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A 47-year-old man lost his consciousness and brought to our hospital by ambulance. On admission, he had aphasia and upper right limb paresis. Diffusion weighted MR image of the brain on admission showed multiple high intensity areas in the left middle cerebral artery (MCA) territory. Brain angiography performed on the 2nd hospital day revealed the left MCA severe stenosis. We started intravenous antithrombotic therapy on the 1st day. The left carotid angiography on 12th day demonstrated that the left MCA stenosis was improved. He had medical history of hypertension, diabetes mellitus and gout. But he had only slight atherosclerosis, and had no arrhythmia and patent foramen ovale. Blood chemistry test showed marked hypoproteinemia and hyperlipidemia, and urine examination showed proteinuria. He was diagnosed as nephrotic syndrome for the first time. Nephrotic syndrome brought hypercoagulability, so we suspected that nephrotic syndrome concerned with brain infarction.
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PMID:[A case of brain infarction with nephrotic syndrome]. 1282 May 63

Neurotoxic side effects of chemotherapy occur frequently and are often a reason to limit the dose of chemotherapy. Since bone marrow toxicity, as the major limiting factor in most chemotherapeutic regimens, can be overcome with growth factors or bone marrow transplantation, the use of higher doses of chemotherapy is possible, which increases the risk of neurotoxicity. Chemotherapy may cause both peripheral neurotoxicity, consisting mainly of a peripheral neuropathy, and central neurotoxicity, ranging from minor cognitive deficits to encephalopathy with dementia or even coma. In this article we describe the neurological adverse effects of the most commonly used chemotherapeutic agents. The vinca-alkaloids, cisplatin and the taxanes are amongst the most important drugs inducing peripheral neurotoxicity. These drugs are widely used for various malignancies such as ovarian and breast cancer, and haematological cancers. Chemotherapy-induced neuropathy is clearly related to cumulative dose or dose-intensities. Patients who already have neuropathic symptoms due to diabetes mellitus, hereditary neuropathies or earlier treatment with neurotoxic chemotherapy are thought to be more vulnerable for the development of chemotherapy-induced peripheral neuropathy. Methotrexate, cytarabine (cytosine arabinoside) and ifosfamide are primarily known for their central neurotoxic side effects. Central neurotoxicity ranges from acute toxicity such as aseptic meningitis, to delayed toxicities comprising cognitive deficits, hemiparesis, aphasia and progressive dementia. Risk factors are high doses, frequent administration and radiotherapy preceding methotrexate chemotherapy, which appears to be more neurotoxic than methotrexate as single modality. Data on management and neuroprotective agents are discussed. Management mainly consists of cumulative dose-reduction or lower dose-intensities, especially in patients who are at higher risk to develop neurotoxic side effects. None of the neuroprotective agents described in this article can be recommended for standard use in daily practise at this moment, and further studies are needed to confirm some of the beneficial effects described.
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PMID:Neurotoxic complications of chemotherapy in patients with cancer: clinical signs and optimal management. 1288 62

Dementia is the development of multiple cognitive deficits that includes memory impairment and at least one of the following--Aphasia, apraxia, agnosia or disturbances in executive functioning. The common causes of dementia among the elderly are Alzheimer's disease, vascular dementia, mixed dementia and Lewy body disease. The concept of reversible dementia was introduced in 1980 when a task force sponsored by National Institute of Ageing found 10-12% of dementia cases in older group to have reversible causes such as metabolic-nutritional, drugs, infections, psychiatric disorders etc. In our series of 76 patients in the presenile age group (<65 years), 34.21% (26/76) had a reversible condition underlying the dementia. 43.42% (33/76) had vascular dementia, 13.15% (10/76) had Alzheimer's disease and 9.21% (7/76) had mixed dementia. Hypertension, hyperlipidemia and diabetes mellitus were commoner in the vascular dementia group as compared to the Alzheimer's group. Evaluation of MRI as a tool in diagnosis of dementia showed increased sensitivity of MRI towards detecting lacunes. The potentially reversible dementias comprised infections 14.47% (11/76), metabolic-nutritional 14.47% (11/76) and autoimmune diseases 3.94% (3/76). These were characterized by a subcortical dementia. Four month follow up of MMSE in this group showed significant and sustained improvement in the metabolic nutritional group.
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PMID:Presenile dementia--etiology, clinical profile and treatment response at four month follow up. 1588 51

