1. Neurologic Emergencies: Perspectives from Europe / Turkey
John Fowler, MD
Izmir, Turkey

2. Overview Turkey Europe: approaches, current research
Its health care system and approaches to neuro. emergencies in various settings
Unusual neurologic problems
Research & educ. in neuro. emergencies
Europe: approaches, current research

3. Disclaimer
Approaches to neurological emergencies vary greatly among physicians in Europe and Turkey
Findings based on:
personal experience (TR)
personal interviews (TR, F, D, E)
questionairre (N, TR, GB, B, D)
Docs in rural areas just want to get by,. Make patients happy and show concern for them. Fancy meds not available. Things like Nootropil might help, probably do no harm.
Will cover a few situations, but can’t cover all possiblities that might come up at every medical center in Turkey!
Lack of money, lack of malpractice system.

4. Turkey’s Health Care System: the patients
Health is often not taught in schools
Few info sources for public
Patients are ‘passive’, doctors speak with authority
Thus the public is poorly informed about their health, and is not very good at recognizing signs of neurologic emergencies

5. Turkey’s Health Care System: the patients
Health is often not taught in schools
Few info sources for public
Patients are ‘passive’, doctors speak with authority
Patients are ill-informed about health problems
Thus the public is poorly informed about their health, and is not very good at recognizing signs of neurologic emergencies

6. Turkey’s Health Care System: finances and insurance
25% ‘everything paid for’ insurance (pts. usually go to univ. hospitals)
30% ‘govt. HMO’ insurance, with own hospital and clinic system
20% self-employed insurance: govt. hospitals
25% no insurance: govt. hospitals
Instead of admission, some observe in ED for a day.
A large proportion of pts are bound to govt hospitals, which are not well-equipped

7. Turkey’s Health Care System: facilities
5900 public health clinics
1300 hospitals (950 govt.; 40 univ.)
Little access to journals and internet in government hospitals
Private health sector increasing
PHCs only have stethescope and BP cuff and suturing supplies usually. Govt hospital docs often behind on current literature
Other 310 hospitals are private

8. Turkey’s Health Care System: facilities
More MR machines in Istanbul (80!) than in the UK.
Head CT $40-50, head MR $80-100

9. Turkey’s Health Care System: pre-hospital
Pre-hospital care (large-med. cities)
‘112’ national ambulance system
25% trauma, 20% cardiac, 10% neuro.
Transport (blue) and ALS (red) ambul.
10% of customers have neuro emergencies

10. Turkey’s Health Care System: pre-hospital
In large-med. cities, ‘112’ national ambulance system
25% trauma, 20% cardiac, 10% neuro.
Still not widely available or used
Taxi or private car used to transport 60% of stroke patients

11. Turkey’s Health Care System: emergency department
Initial care given by GPs in 99%
Neurologists in ED (very large govt. hospitals)
Little initial documentation, little or no documentation upon transfer
Head CT’s $30-40, head MR scans $70-100

12. Turkey’s Health Care System: emergency department
Initial care given by GPs in 99%
Neurologists on staff (medium-large hospitals)
Little initial documentation, little or no documentation upon transfer
About 100 EM specialists nationwide, most at university medical centers

13. Turkey’s Health Care System: intensive care units
In large university medical centers, but few beds
‘Monitored units’ in government hospitals

14. Ischemic Stroke: demographics (TR)
Present to health care provider (clinic or hospital without ICU) within 2 hours in 50%, and are then transferred to a tertiary-care hosp.
About 30% arrive to a tertiary-care hospital within 2 hours

15. Ischemic Stroke: demographics
Reasons for arriving late: (Dora B, et al, Akdeniz Univ. Dept. of Neurology)
‘Thought it would go away by itself’
Transportation problems
Live far away
‘Didn’t realize it was an illness’
Not a lot different than in other communities perhaps

16. Ischemic Stroke: University Medical Centers
History and physical exam
Lots of blood tests; head CT
[IV heparin]; almost no IV tPA
One center: intra-arterial tPA
Aspirin if no intracranial hemorrhage
[IV furosemide or ACE inhib. for high BP]
Hesitant to use tPA, one case of ICH ruins ones reputation… diuretics in D for HBP

17. Ischemic Stroke: University Medical Centers
Cont’d:
If cerebral edema worsens,
Mannitol and fluid restriction
In one center: craniectomy for severe cerebral edema
How many here have craniectomy done for neurosurgical ICU patients??

