STUDY OF SIGNIFICANCE OF PHASE MASK IMAGE IN ACUTE STROKE PATIENTS

Background: Phase images contains information regarding local susceptibility changes between the tissues, which can help measure the iron and other content which changes the local field. Typically, this information is ignored before looking at console. Susceptibility weighted imaging (SWI) is a magnetic resonance (MR) technique detects an early hemorrhagic transformation within the infarct to provide insight into cerebral hemodynamics following the stroke. Objective: Significance of “phase mask imaging in differentiation of hemorrhage and calcifications” in acute stroke patients. Methods: An observational non-interventional study carried out on 100 patients with stroke and headache symptoms. MRI Brain Stroke Profile with FLAIR, DWI, ADC, SWAN, and Phase mask sequences, done on 3T GE MRI scanner. Results: All patients underwent MRI study with SWI sequence. Of 183 cases, 33%(n=60) patients had microbleeds, 5%(n=10) patients had granulomas, 32%(n=58) patients had arterial thrombus with infarct, 11%(n=20) patients had falx calcifications, 11%(n=20) patients had intraparenchymal haemorrhage, and 8%(n=15) patients had infarcts with haemorrhagic transformation. The sensitivity of phase imaging in the detection of calcification was 90%. Conclusion: Phase mask imaging plays an important role to detect intracranial calcifications and chronic microbleeds. Phase mask imaging acts as a supplement tool in acute stroke patients, which guides further management.

Rupture of a de novo dural AV fistula following adult cerebral AVM resection

Acquired unruptured dural arteriovenous fistulas (DAVFs) have been described; however, ruptured de novo DAVFs remain exceedingly rare. We describe the case of a man in his 40s who presented with a recurrent intraparenchymal haemorrhage several years after angiographic cure of an intracranial arteriovenous malformation (AVM). Repeat angiography identified a new Cognard type IV DAVF anterior to the prior craniotomy. He underwent preoperative embolisation followed by craniotomy to completely obliterate the fistulous point. This case illustrates the need for close monitoring of AVM patients, even after complete obliteration, as local recrudescence of arteriovenous shunting can occur even in adulthood.

Ayurvedic Management of Pakshaghata (Left Hemiplegia) – A Case study

Hemiplegia is the commonest manifestation of a Stroke with neurological deficit affecting the face, limbs and trunk on one side or either side of the body. Stroke is one of the leading causes of death and disability in India. The aggravated Vata paralyze one side of the body either right or left , leads to immobility is called as Pakshaghata. The present case study deals with a 63years old male patient with chief complaints weakness in left half of the body and was unable to walk. He was a diagnosed case of Haemorrhagic Stroke presenting with Left Sided Hemiplegia with Acute Intraparenchymal Haemorrhage in C.T. brain. The Ayurvedic diagnosis of Pakshaghata was made and managed with treatment principle which is mentioned by Acharya Charaka. Snehana, Swedana and Mridu Virechana along with Panchakarma procedures Shirodhara, Shiropichu and Basti for 21 days. Samshamana Aushadhis(Oral medicines) and Physiotherapy were adopted at various stages of the diseases. Maximum improvement was noticed in upper and lower extremity functions at the end of the treatment. Patient showed remarkable recovery in Speech ability and Mobility. Panchakarma is a minimal invasive Bio-Cleansing procedure which can be adopted in life style, metabolic, autoimmune diseases and also periodic healthy individual as preventive measures.

Rare Presentation of Acute Lymphoblastic Leukemia – A Case Report

Acute lymphoblastic leukaemia / lymphoblastic lymphoma is the most common childhood malignancy. Leukaemia and lymphoma are clinical presentations of the same disease. It is estimated that approximately 2500 to 3500 new cases are diagnosed each year in the United States, with an incidence of approximately 3.4 cases per 100,000. Number of the cases vary all over the world which is due to diagnostic and reporting differences.1,2 Leukaemia, especially acute types, can lead to intracranial haemorrhage (ICH) with high morbidity and mortality. It was reported that ICH occurred in 2.8 % adult patients with haematological malignancies. 3,4 But majority of cases presented with intraparenchymal haemorrhage, only rare cases have been seen to present with sub dural haemorrhage.

