1379 Coordinated care across healthcare systems, a disease management concept: The singapore model for stroke care

$450

Thursday, November 10, 2005

Poster Abstracts

Vakifi, A ~, Dehghani, G a, Nekooeian, A 3. 1Semnan University

Background: CVT is encountered frequently in South India (1% of all

Of Medical Sciences, Semnan, Iran; ~Departments of Physiology, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, !ran; 3Departments of Pharmacologyl, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, !ran

strokes). It has variable temporal profile, clinical presentation and excellent outcome. Methods: 30 cases of CVT were studied between June 2002 and August 2004. Detailed lfistory and clinical exanfinations were done. Underlying medical illnesses, joint pains, genital & oral ulcer, alcoholism, oral contraceptive usage, dehydration, fever, sepsis and anemia were taken into account. Routine Blood count, ESR, Electrolytes, Renal and Liver Function tests, Coagulation profile, Protein C, Protein S, antithrombin -l-l-I, ACL antibodies and Serum homocysteine were assayed. CSF was studied in selected cases (118/30). MRI Brain & M R Venogram were done in all cases. Two cases had digital subtraction angiography. Results: There were 16 males & 14 females. Predisposing factors in females were pregnancy (28.4%), oral contraceptives (121.4%) and dehydration (17.1%), and in males - chronic alcoholism (43.8%) and dehydration (6.2%). Headache with papilledema were observed in 86.7%, meuingeal signs in 23.3%, seizures in 30%, hemiplegia in 30% and altered sensorium in 13.3%. Superior sagital sinus was involved in 90%. CSF was normal in 12 and had features of tuberculous meningitis in 6.3 patients had elevated serum homocysteine and 2 had elevated anti phospholipid antibodies. Patients were treated with low molecular weight heparin, oral anti coagulants, anti epileptic drugs and supportive measures. Outcome: 29 patients improved and 1 died. Conclusion: CVT is not uncommon. Neurotuberculosis and alcoholism in men and pregnancy/oral contraceptives in women were major etiological causes. Treated appropriately, CVI" carries good prognosis.

Pentoxifylline (PTX) is used in human for intermittent claudication and cerebral vascular disorders including cerebrovascular dementia. It also inhibits the synthesis of tumor necrosis factor-7, which is believed to be neurotoxicin animal models of cerebral ischemia. As far as the literature is concerned, there is no published study investigating the role o f TNF
1378 Fznbolisation in lntracrmfial Aneurysms - out experience

1376

Vehnurugendxan C.U 1, Smfil M Kalhir 1, Vasudevan D 1,

Stroke unit in Seiniijold Central Hospital, Finland

Meenakslfi Sundaram U 1, ArulselvanV.L 1, Murali ~, Santhosh Joseph 1.

Viilimiild, M 1, Hiiuliiliiinen, M 1. ZSeindjoki Central Hospital, Finland

1Sri Ramaehandra Medical College & Research Institute ("Deemed University), Chomai, Tamilnadu, India

About 14 000 Finnish people have a stroke every year. It is our third cause of death and a leading cause of severe, long-term disability. The expense goes up to 900 milj. Euros/year. Seinfijoki Central hospital is a district hospital caring of 194 000 inhabitants in the rural area of Finland. In Seinfijoki Central Hospital we have a 4 bed semi intensive Stroke Unit near com~ection with Intensive Care Unit, wlfich gives us broad competence both in intensive and neurological treatment. Stroke Unit was started January 1997. It is a multidiscipline unit prepared with a wide range on patient monitoring (including ekg, invasive and non invasive blood pressure, saturation, respiration and temperature measurements) systems. PiNs Care Suite (Critical Care Manager) has taken place in collecting patient information. Continuous EEG monitoring is also available. We treat about 400 neurological patients annually. Most of these are stroke related problems (80%). The average care period for a stroke patient is 2,5 days. Our Stroke Uuit has attended numerous projects and studies to develop medical and nursing care. Thrombolysis (tPA) has taken its place as acute stroke treatment. We have been involved to ECASS II and SAINT I studies. Intensive Care Nursing Scoring System gives information of our nursing staff resources. Work analysis was done during 2000-2001 in our hospital. According to this study the proper dimension of our stroke unit was 6,25 registered nurses, 0,5 neurology and 0,5 physiotherapist. Our stroke uuits expenses were 500 000 Euros/year.

