the development of aspirin resistance.
Method: This was a cross-sectional, observational study conducted on patients admitted to our centre with an acute stroke who were aspirin-naïve. The diagnosis of an acute stroke was confirmed by clinical history and brain imagi
ng. Fifty consecutive patients were prospectively enrolled. Socio demographic data were collected and baseline blood investigations were performed. Patients were tested for biochemical aspirin resistance using Multiplate platelet
analyser (Dynabyte, Munich, Germany) after 5 doses of aspirin, corresponding to a total dose of 900 mg.
Results: The median age of patients was 65.5 years and 54 % of patients were female. There were 11 smokers; of these 10 were male. Twenty-six (52 %) patients were Chinese, 21 (41%)
were Malay and 3 (6.0 %) were Indian. Aspirin resistance was present in 14 % of our patients.There was an inverse relationship between the presence of aspirin resistance and plasma HDL levels (r = -0.394; p = 0.005). There was no relationship observed between aspirin resistance and total cholesterol, triglycerides, LDL, HbA1c, ALT, ALP, urea and creatinine levels. There were no significant differences in demographic profiles or smoking status between the aspirin resistant and non-aspirin resistant groups. We did not find any link between ethnicity and aspirin resistance.
Conclusions: Our results indicate that a lower HDL leve
l is associated with biochemical aspi-rin resistance. This may increase platelet aggregation and consequently increase the risk of a recurrent stroke. The clinical implications
for aspirin resistance are far reaching. Any evidence that correctable factors may negatively influence the action of aspirin warrants further investigation. The prevalence rate of biochemical aspirin resistance in our study is comparable to the findings in other studies performed in an Asian population. Further research is required to determine how our findings translate into clinical aspirin resistance and stroke recurrence
Successful intravenous thrombolysis of a wake-up stroke with underlying valvular atrial fibrillation
A 42-year-old female admitted with new-onset atrial fibrillation had a wake-up stroke on the high-dependency unit and the time last seen well (TLSW) was 6.5 h. She suffered left-sided body weakness and her National Institutes of Health Stroke Scale (NIHSS) score was 17. An emergency CT perfusion showed right M1 segment occlusion with more than 50% penumbra. She was given recombinant tissue plasminogen activator (r-tPA) at 9 h from TLSW. An immediate diagnostic angiogram with intention to treat, owing to the presence of large vessel occlusion, showed complete reperfusion after intravenous r-tPA. She was discharged with NIHSS of 2, and at 3-month follow up her Modified Rankin Scale was 0. We demonstrated a successful reperfusion and excellent clinical recovery with intravenous thrombolysis in a patient who presented with a wake-up stroke with underlying valvular atrial fibrillation despite evidence of large vessel occlusion. © 2018, Royal College of Physicians of Edinburgh. All rights reserved
The effects of intravenous infusion of autologous mesenchymal stromal cells in patients with subacute middle cerebral artery infarct: a phase 2 randomized controlled trial on safety, tolerability and efficacy
Background aims Mesenchymal stromal cells (MSCs) are characterized by paracrine and immunomodulatory functions capable of changing the microenvironment of damaged brain tissue toward a more regenerative and less inflammatory milieu. The authors conducted a phase 2, single-center, assessor-blinded randomized controlled trial to investigate the safety and efficacy of intravenous autologous bone marrow-derived MSCs (BMMSCs) in patients with subacute middle cerebral artery (MCA) infarct. Methods Patients aged 30-75 years who had severe ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of 10-35) involving the MCA territory were recruited within 2 months of stroke onset. Using permuted block randomization, patients were assigned to receive 2 million BMMSCs per kilogram of body weight (treatment group) or standard medical care (control group). The primary outcomes were the NIHSS, modified Rankin Scale (mRS), Barthel Index (BI) and total infarct volume on brain magnetic resonance imaging (MRI) at 12 months. All outcome assessments were performed by blinded assessors. Per protocol, analyses were performed for between-group comparisons. Results Seventeen patients were recruited. Nine were assigned to the treatment group, and eight were controls. All patients were severely disabled following their MCA infarct (median mRS = 4.0 [4.0-5.0], BI = 5.0 [5.0-25.0], NIHSS = 16.0 [11.5-21.0]). The baseline infarct volume on the MRI was larger in the treatment group (median, 71.7 [30.5-101.7] mL versus 26.7 [12.9-75.3] mL, P = 0.10). There were no between-group differences in median NIHSS score (7.0 versus 6.0, P = 0.96), mRS (2.0 versus 3.0, P = 0.38) or BI (95.0 versus 67.5, P = 0.33) at 12 months. At 12 months, there was significant improvement in absolute change in median infarct volume, but not in total infarct volume, from baseline in the treatment group (P = 0.027). No treatment-related adverse effects occurred in the BMMSC group. Conclusions Intravenous infusion of BMMSCs in patients with subacute MCA infarct was safe and well tolerated. Although there was no neurological recovery or functional outcome improvement at 12 months, there was improvement in absolute change in median infarct volume in the treatment group. Larger, well-designed studies are warranted to confirm this and the efficacy of BMMSCs in ischemic stroke