Glucose is the main cerebral fuel throughout life. Inadequate cerebral glucose supply, due to recurrent episodes of severe hypoglycemia during the neonatal period or infancy, when the brain is still developing, lead to serious long-term neurological impairments, ranging from mild neurocognitive dysfunction to severe mental retardation, epilepsy, microcephaly or even hemiparesis or aphasia. Moreover, in the most common form of severe recurrent hypoglycemia of infancy due to hyperinsulinism, not only abnormalities in neurocognitive function, but also the later development of diabetes mellitus are observed. Furthermore, recurrent hypoglycemia, supervening as a side-effect of intensified insulin treatment in young diabetic children, may also induce mild neurocognitive dysfunction and, specifically, memory deficits that predispose these children to new hypoglycemic episodes and hypoglycemia unawareness. In conclusion, prompt and meticulous management of hypoglycemia and its prevention during the neonatal period, infancy and childhood constitute the main goal of physicians taking care of these patients in order to ascertain a long-standing quality of life devoid of long-term sequelae.
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PMID:Hypoglycemia in childhood: long-term effects. 1644 88

Cerebral angioinvasive aspergillosis is a rare manifestation of disseminated aspergillosis which may result in stroke in immunocompromised individuals. Reports of such disease in patients with diabetes mellitus are rare. We describe a 45-year-old man with diabetes mellitus who presented with a three-day history of right-sided limb weakness and aphasia. Cerebral computed tomography showed features of an acute infarct involving the left anterior and middle cerebral arteries. He was initially treated for an acute ischaemic stroke. Further history revealed that he was investigated for a growth in the sphenoid sinus two months earlier. Culture of the biopsied material from the sphenoid sinus grew Aspergillus fumigatus. Magnetic resonance imaging showed an extension of the growth to the brain, causing the acute ischaemic stroke. He was subsequently diagnosed with angioinvasive cerebral aspergillosis and was commenced on intravenous amphotericin B. Unfortunately, he succumbed to his illness despite treatment.
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PMID:Angioinvasive cerebral aspergillosis presenting as acute ischaemic stroke in a patient with diabetes mellitus. 1724 96

Delay in arrival to the emergency room (ER) may negatively influence outcome of stroke patients. We aim to analyze factors that influence extra-hospital delay in stroke patients. Two hundred and ninety-two consecutive stroke patients admitted in the ER were prospectively studied. Analysis was made to identify variables associated with <1- and <3 h delays from onset. About 18.8% of patients arrived before 1 h and 57.5% before 3 h. Factors independently associated with <3 h delay were decision to go immediately to ER (OR = 8.17; 95% IC = 4.47-18.8), ambulance transportation (OR = 2.35; 1.36-4.05) and total anterior circulation syndrome (TACS) (OR = 3.74; 1.51-9.24). History of >1 vascular risk factor was associated with a greater delay (OR = 0.47; 0.26-0.86). Factors associated with a <1 h delay were: (i) immediate decision to attend the ER (OR = 3.55; 1.85-6.81), (ii) stroke on Sunday (OR = 3.46; 1.56-7.66), (iii) aphasia (OR = 2.41; 1.23-4.74), (iv) absence of stairs at home (OR = 0.37; 0.17-0.81) and (v) absence of diabetes mellitus (OR = 0.42; 0.20-0.88). In our area, nearly 60% of stroke patients arrive to ER before 3 h from onset. Immediate decision to attend the ER has the strongest association with a short delay. Patients with TACS arrived mainly before 3 h and those with isolated aphasia arrived before 1 h. Patients with vascular risk factors attended the hospital later. Ambulance transportation is associated with <3 h delay, but not with <1 h.
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PMID:Emergency perception and other variables associated with extra-hospital delay in stroke patients in the Maresme region (Spain). 1835 21