18. Ischemic Stroke: Large Govt. Hospitals
H&P, blood tests and head CT
Steroids as anti-edema therapy
no tPA
Heparin if a small infarct, ± clopidogrel
[Piracetam]

19. Ischemic Stroke: Rural Govt. Hospitals
Nothing, then transfer patient, or
Dexamethasone + mannitol + transfer
[Furosemide ± mannitol if change in MS]
[SL nifedipine for high BP]

20. Ischemic Stroke: Folk Remedies in Turkey
Cold water, applied to the head
Blood pressure medicine
Perfumed water - cologne
Massage of affected limbs
Lemon juice; garlic; yogurt drink
Therapies listed below are less common
Cold water to the head specifically

21. Ischemic Stroke: Treatment in Europe
Spain: tPA if <3 hrs; in large centers
Norway: tPA if <3 hrs, etc
Neurology if pt <60 y/o, int. med. if >60
Germany: patients cared for in ICU (anesth.);
tPA in large hospitals (as per NINDS)
heparin in small hospitals
Less aggressive in older patients
Same txs in Spain and UK. Mobile storke teams in Spain at large centers.

22. Ischemic Stroke: experimental studies (Eu)
DIAS: Desmoteplase in Acute Stroke
‘DEDAS’ in the USA
Vampire bat saliva
3-9 hours, if penumbra seen on MR
ECASS III: tPA
3-4 hour window
Same txs in Spain and UK

23. Ischemic Stroke: experimental studies (Eu)
IMAGES: MgSO4
within 12 hrs; 5 gm load, 10 gm over 24 hrs
ENOS: Efficacy of Nitric Oxide in Stroke
Within 48 hrs; daily transdermal glyceryl trinitrate patch (NO donor) x 7 days
IST-3: International Stroke Trial-3: tPA
Within 6 hours; 0.9 mg/kg, 10% bolus…
Same txs in Spain and UK
The rest of IST tPA is given over an hour.

24. Ischemic Stroke: Who should give tPA? (E, ?)
The internist in the ED?
The neurologist on the stroke team?
Not enough neurologists for a stroke team in every hospital, 24/7
Same txs in Spain and UK

25. Transient Ischemic Attack: University Medical Centers
CT and admit for observation
[CT & admit if >4 attacks in 2 weeks]
ASA or ticlopidin or clopidogrel or ASA+dipyridamole
[heparin if ‘unstable TIAs’]
Only ones not admitted are pts on warfarin already, whose INR dropped low. They increase the warfarin dose and send them home if the pt had a minor TIA.

26. Transient Ischemic Attack: University Medical Centers
After admission, imaging: (MR, carotid doppler, echocard., transcranial doppler)
Treat underlying disease
Clopidogrel
If high-grade stenosis, endarterectomy

27. Transient Ischemic Attack: Large Govt. Hospitals
[High-risk: heparin]
Low-risk: aspirin
Discharge to follow up in clinic
Waiting for more info

28. Transient Ischemic Attack: Rural Govt. Hospitals (TR)
Aspirin + discharge to clinic
Waiting for more info

29. Transient Ischemic Attack (Eu)
Norway, Spain, UK:
160 mg aspirin/day + inpt. or outpatient work-up
If crescendo pattern: heparin/LMWH then coumadin
Waiting for more info

30. Undifferentiated Coma: University Medical Centers
H & P
Lots of tests + head CT
Waiting for more info

31. Undifferentiated Coma: Rural Govt. Hospitals (TR)
± fingerstick glucose
[SL nifedipine if hypertensive]
IV mannitol
IV furosemide
Transfer to a larger hospital (univ. or govt. - depending on insurance or lack thereof)

32. Subarachnoid Hemorrhage: University Medical Centers
Head CT, then MR angio, DSA
Prophylactic nimodipine if more than mild
Prophylactic diphenylhydantoin
For high BP, IV nitroglycerine or nitroprusside
Sedation; pain relief for headache
No labetalol is available in Turkey!