Effect of tranexamic acid on intracranial haemorrhage and infarction in patients with traumatic brain injury: a pre-planned substudy in a sample of CRASH-3 trial patients

BackgroundEarly tranexamic acid (TXA) treatment reduces head injury deaths after traumatic brain injury (TBI). We used brain scans that were acquired as part of the routine clinical practice during the CRASH-3 trial (before unblinding) to examine the mechanism of action of TXA in TBI. Specifically, we explored the potential effects of TXA on intracranial haemorrhage and infarction.MethodsThis is a prospective substudy nested within the CRASH-3 trial, a randomised placebo-controlled trial of TXA (loading dose 1 g over 10 min, then 1 g infusion over 8 hours) in patients with isolated head injury. CRASH-3 trial patients were recruited between July 2012 and January 2019. Participants in the current substudy were a subset of trial patients enrolled at 10 hospitals in the UK and 4 in Malaysia, who had at least one CT head scan performed as part of the routine clinical practice within 28 days of randomisation. The primary outcome was the volume of intraparenchymal haemorrhage (ie, contusion) measured on a CT scan done after randomisation. Secondary outcomes were progressive intracranial haemorrhage (post-randomisation CT shows >25% of volume seen on pre-randomisation CT), new intracranial haemorrhage (any haemorrhage seen on post-randomisation CT but not on pre-randomisation CT), cerebral infarction (any infarction seen on any type of brain scan done post-randomisation, excluding infarction seen pre-randomisation) and intracranial haemorrhage volume (intraparenchymal + intraventricular + subdural + epidural) in those who underwent neurosurgical haemorrhage evacuation. We planned to conduct sensitivity analyses excluding patients who were severely injured at baseline. Dichotomous outcomes were analysed using relative risks (RR) or hazard ratios (HR), and continuous outcomes using a linear mixed model.Results1767 patients were included in this substudy. One-third of the patients had a baseline GCS (Glasgow Coma Score) of 3 (n=579) and 24% had unilateral or bilateral unreactive pupils. 46% of patients were scanned pre-randomisation and post-randomisation (n=812/1767), 19% were scanned only pre-randomisation (n=341/1767) and 35% were scanned only post-randomisation (n=614/1767). In all patients, there was no evidence that TXA prevents intraparenchymal haemorrhage expansion (estimate=1.09, 95% CI 0.81 to 1.45) or intracranial haemorrhage expansion in patients who underwent neurosurgical haemorrhage evacuation (n=363) (estimate=0.79, 95% CI 0.57 to 1.11). In patients scanned pre-randomisation and post-randomisation (n=812), there was no evidence that TXA reduces progressive haemorrhage (adjusted RR=0.91, 95% CI 0.74 to 1.13) and new haemorrhage (adjusted RR=0.85, 95% CI 0.72 to 1.01). When patients with unreactive pupils at baseline were excluded, there was evidence that TXA prevents new haemorrhage (adjusted RR=0.80, 95% CI 0.66 to 0.98). In patients scanned post-randomisation (n=1431), there was no evidence of an increase in infarction with TXA (adjusted HR=1.28, 95% CI 0.93 to 1.76). A larger proportion of patients without (vs with) a post-randomisation scan died from head injury (38% vs 19%: RR=1.97, 95% CI 1.66 to 2.34, p<0.0001).ConclusionTXA may prevent new haemorrhage in patients with reactive pupils at baseline. This is consistent with the results of the CRASH-3 trial which found that TXA reduced head injury death in patients with at least one reactive pupil at baseline. However, the large number of patients without post-randomisation scans and the possibility that the availability of scan data depends on whether a patient received TXA, challenges the validity of inferences made using routinely collected scan data. This study highlights the limitations of using routinely collected scan data to examine the effects of TBI treatments.Trial registration numberISRCTN15088122.

