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Introduction References
Neurological
Emergencies: approaches in Europe and Turkey
Case
Presentation
The approach to
neurologic emergencies varies throughout Europe, depending on the treament
setting, the training of the practitioner, the resources available to
the patient and practitioner, and active involvement in research projects.
The findings in this brief characterization of the approach used in emergency
departments throughout Europe and Turkey is of course limited in scope.
The following comments are based upon personal experience in Turkey, personal
interviews with health personnel (E, F, G, TR), and answers to a short
questionnaire that was sent to physicians around Europe (B, D, GB, N,
TR). The general health care environment and approaches to various neurological
emergencies in different settings in Turkey are described. Then, common
treatments used by European physicians for the same clinical problems
are listed, as well as some of the current experimental studies being
conducted in Europe for patients with ischemic stroke.
Key Questions
- What are some characteristics
of the population and the health care environment in Turkey that influence
the care given for neurological emergencies?
- What are some of the experimental
therapies for ischemic stroke currently being studied in Europe?
- Where can more information
be obtained about neurological emergencies in Europe?
Key Learning Points
- Physicians with various
training backgrounds give initial care and in-hospital care to patients
with neurologic emergencies.
- Physicians in Europe and
Turkey approach patients with neurologic emergencies in various ways,
depending on patient and institutional resources.
- A variety of medications
are currently being studied for the treatment of ischemic stroke.
TOP
Neurological
Emergencies: approaches in Europe and Turkey
Introduction
Health Care
in Turkey
Because health
is not routinely taught in schools and few information resources are available
to the public, atients in Turkey are often ill informed about their health.
Culturally, patients tend to be passive, not questioning the decisions
or decision-making of the doctors.
To serve a population
of about 70 million, Turkey has 5900 public health clinics, 1300 hospitals
(950 government, 40 university, and the rest private). Access of the clinicians
to journals and the internet at the government hospitals is usually not
available. Emergency departments of these hospitals are staffed by medical
school graduates, with no board certification or further training beyond
medical school. The first EM residency graduate finished his training
in 1998, and to date only 90 have finished their training at EM residencies
around the country. In some very large government hospitals, neurologists
are stationed in the ED, along with an assortment of general practitioners,
orthopedists, internists, general surgeons, anesthesiologists, and neurosurgeons.
Except in EM residency program EDs, documentation of the patient encounter
is very scant. Intensive care units are only found in large university
medical centers, other facilities typically have only a 'monitored bed'
unit.
Most of the population
is bound by insurance status (or lack of insurance) to receive care in
a government hospital, which are typically underequipped and undersupplied.
Because of limited supplies and equipment and long delays in clinic care
in the government hospital systems, patients who can afford paying out
of pocket are increasingly choosing private medical care. The number of
private hospitals has doubled in the past 10 years, and new emergency
medicine graduates are in great demand by the private sector. Additional
facts concerning the private medical sector in Turkey: more MR machines
(80!) are located in Istanbul than in the whole UK; and competition has
driven down costs for diagnostic tests, $40-50 for a head CT, and $80-100
for an MR.
A large pre-hospital
ambulance system was set up in 1993, and further legislation in 2002 designated
mandatory equipment and staffing for both BLS and ALS ambulances. Patients
transported are among the following types: 25% trauma, 20% cardiac, and
10% neurologic. The ambulance system is still not widely used though;
a study in 2002 found that 60% of stroke patients presenting to one university
ED arrived by taxi or private car.
As has been reported
in other countries, patients with ischemic stroke often present for health
care many hours after the onset of symptoms. In one study from Turkey,
50% of stroke patients presented within two hours to a health care provider
(to a clinic or hospital without an ICU), but only 30% came to a tertiary-care
hospital within 2 hours. The most common reasons for coming late were:
'Thought it would go away by itself', transportation problems, distance
from care, and 'Didn't realize it was an illness'.1 In summary, the public
is often ill-informed about their health status, and does not fully utilize
access to emergency care for neurologic problems. Health personnel in
many settings have limited access to up-to-date references for neurologic
emergencies.
Ischemic Stroke
In univeristy hospital settings across Europe, persons presenting with
symptoms and signs of acute ischemic stroke undergo a careful history
and physical exam, and then are subject to extenisve laboratory testing
and a non-contrast head CT scan. In Turkey, very few centers use IV tPA
routinely. One center has used intra-arterial tPA a few times. Usual treatment
then consists of aspirin or heparin, if the symptoms are mild. Labetalol
is not available in Turkey, so oral ACE inhibitors or IV furosemide are
used for high blood pressure, and if intracranial pressure is thought
to be increasing, mannitol is given and fluids are restricted. One center
had performed craniectomy in several patients for severe cerebral edema
after stroke. In large government hospitals in Turkey, the general approach
is the same, but tPA is never used, heparing is given with or without
clopidogrel for small infarcts, and piracetam is sometimes added as adjunctive
therapy. Steroids are routinely given as 'anti-edema' therapy. In rural
government hospitals, stroke patients may be transferred immediately without
any initial treatment, or they might be given dexamethasone and mannitol
before transfer. The use of sublingual nifedipine has declined significantly
in the last ten years in Turkey, but is still used in some outlying centers.
Patient with symptoms of acute
stroke are sometimes delayed in their presentation to the health system
due to application of folk remedies. In Turkey, common remedies include
applying cold water to the patient's head, giving an additional dose of
blood pressure medicine, or pouring cologne on the patient. Less commonly,
relatives will massage the affected limbs of stroke patients, and/or give
the patient lemon juice or yogurt water to drink.