Background: To study the usefulness of early endovascular manage-

ment of intracranial aneurysms in patients presenting with acute subarachnoid hemorrhage (SAH) at our center. Methods: 25 patients (113 men and 12 women) in the age group o f 2565 years presenting with aneurysmal SAH were studied. The presenting SAH Grade was: Grade 1-14, Grade I1-6, Grade II1-1, Grade IV-1. Digital Subtraction Angiography was done with GE Biplane DSA System with 3D rotational angiography. The distribution of aneurysms were ACA-7, Carotid ophthalmic -6, M C A -3, P C O M -2, Posterior Fossa -4, Peripheral aneurysms -3. Under GA, following femoral catheterization and guiding catheter placement in appropriate vessel, using micro catheter/micro wire combination, embolisation was done with either Gugleilmi detachable coils or N-butyl cyano acrylate (NBCA) glue. Patients were followed up for 2-14 months. Results: 22 patients were embolised with coil and 3 patients with peripheral aneurysms with NBCA. Anticoagulants and antiepileptic were used post procedure. Cheek angiogram showed successful embolisation of all aneurysms. 22 patients had no complications and were discharged home. Hemiplegia, Vitreous hemorrhage and fatal retroperitoneal hemorrhage occurred in one patient each. No patient had recurrence of SAH during follow up. Conclusion: Endovaseular coiling o f aneurysms is a relatively safe and effective procedure and early results are encouraging.

Cerebral Venous Thrombosis (CVT): a cli~fical profile seen in South India

1379 Coordinated care across healthcare sTstems, a Disease Management Concept: the Singapore Model for Stroke Care

Vehnurugendxan CU 1, Nagesh T ~, Vasudevan D 1, Meenakstfi

Veld~etasubraulanian, N 1, Yin, A 2, Heng, B2, Cheah, j2. ZNational

Sundaram U 1, Arulselvan VL 1. ZSri Ramachandra Medical College &

Neuroscience Institute, Singapore; 2National Healthcare Group, Singapore

1377

Research Institute (Deemed University), Chennai, amilnadu, India

Poster Abstracts

Thursday, November 10, 2005

$451

Background: Singapore is a small tropical island city-state of 4 million

Kruthika, V l, Nagaraja, D ~, Christopher, R 1, Arunodaya, G 1.

people, with 10000 hospital admissions and 1600 deaths annually from stroke. Methods: The National Healthcare Group (NHG) is a govetmnentowned cluster of 3 acute care hospitals and 9 polyclinics catering to half the Singapore population. The N H G Stroke Disease Management Workgroup was established in 2001 to coordinate stroke-related medical resources across the healthcare delivery system. The Workgroup comprises specialists in Neurology, Geriatrics, Rehabilitation and Fanffly Medicine, case managers and adininistrators. Results: The Workgroup has instituted the following: 1) Public Education - biannual public Forums, education video, posters, multilingual booklets; 2) Risk Factor Screening and Management opportunistic screening For all attendees aged 40 yr and above at N H G polyclinics, management using standardised algorithms, TIA clinics in hospitals; 3) Acute Stroke Management - stroke units/teams in all hospitals, clinical carepaths, bedside counselling by support groups; 4) In-patient Rehabilitation - rehabilitation units in all hospitals; 5) Out-patient Rehabilitation - community-based rehabilitation centres; 6) Follow-up Medical Care - carepath-based care in polyclinics; 7) Home Services - conmmnity based services are tapped; 8) Other Support Services - support groups, stroke clubs; 9) Staff Education - quarterly lecture series; 10) Stroke Audit - annual audit of hospital-based stroke care. The Workgroup is currently developing a case manager network involving the hospitals and community case managers. Efforts are being made to involve private practice Family physicians and NGOs. Conclusions: It is hoped that stroke incidence, mortality and disability will be reduced by tiffs disease management plan.

