Unusual neurological manifestations of bilateral medial medullary infarction: A case report

Bilateral medial medullary infarction (BMMI) is an extremely rare type of cerebrovascular accident often resulting in poor functional consequences. “Heart appearance” on diffusion-weighted imaging (DWI) of magnetic resonance imaging (MRI) is the unique presentation of BMMI. In this article, we present an acute ischemic stroke patient whose brain MRI showed the atypical “heart appearance” sign, manifested unusual bilateral central facial paralysis concurrently. For an early diagnosis of BMMI, it is essential to recognize the characteristic clinical and MRI findings of this rare type of stroke. Abnormal small dot or linear DWI signal at the midline of the brainstem should not be ignored at the early stage of stroke.

Thrombolysis in Acute Stroke

The first step in stroke care is early detection of stroke patients and recanalization of the occluded vessel. Rapid and effective revascularization is the cornerstone of acute ischemic stroke management. Intravenous thrombolysis is the only approved pharmacological reperfusion therapy for patients with acute ischemic stroke. Patient selection criteria based on patient characteristics, time, clinical findings and advanced neuroimaging techniques have positively affected treatment outcomes. Recent studies show that the presence of salvageable brain tissue can extend the treatment window for intravenous thrombolysis and that these patients can be treated safely. Recent evidence provides stronger support for another thrombolytic agent, tenecteplase, as an alternative to alteplase. Endovascular thrombectomy is not a contraindication for intravenous thrombolysis. Evidence shows that the bridging approach provides better clinical outcomes. It is seen that intravenous thrombolysis is beneficial in stroke patients, whose symptom onset is not known, after the presence of penumbra tissue is revealed by advanced neuroimaging techniques. Reperfusion therapy with intravenous thrombolysis is beneficial in selected pregnant stroke patients. Pregnancy should not be an absolute contraindication for thrombolysis therapy. This chapter aims to review only the current evaluation of intravenous thrombolytic therapy, one of the reperfusion therapies applied in the acute phase of stroke.

High Platelet Lymphocyte Ratio as Predictor of Bad Outcome in Patient with Acute Ischemic Stroke

Background/Aim: Stroke is a major cause of death and disability worldwide. Inflammatory markers for poor outcomes in stroke patients have been widely studied, but these examinations are often constrained by limited costs and facilities. Platelet lymphocyte ratio is one of the markers of inflammation that is easily examined, only a few researches were studied on stroke patients, especially ischemic type. This article aimed to understanding high platelet lymphocyte ratio as a risk factor for poor outcome in acute ischemic stroke patients. Method: The design of this research is literature review by literature from 32 journal and 5 textbooks. Journals obtained from search engines Pubmed, Google Scholar, and NCBI. Result: Based on the results of the literature review, circulating platelets play an important role in the development and resolution, not only because of their direct effect on the endothelium but also by releasing inflammatory mediators. Acute ischemic stroke will induce lymphocyte apoptosis, which causes impaired immune system. High platelet counts and low lymphocytes contribute to micro-thrombus formation, which increases the risk of stroke and has a poor prognosis in patient. Conclusion: There is an increase platelet lymphocyte ratio can be an independent predictor of poor outcome in acute ischemic stroke patient Keywords: acute ischemic, stroke, platelet lymphocyte ratio, poor outcome

Angioedema Secondary to tPA Use in Acute Ischemic Stroke Patient with Hypertension: A Case Report

Introduction: A well-documented complication of administering tissue plasminogen activator (tPA) in stroke patients is acute intracranial bleeding. A lesser known but still significant complication is angioedema secondary to tPA administration, which can develop in certain individuals with risk factors such as angiotensin converting enzyme (ACE) inhibitor use and location of the stroke. Knowing the potential for this life-threatening complication and being prepared for its proper management is vital for emergency physicians. Case Report: We report a 53-year-old Black female who presented to the emergency department with sudden onset of slurred speech and a facial droop. She was found to have an acute ischemic stroke and tPA was administered. She subsequently developed angioedema. Retrospectively, the patient was found to have risk factors that are thought to predispose patients to tPA-induced angioedema. Conclusion: Risk factors associated with angioedema secondary to tPA administration have been documented in patients taking ACE inhibitors, as well as patients who develop strokes in the frontal lobe. While many cases may be mild, some patients may develop life-threatening angioedema. Although this complication does not necessarily contraindicate tPA use, it is prudent for the emergency physician to be vigilant for its development, prepared for its treatment, and to be diligent in assessing the need for control of the patient’s airway.

Risk Screening and Educating of Pharmacy Network in Khon Kaen as a Part of Stroke Fast Track Service

Background: “Stroke Fast Track” is a service that aims to save acute stroke patients. The service is based on the concept that the acute ischemic stroke patient must be treated with rt-PA within 270 minutes. The pharmacist and pharmacy play an important role in education of stroke, risk screening and behavior change. Materials and Methods: The present study focused on collecting past data of patients from service of 7 pharmacies in the Khon Kaen Pharmacy Network from January 15 to April 1, 2016 and categorized into 3 types: educating, risk screening, and pharmacist role. Results: Educating data were collected from 242 participants. Out of a total score of 16, pre- and post-education scores were 10.79+3.81 and 15.83+0.49 (p<0.05), respectively. The number of service users who had heard of the phrase “Stroke Fast Track” increased from 2.54% to 100% (p<0.05), understanding of the signs of stroke increased from 21.14 to 100 (p<0.05). Risk screening data were collected from 318 service users. The majority of 72.64 percent, was at medium risk (1 to 6 points). The risks found in the present study were 54.7 percent of the service users had an oversized waist circumference and body mass index and 32.7 percent had high blood pressure (over 140/90 mmHg). In role of pharmacist, the results indicated that 100 percent of pharmacists educated participants about “Stroke Fast Track” and gave advice on behavior change to the service users. Conclusion: Pharmacy Network can enhance knowledge about strokes, screen risk, and advice people on behavior change. It definitely leads to stroke risk reduction in the future. The linkage of this project to the national health system will have a clear benefit in helping people access “Stroke Fast Track”. Keywords: Risk screening, Stroke, Pharmacy, Community pharmacy

Focus group and Delphi process: Stroke and potential drug-drug Interactions (pDDI) in the neurological Intensive Care Unit (NICU)

Introduction: The clinical significance of potential drug-drug interactions (pDDIs), especially in the intensive care unit (ICU) manifested mostly as adverse drug reactions. Aim: The goal of this research was to conduct a focus group, in which the participants were decisionmakers in acute ischemic stroke patient treatment. Also, the aim was to reach a consensus, due to the Delphi process, between neurologists and clinical pharmacologists regarding this highly vulnerable group of patients. Material and Methods: In this academic research, so-called applied focus group (the goal was to reach practical decisions) and clinical focus group (determining motives, predeterminations, bias, prejudice and analyzing the behavior leading to a certain outcome) was done. Results: Continuing medical education of neurologists is needed regarding pDDIs and the use of an online pDDIs checker. Certain groups of patients with AIS are at particular risk of exposure to pDDIs. Certain drug groups are more likely to interact with other drugs. Conclusions: Defining medical recommendations/guidelines on evidence base medicine about pDDIs in patients with AIS would significantly contribute to reducing their frequency in this vulnerable patient population.