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“Comparison of Clinical Stroke Scores and Ct Brain “COMPARISON OF CLINICAL STROKE SCORES AND CT BRAIN IN THE DIAGNOSIS OF INTRACEREBRAL HAEMORRHAGE AND INFARCT IN ACUTE STROKE PATIENTS” Dissertation submitted to The Tamil Nadu Dr.M.G.R. Medical University In partial fulfillment of the regualtions for The award of the degree of M.D. General Medicine [Branch – 1] K.A.P.VISWANATHAM GOVERNMENT MEDICAL COLLEGE & M.G.M. GOVERNMENT HOSPITAL, TIRUCHIRAPPALLI. THE TAMIL NADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI 2016 CERTIFICATE This is to certify that the dissertation entitled “COMPARISON OF CLINICAL STROKE SCORES AND CT BRAIN IN THE DIAGNOSIS OF INTRACEREBRAL HAEMORRHAGE AND INFARCT IN ACUTE STROKE PATIENTS” is a bonafide original work of Dr. RAMYAPRASAD in partial fulfillment of the requirements of M.D., General Medicine [Branch- 1] examination of THE TAMILNADU Dr. M. G. R. MEDICAL UNIVERSITY to be held in April 2016. Prof.Dr.P.KANAGARAJ.M.D Prof.Dr.M.K.MURALIDHARAN.M.S.,Mch HOD & UNIT-1 CHIEF DEAN Department of Medicine K.A.P.V. Govt. Medical College K.A.P.V. Govt. Medical College M.G.M. Govt. Hospital, M.G.M. Govt. Hospital, Tiruchirappalli. Tiruchirappalli. 2 DECLARATION I Solemnly declare that the dissertation titled “COMPARISON OF CLINICAL STROKE SCORES AND CT BRAIN IN THE DIAGNOSIS OF INTRACEREBRAL HAEMORRHAGE AND INFARCT IN ACUTE STROKE PATIENTS” is done by me at K.A.P. VISWANATHAM GOVT MEDICAL COLLEGE, TIRUCHIRAPPALLI under the guidance and supervision of Prof. Dr. P. KANAGARAJ. M.D., This dissertation is submitted to The Tamilnadu Dr. M.G.R. Medical University towards the partial fulfillment of requirements for the award of M.D Degree (Branch-1) in General Medicine. Place: Tiruchirappalli Dr. RAMYAPRASAD Date: Post Graduate Student M.D. General Medicine K.A.P.V. Govt Medical College & M.G.M. Govt Hospital Tiruchirappalli. 3 ACKNOWLEDGEMENT I express my sincere gratitude to The DEAN Prof. Dr. M.K. MURALIDHARAN M.S.,Mch., for allowing me to utilize the clinical material for this study. I am extremely grateful to Prof. Dr. P. KANAGARAJ M.D., Professor and Head of the Department, Department of Internal Medicine, K.A.P.V. Govt Medical College and M.G.M. Govt Hospital for permitting me to carry out this study and for his constant encouragement and guidance. I whole heartedly thank Prof. Dr. M.ANGURAJ M.D., D.M., (Neuro), HOD i/c, Department of Neurology, for his constant motivation and valuable guidance throughout my dissertation work. I express my sincere thanks to Prof. Dr. G. Anitha M.D., Prof. Dr. K.Parimaladevi M.D., Prof. Dr. N.K. Senthilnathan M.D., Prof. Dr. A. Sethuraman M.D., and Prof. Dr. D. Nehru M.D., for their valuable guidance and motivation. I express my sincere gratitude to Prof. Dr. R. RAVI (Radiologist), HOD Department of Radiology for his support. I express my sincere gratitude to DR. E.ARUNRAJ M.D., D.M., (Neuro) Assistant Professor of Neurology, for his guidance and help during this study. 4 I thank my unit Assistant Professors Dr.RAJAMAHENDRAN M.D., Dr.THENMOZHI M.D., and Dr.M.SUBRAMANI M.D., for their continuous motivation and valuable guidance throughout my work. I whole heartedly thank my family, colleagues, friends and staff of our hospital for their support. I owe my sincere thanks to all the patients for their kind cooperation throughout the study. 5 CONTENT S.NO TITLE PAGE NO 1 INTRODUCTION 1 2 REVIEW OF LITERATURE 3 3 AIMS AND OBJECTIVES OF STUDY 38 4 MATERIALS AND METHODS 40 5 RESULTS 48 6 SUMMARY 64 7 DISCUSSION 70 8 CONCLUSION 76 9 BIBLIOGRAPHY 78 10 ANNEXURES 1. MASTER CHART 87 2.PROFORMA 89 3. ABBREVIATIONS 90 4.ETHICAL COMMITTEE APPROVAL 93 5.PLAGIARISM REPORT 94 6 INTRODUCTION 7 INTRODUCTION Cerebrovascular accident / stroke, the second leading cause of death in the World1, is also an important cause of morbidity. Because of the varied epidemiological factors, the burden of stroke keeps increasing in the developing countries2, including India. Early diagnosis and prompt treatment can help in preventing the morbidity and also mortality. The prompt management of stroke depends on the correct diagnosis of its subtypes, mainly ischemic or hemorrhagic, so that thrombolytic therapy can be instituted for the needed. CT Brain is a safe and accurate diagnostic tool for the differentiation of ICH and Ischemic Stroke. However, a relatively good number of patients in developing countries have only poor access to CT or could not afford for CT. The clinical features of ICH and IS has much overlap3 and hence making the clinical differentiation difficult. Several clinical scoring systems were designed for their differentiation. SIRIRAJ SCORE4 AND ALLEN SCORE5are among the various scores. The aim of this study is to compare and validate the two scores and to assess their predictive accuracy by comparing them with CT Brain. 