A Spatial Variation Analysis of In-Hospital Stroke Mortality Based on Integrated Pre-Hospital and Hospital Data in Mashhad, Iran

BACKGROUND

Despite significant advances in the quality and delivery of specialized stroke care, there still persist remarkable spatial variations in emergency medical services (EMS) transport delays, stroke incidence, and its outcomes. Therefore, it is very important to investigate the possible geographical variations of in-hospital stroke mortality and to identify its associated factors.

METHODS

This historical cohort study included suspected stroke cases transferred to Ghaem Hospital of Mashhad by the EMS from March 2018 to March 2019. Using emergency mission IDs, the pre-hospital emergency data were integrated with the patient medical records in the hospital. We used the Bayesian approach for estimating the model parameters.

RESULTS

Out of 301 patients (142 (47.2%) females vs. 159 (52.8%) males) with a final diagnosis of stroke, 61 (20.3%) cases had in-hospital mortality. Results from Bayesian spatial log-logistic proportional odds (PO) model showed that age (PO=1.07), access rate to EMS (PO=0.78), arrival time (evening shift vs. day shift, PO=0.09), and sequelae variables (PO=9.20) had a significant association with the odds of in-hospital stroke mortality (P<0.05). Furthermore, the odds of in-hospital stroke mortality were higher in central urban areas compared to suburban areas.

CONCLUSION

Marked regional variations were found in the odds of in-hospital stroke mortality in Mashhad. There was a direct association between age and odds of in-hospital stroke mortality. Hence, the prognosis of in-hospital stroke mortality could be improved by better control of hypertension, prevention of the occurrence of sequelae, increasing the access rate to EMS, and optimizing shift work schedule.

Safety and Outcomes of Intravenous Thrombolytic Therapy in Ischemic Stroke Patients with COVID-19: CASCADE Initiative

BACKGROUND

There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19.

METHODS

This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes.

RESULTS

A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054).

CONCLUSION

IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients

BACKGROUND

Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran.

METHODS

The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2).

RESULTS

A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation.

CONCLUSION

Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Emotion Regulation Difficulties and Repetitive Negative Thinking in Patients With Tension Headaches and Migraine

Background: Tension and migraine headaches are the most prevalent types of headaches. Some emotional and psychological factors are associated with these headaches. Objectives: To elucidate the nature of individual differences in emotion regulation and repetitive negative thinking among patients with tension headaches and migraine and compare it with normal subjects. Materials & Methods: In this cross-sectional, comparative study, the participants consisted of patients with tension headaches and migraine referring to the two neurology clinics in Isfahan City, Iran from 2019 to 2020. A diverse sample of patients (n =240) completed the difficulties in emotional regulation scale and perseverative thinking questionnaire. The Chi-square tests, Fisher’s exact test, GLM (generalized linear model), Tukey post hoc test, and LSD (least significant difference) test were used to analyze the obtained data in SPSS V. 21. Results: The results indicated that patients with a high level of repetitive negative thinking reported increased difficulties in emotional regulation and impulse control, limited access to emotion regulation strategies, and lack of emotional clarity (P<0.05). Moreover, the tension headaches group showed a higher level of difficulties in emotional regulation and repetitive negative thinking than the migraine and control groups (P<0.001). Conclusion: Weak emotional regulation and repetitive negative thinking are associated with migraine and, especially tension headaches. Therefore, therapeutic plans based on emotion regulation and thinking problems should be considered as a complementary and necessary treatment for these types of headaches.

Clinical Trial of Subcutaneous Steroid Injection in Patients with Migraine Disorder

BACKGROUND

Neurologic literature on therapeutic effect of subcutaneous corticosteroids in patients with migrainous chronic daily headache is scarce. The aim of this research is to assess the therapeutic effects of this management in such patients.

METHODS

Consecutive patients with migrainous chronic daily headache enrolled a prospective before-after therapeutic study during 2010-2013. Methylprednisolone 40 mg was divided into four subcutaneous injection doses. Two injections were administered in the right and left suboccipital area (exactly at retromastoid cervicocranial junction) and the other two injections in the lower medial frontal area (exactly at medial right and left eyebrows). A daily headache diary was filled out by the patients before and one month after the intervention. The severity of pain was classified based on a pain intensity instrument using numeric rating scale from 0-10 point scale. Paired t-test and Chi-square test were used for statistical analysis.

RESULTS

504 patients (378 females, 126 males) with migrainous chronic daily headache were enrolled in the study. Dramatic, significant, moderate, mild, or no improvements respectively constituted 28.6%, 33.3%, 23.8%, and 14.3% of the post treatment courses. Therapeutic effect of intervention on mean pain scores was significant; t=7.38, df=20, P=0.000. Two cases developed subcutaneous fat atrophy in frontal injection site and three cases experienced syncope during injection.

CONCLUSION

Subcutaneous corticosteroids could be used as an adjunct therapy in patients with migrainous chronic daily headache.

