Availability Of Brain Imaging Research Articles

STROKE REHABILITATION SERVICES IN PAKISTAN: CURRENT STATUS AND FUTURE DIRECTIONS

Stroke is a leading cause of adult mortality and morbidity worldwide. The incidence of stroke is falling in developed countries, while on the rise in developing countries.1 Pakistan is a low middle-income country with an underdeveloped health care system whose major focus is on the management of communicable diseases.2 Epidemiological data on stroke in Pakistan is limited, based mostly on small samples reported from hospital data.3 Due to the combined efforts of the Pakistan Society of Neurology, Pakistan Stroke Society and the Faculty of Neurology at the College of Physicians and Surgeons of Pakistan (CPSP), the number of neurologists and stroke medicine physicians in the country has increased in the last decade.4 Diagnosis, acute evaluation and management of stroke has also improved. Areas of noted progress include early recognition of signs and symptoms of stroke, timely evacuation to a hospital, early neurology consult, availability of brain imaging (Computed Tomographic scan and Magnetic Resonance Imaging) and access to treatments including tissue plasminogen activator and endovascular procedures.4 At present, this is available only in major cities and hospitals. Despite such improvements in acute stroke management, functional outcomes and community reintegration for stroke patients in Pakistan is generally inadequate, due largely in part to the lack of multi-disciplinary stroke rehabilitation services. We aim to describe the current status of stroke rehabilitation services in Pakistan and discuss the main challenges and barriers towards providing multi-disciplinary stroke rehabilitation. Recommendations to overcome these challenges are also provided.

Repeat Head CT for Neurologically Stable Patients With Mild Traumatic Subarachnoid Hemorrhage During Interfacility Transfer and Follow-Up Does Not Alter Patient Care [Formula: see text

To evaluate the impact of repeat head computed tomography (CT) during (1) interfacility transfer and (2) inpatient and/or outpatient follow-up on management, cost-effectiveness, and radiation dose in neurologically stable patients with mild traumatic subarachnoid hemorrhage (tSAH). This is a single-center retrospective study evaluating patients with mild tSAH presenting between January 2017 and July 2019. A total of 101 and 140 patients met the eligibility criteria for the first and second subgroups, respectively. Common inclusion criteria were isolated mild tSAH, Glasgow Coma Scale between 13 and 15, and neurological stability. Additional inclusion criteria for the first subgroup were availability of brain imaging at the outside institution prior to transfer and the second subgroup was the availability of follow-up imaging. In the first subgroup, 76.20% of patients had stable SAH, 18.80% had reduced SAH, while 5% had an interval increase in SAH. None required any surgical intervention. Additional per-patient mean radiation exposure was 1.77 ± 0.26 mSv. In the second subgroup, all 140 patients had complete resolution of tSAH. One patient had a new tiny subdural hemorrhage, which subsequently resolved on follow-up. The additional mean radiation exposure was 2.47 ± 1.29 mSv. A total of 256 avoidable CT scans were performed resulting in excess health care costs of about US$531 696. In neurologically stable isolated tSAH patients, repeat brain imaging during interfacility transfer and inpatient and/or outpatient follow-up do not alter patient management despite increased health care costs and radiation burden.

Delayed Posterior Reversible Leukoencephalopathy Syndrome Triggered by FLOT Chemotherapy

Posterior reversible encephalopathy syndrome (PRES) is a potentially severe disorder of the autoregulation of cerebral perfusion. The major clinical manifestations are headache, seizures, altered mental status, and visual loss. The typical radiological finding is vasogenic edema predominating in the white matter of occipital and parietal lobes. PRES is increasingly recognized as a clinico-radiological entity owing to improvements and fast availability of brain imaging, especially magnetic resonance imaging (MRI). We present the exceptional case of a 67-year-old female patient with a gastric adenocarcinoma at stage IIB (T3N0M0) treated by FLOT chemotherapy (5-fluorouracil, oxaliplatin, docetaxel, and folinic acid). Two months after the unique administration of FLOT regimen, she developed sudden posterior headache and visual loss. Blood pressure values were normal. Cerebral tomography showed ischemic-like occipital bilateral lesions, and angiographic sequences revealed breakdown of the blood–brain barrier (BBB). MRI revealed bilateral parieto-occipital T1 hypointensity and T2 hyperintensity, which demonstrated vasogenic edema. The rest of the parts of the lesions were T1 hyperintensity, T2 hyperintensity, and diffusion-weighted imaging (DWI) hyperintensity, which indicate cortical laminar necrosis. After injection of gadolinium, a linear enhancement of the cortex was observed. She was treated with oral nimodipine. Follow-up was characterized by permanent visual sequelae and tetraparesis. PRES represents an urgent neurological condition. Our observation highlights that PRES should be considered in patients under chemotherapy, even when their blood pressure remains within normal range. This is the first report of PRES triggered by FLOT chemotherapy and with a silent window of 2 months between chemotherapy and PRES, widening further the spectrum of chemotherapy-induced PRES. Our case highlights the potential role of FLOT regimen in the pathogenesis of PRES and the need for a novel approach in terms of prevention of this potentially fatal complication when patients receive chemotherapy.

