RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
DR. SREEDHARA M.R.
Name of the
candidate and
1
address ( in
block letters)
:
M.D. GENERAL MEDICINE
MAHADEVAPPA RAMPURE MEDICAL COLLEGE,
GULBARGA-585105.
KARNATAKA.
:
DR. SREEDHARA M.R.
S/O RAMANJANEYALU. K. H
GANGASAGARA VILLAGE, PAVAGADA TALUK,
TUMKUR DIST.
:
H.K.E. SOCIETY’S MAHADEVAPPA
RAMPURE MEDICAL COLLEGE,
GULBARGA – 585105
Course of study
and subjects
:
M.D.(GENERAL MEDICINE)
Date of
4 admission to the
course
:
13/09/2011
:
CORRELATION OF NEUROLOGIC DYSFUNCTION
WITH C T SCAN BRAIN FINDINGS AND CAROTID
DOPPLER STUDY IN ACUTE ISCHAEMIC STROKE
Permanent
address
Name of the
2
institution
3
5 Title of Topic
6 Brief Resume of the intended work
6.1
Need for the study:
Stroke is defined as an abrupt onset of neurologic deficit due to
vascular cause . It is a major cause of disability and remains the second leading
cause of death worldwide2, after ischemic heart disease.
1
Early diagnosis and treatment is necessary to prevent mortality
and morbidity . There are many investigations to confirm the diagnosis of stroke,
among which CT and MRI play major role. Though MRI is superior to CT scan,
the higher cost of MRI4 and the easy availability of CT scan brain makes CT scan
the commonest investigation in diagnosis and treatment of acute stroke.
3
CT plays a major role in stroke to assess the site, size and nature
of the lesion . 85% of stroke causes are due to infraction and 15% are due to
hemorrhage. Carotid atherosclerosis remains an important cause of ischemic
stroke.
A simple non-invasive screening procedure like Doppler
sonography of the carotid arteries could therefore have profound diagnostic and
therapeutic implications in predicting and preventing a potentially fatal and
devastating consequences of stroke.
5
6.2
Review of Literature
Stroke is a common cause of physical disability in both developing
and developed countries. It is a leading cause of death6. Atherosclertic disease of
the carotid arteries outside the cranial cavity has long been recognized as the most
common source of emboli that travel to the brain causing stroke7. High degree
internal carotid artery stenosis is the known risk factor for the development of
cerebrovascular events8.
Raymond Englund et al advocated the addition of CT scan of the
brain to the routine non-invasive assessment of patient with neurological
symptoms which may be secondary to carotid artery pathology9.
Plain CT remains the standard tool for initial assessment in most
centers because the large thrombolysis trails were all CT based10,11. Apart from
ruling out haemorrhage, early tissue ischaemic changes can be identified by CT
within three hours of onset in up to 75% of patients with Middle Cerebral
Artery(MCA) stroke12.
Sethi et al in their study concluded that the introduction of Doppler
imaging has dramatically changed the diagnostic evaluation of suspected carotid
disease. Doppler sonography provides a rapid, non-invasive, relatively inexpensive
and accurate means of diagnosing carotid stenosis and highlighted on the
importance of Doppler sonography in stroke prevention13.
Michael et al in their study concluded that detection of MCA territory
hypodensity on hyperacute CT scan is a sensitive, prognostic and reliable indicator
of the amount of MCA territory undergoing infraction14.
Norris et al in their study concluded that the more severe the carotid
stenosis, the higher the incidence of cerebral infraction ipsilateral to the stenosis15.
Gillain et al in their study, the findings suggested that ipsilateral carotid
disease is an important cause of stroke for those with anterior circulation infracts
but not for those with lacunar infract or posterior circulation infract16.
Diederik et al concluded that their findings support the hypothesis that
early CT signs of infraction indicate more extensive and severe cerebral ischemia
as reflected by lower apparent diffusion coefficient17.
Marks MP in his study CT IN ISCHEAMIC STROKE concluded that
the use of CT coupled with early phase therapy of stroke such as thrombolytic
therapy has been shown to improve outcome in the acute stroke patient18.