Differentiation of true transient ischemic attack versus transient ischemic attack mimics

BACKGROUND

Previous literatures have shown a transient ischemic attack (TIA) mimic rate of 9-31%. We aimed to ascertain the proportion of stroke mimics amongst suspected TIA patients.

METHODS

A prospective observational study was performed in Ghaem Hospital, Mashhad, Iran during 2012-2013. Consecutive TIA patients were identified in a stroke center. The initial diagnosis of TIA was made by the resident of neurology and final diagnosis of true TIA versus TIA mimics was made after 3 months follow-up by stroke subspecialist.

RESULTS

A total of 310 patients were assessed during a 3-month period of which 182 (58.7%) subjects were male and 128 (41.3%) were female. Ten percent of the patients was categorized as a TIA mimic. The presence of hypertension, aphasia, duration of symptoms, and increased age was the strongest predictor of a true TIA. Migraine was the most common etiology of stroke mimic in our study.

CONCLUSION

It seems that many signs and symptoms have low diagnostic usefulness for discrimination of true TIA from non-cerebrovascular events and predictive usefulness of any sign or symptom should be interpreted by a stroke neurologist.

Decompressive craniectomy after unsuccessful intravenous thrombolysis of malignant cerebral infarction

BACKGROUND

Intravenous recombinant tissue plasminogen activator (rt-PA) is an approved treatment for acute ischemic stroke within 4.5 h of symptoms onset. Decompressive craniectomy (DC) has been shown as an effective therapeutic modality in malignant middle cerebral artery (MCA) infarction. As rt-PA could result in hemorrhagic complication during or after any surgery DC may be associated with severe bleeding after intravenous thrombolysis.

CASE DESCRIPTION

A 57-year-old woman was presented 90 min after the sudden onset of left hemiplegia. Despite intravenous thrombolytic therapy, she lost consciousness within 48 h and brain CT scan showed a right malignant MCA infarction associated with a small bleeding. DC was performed without any complication. The patient improved dramatically.

CONCLUSION

DC could be done safety for malignant MCA infarction after unsuccessful intravenous thrombolytic therapy even the later was complicated with intra-infarction hemorrhage.

Challenging comparison of stroke scales

Stroke scales can be classified as clinicometric scales and functional impairment, handicap scales. All studies describing stroke scales were reviewed by internet searching engines with the final search performed on January 1, 2013. The following string of keywords was entered into search engines; stroke, scale, score and disability. Despite advantages of modified National Institute of Health Stroke Scale and Scandinavian stroke scale comparing to the NIHSS, including their simplification and less inter-rater variability; most of the stroke neurologists around the world continue using the NIHSS. The modified Rankin scale (mRS) and Barthel index (BI) are widely used functional impairment and disability scales. Distinction between grades of mRS is poorly defined. The Asian stroke disability scale is a simplified functional impairment, handicap scale which is as valid as mRS and BI. At the present time, the NIHSS, mRS and BI are routine stroke scales because physicians have used to work with these scales for more than two decades, although it could not be an acceptable reason. On the other side, results of previous stroke trials, which are the basis of stroke management guidelines are driven using these scales.

Randomized clinical trial of intravenous valproate (orifil) and dexamethasone in patients with migraine disorder

BACKGROUND

Intravenous Valproate (IVVP) has been used in the treatment of migraine in some studies; however, it is far better known in the management of status epilepticus.

METHODS

Consecutive patients with migraine in our Headache Clinic were enrolled in this prospective, randomized clinical trial in 2011. The patients were randomized into two therapeutic groups, one receiving 900 mg IVVP (Orifil) and the other 16 mg IV Dexamethasone (IVDEX) diluted in 150 CC normal saline and infused for 10 minutes. Worst severity of pain before treatment and least severity at 3 hours after the infusion using a 0-10 point numeric rating scale were recorded. An interview with the patient was performed 72 hours after treatment to detect a possible relapse of headache.

RESULTS

Thirty-one migraine status patients, comprising 28 women and 3 men at a mean±SD age of 33.355±12.373 SD, were investigated. Differences in the therapeutic effects of IVVP (Orifil) and IVDEX on pain score were not significant between the two groups (t=0.933, df=29; P=0.358). Relapse of headache occurred in 68.42% of the IVVP (Orifil) group and 66.67% of the IVDEX group. Distribution of relapse was not significantly different between the two therapeutic groups of patients (P=0.870).

CONCLUSION

IVVP (Orifil) was similar in efficacy to IVDEX as abortive therapy in patients with migraine status. IVVP (Orifil) appears to offer a safe and well-tolerated abortive treatment.

TRIAL REGISTRATION NUMBER

IRCT13891146234N2.

Risk factors of short-term stroke recurrence in patients with minor ischemic cerebrovascular events

BACKGROUND

Assessing the risk of recurrent ischemic events in patients with transient ischemic attack (TIA) and minor ischemic stroke (MIS) is of a great importance in clinical practice.

