Mini review: MANAGING POST STROKE HYPERGLYCAEMIA: MODERATE GLYCAEMIC CONTROL IS BETTER? AN UPDATE

ABSTRACT Post stroke hyperglycaemia (PSH) is prevalent in acute ischaemic stroke (AIS) patients and it has been associated with a dismal outcome of death and disability. Insulin has been proven to attenuate glucose effectively in stroke patients, thus many trials over the years had studied the efficacy of intensive treatment aiming at normalization of blood sugar level in order to improve the bleak outcomes of PSH. However, tight glycaemic control failed to be translated into clinical benefits and the outcomes are no different from the conventional approach, despite the costly healthcare expenditure invested. On the contrary, it brings more significant harm than the intended benefit, as 1 in every 9 treated patients had symptomatic hypoglycaemia. Thus, the benefits of tight glucose control, if any, are overshadowed by this potential risk of hypoglycaemia causing permanent neurological injury. Therefore, international practice guidelines recommend for less aggressive treatment to maintain blood glucose level within an appropriate range in AIS patients. However, there are limited details for stroke-specific glycaemic management and this made management of PSH particularly difficult. This review is to discuss and provide suggestions concerning glycaemic control in acute ischaemic stroke; the direction of its future prospective clinical trials and the treatment strategy required based on recent literature

No coma, but expressive dysphasia with cerebellar signs: an unique presentation of cerebral malaria

Malarial infection is not uncommonly complicated by cerebral involvement and poses significant mortality and morbidity especially in children. Similar complications may be seen in the adult population. Cerebral malaria is defined as encephalopathy that presents with impaired consciousness, delirium, and/or seizures. Neurological deficits are commonly seen as sequelae of cerebral malaria rather than as presenting symptoms or signs. We present here a unique case of cerebral malaria with focal neurological deficits but without alteration in conscious level. Keeping rare presentations of common illnesses in mind, clinicians should consider the possibility of cerebral malaria in a patient with neurological deficits and a history of fever and travel in endemic areas

Managing post stroke hyperglycaemia

Post stroke hyperglycaemia (PSH) is prevalent in acute ischaemic stroke (AIS) patients and it has been associated with a dismal outcome of death and disability. Insulin has been proven to attenuate glucose effectively in stroke patients, thus many trials over the years had studied the efficacy of intensive treatment aiming at normalization of blood sugar level in order to improve the bleak outcomes of PSH. However, tight glycaemic control failed to be translated into clinical benefits and the outcomes are no different from the conventional approach, despite the costly healthcare expenditure invested. On the contrary, it brings more significant harm than the intended benefit, as 1 in every 9 treated patients had symptomatic hypoglycaemia. Thus, the benefits of tight glucose control, if any, are overshadowed by this potential risk of hypoglycaemia causing permanent neurological injury. Therefore, international practice guidelines recommend for less aggressive treatment to maintain blood glucose level within an appropriate range in AIS patients. However, there are limited details for stroke-specific glycaemic management and this made management of PSH particularly difficult. This review is to discuss and provide suggestions concerning glycaemic control in acute ischaemic stroke; the direction of its future prospective clinical trials and the treatment strategy required based on recent literature

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

Acute disseminated encephalomyelitis in dengue viral infection

Dengue is the most common arboviral disease affecting many countries worldwide. An RNA virus from the flaviviridae family, dengue has four antigenically distinct serotypes (DEN-1-DEN-4). Neurological involvement in dengue can be classified into dengue encephalopathy immune-mediated syndromes, encephalitis, neuromuscular or dengue muscle dysfunction and neuro-ophthalmic involvement. Acute disseminated encephalomyelitis (ADEM) is an immune mediated acute demyelinating disorder of the central nervous system following recent infection or vaccination. This monophasic illness is characterised by multifocal white matter involvement. Many dengue studies and case reports have linked ADEM with dengue virus infection but the association is still not clear. Therefore, this article is to review and discuss concerning ADEM in dengue as an immune-medicated neurological complication; and the management strategy required based on recent literature

