Focusing on the locus of the breakdown for treatment of anomia: a pilot study

The primary goal of this study was to evaluate the treatment effects of semantic feature analysis (SFA) and phonological components analysis (PCA) on word retrieval processing in persons with aphasia (PWAs). After identifying the locus of the breakdown in lexical retrieval processing, 15 monolingual native Persian speakers with aphasia were divided into two groups. After three naming trials, participants with dominant semantic deficits received SFA, and participants with primary phonological deficits were provided with PCA three times a week for eight weeks. Both approaches improved participants' naming and performance on language tests, including spontaneous speech, repetition, comprehension, and semantic processing. However, the correct naming of treated and untreated items was higher in mild-to-moderate participants, with mostly circumlocution and semantic paraphasias in the SFA group. The same holds for mild-to-moderate participants with mostly phonemic paraphasia who received PCA therapy. Moreover, the results showed that participants' baseline naming performance and semantic abilities could be associated with the treatment outcomes. Although limited by a lack of a control group, this study provided evidence supporting the possible benefits of focusing on the locus of the breakdown for treating anomia through SFA and PCA approaches, specifically in participants with mild to moderate aphasia. However, for those with severe aphasia, the treatment choice may not be as straightforward because several variables are likely to contribute to this population's word-finding difficulties. Replication with larger, well-stratified samples, use of a within-subjects alternating treatment design and consideration of treatments' long-term effects are required to better ascertain the effects of focusing on the locus of breakdown for treatment of anomia.

Posterior reversible encephalopathy syndrome in SARS‐CoV‐2 infection: A case report and review of literature

Consider PRES in SARS‐CoV‐2 infected patients who develop encephalopathy, seizures or impaired vision; especially if the disease is complicated by respiratory distress and need for mechanical ventilation.

Consider PRES in SARS‐CoV‐2 infected patients who develop encephalopathy, seizures or impaired vision; especially if the disease is complicated by respiratory distress and need for mechanical ventilation.

Iran Quality of Care in Medicine Program (IQCAMP): Design and Outcomes

BACKGROUND

Assessment of quality and cost of medical care has become a core health policy concern. We conducted a nationwide survey to assess these measures in Iran as a developing country. To present the protocol for the Iran Quality of Care in Medicine Program (IQCAMP) study, which estimates the quality, cost, and utilization of health services for seven diseases in Iran.

METHODS

We selected eight provinces for this nationally representative short longitudinal survey. Interviewers from each province were trained comprehensively. The standard definition of seven high-burden conditions (acute myocardial infarction [MI], heart failure [HF], diabetes mellitus [DM], stroke, chronic obstructive pulmonary (COPD) disease, major depression, and end-stage renal disease [ESRD]) helped customize a protocol for disease identification. With a 3-month follow-up window, the participants answered pre-specified questions four times. The expert panels developed a questionnaire in four modules (demographics, health status, utilization, cost, and quality). The expert panel chose an inclusive set of quality indicators from the current literature for each condition. The design team specified the necessary elements in the survey to calculate the cost of care for each condition. The utilization assessment included various services, including hospital admissions, outpatient visits, and medication.

RESULTS

Totally, 156 specialists and 78 trained nurses assisted with patient identification, recruitment, and interviewing. A total of 1666 patients participated in the study, and 1291 patients completed all four visits.

CONCLUSION

The IQCAMP study was the first healthcare utilization, cost, and quality survey in Iran with a longitudinal data collection to represent the pattern, quantity, and quality of medical care provided for high-burden conditions.

The Incidence of Aphasia, Cognitive Deficits, Apraxia, Dysarthria, and Dysphagia in Acute Post Stroke Persian Speaking Adults

Stroke is a major cause of serious disabilities in adults. While communication deficits post stroke are prevalent and disabling, early detection of them is important during acute phase. There is limited data published on the incidence of communication disorders in Persian speaking adults following post stroke to our knowledge. The present study aims to determine the incidence and associated factors of aphasia, cognitive deficits, motor speech disorders (apraxia and dysarthria) as well as dysphagia following acute post stroke in Persian speaking adults. 100 stroke patients were assessed using P-WAB, MMSE, Oral Apraxia test, Informal Dysarthria assessment, and MASA. The data was collected from 2 hospitals in Tehran using convenient sampling for the duration of 1 year. Based on our findings, the incidence of aphasia, cognitive deficits, oral apraxia, dysarthria, and dysphagia was in respectively 61.8%, 76%, 30%, 61%, and 39% of stroke patients during the acute phase. Patients with aphasia were significantly older (mean age, 59.29 vs. 64.95), and had fewer education years (9.21 vs. 5.45) compared to individuals without aphasia (p < .05). Co-occurrence of aphasia and dysarthria, dysphasia, cognitive deficits, and apraxia was in respectively 40%, 31%, 55%, and 25%. Due to the high incidence of neurogenic communication disorders and dysphagia during the acute post stroke, especially in the elderly and the less educated patients, prompt and rapid detection of these deficits and rehabilitation is essential to ameliorate patients' quality of life and social participation, and reduce the comorbidities risk.