METHODS

Consecutive patients with TIA or MIS who were visited in Ghaem Hospital, (Mashhad, Iran) were enrolled in a prospective cohort study during 2010 to 2011. Diagnosis of TIA or MIS was accomplished by a stroke neurologist. Only those who presented within 24 hours from the onset of symptoms were recruited. MIS was considered as an ischemic stroke with National Institutes of Health Stroke Scale (NIHSS) < 4. The endpoint of the study was a new ischemic cerebrovascular event or vascular death in 90 days and additionally in 3 days. The decision to admit and type of treatment in each case was left to the discretion of the stroke neurologist. The association between 20 potential factors with recurrent ischemic events in 3 and 90 days was investigated using univariate and multivariate analysis (MVA).

RESULTS

393 TIA patients (238 males and 155 females) and 118 MIS patients (77 males and 41 females) were enrolled in the study. Stroke occurred in 117 (23.2%) patients, TIA in 99 (19.6%), and there was 11 (2.2%) vascular deaths within 3 months in the total 511 patients with minor ischemic events. Crescendo TIAs and multiple TIAs were associated with greater risk of stroke in 3 days in a univariate analysis (OR = 5.12, P < 0.001) and (OR = 3.98, P = 0.003), respectively. Patients with index stroke had 11.5% lower risk of recurrent stroke in 3 days than patients with index TIA in multivariate analysis (OR = 0.115, P = 0.039). Diabetes was independently associated with 3 months stroke recurrence in the patients with minor ischemic events (OR = 2.65, P = 0.039).

CONCLUSION

Multiple and crescendo TIAs are the main predictors of stroke recurrence, derived from the univariate analysis of the patients with minor ischemic events.

Design of a standard Iranian protocol of Intravenous thrombolysis with tissue plasminogen activator: A national project

Standard protocols should be established for treating eligible stroke patients with tissue plasminogen activator (TPA) (recommendation class I, level of evidence B). The Iranian standard protocol of Intravenous Thrombolysis with recombinant Tissue Plasminogen Activator (IVTTPA) is the best possible and easy to use method for performing intravenous thrombolysis in Iran. This protocol overcomes problems and limitations of IVTTPA in Iran. The protocol achieves the best selection criteria and assessment method of IVTTPA for our residents and neurologists. This protocol was provided in Persian language and could be easily downloaded from Google site by writing Thrombolysis and Iran in Persian.

Exploring gender distribution in patients with acute stroke: A multi-national approach

BACKGROUND

Gender distribution of acute stroke patients varies considerably among stroke registries throughout the world, but factors responsible for this phenomenon remained vastly unknown.

MATERIALS AND METHODS

Using data from prospective hospital-based stroke registries in China (n = 752 acute stroke patients), Germany (n = 96054), India (n = 1500), and Iran (n = 1392), this descriptive study explored gender distribution of stroke patients and its determinants. In addition, the proportions of males and females to be expected in fictive study populations were calculated, and differences in gender distribution between stroke databases throughout the world were described.

RESULTS

In the German dataset, a maximum male preponderance was found for patients aged between 55 and 64 years (proportion of male patients 0.67 [95% CI: 0.66-0.67]), whereas patients older than 84 years revealed a strong overbalance of females (0.27 [0.26-0.28]). In Germany, age-specific gender distribution of stroke patients is well explained by the numbers of females and males in the general population and by gender-specific stroke incidence rates. Both in China and India, a strong preponderance of male stroke patients was found for the majority of age categories with a maximum proportion of male patients of 0.82 in the 35-44 years age group. In contrast, the Iranian stroke register revealed an overbalance of females (0.13 [0.11-0.14]) in nearly all age categories. A total of 1392 Iranian ischemic stroke patients (738 female, 654 male) were investigated.

CONCLUSION

Gender distribution of acute stroke patients is highly variable. Gender distribution varied considerably between countries. Apart from demographic factors reflecting gender ratio in the general population and gender-specific stroke incidence rates, sociocultural peculiarities may also play an important role in this context.

Safety assessment of anticoagulation therapy in patients with hemorrhagic cerebral venous thrombosis

BACKGROUND

Anticoagulation therapy is a routine treatment in patients with hemorrhagic cerebral venous thrombosis (CVT). However, fear of hemorrhagic complications and deterioration course following anticoagulation often disturbs the responsible physician.

METHODS

This was a Prospective observational study on consecutive CVT patients with hemorrhagic venous infarction or subarachnoid hemorrhage (SAH) admitted in Ghaem Hospital, Mashhad, Iran, during 2006-2012. The diagnosis of CVT in suspected cases was confirmed by magnetic resonance imaging/magnetic resonance venography (MRI/MRV), and computerized tomography (CT) angiography following established diagnostic criteria. Demographic data, clinical manifestations from onset to end of the observation period, location of thrombus, location and size of infarction and hemorrhage, and clinical course during treatment were recorded. Choice of the treatment was left to the opinion of the treating physician. Clinical course during 1 week of treatment was assessed based on the baseline modified National Institute of Health Stroke Scale (NIHSS) score. Three or more points decrease or increase of modified NIHSS after 1 week of treatment was considered as improvement or deterioration courses, respectively. Other clinical courses were categorized as stabilization course.