The study was a cross sectional study conducted among 48 stroke patients in Medicine & Neuromedicine department of Mymensingh Medical College & Hospital. The objective of the study was to reveal the risk factors and other relevant information & immediate outcome of stroke patients. The sample size was 48 who were selected purposively and study area was selected for easy access. Study period was from 15th May 2007 to 15th July 2007. Forty eight (48) respondents and their reliable attendants were interviewed by pre tested structured questionnaire. Among 48 stroke patients 60% were male& 40% were female. Occupations of the patients were 21% desk job, 15% laborious work, 37% housewife, 6% businessman &21% in other profession. Age group of respondents were 13% below 45 years of age, 25% were 45-55 years of age, 29% were 55-65 years of age & 33% were over 65 years of age. Among 48 stroke patients 62.5% had 1st attack & others had multiple attacks. Among all the stroke patients 37.5% performed physical exercise. Forty six percent (46%) patients have family history of Hypertension. 27% have no family history of Hypertension & 27% have no idea. Sixty six percent (66%) patients have suffering from Hypertension, 23% have no history of Hypertension & 10% have no idea. Sixty percent (60%) patients had habit of Smoking, 40% had no habit of Smoking. 21% patients have family history of Diabetes, 48% have no family history of Diabetes & 31% have no idea about family history of Diabetes. Complications among stroke patients are 51% have Hemiplegia, 10% have Paraplegia, 23% have Paresis, 10% have Aphasia & 6% have others complications.
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PMID:Epidemiological study of risk factors of stroke and its immediate consequence. 1862 44

Advances in critical care medicine have led to improved survival rates among patients admitted to the Intensive Care unit (ICU), but complications experienced during admittance in an ICU may influence long-term outcome and the neurocognitive state of these patients. Coagulation disorders, glucose intolerance, diabetes, pro-inflammatory state and underlying severe pathologies are common risk factors for stroke development in ICU patients. Stroke may result in very serious consequences like motor function impairment, neglect and aphasia, but in some cases, stroke may not result in any clinical sign in acute phase. Recently, more attention has been given to this condition called ''silent stroke.'' ''Silent stroke'' could be the foundation of the development of neurocognitive impairment and vascular dementia. In ICU survivors, approximately 1/3 of patients or more will develop chronic neurocognitive impairment. With the advent of sensitive techniques for brain imaging, silent brain lesions, including brain infarct and white matter changes, have been frequently recognized. Until now, epidemiological studies in this field evaluating incidence and consequences of stroke in ICU setting are lacking, and prospective studies are required to evaluate the impact of this condition on the quality of life, neurocognitive outcome and mortality of ICU patients. We believe that when stroke occurs in critically ill patients, more attention is typically given to the underlying pathologies than stroke, and this may influence the long-term outcome. Guidelines for the early management of stroke, commonly used in Stroke Units, should be followed, even in critically ill patients in an ICU setting.
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PMID:Stroke in critically ill patients. 1863 61

In February 2011, the Food and Drug Administration informed that prescription of proton pump inhibitor (PPI) drugs may cause low serum magnesium levels if taken for prolonged periods of time. We present an ex-smoker, 76-year-old man, with high blood pressure, diabetes mellitus and Barrett's oesophagus (treated with esomeprazole since 2003) admitted due to fluctuating aphasia. Neurovascular and neuroimaging studies were normal. Dyslipidemia and atrial arrhythmia were discovered. The patient was discharged with the diagnosis of left middle cerebral artery transient ischaemic attack and anticoagulation treatment was recommended. The patient returned to the emergency department on further two occasions (confusional episodes) and was admitted in order to complete the neurological study that was normal. The patient was discharged with the diagnosis of probable epileptic seizures. After a week, he was admitted due to generalised temblor and unsteadiness. A complete blood test was performed and showed a severe hypomagnesaemia (not previously performed).
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PMID:Recurrent confusional episodes associated with hypomagnesaemia due to esomeprazol. 2391 71

Hypoglycemia is a common presenting feature of diabetes in the emergency department. Cardiovascular and neuroglycopenia features are well documented in the literature. We here report a case of 55-year-old female who came to our emergency with clinical features suggestive of cerebellar stroke. Laboratory investigations revealed severe hypoglycemia. The cerebellar signs and symptoms improved completely with intravenous dextrose infusion. Her MR imaging and Doppler of carotid and vertebrobasilar arteries were noncontributory. Hypoglycemia causes behavioral changes, confusion, loss of consciousness, and seizures. It is also well known to cause hemiplegia and aphasia. Hypoglycemia presenting as cerebellar stroke is rarely reported in the literature. This case highlights an uncommon manifestation of a common clinical condition. Physician must rule out hypoglycemia in every stroke patients.
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PMID:Severe hypoglycemia masquerading as cerebellar stroke. 2565 61


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