In other European countries,
stroke patients are typically cared for by internists initially in the
emergency department, and if older (>65 years old), may be cared for
by internists as inpatients (Norway). Neurologists would care for the
younger stroke patients. In Germany, stroke patients are initially cared
for by anesthesiologists in their ICU. Neurologists see the patients after
they have 'been stabilized.' Throughout Europe, tPA is used in large centers
for ischemic stroke patients who meet NINDS guidelines. Spain has 'stroke
teams' in many of the larger medical centers. Its neurologists have phones
which can be directly dialed by ambulance personnel, which enable them
to meet the patient immediately in the emergency department. IN countries
where internists play a prominent role in the initial treatment of ischemic
stroke patients, the decision to use and administration of tPA is controversial
- are the internists able to give tPA, or should one wait until a neurologist
is available to evaluate the patient before tPA is given? Most hospitals
do not have enough neurologists on staff to be on a 24/7 stroke team (Spain).
In general, smaller hospitals do not typically use tPA, and physicians
are less aggressive with older patients in their treatment for ischemic
stroke.
The following are just some
of the experimental studies being performed throughout Europe:
- DIAS: Desmoteplase in Acute
Stroke ('DEDAS' in North America). This study enrolls ischemic stroke
patients from 3-9 hours of stroke onset, if a penumbra is seen on diffusion-weighted
MR. The agent is the active ingredient in vampire bat saliva. The first
preliminary study was published as an abstract this year, and was positive
when compared with placebo.
- ECASS III: This study enrolls
ischemic stroke patients from 3-4 hours of stroke onset.
- IMAGES: This study enrolls
ischemic stroke patients from 12 hours of stroke onset. The study medication
is MgSO4, which is given as a 5 gm IV load, then continued as a 10 gm
over 24 hour infusion.
- ENOS: Efficacy of Nitric
Oxide in Stroke. This study enrolls ischemic stroke patients from 48
hours of stroke onset. The study medication is a transdermal glyceryl
trinitrate patch (a NO donor), which is applied daily for seven days.
- IST-3: International Stroke
Trial-3: This study enrolls ischemic stroke patients from 6 hours of
stroke onset. The study medication is tPA (0.9 mg/kg), which is given
as a bolus (10% of the total dose) and then as an infusion (90% of the
total dose).
Transient Ischemic Attack
At university medical centers around Europe, patients with symptoms and
signs of TIA are typically subjected to many blood tests, and a head CT.
Patients are admitted for observation and may be treated with a variety
of combinations of the following: aspirin, ticlopidin, clopidogrel, and
dipyridamole. If the patient reports a crescendo pattern, patients are
usually treated with heparin (LMWH in some centers). Additional imaging
studies are usually performed after admission, and include MR, carotid
doppler, echocardiogram, and transcranial doppler. Endarterectomy is reserved
for patients with high-grade stenosis.
In large government hospitals
in Turkey, high-risk patients are given heparin, and low-risk patients
aspirin. Patients are discharged to be followed-up as outpatients by neurologists.
Other Neurologic Problems
Some neurologic problems seen more commonly in Turkey than in North America
include Behçet's disease, Wilson's disease, and complications of
infectious diseases. Behçet's disease is recurrent inflammatory
disease, which has the following clinical manifestations: aphthous oral
ulcers, genital ulcers, uveitis, and erythema nodosum. In 30% of patients,
neurologic signs are present and may include: recurrent meningoencephalitis,
CN palsies, and transient brainstem dysfunction. Wilson's disease ("progressive
hepatolenticular degeneration") is an autosomal recessive disease,
which can manifest itself with tremor of the tongue, jaw muscle dysfunction
which results in dysphagia and drooling, and rigid or slow moving limbs.
Infectious diseases frequently resulting in neurologic complications (menengitis
and vertebral osteomyelitis) are brucella and tuberculosis.
Medications in Europe
Europe and Turkey have some medications available for patients with neurologic/psychiatric
emergencies which have not yet received approval in the USA:
- Piracetam (Nootropil®).
This is widely used for "psycho-organic syndromes" in Turkey
- memory loss, vertigo, learning difficulties, and even TIA. Of the
many studies done with piracetam, most are animal studies, non-blinded,
non-randomized, and finding "a trend towards significance",
but no statistically significant results for any clinical finding in
humans.
- Clomethiazole. This is
a hypnotic widely used to attenuate alcohol withdrawal symptoms in Germany.
- Olanzapine. Another atypical
antipyschotic, which has a rapid dissolving tablet formulation for under
the tongue application.
Education in Neurologic
Emergencies
Most countries have neurology and emergency medicine societies, which
are giving educational conferences, some portion of which is dedicated
to neurologic emergency topics. Textbooks also contain information on
these topics. In Turkey, Emergency Medicine: a companion handbook, 5th
ed. (by Ma & Stein), has been translated into Turkish, as well as
several neurology texts: Neurology for the House Officer and Merrit's
Neurology.
Organizations for further information
British Association of Stroke
Physicians (www.basp.ac.uk)
European Federation of Neurological Societies (www.efns.org)
European Stroke Initiative (www.eusi-stroke.com)
European Stroke Council (eurostroke.org)
European Brain Council (www.europeanbraincouncil.com)
TOP
Neurological
Emergencies: approaches in Europe and Turkey
Reference
List
1. Dora B, Yardimsever
M, Balkan S. Acute stroke therapy, are we ready? Admission time and
factors delaying admission in acute stroke. Akdeniz University Dept.
of Neurology, Antalya, TR.
Web sites of a few ischemic
stroke studies:
DIAS study (desmoteplase 3-9 hrs.):
ENOS study (NO 0-48 hrs.): www.nottingham.ac.uk/strokemedicine/enosindex.htm
IMAGES study (Mg 0-12 hrs.): www.medther.gla.ac.uk/studies/images
IST-3 (tPA 3-4 hrs.): www.dcn.ed.ac.uk/ist3
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