Efficacy of mechanical thrombectomy in stroke patients with large vessel involvement

Ischemic stroke is a common disease worldwide and leads to a significant rate of mortality and disability in patients every year, and imposes high costs on the health care system. The aim of this study was to evaluate the efficacy of the invasive method of mechanical thrombectomy for rapid intervention in ischemic stroke patients with large vessel involvement. Patients suspected of having a stroke, who were referred to Imam Hossein Hospital, were examined, and the diagnosis of stroke was confirmed. In the next stage, patients' MRS index was measured and the possibility of emergency thrombectomy was evaluated in patients. Patients who underwent thrombectomy were considered as the case group and the other patients were contemplated as the control group; then, the cases of the two groups were evaluated and compared. The mean age of patients was 66.63 ± 12.26 years. the use of emergency thrombectomy in the study group significantly reduced the MRS index of patients after 90 days (p <0.001), while a significant increase in the mean scores of the MRS index was seen in patients receiving pharmacological treatments. Also, there was no significant difference in terms of gender between the group of patients undergoing thrombectomy and the group receiving other treatments (p = 0.375). Emergency mechanical thrombectomy significantly reduces disability in stroke patients in the long term and can be a good alternative to conventional drug treatments..

Transcranial direct current stimulation in patient with J wave syndrome and implantable cardioverter defibrillator

J wave syndrome is a spectrum of proarrhythmic disorders including Brugada syndrome and early repolarization syndrome, that are prone to ventricular fibrillation and sudden cardiac death. In this case report we present a patient with Early repolarization syndrome and aborted sudden cardiac death complicated with cognitive impairment. We also investigated whether performing transcranial direct current stimulation to target his cognitive impairment, interfered with the function of his implantable cardioverter defibrillator. This article is protected by copyright. All rights reserved.

Coronavirus disease 2019 and stroke in Iran: a case series and effects on stroke admissions

OBJECTIVE

The coronavirus disease 2019 pandemic has affected healthcare systems around the globe and massively impacted patients with various non-infectious, life-threatening conditions. Stroke is a major neurological disease contributing to death and disability worldwide, and is still an ongoing issue during the pandemic. Here we investigate the impact of the coronavirus disease 2019 outbreak on stroke manifestations, treatment courses, the outcome of stroke patients, and the hospitalization rate in a referral center for stroke management in Tehran, Iran.

METHODS

We extracted data regarding 31 stroke patients (10 patients with laboratory-confirmed coronavirus disease 2019) and compared the demographic and pathological characteristics of the patients with or without coronavirus disease 2019 infection. The association of demographic/pathological characteristics of stroke patients during the coronavirus disease 2019 pandemic and a corresponding period during the previous year (49 patients) and an earlier period during the same year as the pandemic (50 patients) was also evaluated.

RESULTS

The absolute number of admissions decreased about 40% during the coronavirus disease 2019 pandemic. Except for the stroke severity (P = 0.002), there were no significant changes in the demographic and pathological characteristics of the stroke patients during the three studied periods. A significantly higher mean of age (75.60 ± 9.54 versus 60.86 ± 18.45; P = 0.007), a significant difference in the type of stroke (P = 0.046), and significantly higher stroke severity (P = 0.024) were observed in stroke patients with coronavirus disease 2019 compared with those of stroke patients without coronavirus disease 2019. Treatment approaches, duration of hospitalization, and mortality rates did not differ significantly.

CONCLUSIONS

This report shows that the pandemic caused the number of acute stroke admissions to plummet compared to other periods. Although the pandemic did not affect the treatment plans and care of the patients, stroke cases with coronavirus disease 2019 had higher age, more large vessel ischemic stroke, and more severe stroke. Further studies are urgently needed to realize the probable interaction of the coronavirus disease 2019 pandemic and the neurologic disease.