8 REVIEW OF LITERATURE 9 REVIEW OF LITERATURE A cerebrovascular accident is defined as an abrupt onset of a neurological deficit, that is attributable to a focal vascular cause1.Thus stroke is more of a clinical diagnosis, which is supported by imaging studies. The definition of TIA needs that all neurologic signs and symptoms resolve within 24 hours without any evidence on brain imaging 1.when it lasts for more than 24 hours or the brain infarction is demonstrable, then it implies that stroke has occurred. The 24 hours time limit differentiating TIA and stroke is important, because both do not have the same differential diagnosis. TIA, is never caused by intracerebral haemorhage and stroke is more uniformly defined and more likely to be reported than TIA, but the investigations being almost identical for both. As per WHO, about 15 million people suffer from stroke each year worldwide. Among them, about 5 million die and about 5 million suffer permanent disablement. In US, stroke is the third leading cause of death, with about three quarters of all strokes occurring among people more than 65 years . 10 In India, the incidence rate being 119- 145 per lakh. Prevalence rate among rural population being 334 – 424 per lakh and urban being 84 – 262 per lakh 6. Average age being 15 years younger for stroke patients in india, when compared to developed nations and about one fifth being below 40 years. However the mean age for stroke being 66-67 years in India. The age standardized incidence rate being higher in men than women, that is, 162 per lakh person years for men, against 142 per lakh person years in women. Stroke occurs in relatively older age in women than men.(68.9 years in women and 63.4 years in men). Among the stroke subtypes, ischemic stroke being common than haemorhagic Stroke. The main risk factors for stroke in India being hypertension, diabetes mellitus, hypercholesterolemia and smoking. On comparing urban and rural populations, the annual incidence was higher among rural population, the main contributing factors being smoking and the presence of multiple risk factors together. On the contrary, the number of patients undergoing imaging was significantly lower in rural population . 11 RISKFACTORS : AGE : Age is the strongest risk factor for stroke, with the stroke in people aged 75 to 84 years being 25 times more common than in people aged 45 to 54 years . SEX : Small excess incidence in males is observed . BLOOD PRESSURE : There seems to be a log linear relationship between the usual diastolic blood pressure and stroke throughout the normal range ,with no evidence of a threshold below which the risk becomes stable . This applies even to patients, who have already experienced cerebrovascular symptoms7. The association between increasing blood pressure and stroke seems to become less in the elderly, when compared to middle age. In the very elderly, stroke may be associated with low blood pressures, with the low blood pressure being a reflection of pre existing cardiovascular and other diseases 8. 12 SMOKING : There seems to be a dose response relationship, with both the males and females being equally affected .There seems to be association with passive smoking also9,10.Ex smokers have a sustained excess risk of stroke for some years 11. BLOOD LIPIDS : Increased serum lipoprotein (a) carries risk for stroke .There seems to be a negative association of cholesterol with intracranial haemorhage, which obscures any positive association with the ischemic stroke in studies of ‘all strokes’12. DIABETES MELLITUS : The presence of diabetes mellitus almost doubles the stroke risk when compared with non diabetics .Also strokes in diabetics are likely to be fatal13. Among the hemostatic variables, increasing fibrinogen, raised factor VII coagulant activity, raised tissue plasminogen activator antigen, raised vwf seems to be risk factors for stroke14. ATRIAL FIBRILLATION By virtue of forming clot in the left atrium and its appendage, atrial fibrillation is the most frequent potential cardiac source of embolism to the 13 brain, with the non rheumatic atrial fibrillation contributing more than the rheumatic atrial fibrillation, with the lone AF (i.e., without other cardiac disease ) also being a risk factor. Among the fibrillating population, further high risk exists for those with a previous embolic event, hypertension, diabetes mellitus, increasing age and left ventricular dysfunction15. ALCOHOL : Heavy alcohol consumption being an independent risk factor, more for haemorhagic than ischemic stroke 16. Alcohol raises blood pressure, affects blood lipids, can cause cardiomyopathy and atrial fibrillation and could contribute to stroke in these ways also. OBESITY: Increased risk for stroke, because of associated hypertension, dyslipidemia and insulin resistance17. DIET : Deficiency of fresh fruits and vegetables, vitamin E, vitamin C, beta carotene, flavanoids (antioxidants) are the proposed risk factors. High intake of potassium reduces and excessive salt intake increases stroke risk. 14 Lack of Exercise has association with stroke18.
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