Posterior Reversible Encephalopathy Syndrome: Case Report

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by headache, seizures, altered mental status, and visual loss, as well as white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain predominantly. This clinical syndrome is increasingly recognized due to improvement and availability of brain imaging, specifically magnetic resonance imaging (MRI). A 35-year-old female with history of unsafe abortion and massive blood transfusion 10 days ago was brought to the emergency room with three episodes of generalized tonic clonic seizures, urinary incontinence and altered sensorium since 3 hours. Brain MRI showed bilateral occipital, parietal, frontal cortex and subcortical white matter T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities, suggestive of PRES. Patient improved after management with intravenous fluids, antibiotics, antiepileptics and monitoring of blood pressure. If recognized and treated early, the clinical syndrome commonly resolves within a week. PRES can be a major problem in rapid and massive blood transfusion. High index of suspicion and prompt treatment can reduce morbidity and mortality, and pave the path for early recovery. J Neurol Res. 2016;6(5-6):106-110 doi: https://doi.org/10.14740/jnr402w

Posterior Reversible Encephalopathy Syndrome: Case Report

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by headache, seizures, altered mental status, and visual loss, as well as white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain predominantly. This clinical syndrome is increasingly recognized due to improvement and availability of brain imaging, specifically magnetic resonance imaging (MRI). A 35-year-old female with history of unsafe abortion and massive blood transfusion 10 days ago was brought to the emergency room with three episodes of generalized tonic clonic seizures, urinary incontinence and altered sensorium since 3 hours. Brain MRI showed bilateral occipital, parietal, frontal cortex and subcortical white matter T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities, suggestive of PRES. Patient improved after management with intravenous fluids, antibiotics, antiepileptics and monitoring of blood pressure. If recognized and treated early, the clinical syndrome commonly resolves within a week. PRES can be a major problem in rapid and massive blood transfusion. High index of suspicion and prompt treatment can reduce morbidity and mortality, and pave the path for early recovery. J Neurol Res. 2016;6(5-6):106-110 doi: https://doi.org/10.14740/jnr402w

Epilepsy care in the southern Caribbean.

Very little has been reported about the health resources available for patients with epilepsy in the five English-speaking southern Caribbean countries of Trinidad and Tobago, Barbados, Grenada, Saint Vincent and the Grenadines, and Saint Lucia. There is no comprehensive resource describing their health systems, access to specialty care, antiepileptic drug (AED) use, and availability of brain imaging and EEG. The purpose of this study was to profile epilepsy care in these countries as an initial step toward improving the standard of care and identifying gaps in care to guide future policy changes. In each southern Caribbean country, we conducted study visits and interviewed health-care providers, government health ministers, pharmacy directors, hospital medical directors, pharmacists, clinic staff, radiologists, and radiology and EEG technicians. Health-care providers completed extensive epilepsy care surveys. The five countries all have integrated government health systems with clinics and hospitals that provide free or heavily subsidized care and AEDs for patients with epilepsy. Only Trinidad and Tobago and Barbados, however, have neurology specialists. The three smaller countries lack government imaging and EEG facilities. Trinidad had up to one-year waits for public MRI/EEG. Government formularies in Grenada, Saint Vincent and the Grenadines, and Saint Lucia are limited to first-generation AEDs. One or more second-line agents are formulary in Trinidad and Barbados. Nonformulary drugs may be obtained for individual patients in Barbados. Grenada, Saint Lucia, and Saint Vincent and the Grenadines participate in an Organization of Eastern Caribbean States formulary purchasing system, which added levetiracetam following the survey. Newer generic AED formulations with the lowest risks for pregnancy malformation were not in use. In conclusion, patients with epilepsy in the southern Caribbean have excellent access to government clinics and hospitals, but AED choices are limited. Local medical providers reported that the major limitations in care were lack of specialty care, lack of imaging and EEG services, financial barriers to care, long wait times for care, and limited access to additional AEDs.