RESULTS

102 hemorrhagic CVT patients (80 females, 22 males) with mean age of 38.6 ± 8 years were prospectively investigated. Of the 102 hemorrhagic CVT patients in the acute phase, 52 patients (50.9%) were anticoagulated with adjusted dose intravenous heparin infusion and 50 cases (49.1%) received subcutaneous enoxaparin 1mg/Kg twice daily. Decreased consciousness had a significant effect on the clinical course of the patients (X(2) = 9.493, df = 2, P = 0.009). Presence of SAH had no significant effect on the clinical course of our anticoagulated hemorrhagic CVT cases (X(2) = 0.304, df = 2, P = 0.914). Extension of Infarction in more than two thirds of a hemisphere had a significant influence on the distribution of clinical courses (X(2) = 5.867, df = 2, P = 0.044). Difference in distribution of clinical course among the two groups of our hemorrhagic CVT patients was not significant (X(2) = 8.14, df = 1, P = 0.87).

CONCLUSION

Patients with hemorrhagic CVT without other contraindication for anticoagulation should be treated either with dose-adjusted intravenous heparin or body-weight-adjusted subcutaneous low molecular-weight heparin.

Is opium addiction a risk factor for ischemic heart disease and ischemic stroke?

BACKGROUND

The main source of studies about effects of opium consumption on heart and brain attacks originates from Iran Therefore the aim of the present study was to assess opium addiction as a probable influencing factor for ischemic heart disease and ischemic stroke.

MATERIALS AND METHODS

A cross-sectional study was carried out in two Cardiology and Neurology clinics in Eastern Iran in 2011. Diagnosis of Ischemic Heart Disease (IHD) and Ischemic Stroke (IS) was made by Cardiologist and Stroke Neurologist respectively. The influence of gender, hypertension, diabetes, hyperlipidemia, cigarette smoking, oral and inhaled opium consumption on distribution of IHD and IS were evaluated.

RESULTS

Five hundred fifty eight patients (307 females, 251 males) with mean age 56.2 years enrolled the study. On adjusted odds ratios of our whole 558 patients, only hypertension and diabetes had a significant influence on occurrence of IHD; (P = 0.000 and P = 0.000) respectively. Oral and inhaled routes of opium addiction did not have a significant effect on occurrence of IHD; [OR = 1.172, 95% CI = 0.624-2.203, P = 0.621] and [OR = 1.820, 95% CI = 0.811-4.085, P = 0.147] respectively. Hypertension and diabetes were significant risk factors of IS in our 558 patients at multivariate analysis; (P = 0.000, P = 0.020). Oral opium addiction was as significant protective factor of IS in our study group; OR = 0.211, 95% CI = 0.079-0.564, P = 0.002, while inhaled opium addiction did not have a significant effect on occurrence of IS in our patients at; OR = 1.760, 95% CI = 0.760-4.076, P = 0.187.

CONCLUSION

Oral opium consumption is a protective factor of IS but not IHD. Inhaled opium addiction does not have a significant influence on occurrence of IS and IHD.

The ABCD(2) Score is Highly Predictive of Stroke in Minor Ischemic Stroke Patients

Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in transient ischemic attack (TIA) and minor ischemic stroke (MIS) patients. Consecutive TIA or MIS patients referred to Ghaem Hospital, Mashhad were enrolled in a prospective cohort study during 2010-2011. Only TIA or MIS patients presenting within 24 h from the onset of symptoms were recruited. MIS was considered as ischemic stroke with NIHSS <4. The end point of the study was a new ischemic cerebrovascular event or vascular death at 90 days and additionally at 3 days. The decision to admit and treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD(2) scoring system for recurrent stroke or TIA was quantified by the area under the cure (AUC) using the c statistics. Three hundred ninety-three TIA patients (238 males, 155 females) and 118 MIS patients (77 males, 41 females) were enrolled in the study. One hundred seventeen strokes (23.2%), 99 TIA (19.6%), and 11 vascular death (2.2%) occurred within 3 months postevent in the whole of our 511 patients with minor ischemic events. The ABCD(2) score had a weak predictive value for 3 months and 3 days recurrent stroke in our TIA patients (AUC = 0.599, AUC = 0.591), but a high predictive value for 3 months and 3 days recurrent stroke in our MIS patients (AUC = 0.727, AUC = 0.728), respectively. The ABCD(2) score is highly predictive of short-term recurrent stroke in MIS patients but not TIA cases, despite its creation for TIA cohorts.

Interesting basis of vertebrobasilar arterial territory

BACKGROUND

Vertebrobasilar arterial territory nourishes one-quarter of human brain. It constitutes some vital and strategic parts of the central nervous system.

METHODS

A number of keywords (vertebral, basilar, artery, and territory) were searched in MEDLINE (Ovid and PubMed) as well as Google, ProQuest, Scopus, Cochrane Library, and Science Direct online databases. Only articles containing all keywords were included. We also reviewed archives of libraries in Mashhad University of Medical Sciences (Iran) for all anatomy, embryology, neurology, and neuroscience books and journals about vertebrobasilar arterial territories.