Low-dose versus standard-dose alteplase for intravenous thrombolysis in patients with acute ischemic stroke in Iran: Results from the safe implementation of treatments in stroke registry

Background: Rates of intracranial hemorrhage (ICH) after intravenous thrombolysis (IVT) differ depending on ethnicity, one reason that few Eastern countries have approved a lower dose of alteplase. Data in this regard are scarce in the Middle Eastern region. Methods: The present retrospective study was performed on data extracted from the Safe Implementation of Treatments in Stroke (SITS) registry. Computed tomography (CT) image analysis was based on the SITS-Monitoring Study (SITS-MOST) definition for symptomatic ICH (SICH). Functional outcome at 3 months was assessed using the modified Rankin Scale (mRS). Multivariate logistic regression including adjusted analysis was used for comparison between groups. Results: Of 6615 patients, 1055 were enrolled. A total of 86% (n = 906) received a standard dose and 14% (n = 149) received a low dose of alteplase. Favorable 3-month outcome was achieved in 481 (53%) patients in the standard group and 71 (48%) patients in the low-dose group [adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI): 0.87-1.75, P = 0.218]. SICH occurred in 14 (1.5%) patients in the standard group and 3 (2%) patients in the low-dose group [odds ratio (OR) = 2.77, 95% CI: 0.36-21.04, P = 0.120]. At 3 months, mortality occurred in 145 (16.0%) patients in the standard group and 29 (19.4%) patients in the low-dose group (OR = 1.22, 95% CI: 0.78-1.91, P = 0.346). Conclusion: Low-dose compared to standard-dose alteplase for patients with acute ischemic stroke (AIS) was not associated with fewer hemorrhagic events and there was no significant difference in the favorable 3-month outcome (mRS: 0-2) or mortality rate.

Global impact of COVID-19 on stroke care

Background

The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide.

Aims

We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March–31 May 2020) compared with two control three-month periods (immediately preceding and one year prior).

Methods

Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers.

Results

The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, −19.7 to −18.7), 11.5% (95%CI, −12.6 to −10.6), and 12.7% (95%CI, −13.6 to −11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (−20.5%) had greater declines in mechanical thrombectomy volumes than mid- (−10.1%) and low-volume (−8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions.

Conclusion

The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.

Neurological features and outcome in COVID-19: dementia can predict severe disease

The COVID-19 pandemic has infected more than 22 million people worldwide. Although much has been learned about COVID-19, we do not know much about its neurological features and their outcome. This observational study was conducted on the patients of Imam Hossein Hospital, and 361 adult patients (214 males) with confirmed diagnosis of COVID-19 from March 5, 2020 to April 3, 2020, were enrolled. Data was gathered on age, sex, comorbidities, initial symptoms, symptoms during the disease course, neurological symptoms, and outcome. The mean age of the patients was 61.90 ± 16.76 years. The most common initial symptoms were cough, fever, and dyspnea. In 21 patients (5.8%), the initial symptom was neurological. History of dementia was associated with severe COVID-19 disease (odds ratio = 1.28). During the course of the disease, 186 patients (51.52%) had at least one neurological symptom, the most common being headache (109 [30.2%]), followed by anosmia/ageusia (69, [19.1%]), and dizziness (54, [15%]). Also, 31 patients had neurological complications (8.58%). Anosmia, ageusia, dizziness, and headache were associated with favorable outcome (P < 0.001), while altered mental status and hemiparesis were associated with poor outcome. The mortality rate of patients who had neurological complications was more than twice than that of patients without neurological complication (P = 0.008). Almost half of the patients experienced at least one neurological symptom, which may be the initial presentation of COVID-19. Dementia appears to be associated with severe COVID-19. Mortality was higher in patients with neurological complications, and these patients needed more intensive care.

Combined Balance Training and tDCS Intervention for the Recovery of Postural Control Following Chronic Stroke: A Study Protocol for A Multi-Centre, Double Blind, Randomized Control Trial

Background: Stroke is one of the most debilitating diseases among the adults around the world which leads to persistent rehabilitation needs even at chronic stage. Achievement of good postural control is a critical requirement for daily activities which enhances quality of life in patients with stroke. There is increasing evidence that transcranial direct current stimulation (tDCS) may be considered as a promising adjunct technique to improve motor recovery after stroke. Evidence of augmented neuroplasticity after tDCS suggests that a paired rehabilitation followed by consecutive use of tDCS may optimize recovery outcomes. Although a few RCTs have been conducted on upper limbs rehabilitation in chronic stroke using tDCS, however no study focused on balance training in chronic stroke patients. This randomized, sham-controlled, double-blinded clinical study aims to address brain stimulation targeting postural control using tDCS in chronic stroke. Methods: The study participants will be chronic ischemic stroke individuals with postural control impairments who meet no exclusion criteria. Active or sham anodal tDCS will delivered to lesioned leg motor cortex combined with balance training. Experimental group receive active anodal tDCS stimulation (2mA) for 20 min, daily for 5 days paired with balance training. Linear and nonlinear approaches will be used to analyse postural sway changes pre and post-intervention. Postural sway fluctuation, Functional balance assessment using Berg balance scale, Timed Up-and-Go Test will be compared in active and sham groups. Conclusions: This trial could have significant implications for balance rehabilitation after stroke in the ambulatory setting. If found to be effective, this novel approach may improve rehabilitation protocol in this population.