Neutrophil-to-Lymphocyte Ratio at Hospital Admission as a Novel Predictor of Early Growth of Intraparenchymal Haemorrhage in Patients With Traumatic Brain Injury

BackgroundThis study aimed to explore the association between the neutrophil-to-lymphocyte ratio (NLR) and early growth of traumatic intraparenchymal haemorrhage (tICH) in patients with traumatic brain injury.MethodsA multicentre, observational cohort study was conducted at four hospitals and included patients with cerebral contusion undergoing baseline computed tomography (CT) for haematoma volume analysis within 6 hours after primary injury and who had follow-up visits within 48 hours. Routine blood tests were performed upon admission and analysed with early PIH. Logistic regression and receiver operating characteristic (ROC) analysis was used to explore the predictive value of the NLR for haematoma expansion. ResultsThe final analysis included 1003 patients in the retrospective development and validation cohorts. In the retrospective development cohort, the NLR were higher in the PIH group than in the non-PIH group (P<0.0001). Multivariate logistic regression analysis revealed that a higher NLR was independently associated with PIH (P<0.0001). ROC curve analysis showed that the NLR had a sensitive ability for predicting PIH (AUC, 0.91 [95% CI, 0.88-0.94]). In the validation study, the NLR had a similar ability to predict PIH. ConclusionThe NLR can be used to easily assess the growth of tICH and calculated using routine laboratory tests. A high NLR is independently predictive of early growth of tICH and may aid in risk stratification of patients with tICH on admission.

MOYAMOYA DISEASE PRESENTING AS ACUTE ENCEPHALITIS SYNDROME

Background: Moyamoya disease (MMD) is a chronic, progressive occlusion of the circle of Willis arteries usually affects bilateral carotid arteries than unilateral that leads to the development of characteristic collateral vessels seen on imaging, particularly cerebral angiography. Once the occlusion process begins, tends to continue despite any known medical management unless treated with revascularization surgery Report of the case: A 28 year female gravida four in 34th week of gestation presented with features suggestive of acute meningoencephalitis and CSF examination suggested 75% polymorphs of 300 total leukocytes. After 7 days of optimum management, complaints of headache aggravated so patient was subjected to MRI Brain which reported as early subacute intraparenchymal haemorrhage left frontal lobe in periventricular region with mild surrounding perifocal edema and intraventricular extension. On further MR angiogram, patient was diagnosed as MMD. Patient was asymptomatic in her previous 3 pregnancies and presently underwent planned preterm high risk caesarean section after a week. However condition of patient deteriorated over 2 weeks post delivery, did not remain fit for any neurosurgical intervention and unfortunately succumbed to death. Conclusion: Antenatal patient presenting as acute meningoencephalitis with persistent headache refractory to medical therapy, should be subjected to CT/MR brain imaging for rare possibility of MMD and early neurosurgical interventions in view of its grave prognosis.

Use of the expanded Apgar score for the assessment of intraventricular and intraparenchymal haemorrhage risk in neonates

Background Preterm birth is a key factor contributing to haemorrhage incidence in neonates. This study focused on defining relevant parameters for the assessment of intraventricular and intraparenchymal haemorrhage risks in neonates. Methods Chi-square automatic interaction detection was used to analyse the Apgar score (AS), the Apgar max score, and the course of resuscitation documented according to the expanded AS in 696 infants born between 2009 and 2011 in the Neonatal and Intensive Care Department of the Medical University of Warsaw. Results Gestational age was the most relevant discriminating variable for the prediction of intraventricular and intraparenchymal haemorrhage incidences. Infants born before the 31st week of pregnancy made up 80% of the intraventricular or intraparenchymal haemorrhage cases. Additionally, a fraction of inspired oxygen > 0.8 at ten minutes after birth was a better discriminating variable in the youngest neonates than an Apgar max score ≤ 5, identifying 31.6% and 20.6% of infants with intraventricular and intraparenchymal haemorrhage, respectively. Conclusions Consideration of the oxygen concentration supplied during resuscitation significantly improves the prognosis of intraventricular and intraparenchymal haemorrhages in preemies compared to the use of the classical AS.