RESULTS

The vertebrobasilar arterial (VA) system has a high incidence of variations, anomalies, and persistent fetal vessels. Two important anatomic facts explain why VA origin lesions seldom cause chronic hemodynamically significant low flow to the vertebrobasilar system. First, the VAs are paired vessels that unite to form a single basilar artery. Second, the extracranial VA gives off numerous muscular and other branches as it ascends in the neck. Thus, in the VA system, there is much more potential for development of adequate collateral circulation. Even when there is bilateral occlusion of the VAs at their origins, patients do not often develop posterior circulation infarcts.

CONCLUSION

VA origin disease is more benign than ICA origin disease from hemodynamic aspect. This important point could make influence in therapeutic interventional decisions in asymptomatic VA origin stenosis.

Comparative interrater reliability of Asian Stroke Disability Scale, modified Rankin Scale and Barthel Index in patients with brain infarction

BACKGROUND

This study tried to develop an Asian Stroke Disability Scale (ASDS) and compared its interrater reliability with modified Rankin Scale (mRS) and Barthel Index (BI).

METHODS

Three items including self-care, mobility, and daily activities were selected as variables for development of the ASDS. The variables were provisionally graded on a 2- to 4-point scale based on the importance of each item. Each of the variables was categorized into 3 categories. Afterward, 125 rater-patient assessments for each scale (mRS, BI, and ASDS) were performed on 25 stroke patients by 5 raters. For categorization of functional impairment as minor or major, the scores of mRS, BI and ASDS were categorized as ≤ 2 and > 2, < 90 and ≥ 90, and < 3 and ≥ 3, respectively.125 rater-patient assessments for each of the mRS, BI, and ASDS were performed on 25 stroke patients by five raters.

RESULTS

The quantitative variability of BI, mRS, and ASDS scores was not significant (P = 0.379; P = 0.780; and P = 0.835, respectively). Interrater variability of mRS, BI, and ASDS scores based on qualitative categorization was not significant (P = 1.000; P = 0.978; and P = 0.901, respectively). Paired interrater variability of mRS, BI, and ASDS scores based on qualitative categorization was not significant (P > 0.05).

CONCLUSION

The ASDS is easy to use, requires less than 1 minute to complete and is as valid as mRS and BI in assessment of functional impairment of patients with stroke.

Inter-rater reliability of modified Alberta Stroke program early computerized tomography score in patients with brain infarction

BACKGROUND

The Alberta Stroke Program Early Computerized Tomography Score (ASPECTS) was used to detect significant early ischemic changes on brain CT of acute stroke patients. We designed the modified ASPECTS and compared it to the above system based on the inter-rater reliability.

METHODS

A cross-sectional validation study was conducted based on the inter-rater reliability. The CT images were chosen from the stroke data bank of Ghaem hospital, Mashhad in 2010. The inclusion criteria were the presence of middle cerebral artery territory infarction and performance of CT within 6 hours after stroke onset. Axial CT scans were performed on a third-generation CT scanner (Siemens, ARTX, Germany). Section thickness above posterior fossa was 10 mm (130 kV, 150 mAs). Films were made at window level of 35 HU. The brain CTs were scored by four independent radiologists based on the ASPECTS and modified ASPECTS. The readers were blind to clinical information except symptom side. Cochrane Q and Kappa tests served for statistical analysis.

RESULTS

24 CT scans were available and of sufficient quality. Difference in distribution of dichotomized ≤7 and >7 ASPECT scores between four raters was significant (Q=13.071, df=3, p=0.04). Distribution of dichotomized <6 and ≥6 scores based on modified ASPECT system between 4 raters was not significantly different (Q=6.349, df=3, p=0.096).

CONCLUSIONS

Modified ASPECT method is more reliable than ASPECTS in detecting major early ischemic changes in stroke patients candidated to tPA thrombolysis.

Results of surgical and nonsurgical treatment of aneurysms in a developing country

Background. The impact of invasive methods of treatment on results in developing countries may differ from that in developed countries. Methods. This is a prospective clinical study of consecutive patients with Subarachnoid Haemorrhage (SAH) admitted to the Ghaem Hospital, Mashhad during the period from 2005 to 2009. The initial diagnosis and investigations were carried out by neurologists. The patients were divided into two groups. One received surgical treatment whilst the other group was managed medically. The decision as to the choice of the method of treatment was made by the neurosurgeons. The initial medical treatment was standardised for all the patients. The rate of complications and mortality was compared in both medical and surgical groups. Results. 120 SAH patients (52% females) with a mean age of 50.6 ± 7 years were evaluated. The angiography revealed the presence of an aneurysm in 62 patients. 63.5% of the patients received medical treatment and 37.5% underwent aneurysmal surgery. Difference of rebleeding rate in the two therapeutic groups was not significant; X² = .014, P = .91. The effect of rebleeding on mortality was not significant; X² = 2.54, P = .14. Within 62 SAH patients with cerebral aneurysm, the mortality rate in both therapeutic groups was also not significantly different; X² = .16, P = .77. Conclusion. There is no significant difference in the mortality rate between the “surgical” and non-“surgical” groups of Iranian patients with SAH. This could be due to delay in performance of surgery in Iranian neurovascular centers.