Impulse control behaviours in a Malaysian Parkinson’s disease population
Background: Impulse control behaviours are repetitive and excessive activities that may be sub-syndromal and not fulfill the criteria for impulse control disorder. These activities have potential to negatively impact on the daily lives of sufferers. We conducted a study to investigate the prevalence of impulse control behaviors and its associated features in Parkinson’s disease in our population. Methods: We conducted a prospective cross-sectional study on consecutive patients attending neurology clinic. Inclusion criteria include idiopathic Parkinson’s disease patients with Hoehn & Yahr stage I-IV. Eighty patients were enrolled and screened for impulse control behaviors using the Questionnaire for Impulsive-Compulsive Disorder for Parkinson’s disease (QUIP). Results: Prevalence of impulse control behaviors among our cohort was 11.3%; the features significantly associated with it were higher level of education (p=0.02), advanced stage of disease (p=0.03) and higher levodopa dosage (p= 0.01). The commonest impulse control behavior in our cohort was compulsive medication use (7.5%), followed by hobbyism (6.3%), hypersexuality (5%), compulsive buying (3.75%), punding (2.5%), walkabout (2.5%), compulsive eating (1.25%) and pathological gambling (1.3%). Conclusions: There is an association between impulse control behavior and higher levodopa dosage in a study on patients with Parkinson’s disease in Malaysia. We also found a low prevalence of pathological gambling as compared to studies performed in the West
Pyridostigmine-induced dystonic blepharospasm in a patient with ocular myasthenia gravis.
Knowledge of Acute Stroke Management Among Healthcare Professionals: Development and Validation of Acute Stroke Management Questionnaire (ASMaQ)
Background: Around 15.0% of all strokes occurred in hospitalised patients and studies
showed significant delay in the stroke recognition and lack of awareness on
thrombolytic therapy for acute ischaemic stroke (AIS) which lead to higher mortality
for in-hospital stroke. We aimed to develop and validate a new instrument
known as acute stroke management questionnaire (ASMaQ) to evaluate the awareness
of healthcare professionals in managing acute ischaemic stroke cases.
Methods: This study consisted of 3 steps; the formulation of ASMaQ draft, content
validation and construct validity. A total of 110 questions were drafted with 5-point
Likert scale answers. From the list, 31 were selected and subsequently tested on 158
participants. The results were analysed and validated using exploratory factor analysis
on SPSS. Components were extracted and questions with low factor loading
were removed. The internal consistency was then measured with Cronbach’s alpha.
Results: Following analysis, 3 components were extracted and named as general
stroke knowledge, hyperacute stroke care and advanced stroke management. Two
items were deleted leaving 29 out of 31 questions for the final validated ASMaQ.
Internal consistency showed high reliability with Cronbach’s alpha of 0.82. Our
respondents scored a total cumulative mean of 113.62 marks or 66.6%. A sub analysis
by occupation showed that medical assistants scored the lowest in the group
with a score of 57% whilst specialists including neurologists scored the highest at
79.4%. Conclusion: The ASMaQ is a newly developed and validated questionnaire
consisting of 29 questions testing the respondents’ acute stroke management
knowledge
Parkinsonism complicating acute organophosphate insecticide poisoning
Organophosphate insecticides have a triphasic effect
on the central nervous system, namely acute cholinergic
crisis, intermediate syndrome and delayed polyneuropathy.
Although acute organophosphate poisoning is relatively
common, case reports describing parkinsonism as a
neurological complication following an acute intoxication
are limited.
1
We report a case of parkinsonism noted on day
24 of admission following an acute severe organophosphate
poisoning which was successfully treated with benzhexol
and levodopa. Previously, response to levodopa was reported
to be poor in 3 patients studied by Bhatt et al
1whereas amantidine, dopamine agonist and bipiriden have been shown to be helpful.
2To the best of our knowledge, this is
the fi rst case of parkinsonism complicating organophosphate
poisoning which responded to levodopa and benzhexol
therapy
Mastoid osteoma: Report of a rare case
Mastoid osteoma is a rare tumour with incidence of 0.1–1% of all benign head and neck tumours. It usually presents as a slow growing, hard and painless posterior auricular swelling in which medical attention is sought most commonly on cosmetic grounds. This report discusses our finding of such a rare case that was managed in our department and from its presentation, clinical findings, differential diagnosis, and treatment aspects