Nasopharyngeal B-cell lymphoma with pan-hypopituitarism and oculomotor nerve palsy: a case report and review of the literature

BACKGROUND

Primary nasopharyngeal lymphoma (NPL) is a very rare tumor of Waldeyer ring (WR) lymphoid tissue. It is challenging to differentiate lymphoma infiltration of pituitary from a pituitary adenoma, meningioma infiltration, and other sellar lesions to plan a suitable treatment strategy. We presented for the first time a unique case of NPL with an unusual presentation of oculomotor nerve palsy associated with pan-pituitary involvement in a diabetic patient.

CASE PRESENTATION

A 64-year old diabetic woman with no previous history of malignancy presented with intermittent diplopia for about the last nine months. Severe headache, left eye ptosis and hypoglycemic episodes were added to her symptoms after a while. Further complaints include generalized weakness, loss of appetite, generalized musculoskeletal pain, and 6-7 kg weight loss within six months. Her family history was unremarkable. Physical examinations of eyes indicated left eye 3rd, 4th, and 6th nerve palsy. But, she was not anisocoric, and the pupillary reflexes were normal on both eyes. No lymphadenopathy, organomegaly and other abnormalities were found. Magnetic resonance imaging (MRI) showed a heterogeneous enhancement in the seller and suprasellar regions, enlargement of the stalk, parasellar dural enhancement and thickening of the sphenoid sinus without bone erosion. Also, both cavernous sinuses were infiltrated and both internal carotid arteries were encased by the neoplastic lesion. It suggested an infiltrative neoplastic lesion which compressed the cranial nerves. Pituitary hormone levels assessment indicated a pan-hypopituitarism. Following nasopharyngeal mucosal biopsy, the immunohistochemistry (IHC) findings revealed a low-grade non-Hodgkin's B-cell lymphoma. Systemic workup, including cerebrospinal fluid (CSF) studies, bone marrow aspiration, chest and abdominopelvic high-resolution computed tomography (HRCT) indicated no other involvement by the lymphoma. After chemotherapy courses, central adrenal insufficiency, partial central diabetes incipidious (CDI) and central hypothyroidism have been resolved. To our best knowledge, we found 17 cases of NPL with cranial nerve palsy, 1 case of NPL with pan-hypopituitarism and no NPL case with both cranial nerve palsy and pituitary dysfunction.

CONCLUSIONS

The incidence of cranial neuropathy in patients with diabetes should not merely be attributed to diabetic neuropathy without further evaluation.

Intravenous Thrombolysis for Acute Ischemic Stroke Due to Cardiac Myxoma

Background:

Myxoma may cause systemic embolization and frequently presents as ischemic stroke.

Case Presentation:

There have been debates about whether it is safe to use recombinant tissue plasminogen activator (rt-PA) in patients with cardiac myxoma who referred with ischemic stroke to the hospital’s emergency.

Results:

The patient was a young case of atrial myxoma with initial presentation of acute cerebral infarction symptoms who was treated with intravenous rt-PA with no complications.

Conclusion:

The case provides an evidence of the efficacy and safety of intravenous rt-PA in cases of cardiac myxoma. However, we cannot always expect thrombolytic therapy to be effective, especially in tumor emboli.

Transbulbar B-mode sonography in multiple sclerosis without optic neuritis; clinical relevance

OBJECTIVE

Trans bulbar B-mode sonography (TBS) is a recently proposed method but there is little known about its diagnostic accuracy in patients with multiple sclerosis without acute optic neuritis. Therefore we assessed the correlation between OND, ONSD and OND/ONSD ratio with clinical/para clinical parameters.

METHODS

In a comparative study, we intended to examine possible differences in optic nerve diameter (OND) and optic nerve sheath diameter (ONSD) between 60 patients with multiple sclerosis (MS) and 60 individuals as matched healthy controls.

RESULTS

The OND, ONSD and OND/ONSD ratio in both eyes showed significantly lower amounts in patients compared to healthy controls (p < 0.05). There were no correlations, between either OND or ONSD and factors including gender, age, P100 amplitude, disease duration, history of optic neuritis and number of T2 lesions in MRI (P ≥ 0.05). Expanded disability status scale (EDSS) and p100 Latency were correlated with both OND and ONSD values (P < 0.05).

CONCLUSIONS

TBS showed significantly lower amounts of OND, ONSD and OND/ONSD ratio in MS patients without current attack compared to their healthy controls indicating a subclinical axonal loss over time. It is suggested that TBS could be an applicable tool for early detection of optic nerve damages along with clinical and para-clinical findings.