Barriers of thrombolysis therapy in developing countries

The developing world carries the highest burden of stroke mortality and stroke-related disability. The number of stroke patients receiving r-tPA in the developing world is extremely low. Prehospital delay, financial constraints, and lack of infrastructure are main barriers of thrombolysis therapy in developing countries. Until a cheaper thrombolytic agent and the proper infrastructure for utilization of thrombolytic therapy is available, developing countries should focus on primary and secondary stroke prevention strategies. However, governments and health systems of developing countries should efforts exerb for promotion of their infrastructure of stroke care.

Results of surgical and non-surgical treatment of aneurysms in iran

BACKGROUND

Direct surgery or endovascular procedures are an accepted way of treating patients with Aneurismal Subarachnoid Haemorrhage (SAH). However the impact of invasive methods of treatment on results in developing countries may differ from that in developed countries.

METHODS

This is a prospective clinical study of consecutive patients with Subarachnoid Haemorrhage (SAH) admitted in Ghaem hospital in Mashhad during 2005-2010. The initial diagnosis and investigations were carried out by neurologists. The patients were divided into two groups. One received surgical treatment whilst the other group was managed medically. The decision as to the choice of method of treatment was made by the neurosurgeons. The initial medical treatment was standardised for all the patients. The rate of complications and mortality was compared in both medical and surgical groups.

RESULTS

20 SAH patients (52% females) with a mean age of 50.6±7 years were evaluated. The angiography revealed the presence of an aneurysm in 62 patients. 63.5% of patients received medical treatment and 37.5% underwent aneurysmal surgery. Difference of rebleeding rate in two therapeutic groups was not significant; χ(2)=0.014, P=0.91. The effect of rebleeding on mortality was not significant; χ(2)=2.54, P=0.14. Within 62 SAH patients with cerebral aneurysm, the mortality rate in both therapeutic groups was also not significantly different; χ(2)=0.16, P=0.77.

CONCLUSION

There is no significant difference in the mortality rate between the "surgical" and non "surgical" groups of patients with SAH. This could be due to delay in performance of surgery in neurovascular centers in Iran.

Clinical evaluation of patients with spinal cord infarction in mashhad, iran

Background. Spinal Cord Infarction (SCI) is a rare and disabling disease. This hospital-based study was conducted for clinical evaluation of SCI patients in east of Iran. Methods. Consecutive SCI patients admitted in Ghaem hospital,Mashhad during 2006–2010 were enrolled in a prospective clinical study. Diagnosis of SCI was made by neurologists and radiologists. Demographic features, clinical syndrome, and Magnetic Resonance Imaging (MRI) findings were recorded. All of the patients underwent a standard battery of diagnostic investigations. All of the patients suspected to SCI had MRI of spinal cord at the symptomatic level of cord with a 0.5 Tesla generation, Philips NT Intra, Netherland equipment. An equal number of patients with Brain Infarction (BI) were randomly selected from our stroke registry data bank. Etiology and degree of disability were compared between these groups of patients. Results. Fourteen SCI patients (9 females, 5 males) with mean age 38.8 ± SD: 19.9 years were evaluated. Miscellaneous causes consisted 50% of etiologies in patients with SCI. Uncertain etiology, atherosclerosis, and cardioembolisms consisted 35.7%, 7.1%, and 7.1% of SCI causes, respectively. Distribution of etiologies was significantly different between SCI and BI patients, X² = 12.94, df = 3, P = .003. Difference in mean disability score at acute phase of stroke was not significant between two studied groups, z = 1.54, P = .057. Difference in mean changes of disability score at 90 days postevent was significant in two groups of patients, z = 2.65, P = .019. Conclusion. SCI is a rare disease with poor recovery. Distribution of etiologies of SCI patients is quite different than of BI patients.

Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review

OBJECTIVES

Antiplatelet therapy (APT) promotes bleeding; therefore, APT might worsen outcome in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to address the hypothesis that pre-ICH APT use is associated with mortality and poor functional outcome following ICH.

METHODS

The Medline and Embase databases were searched in February 2008 using relevant key words, limited to human studies in the English language. Cohort studies of consecutive patients with ICH reporting mortality or functional outcome according to pre-ICH APT use were identified. Of 2,873 studies screened, 10 were judged to meet inclusion criteria by consensus of 2 authors. Additionally, we solicited unpublished data from all authors of cohort studies with >100 patients published within the last 10 years, and received data from 15 more studies. Univariate and multivariable-adjusted odds ratios (ORs) for mortality and poor functional outcome were abstracted as available and pooled using a random effects model.

RESULTS

We obtained mortality data from 25 cohorts (15 unpublished) and functional outcome data from 21 cohorts (14 unpublished). Pre-ICH APT users had increased mortality in both univariate (OR 1.41, 95% confidence interval [CI] 1.21 to 1.64) and multivariable-adjusted (OR 1.27, 95% CI 1.10 to 1.47) pooled analyses. By contrast, the pooled OR for poor functional outcome was no longer significant when using multivariable-adjusted estimates (univariate OR 1.29, 95% CI 1.09 to 1.53; multivariable-adjusted OR 1.10, 95% CI 0.93 to 1.29).