Kim et al in his study of Reversed Discrepancy between CT and
Diffusion-Weighted MR Imaging in Acute Ischemic Stroke concluded that
reversed discrepancy (RD) was uncommonly found mainly in basal ganglia, and all
RD lesions progressed to infarction at follow-up. Early CT ischemic lesion
showing parenchymal hypoattenuation may be undetectable on diffusion-wieghted
imagine(DWI). DWI may underestimate extent of severe ischemic tissue in
patients with acute MCA infraction19.
Gregory et al in their study concluded that in patients presenting with
a high pretest probability of posterior circulation stroke based on clinical
symptoms, the presence of the HDBA sign on unenhanced CT is a strong predictor
of basilar artery thrombosis, in both short- and long-term outcome20.
Noor et al in their study concluded that the frequency of carotid
stenosis as detected by Doppler ultrasonography in ischeamic stroke is 56%21.
6.3
Objectives of the study
1. To study the role of CT scan in the diagnosis of stroke.
2. To correlate the nature of lesion, site of lesion and severity of lesion
on clinical grounds with CT scan findings.
3. To find out the prevalence of carotid artery stenosis in acute
stroke patients.
ischaemic
4. To find out whether there is any association between carotid artery stenosis
and risk factors such as diabetes mellitus, hypertension, hyperlipidemia,
smoking and age.
7 Materials and methods
7.1
Source of data
All patients admitted to Basaveshwar teaching and general hospital,
Gulbarga with neurological deficit due to suspected cerebrovascular accidents
during the period of two years.
7.2
Methods of collection of data ( including sampling procedure, if any)
Study subjects:
Number of subjects included: 100 patients.
All patients admitted to Basaveshwar teaching and general hospital,
Gulbarga with neurological deficit due to suspected cerebrovascular accidents
during the period of two years.
Study Design
Hospital based cross sectional study
Inclusion criteria:
All patients admitted to Basaveshwar teaching and general hospital,
Gulbarga with neurological deficit due to suspected cerebrovascular accidents less
than one week duration during the period of two years.
Exclusion criteria:
a) Duration of stroke > 1 week.
b) Patients with haemorrhagic stroke.
c) Patients with H/O head injury
d) Systematic illness like hemodynamically unstable patients, malignancy,
unconscious patients, stroke like syndromes like TB, metabolic
emergencies and poor general condition.
Statistical Method
a) Correlation
b) T- tests
c) Chi-square test.
Period of study

For two years.
Collaborating Department:



7.3
Department of Radiology
Department of Pathology
Department of Biochemistry
Does the study require any investigation or intervention to be conducted on
patients or other humans or animals? if so please describe briefly
Yes. The study requires investigations like Hb%, TC, DC, ESR, Platelet count,
FBS, PPBS, HbA1c, Blood urea, Serum creatinine, Fasting lipid profile, Urine
routine, ECG, CT Scan Brain (Plain) and carotid Doppler.
7.4
Has ethical clearance been obtained from your institution in case of 7.3 ?
Yes. Ethical clearance has been obtained from the institution. There is a post
graduate committee consisting of Head of the department, Professors in Medicine,
chaired by The Dean. This committee selects the subject for dissertation, decides
the study protocol in addition to giving ethical clearance. The committee
periodically guides and supervises the progress of the study
An informed consent is taken from the patient before the study is initiated.
8 List of References
1. Longo DL, Fauci AS, Kasper DL et al, editors. Harrison’s principles of internal
medicine. 18th ed. New York: Mc Grath Hill; 2011.
2. Murray CJ, Lopez AD et al. Mortality by cause for eight regions of world. Global
burden of disease study LANCET 1997 May 3;349:1269-76.
3. Murray CJ, Lopez AD et al. Glodal mortality, disability and the contribution of risk
factor: Global burden of disease study. Lancet 1997;349:1439-42.
4. Mohr JP, Biller J et al. Magnetic Resonance versus computed tomographic imaging in
acute stroke. Stroke 1995;16:807-12.