Beta-Amyloid-Dependent miRNAs as Circulating Biomarkers in Alzheimer's Disease: a Preliminary Report

MicroRNAs (miRNAs) are considered among the most reliable biomarkers to diagnose and predict Alzheimer's disease (AD), due to their regulatory nature. The main goal of this study was to evaluate the expression of miR4422 and miR3714, as the main regulators of GSAP and BACE1 expression, in AD patients compared with healthy subjects. Twenty patients with a mild to moderate AD (58-71 years old) and 15 healthy subjects (58-73 years old) participated in this study. The expression levels of miR4422 and miR3714 as the target genes and 5S rRNA and miRlet7a-5p as the reference genes were measured in the two groups. To compare the expression between the case and the control groups, the t test or the Wilcoxon test was used, based on the data distribution patterns. The efficiencies of amplification of the miR4422, miR3714, 5S rRNA, and miRlet7a-5p genes all were in the acceptable range. The mean miR4422-5S rRNA dCt value was significantly different between the two groups (p = 0.018). The relative fold change of the expression was 0.43. The mean miR4422-miRlet7a-5p dCt value (p = 0.41), the mean miR3714-5S rRNA dCt value (p = 0.10), and the mean miR3714-miRlet7a-5p dCt value (p = 0.063) were not significantly different between the two groups. We indicated that miR4422 could be a reliable biomarker for Alzheimer's diagnosis. It seems that the reduced expression of miR4422 that targets GSAP and BACE1 expression can lead to an increase in the formation of Aβ plaque.

The association between serum 25-hydroxyvitamin D level and subclinical atherosclerosis in healthy population

Background: Subclinical atherosclerosis is the asymptomatic phase of carotid atherosclerosis, and its early diagnosis is important to prevent cerebrovascular diseases. Although the vitamin D plays a role in the structure of vessels, the association between the serum level of vitamin D and subclinical atherosclerosis has not been well-studied. We aimed to investigate the association between serum vitamin D level and carotid artery intima-media thickness (CIMT) in Iranian population. Methods: One hundred individuals with the age range from 20 to 50 years with no history of cardiovascular risk factors were selected for the analysis. Measurements of serum 25-hydroxyvitamin D3 [25(OH) D3] concentration and CIMT were made. Confounding factors such as diabetes, hypertension (HTN), smoking, alcohol, tobacco, dyslipidemia, cardiovascular disease (CVD), high body mass index (BMI), history of drug intake especially calcium, vitamin D, statins, and anti-hypertensive drugs were considered and then excluded from our study. Results: The mean serum vitamin D level was 15.55 ± 0.42 ng/ml, whereas in the increased intima-media thickness (IMT), it was 12.50 ± 9.50 ng/ml. 55% of the subjects were diagnosed with subclinical atherosclerosis (IMT ≥ 0.75 mm). Mean IMT was 0.74 ± 0.12 mm; however, it was higher (0.86 ± 0.30) in severe vitamin D deficiency group. The analysis showed an association between serum 25(OH) D3 level and CIMT (P = 0.002). 44% of those participants with subclinical atherosclerosis had also a severe vitamin D deficiency, while only 13% of normal people had a severe vitamin D deficiency. Also, a correlation was observed between severe vitamin D deficiency and the presence of plaque or higher IMT. Conclusion: Serum 25(OH) D3 level was inversely correlated with CIMT in our investigated subjects with no cardiovascular risk factor.

A case of aberrant bilateral vertebral arteries orgin presenting with right VA dissection

Background

Knowledge of variations in the origin of vertebral artery (VA) is indispensable to vascular surgeons. Aberrant origin of vertebral artery on either side is an uncommon finding. There are unilateral and bilateral variability in VA origin.

Case presentation

We present a case of vertebral artery dissection who was found to have bilateral VAs aberrant origin. The right VA took origin from the right common carotid artery (CCA) which is a completely a rare finding, and the left VA originated from the arch of aorta.

Conclusion

Unlike most similar reported cases, the VA diameter at origin was larger on the left than on the right side. The possible embryological mechanism is discussed.

Intra-arterial Drug Delivery to the Ischemic Brain in Rat Middle Cerebral Artery Occlusion Model

Rat transient middle cerebral artery occlusion (tMCAO) model is one of the most commonly used animal models in ischemic stroke studies. In the model, increasing safety and efficacy of therapeutic agent administration, such as stem cells and drugs directly to the ischemic brain using the internal carotid artery (ICA) is essential, because using the common carotid artery (CCA) for injection can close CCA completely and cause many complications after tMCAO surgery. Also, the pterygopalatine artery (PPA) is an arterial branch of the ICA that supplies blood circulation of the external part of the brain and removing the blood circulation of the PPA is required for more complete induction of ischemia to the brain. Herein, we present the insertion of intra-arterial catheter in the ICA via the external carotid artery (ECA) after the PPA in rats subjected to tMCAO surgery.