CONCLUSIONS

In cohort studies, APT use at the time of ICH compared to no APT use was independently associated with increased mortality but not with poor functional outcome.

Frequency and clinical patterns of stroke in Iran - Systematic and critical review

Background

Cerebrovascular disease is the second commonest cause of death, and over a third of stroke deaths occur in developing countries. To fulfil the current gap on data, this systematic review is focused on the frequency of stroke, risk factors, stroke types and mortality in Iran.

Methods

Thirteen relevant articles were identified by keyword searching of PubMed, Iranmedex, Iranian University index Libraries and the official national data on burden of diseases.

Results

The publication dates ranged from 1990 to 2008. The annual stroke incidence of various ages ranged from 23 to 103 per 100,000 population. This is comparable to the figures from Arab Countries, higher than sub-Saharan Africa, but lower than developed countries, India, the Caribbean, Latin America, and China. Similarly to other countries, ischaemic stroke was the commonest subtype. Likewise, the most common related risk factor is hypertension in adults, but cardiac causes in young stroke. The 28-day case fatality rate is reported at 19-31%.

Conclusions

Data on the epidemiology of stroke, its pattern and risk factors from Iran is scarce, but the available data highlights relatively low incidence of stroke. This may reflect a similarity towards the neighbouring nations, and a contrast with the West.

Complications of angioplasty and stenting of cervicocerebral arteries in Iran

Angioplasty and stenting of the cervicocerebral arteries is a novel treatment for atherosclerotic stenosis, which has periprocedural complications. Data were collected prospectively from 2007 to 2009 in a multicenter cohort of patients undergoing interventions for cervicocerebral stenosis. Retrospective assessment of the 2003-2006 archives of the same interventionists and a review of their published work is the second part of this national survey. In 592 extracranial internal carotid artery angioplasty and stenting procedures in 581 patients (73% male; mean age, 63.4 + or - 7 years), transient ischemic attack, stroke, intracerebral hemorrhage, and death occurred in 1.7%, 1.7%, 0.34%, and 1.52%, respectively. In 114 extracranial vertebral artery angioplasty and stenting procedures in 110 patients (68% male; mean age, 65.3 + or - 6 years), transient ischemic attack and stroke each developed in 1 (0.92%) patient, but there was no intracerebral hemorrhage or death. In 70 intracranial angioplasty and stenting procedures in 67 patients (76% male; mean age, 68.5 + or - 8 years), transient ischemic attack, stroke, intracerebral hemorrhage, and death were observed in 1.4%, 8.6%, 1.4%, and 2.9%, respectively. The frequency of periprocedural complications in angioplasty and stenting of cervicocerebral arteries by our neurointerventionists was similar to that in developed countries.

Clinical evaluation of patients with migraine induced stroke in mashhad, iran

BACKGROUND

Migraine Induced Stroke (MIS) is an important cause of brain infarction in the young people.

METHODS

Consecutive patients with MIS admitted in Ghaem hospital, Mashhad during 2006-2010 enrolled a prospective clinical study. All of the patients suspected to MIS had brain MRI with a 0.5 Tesla generation, Philips NT Intra, Netherland. All of the MIS patients underwent a standard battery of diagnostic investigations for detecting etiology of stroke. Disability of MIS patients was detected based on the modified Rankin scale at 90 days post stroke.

RESULTS

32 MIS patients (18 females, 14 males) with mean age 37.2 ± 3.8 years ranged 15-58 years were evaluated. Hypodense area of infarction corresponding to clinical manifestations was detected in MRI in 32% of our MIS patients. The mean disability score in our MIS patients was 1.09 ± 0.32, which is significantly lower than other stroke patients (z = 2.55, P = 0.007)

CONCLUSION

MIS is an important cause of stroke in Persian young adults which have good prognosis.

Khorasan stroke registry: analysis of 1392 stroke patients

BACKGROUND

The hospital-based stroke registry is useful for understanding diverse clinical characteristics of stroke related to geographical, racial, or environmental differences.

METHODS

The Khorasan Stroke Registry was established for evaluation of incidence, clinical manifestations, risk factors, topography, and etiology of ischemic stroke in Southern Khorasan, Iran, during 2001 - 2005. Consecutive stroke patients underwent a standard battery of diagnostic investigations by a stroke neurologist. Topography and etiology of brain infarction was determined based on the Practical Iranian Criteria classification.