5. Barder PA, Demchuk AM et al. Validity and reliability of a quantitative computed
tomography score in predicting outcome of hyperacute stroke before thrombolytic
therapy. LANCET 2000;355(9216):1670-74.
6. Wilkinson I, Lennox G. Essential neurology.4th ed. Massachusetts: Blackwell
Publishing Ltd; 2005
7. Eliasziw M, Kennedy J, Hill MD et al. Early risk of stroke after a transient ischemic
attack in patients with internal carotid artery disease. Can Med Assoc J 2004;170:
1105-9.
8. Liapis CD, Kakisis JD, Kostakis AG. Stroke 2001;32:2782
9. Raymond E, JOHN F, Peter FB at el. Annals of the Royal College of Surgeons of
England (1985) vol. 67 Correlation of clinical findings, duplex carotid artery scanning
and CT scanning of the brain in 54 consecutive patients with bruits over the carotid
artery bifurcation
10. Tissue plasminogen activator for acute ischemic stroke. The National Institute of
Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995,
333:1581-7.
11. Hacke W, Kaste M, Fieschi C et al. Randomised double-blind placebo-controlled trial
of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS
II). Second European–Australasian Acute Stroke Study Investigators. Lancet
1998;352:1245-51.
12. Barber PA, Demchuk AM, Zhang J et al. Validity and reliability of a quantitative
computed tomography score in predicting outcome of hyperacute stroke before
thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT
Score. Lancet 2000;355:1670-4.
13. Sethi SK, Solanki RS, Gupta H et al. Color and duplex Doppler imaging evaluation of
extra cranial carotid artery in patients presenting with transient ischaemic attack and
stroke –A clinical and radiological correlation. Ind J Radio Imag 2005;15(1):91-98.
14. Michael P. Marks, Eric B et al. Evaluation of Early Computed Tomographic Findings
in Acute Ischemic Stroke. Stroke 1999;30:389-92.
15. Norris JW, CZ Zhu. Silent stroke and carotid stenosis. Stroke 1992;23:483-85.
16. Gillian EM, Helen S, Anne F et al. Carotid disease in acute stroke. Age and ageing
British Geriatrics Society 1998;27:677-82.
17. Diederik M, Somforda B, Micheal P et al. Association of early CT Abnormalities
infarct size and apparent diffusion coefficient reduction in Acute Ischemic Stroke.
American society of Neuroradiology 2003.
18. Marks MP. CT in ischemic stroke Neuroimaging clin N Am 1998 Aug;8(3):515-23.
19. Kim E Y, Ryoo JW, Roh HG et al. Reversed Discrepancy between CT
and
Diffusion-Weighted MR Imaging in Acute Ischemic Stroke. Am J Neuroradiol 2006
Oct;27:1990–95.
20. Gregory VG, Erica CS, Camargo et al. Hyperdense Basilar Artery Sign on
Unenhanced CT Predicts Thrombus and Outcome in Acute Posterior Circulation
Stroke. Stroke 2009;40:134-39.
21. Noor ul H, Rukhsana et al. Freq of carotid artery stenosis in ischeamic stroke by using
carotid DopplerUSG in teaching hospital. Gomal journal of med sciences 2009;7(2).
Signature of Candidate
9
10
Remarks of guide
11
11.1
Name and designation of the
Guide
11.2
Signature
11.3
Co- guide (if any)
11.4
Signature
11.5
Head of the Department
11.6
Signature
12.1
Remarks of the Chairman and
Principal
12.2
Signature
12
a) Present study is taken as stroke is very
common in this part of the state and to
diagnose and treat effectively with
minimal investigations.
b) First of its kind in Hyderabad
Karnataka area. Hence study is taken.
Dr. BHARAT L. KONIN
M.D,DM(NEUROLOGY)
ASSOCIATE PROFESSOR,
DEPARTMENT OF MEDICINE,
M.R. MEDICAL COLLEGE, GULBARGA
Dr. G.VEERANNA
M.D.,D.M(Cardiology)
PROFESSOR AND HOD
DEPARTMENT OF MEDICINE
M.R.MEDICAL COLLEGE, GULBARGA