Thrombolytic treatment in stroke mimic, inevitable but fortunately safe: An observational study from Iran

Background: A number of patients with symptoms of acute cerebral ischemia may have other causes called stroke mimics (SM). The prevalence of SM can be as high as 31% in some reports, and these patients are potentially at the risk of intravenous thrombolysis (IVT) therapy and its complications. This study was designed to determine the prevalence of our center's SM (Firoozgar Hospital) among patients who received IVT, their baseline characteristics, final diagnoses, and outcomes. Methods: We reviewed the medical records of all patients who received IVT between June 2015 and May 2018. The following variables were collected: demographic characteristics, past medical history, onset-to-needle (OTN) time, door-to-needle (DTN) time, National Institutes of Health Stroke Scale (NIHSS) score at admission, brain imaging, and all paraclinic findings. Functional outcome at discharge based on modified Rankin Scale (mRS) was also assessed. Results: 10 out of 165 (6.0%) patients including 8 men and 4 women were finally diagnosed with SM. The median age and NIHSS score at presentation were 60 years and 7, respectively. Final diagnoses were seizure (n = 6), hemiplegic migraine (n = 2), conversion (n = 1), and alcohol intoxication (n = 1). All patients were discharged with a mRS score of 0 and 1 without experiencing any thrombolytic adverse effects. Conclusion: None of the patients with SM experienced any adverse effect of tissue plasminogen activator (tPA) including hemorrhage and all of them reached good mRS score. This shows that tPA is generally safe and the risk of treating patients with SM is very low and making a vital treatment decision may outweigh the risk of neglected cases in a time-sensitive setting.

Analysis of brain functional connectivity network in MS patients constructed by modular structure of sparse weights from cognitive task-related fMRI

Cognitive dysfunction in multiple sclerosis (MS) seems to be the result of neural disconnections, leading to a wide range of brain functional network alterations. It is assumed that the analysis of the topological structure of brain connectivity network can be used to assess cognitive impairments in MS disease. We aimed to identify these brain connectivity pattern alterations and detect the significant features for the distinction of MS patients from healthy controls (HC). In this regard, the importance of functional brain networks construction for better exhibition of changes, inducing the improved reflection of functional organization structure should be precisely considered. In this paper, we strove to introduce a framework for modeling the functional connectivity network by considering the two most important intrinsic sparse and modular structures of brain. For the proposed approach, we first derived group-wise sparse representation via learning a common over-complete dictionary matrix from the aggregated cognitive task-based functional magnetic resonance imaging (fMRI) data of all subjects of the two groups to be able to investigate between-group differences. We then applied the modularity concept on achieved sparse coefficients to compute the connectivity strength between the two brain regions. We examined the changes in network topological properties between relapsing-remitting MS (RRMS) and matched HC groups by considering the pairwise connections of regions of the resulted weighted networks and extracting graph-based measures. We found that the informative brain regions were related to their important connectivity weights, which could distinguish MS patients from the healthy controls. The experimental findings also proved the discrimination ability of the modularity measure among all the global features. In addition, we identified such local feature subsets as eigenvector centrality, eccentricity, node strength, and within-module degree, which significantly differed between the two groups. Moreover, these nodal graph measures have been served as the detectors of brain regions, affected by different cognitive deficits. In general, our findings illustrated that integration of sparse representation, modular structure, and pairwise connectivity strength in combination with the graph properties could help us with the early diagnosis of cognitive alterations in the case of MS.

Melatonin regulates neuroinflammation ischemic stroke damage through interactions with microglia in reperfusion phase

Even today, ischemic stroke is a major cause of death and disabilities because of its high incidence, limited treatments and poor understanding of the pathophysiology of ischemia/reperfusion, neuroinflammation and secondary injuries following ischemic stroke. The function of microglia as a part of the immune system of the brain following ischemic stroke can be destructive or protective. Recent surveys indicate that melatonin, a strong antioxidant agent, has receptors on microglial cells and can regulate them to protective form; yet, more findings are required for better understanding of this mechanism, particularly in the reperfusion phase. In this study, we initially aimed to evaluate the therapeutic efficacy of melatonin intra-arterially and to clarify the underlying mechanisms. After that by using an in vitro approach, we evaluated the protective effects of melatonin on microglial cells following the hypoxia condition. Our results proved that a single dose of melatonin at the beginning of reperfusion phase improved structural and behavioral outcomes. Melatonin increased NeuN and decreased GFAP, Iba1 and active caspase-3 at protein level. Furthermore, melatonin elevated BDNF, MAP2, HSPA1A and reduced VEGF at mRNA level. We also showed that melatonin receptor 1B highly expressed in microglial cells after 3 h hypoxia. Besides, melatonin increased the ratio of TREM2/iNOS as a marker of the most protective form of microglia (M2). In summary, our data suggest that melatonin has the possibility to serve as targeting microglial action for preventing secondary injury of reperfusion phase after ischemic stroke.