33. Subarachnoid Hemorrhage: Large Govt. Hospitals
Head CT (+ DSA if possible)
IV nitroglycerine for high BP
Dexamethasone, nimodipine, diphenylhydantoin
Sedation
Waiting for more info

34. Subarachnoid Hemorrhage: Rural Govt. Hospitals
No CT scanner available
LP is not done
If patient looks well, might be discharged
If patient worse, transferred after getting mannitol + furosemide + steroids
Waiting for more info

35. Guillain-Barré Syndrome: University Medical Centers
Attention to airway & breathing…
If any question about the dx, LP and EMG
Plasmapheresis then IV immunglobulin
IV immunglobulin only if no plasmapheresis

36. Guillain-Barré Syndrome: Large Govt. Hospitals
Attention to airway & breathing…
Imaging if diagnosis is unclear
Plasmapheresis then IV immunglobulin
If no insurance, plasmapheresis only
± IV steroids
If no money give steroids

37. Guillain-Barré Syndrome: Rural Govt. Hospitals
Attention to airway & breathing…
Supportive care only (if no money for transfer, immunglobulin or plasmapheresis)
Waiting for more info

38. Other neurologic problems (TR)
Behçet’s disease
Recurrent inflammation
Aphthous oral ulcers, genital ulcers, uveitis, erythema nodosum
Most often though, these patients are handled through the neuro clinics. Neuro symps last several weeks.

39. Other neurologic problems (TR)
Behçet’s disease
Recurrent inflammation
Aphthous oral ulcers, genital ulcers, uveitis, erythema nodosum
CNS involvement in 30%
Recurrent meningoencephalitis, CN palsies, transient brainstem dysfunction
Brisk onset, CSF pleiocytosis, nl glucose
Neuro symps last several weeks. Give steroids

40. Other neurologic problems (TR)
Wilson’s disease (“progressive hepatolenticular degeneration”)
Autosomal recessive
Tremor of tongue, jaws…
Dysphagia + drooling
Rigid and slow moving limbs
Motor problems in bulbar muscles first, then spread caudally (opposite of Parkinsonism)
Will definitely see kaiser-Fleisher rings in eyes (deepest layer of cornea, in Descemet’s memberane)
Low serum copper, increased copper excretion, high liver copper content on biopsy. Tx = reduce copper intake and take D-penicillamine by mouth.

41. Other neurologic problems (TR)
Complications of Brucella & TB
Meningitis
Vertebral osteomyelitis
Must elaborate on neuro presentations for Behcet patients. Most often though, these patients are handled through the neuro clinics

42. Piracetam (Nootropil®) in TR
Used widely for “psycho-organic syndromes” in Turkey
Memory loss
Vertigo
Learning difficulties
TIA
[epilepsy, TIA and strokes]
Perhaps many in the audience here today are using this at their facilities…

43. Piracetam (Nootropil®) in TR
Used widely for “psycho-organic syndromes”
Memory loss, Vertigo
Learning difficulties, TIA
[epilepsy, TIA and strokes]
Non-blinded, non-randomized; some human, many animal studies; results mostly: “a trend towards…”
Like vitamins - maybe it’ll help… probably not harmful

44. Other medications (Eu):
Clomethiazole - hypnotic used to attenuate alcohol withdrawal symps
Olanzapine - atypical antipyschotic, rapid dissolving tablet

45. Neurologic Emergencies: education (TR)
Textbooks and handbooks:
Some written locally
Some translated from English
Emergency Medicine: companion handbook, 5th ed. (Ma & Stein)
Neurology for the House Officer
Merrit’s Neurology
No emergency neurology book yet in Turkish

46. Neurologic Emergencies: education (TR)
Emerg. Med. Assoc. of Turkey
Emerg. Med. Physician’s Assoc.
Neurology Assoc. of Turkey
Working group on neurological critical care and emergencies
Education given in conferences

47. Neurologic Emergencies: national EM & neuro. societies +
British Association of Stroke Physicians (
European Federation of Neurological Societies (
Europ. Stroke Initiative (
European Stroke Council (eurostroke.org)
Education given in conferences

48. Neurologic Emergencies: research in Turkey
Stroke research
Observational
Headache
Metoclopramide vs. meperidine
Epilepsy
observational
Must contact Ministry of Health to see if tPA approved for stroke, find out about tPA study from Ministry of Health. Still waiting for reply from Genentech.

49. Neurologic Emergencies: treatment guidelines
None yet by national neurology or EM associations in Turkey
Foreign guidelines followed in many univ. medical centers
Disadvantage of not knowing about local meds.Implementation varies according to financial status and insurance.

50. Summary (TR)
In many settings, public not well informed about emerg. health care
Strokes are treated aggresively in large centers only
Access to current medical info is limited (esp. in rural settings)
Unproven therapies are used more often in rural settings
Avoiding a bad outcome is the priority

51. Summary (Eu) In large centers, stroke teams: treat patients with tPA
Enrolling patients in various trials
tPA: 3-4 hours (ECASS III)
Desmoteplase: 3-9 hrs
tPA: 0-6 hours (IST-3)
Mg: 12 hours
NO (NTG patch): 48 hours
Avoiding a bad outcome is the priority