~Nationa[ Institute of Mental Health and Neuro Sciences Bangalore, India Background: Puerperal cerebral venous thrombosis is (PCVT) 10 12

times more frequent in India compared to the West. The exact predisposing factor for this condition is yet unknown. Factor V G1691A (FV Leiden), and Prothrombin G20210A mutations are the most common genetic risk factors for venous thrombosis. Our aim was to study the role of these genetic polymorplffsms as risk factors in puerperal CVT. Methods: The study was carried out in 86 women with CVT during the puerperal period and 86 clinically normal control subjects. The diagnosis of PCVT of all study patients was confirmed by MRI of the brain. Factor V Leiden, and Prothrombin G20210A mutations were detected by polymerase chain reaction, followed by digestion with specific restriction enzymes (RFLP). Results: Two (2.3%) o f the 86 patients and one (1.6%) of the 86 normal control subjects were heterozygous carriers of the Factor V Leiden mutation. No homozygous carrier of this mutation was detected in the patient as well as the control group. The odds ratio (OR) for puerperal CVT in carriers for the Factor V Leiden mutation was 0.49 (95% CI - 0.027.12, p -- 1.000). Prothrombin G20210A mutation was not detected in either the patient or control group. Conclusion: In tiffs study neither Factor V Leiden nor prothrombin G20210A mutation is a risk factor for puerperal CVT in South Indian patients. 1382 Medical management of Cerebral Venous Thrombosis: a study of routine practice in France

Vuillier, F 1, Moulin, T 1, Ricolfi, F 2, Cattin, F 1, Woimant, F 3. 1380 Unusual prtentations of Stroke in young: case series of ibm patients Venna a a, Desai pa, Priyanka 1. ~Department of Neurology, King

1Federation of Neurosciences Besan,con University Hospital, Besancon, France," 2Federation of Neurosciences, Dijon University Hospital, Dijon, France.." 3Neurology Department, Lariboisigre University Hospital, Paris, France

George's iVledica[ University, Lucknow, India

Background: Although anticoagulant randomJsed trials have been

Background: Stroke in young adults is rare but can be devastating for

carried out, medical management of cerebral venous thrombosis (CVT) varies to a large extent. The implementation of guidelines and routine management have not been evaluated. Method: We developed a series of 31 open questions about the medical management of acute C.VT and in the first Few months of Follow-up. Tiffs questionnaire was sent to 51 Neurology Units in French hospitals, with 37 responses. Results: In 27/37 centres initial emergency treatment was begun based on clinical findings in 15, and on radiological evidence of C.VT in the remaining 12 centres. All centres administered initial anti-thrombotic treatment to achieve effective anti-coagulation. In 30/37 centres (80%) intravenous heparin was most often used. The main contraindication for anticoagulants is the risk of bleeding. Intracranial hypertension was most often treated by osmotic diuretics and based on clinical and imaging arguments. The main deciding factor For prescribing anti-epileptics was a seizure in the acute phase in 35/37 centres (94o';) and intravenous clonazepam was used in 38%. Oral anticoagulants were prescribed in all centres, peaking on day 8 in 13/37 centres (35%) depending on the clinical course and aspect of cerebral lesions. The first follow-up visit was routinely organised at month 3, any decision to discontinue anti-coagulants depended on CVT etiological origin and on the aspect of the dural sinuses. Discussion: Diagnostic methods and emergency management were not yet standardised enough while anticoagulants were systematically used. Data is more variable concerning the investigation of etiology, follow up and treatment duration.

the affected individuals and their families. Recently there has been increasing interest in tiffs topic owing to increasing stroke rates in the younger age group and improved patient evaluation and treatment options. Method: Four patients of stroke in young has been evaluated clinically and etiology has been ascertained based on clinical assessment and investigations. Result: First patient presented with acute onset vertigo, vomiting, unsteadiness and difficulty in walking. Magnetic resonance imaging revealed bilateral superior cerebellar artery infarcts. Patient was diagnosed as case o f stroke in young due to hereditary thrombophilia (Protein C & S deficiency). Our second patient again was diagnosed as case o f bilateral cerebellar infarcts due to inherited thrombophilia ( M T H F R polymorphism). Tlffrd patient was a case of secondary Antiphospholipid antibody syndrome with hypertension presented with anterior conmmnicating artery aneurysmal bleed followed by infarct in anterior cerebral artery territory due to vasospasm. Our last patient was diagnosed as case of primary Antiphoshpholipid antibody syndrome associated with migraine with visual aura. This patient developed acute vision loss due to retinal infarct. Conclusion: Stroke in the young is multifactoeial causing high morbidity and mortality. Younger patients presenting with stroke has a wider etiological spectrum than in older patients, Hypercoagulable state and migraine are rare causes of stroke in the younger population.

1381 Factor V Leiden and Prothroinbin G20210A polymorphism in puerperal Cerebral Venous Thrombosis

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Racial ditti~rences in risk factors and outcome in Intracxatfial Atherosclerotic Arterial Stenosis