Sex steroid hormones and sex hormone binding globulin levels, CYP17 MSP AI (-34T:C) and CYP19 codon 39 (Trp:Arg) variants in children with developmental stuttering

Developmental stuttering is known to be a sexually dimorphic and male-biased speech motor control disorder. In the present case-control study, we investigated the relationship between developmental stuttering and steroid hormones. Serum levels of testosterone, dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA), oestradiol, progesterone, cortisol, and sex hormone binding globulin (SHBG), as well as the 2nd/4th digit ratio (2D:4D), an indicator of prenatal testosterone level, were compared between children who stutter (CWS) and children who do not stutter (CWNS). Moreover, two SNPs (CYP17 -34 T:C (MSP AI) and CYP19 T:C (Trp:Arg)) of cytochrome P450, which is involved in steroid metabolism pathways, were analysed between the groups. Our results showed significantly higher levels of testosterone, DHT, and oestradiol in CWS in comparison with CWNS. The severity of stuttering was positively correlated with the serum levels of testosterone, DHEA, and cortisol, whereas no association was seen between the stuttering and digit ratio, progesterone, or SHBG. The CYP17CC genotype was significantly associated with the disorder.

A Mitochondrial Disorder in a Middle Age Iranian Patient: Report of a Rare Case

Introduction

Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) can involve multiple systems and cause stroke-like episodes and status epilepticus.

Case Presentation

A 48-year-old female with history of early fatigability, migraine-type headaches, and bilateral sensory-neural hearing loss presented 3 episodes of serial seizures. On admission she was affected by Wernicke aphasia and, then, right hemiparesis. Investigations showed elevated arterial lactate and ragged red fibers on muscle biopsy.

Conclusion

Though more commonly diagnosed during childhood, some cases of adult-onset MELAS syndrome are reported. This syndrome should be considered in patients with stroke-like events in adults without cerebrovascular risk factors and difficult-to-treat seizures.

Acute management of stroke in Iran: Obstacles and solutions

Background: Stroke is among the leading causes of mortality and permanent disability in the world. Iran is located in the stroke belt and has a high age-adjusted stroke incidence rate. In this multistep prospective qualitative study, we aimed at investigating the status and challenges of stroke management in Iran and explore possible solutions. Methods: In the first and second phase, we attempted to define the status of stroke management in Iran by searching the relevant literature and conducting semi-structured interviews with health-care providers in thirteen hospitals located in seven large cities in Iran. In the third phase, we tried to recommend possible solutions based on international standards and experience, as well as interviews with stroke experts in Iran and the United States. Results: Little public awareness of stroke symptoms and its urgency, low prioritization for stroke management, and an inadequate number of stroke-ready hospitals are some of the major obstacles toward timely treatment of stroke in Iran. Every hospital in our pool except two hospitals had guideline-based algorithms for the administration of intravenous thrombolysis. However, there was no single call activation system for stroke alert. Data from some of the centers showed that hospital arrival of stroke patients to final decision-making took 116-160 minutes. Although there were four endovascular programs in our target areas, there was no center with 24-hour coverage. Conclusion: There are many challenges as well as potentials for improvement of stroke care in Iran. Improving public knowledge of stroke and establishing an organized and comprehensive stroke program in the hospitals will improve acute stroke management in Iran. The Iranian ministry of health should define and advocate the establishment of stroke centers, track the rate of death and disability from stroke, introduce pathways to improve the quality of stroke care through national data monitoring systems, and eliminate disparities in stroke care.

Positive impact of stroke unit establishment on patient recovery in Firoozgar hospital

Background: Firoozgar Comprehensive Stroke Center started up as the first organized care unit in the country in 2014; this study was performed to investigate quality indicators such as reduction in mortality, morbidity and hospital stay. Methods: Two groups of ischemic stroke patients were compared. The first group had been admitted in general neurology ward (non-stroke unit patients) and the second one received specialized stroke care in the stroke unit within a period of two years (stroke unit patients). Non-stroke unit patients were selected from a pool of patients admitted two years before establishment of stroke unit. Variables compared were factors such as modified Rankin Scale (mRS), confinement days in stroke unit or Intensive Care Unit, total days of hospitalization, history of prior stroke, receiving recombinant tissue plasminogen activator (rtPA) and the stroke category indicating anterior or posterior circulation infarct. Quantitative testing was conducted using independent t-test as well as "Mann-Whitney U Test"; Chi-squared test was used for qualitative testing. Results: A total number of 129 patients enrolled in the study (66 cases of non-stroke unit patients and 63 cases of stroke unit patients). The average total days of hospitalization were 17.32 (95% CI: 0.15-36.1) in non-stroke unit patients and 21.19 (95% CI: 4.99 - 38.1) in stroke unit patients (p=0.2). Results for stroke unit patients showed a lower mRS score (OR=1.48, p=0.01). Conclusion: It was concluded that stroke unit patients tend to have a better outcome and a lower mRS score at discharge. No significant difference in hospitalization period was noted between the two groups.