RESULTS

The incidence of ischemic stroke in Khorasan population is 43.17 cases per 100,000 people per year. During a 5-year period 1,392 ischemic stroke patients (738 females, 654 males) were evaluated in the Khorasan Stroke Registry. Atherosclerosis constituted 53.6% of etiologies followed by uncertain causes (19.9%), cardioembolism (11.8%), and miscellaneous etiologies (2.9%). Eleven point seven percent of our patients had both atherosclerosis and cardioembolic mechanisms. Rheumatic valvular disease was present in 44.8% of cardioembolic strokes and caused 4.31 preventable stroke cases per 100,000 Iranian population per year. Hypertension and history of ischemic cerebrovascular events were the most frequent risk factors, 53.1% and 22.3% respectively. In-hospital mortality of our ischemic stroke patients was 7.3%.

CONCLUSION

High frequency of atherosclerotic etiology in the Khorasan Stroke Registry is because of its classification criteria, which does not separate small vessel territory infarcts as a different etiologic subtype. Rheumatic valvular disease is an important cause of stroke in Khorasan population.

The Khorasan Stroke Registry: Results of a Five-Year Hospital-Based Study

The hospital-based stroke registry is useful for understanding the diverse clinical characteristics of stroke related to geographical, racial or environmental differences. The Khorasan Stroke Registry (KSR) was established for the evaluation of incidence, clinical manifestations, risk factors, topography and etiology of ischemic stroke in Southern Khorasan, Iran, during 2001-2005. Consecutive stroke patients underwent a standard battery of diagnostic investigations by a stroke neurologist. The topography and etiology of brain infarction were determined by the Practical Iranian Criteria classification. The incidence of ischemic stroke in the Persian population is 43.17 cases per 100,000 people per year. A total of 1,392 ischemic stroke patients (738 females, 654 males) were evaluated in the KSR. The etiologies included atherosclerosis (53.6%), followed by uncertain causes (19.9%), cardioembolism (11.8%) and miscellaneous etiologies (2.9%). Of our patients, 11.7% had both atherosclerosis and cardioembolic mechanisms. Rheumatic valvular disease was present in 44.8% of cardioembolic stroke patients and caused 4.31 preventable stroke cases per 100,000 Persian people per year. Hypertension and history of ischemic cerebrovascular events were the most frequent risk factors, 53.1 and 22.3%, respectively. The in-hospital mortality of our ischemic stroke patients was 7.3%. A total of 336 patients with intracerebral hemorrhage (189 females, 147 males) were evaluated in the KSR. The incidence of intracerebral hemorrhage in the Persian population is 10.43 cases per 100,000 people per year. The high frequency of atherosclerotic etiology in the KSR is due to its classification criteria, which do not separate small vessel territory infarcts as a different etiologic subtype. Rheumatic valvular disease is an important cause of stroke in the Persian population.

Etiology of young adult onset brain infarction in Iran

BACKGROUND

Stroke in young adults causes morbidity in this socioeconomically-active age group. Etiologic frequency of ischemic stroke in young adults is different around the world. This study was conducted to determine the causes of stroke in Iranian young adults.

METHODS

The study population consisted of 314,000 young adult residents in the Southern Khorasan Province, East of Iran. All the patients with stroke, admitted to Vali-e-Asr Tertiary Care Hospital, entered this study. Demographic data, clinical presentation, and investigations of consecutive patients aged 15 - 45 years, presented with ischemic stroke, were registered in Southern Khorasan Stroke Database between 2000 and 2005. All the patients underwent a standard battery of diagnostic investigations by a stroke neurologist. Etiologic classification of stroke in the patients was made based on the Practical Iranian Criteria.

RESULTS

One hundred and twenty-four patients (60 females and 64 males) were prospectively investigated during a 5-year period. The incidence of ischemic stroke in young adults was 8/100,000 per year. Cardioembolic mechanism constituted 54% of all stroke etiologies in young adults. Rheumatic valvular heart disease was present in 32% of the patients and caused 2.5 preventable stroke cases per 100,000 young adults per year.

CONCLUSION

Rheumatic valvular heart disease is the most common cause and a preventable etiology of stroke in Iranian young adults.

Incidence and etiology of ischemic stroke in Persian young adults

BACKGROUND

Stroke in young adults causes morbidity in this socioeconomically active age group. The etiologic frequency of ischemic stroke in young adults differs around the world.

METHODS

The study population consisted of 314,000 'young adult' residents in Southern Khorasan province in Iran. All patients with stroke are routinely admitted to the Valie Asr tertiary care hospital. Data on patients demographics, clinical presentation and investigations of consecutive patients aged 15-45 years with ischemic stroke are registered in Southern Khorasan stroke data bank for the period March 2000 to March 2005. All patients underwent a standard battery of diagnostic investigations by a stroke neurologist. The etiologic classification of stroke in the patients was made based on the trial of ORG 10172 in acute stroke treatment (TOAST) criteria.

RESULTS

One hundred and twenty-four patients (60 female, 64 male) were prospectively investigated during a 5-year period. The incidence of ischemic stroke in young adults was eight cases per 100,000 people per year. Cardioembolic mechanism comprised 54% of stroke etiology in young adults. Rheumatic valvular disease was present in 32% of the patients and caused 2.5 preventable stroke cases per 100,000 'young adults' per year.

CONCLUSION

Rheumatic valvular disease is the most common cause and a preventable etiology of stroke in Persian young adults.