Kimura disease: a case report and review of the literature

Introduction: Kimura disease (KD) is a benign chronic inflammatory disorder attributed to an immune mediated hypersensitivity. KD is commonly presented with unilateral subcutaneous tissue swelling in the head and neck area. The course is usually benign except for the potential cosmetic disfigurement. There is no consensus for the treatment of recurrent disease. Aim: To illustrate a case of an uncommon cause of head and neck swelling. Case study: A 41-year-old male presented with a recurrent painless swelling at his of right lower cheek swelling for 6-months. Head and neck examination revealed a 7 × 7 cm firm, non tender mass over the right mandibular region. Other systemic examination was unremarkable. Magnetic resonance imaging of the mass showed a well defined lesion 6 × 3 × 5 cm in size anterior to the right body of mandible. Surgical excision of the mass was done and histopathological examination of the specimen showed fibrocollagenous and fibrofatty tissue infiltrated by chronic inflammatory cells in the pattern of perivascular lymphoid aggregates. The infiltrate is composed predominantly of small lymphocytes and eosinophils. Results and discussion: Here we described a rare cause of painless subcutaneous head and neck swelling that occurred in a middle-aged Asian man. KD usually presents as a painless subcutaneous soft-tissue swellings and associated with regional lymphadenopathy in the head and neck region. Diagnosis of KD is always a clinical dilemma with no specific diagnostic guideline. Though there is no consensus for the treatment of recurrent disease, the overall outcome is good as there is no association with malignancy. Conclusions: KD should be considered in the differential diagnosis of a recurrent head and neck mass

A rare case of acute psychosis as an isolated manifestation of extrapontine myelinolysis

Aims and Background: Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) are recognized as osmotic demyelination syndrome (ODS). ODS is pathologically characterized by non-inflammatory demyelination of several brain structures with sparing of axons. This condition is usually associated with overzealous correction of hyponatraemia. Acute psychosis as the sole clinical manifestation is extremely rare. Presentation of Case: Hence, we report an interesting case of a middle-aged man who was diagnosed with EPM, following rapid correction of hyponatraemia and subsequently developed acute psychosis. He made a good recovery with supportive treatment alone. Discussion and Conclusion: The possibility of psychosis as a manifestation of ODS, particularly in patients with recent correction of hyponatraemia. The rate of correction of plasma sodium level is the key point for preventing ODS and its complications

Persistent vegetative state after traumatic brain injury - a case report and review of the literature

Persistent vegetative state (PVS) is a chronic neurological disorder of consciousness, in which patients appear to be awake, but show no behavioural evidence of awareness. It cannot be diagnosed with certainty and misdiagnosis is very frequent. Its management has become one of the most controversial and emotive issues in medical ethics and medical law over the past few decades. The results of recent neuroimaging studies along with well-documented reports of significant late recovery of some PVS patients have challenged the long-held view that restoration of function in the severely traumatic brain injury (TBI) patients is not possible. Some clinicians believe that PVS is a misused term with the potential consequences of withdrawal and withholding of care, and tendency towards less aggressive management. Further naming these patients as “vegetative” has been misinterpreted by many groups that the patient is no more a human but “vegetable” like. Recently there has been an attempt to replace PVS by new, more appropriate name "Unresponsive Wakefulness Syndrome" (UWS). As opposed to brain death, PVS is not recognized by statute as death in any legal system. The context within which end of life decisions are being made for these patients has led to outrage especially if decisions were made to terminate hydration and nutrition. We present a case of young boy who is in a PVS following TBI with the aim to review some of the contemporary issues regarding their management

Hunting for a cure: the therapeutic potential of gene therapy in Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is an incurable disease and the search for a cure is a challenging journey. However, with recent encouraging progress, we are seeing a light at the end of a long tunnel. This review focuses on several main strategies in gene therapy, including truncated dystrophin gene transfer via viral vectors, antisense mediated exon skipping to restore the reading frame, and read-through of translation stop codons. An exon skipping agent, eteplirsen, and a termination codon read drug, ataluren, are currently the most promising therapies. With better understanding of the molecular mechanism, gene therapy has improved with regard to the key areas of gene stability, safety, and route of delivery. Consequently, it has emerged as an exciting and hopeful means for novel treatment of this devastating disease

Managing post stroke hyperglycaemia: moderate glycaemic control is better? An update

Post stroke hyperglycaemia (PSH) is prevalent in acute ischaemic stroke (AIS) patients and it has been associated with a dismal outcome of death and disability. Insulin has been proven to attenuate glucose effectively in stroke patients, thus many trials over the years had studied the efficacy of intensive treatment aiming at normalization of blood sugar level in order to improve the bleak outcomes of PSH. However, tight glycaemic control failed to be translated into clinical benefits and the outcomes are no different from the conventional approach, despite the costly healthcare expenditure invested. On the contrary, it brings more significant harm than the intended benefit, as 1 in every 9 treated patients had symptomatic hypoglycaemia. Thus, the benefits of tight glucose control, if any, are overshadowed by this potential risk of hypoglycaemia causing permanent neurological injury. Therefore, international practice guidelines recommend for less aggressive treatment to maintain blood glucose level within an appropriate range in AIS patients. However, there are limited details for stroke-specific glycaemic management and this made management of PSH particularly difficult. This review is to discuss and provide suggestions concerning glycaemic control in acute ischaemic stroke; the direction of its future prospective clinical trials and the treatment strategy required based on recent literature