Jorge E. Mendizabal

Accuracy of paramedic diagnosis of stroke.

BACKGROUND AND PURPOSE Accurate prehospital diagnosis of acute stroke may lead to fewer delays in hospital presentation. In addition, prehospital personnel soon may be administering therapies to patients with presumed stroke. We sought to determine the sensitivity and positive predictive value (PPV) of paramedic diagnosis of stroke in Mobile, Alabama, and to evaluate the impact of an educational program on paramedic diagnostic capability. METHODS We collected data from all paramedic-diagnosed stroke patients transported to a University of South Alabama hospital by Mobile Fire Medics. Final diagnosis was determined by a neurologist and classified as stroke or nonstroke (i.e., PPV). Paramedic diagnoses for all hospitalized stroke patients transported by Mobile Fire Medics were also reviewed (i.e., sensitivity). Sensitivity and PPV were calculated for the period 6/13/95 to 3/13/97. In addition, both indices were calculated for the period before (6/13/95 to 5/5/96) and after (6/25/96 to 3/13/97) an 8-week intensive educational program. RESULTS Seventy-one hospitalized stroke patients were transported by Mobile Fire Medics during the study period. Paramedics correctly identified 67 patients in total (94% sensitivity), 29 during the pre-education period (91% sensitivity), and 29 during the posteducation period (97% sensitivity; P=.33). Twenty-five patients were incorrectly diagnosed with stroke (73% PPV), 15 during the pre-education period (66% PPV), and 9 during the posteducation period (76% PPV; P=.30). CONCLUSION Although paramedics in Mobile misdiagnose few patients with acute stroke, there is a tendency toward overdiagnosis. An educational intervention resulted in a trend toward improved accuracy of diagnosis, but this did not reach statistical significance.

Migrainous stroke causing thalamic infarction and amnesia during treatment with propranolol

We report a case of migraine‐associated ischemic stroke causing amnesia, wherein treatment with propranolol may have been contributory. The possible mechanisms involved in migrainous stroke occurring in association with use of propranolol are discussed.

An Analysis of the “Carry-over Effect” Following Successful Short-term Treatment of Transformed Migraine With Divalproex Sodium

Objective.– To determine whether successful short‐term prophylactic treatment of transformed migraine may be followed by a continued respite from headaches once the treatment has been discontinued (“carry‐over effect”).

Extended-release divalproex sodium improves the quality of life of adolescent migraineurs.

to 1 hour; he treats it with a nonprescription analgesic. The headache is severe in intensity, throbbing over the anterior vertex, and accompanied by photophobia. In October 1996, the patient was watching Clinton’s re-election on TV, which upset him greatly. He subsequently developed his typical visual aura, but it was much more vivid than usual. His visual symptoms were accompanied by tingling of his left arm and hand, developing without a march and lasting for 15 to 30 minutes. He developed a severe headache, photophobia, and generalized weakness. In addition, he was confused and kept repeating the same sentence. The visual disturbance has persisted ever since, affecting his vision as if he is looking through a veil. The “white snakes” in the periphery of both visual fields come and go. Cranial magnetic resonance imaging was normal and without evidence of infarction.

Baseline computed tomography changes and clinical outcome after thrombolysis with recombinant tissue plasminogen activator in acute ischemic stroke.

Objective. Intravenous recombinant tissue plasminogen activator (rt‐PA) is the only therapy of proven value for patients with acute ischemic stroke (AIS). Controversy exists with regard to the prognostic significance of early computed tomography (CT) changes in patients receiving rt‐PA for AIS. The authors retrospectively reviewed all cases of AIS who received intravenous rt‐PA for AIS in University of South Alabama hospitals between January 1996 and May 1999. A neuroradiologist, blinded to clinical outcomes, reviewed all baseline CT scans for the presence of the following signs: hyperdense middle cerebral artery (HMCA), loss of gray‐white differentiation (LGWD), insular ribbon sign (IRS), parenchymal hypodensity (PH), and sulcal effacement (SE). Modified Rankin Scale (mRS) score was recorded 90 days after thrombolysis, and clinical outcome was dichotomized as favorable (0–1) or unfavorable (2–6). The authors performed both univariate and multivariate analyses to investigate the relationship between early CT signs, baseline clinical variables, and functional outcome as measured by the 90‐day mRS scores. Any one early CT finding was detected in 23 (64%) patients. The frequency of specific findings were as follows: SE in 13 patients (36%), LGWD in 12 patients (33%), PH in 9 patients (25%), HMCA in 4 patients (11%), and IRS in 3 patients (8%) patients. There was no statistically significant association between the occurrence of these imaging findings and subsequent functional outcome after thrombolysis. The data suggest that the presence of subtle acute CT changes in AIS patients is not predictive of clinical outcome following administration of rt‐PA as per National Institute of Neurological Disorders and Stroke protocol.

Treatment of Neuropathic Pain

Neuropathic pain is generated by disruption of normal nerve connections and/or abnormal hyperactivity at some level of the pain sensory system. Neuropathic pain syndromes due to peripheral nervous system injury are commonly encountered in clinical practice and often adversely affect patients’ quality of life. Pharmacotherapy is the mainstay of neuropathic pain management, with the majority of clinical data supporting the use of three main drug classes: (1) tricyclic antidepressants; (2) anticonvulsants; and (3) anesthetic-antiarrhythmics. Clonidine, opioids, capsaicin, nonsteroidal anti-inflammatory drugs, immunosuppressants, and the novel antidepressants may also have a role in some patient populations.

PRIMARY CHRONIC DAILY HEADACHE: A REAPPRAISAL

BACKGROUND- Chronic daily headache (CDH) is a disorder commonly encountered in clinical practice. Despite its prevalence, CDH has been poorly characterized, and relatively little is known regarding its biology and optimal medical management.REVIEW SUMMARY- We present a review of the data that support the need to develop a new classification system for the CDH syndromes. The clinical and biological characteristics of chronic tension-type headache, transformed migraine, hemicrania continua, and new daily persistent headache with migrainous features are discussed, and recommendations concerning the medical management of these patients are offered.CONCLUSIONS- CDH is a heterogeneous clinical entity with characteristics and subtypes that require further definition and validation. An accurate classification of CDH may assist the clinician in diagnosis and, likely, reduce the incidence of unnecessary and costly ancillary testing. Preliminary evidence suggests that more careful diagnostic discrimination among the subtypes of CDH will assist in directing pharmacologic intervention.