Association of insulin-like growth factor-I with the severity and outcomes of acute ischemic stroke

Background: The aim of this study was to evaluate whether higher serum levels of insulin-like growth factor-I (IGF-I) in the acute phase of ischemic stroke are associated with less severe strokes and better functional outcome in a period of 12-month follow-up. Methods: From October 2014 to August 2015, patients with the diagnosis of acute ischemic stroke admitted to the stroke unit of Firoozgar Hospital, Tehran, Iran, entered this prospective study. National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (MRS) for stroke scores were used to measure the severity and outcomes of an acute ischemic stroke at the time of admission and 1 year after the stroke, respectively. Results: A total of 60 acute ischemic stroke patients (28 male, 32 female) with the mean age of 71.1 ± 9.0 years were evaluated for the serum level of IGF-I at the time of admission to the stroke unit of Firoozgar Hospital. There was seen a significant correlation between the IGF-I serum level and the MRS scores (P = 0.020; correlation coefficient = -0.32). IGF-I serum level had no significant correlation with NIHSS scores. Conclusion: These results support that the higher serum levels of IGF-I at the time of stroke is associated with a significant better outcome in a 1-year period of follow-up. However, this hormone serum level seems not to have a predictable value for the ischemic stroke severity. Further studies are required to clarify the neuroprotective mechanisms of IGF-I in ischemic stroke process.

Effects of Low-Intensity Continuous Ultrasound on Hematological Parameters of Rats

BACKGROUND

Low intensity ultrasound (US) has some well-known bio-effects which are of great importance to be considered. Objective: We conducted the present study to investigate the effects of low intensity continuous ultrasound on blood cells count in rat.

METHODS

Rats were anesthetized and blood samples were collected before US exposure. Then, they were exposed to US with nominal intensity of 0.2 W/cm2 at frequency of 3 MHz for a period of 10 minutes and this protocol was repeated for 7 days. Twenty four hours after the last US exposure, secondary blood samples were collected and the changes in blood parameters were evaluated.

RESULTS

Analysis revealed that platelets, hematocrit (HCT) and hemoglobin (HGB) were significantly different between experimental and sham groups but no difference between sham and control groups was observed. The results show that HCT and HGB of exposed rats were significantly reduced. Conclusion: This study shows that low intensity US may lead to side effects for hematological parameters such as reduction in the levels of HGB and HCT.

Carotid duplex ultrasound and transcranial Doppler findings in commercial divers and pilots

The risky working environments of divers and pilots, and the possible role of extreme ambient pressure in carotid stenosis, make ischemic stroke an important occupational concern among these professionals. In this study, we aimed to evaluate the association of being exposed to hyperbaric or hypobaric conditions with carotid artery stenosis by comparing common carotid intima-media thickness (CCIMT) and blood flow velocities of cerebral arteries in divers and pilots using carotid duplex ultrasound (CDUS) and transcranial Doppler (TCD). CDUS and transtemporal TCD were performed in 29 divers, 36 pilots and 30 control participants. Medical history, blood pressure, lipid profile and blood sugar were recorded to control the previously well-known risk factors of atherosclerosis. Findings of the CDUS and TCD [including: CCIMT and blood flow velocities of internal carotid artery (ICA), common carotid artery (CCA), and middle cerebral artery (MCA)] of divers and pilots were compared with those of the control group using regression analysis models. Both right and left side CCIMT were significantly higher in divers (P < 0.05) and pilots (P < 0.05) in comparison with the control group. Carotid index [peak systolic velocity (PSV) of ICA/PSV of CCA) of divers and pilots were also higher than the control group. TCD findings were not significantly different between divers, pilots, and the control group. Increased CCIMT and carotid index in diver and pilot groups appear to be suggestive of accelerated atherosclerosis of carotid artery in these occupational groups.

An ABCD1 Mutation (c.253dupC) Caused Diverse Phenotypes of Adrenoleukodystrophy in an Iranian Consanguineous Pedigree

OBJECTIVES

Current study was the first to report a consanguineous Iranian pedigree with ABCD1 mutation.

METHODS

Targeted molecular analysis was initially performed in three affected individuals in one family suspected to have X-ALD due to chronic progressive spasticity. Upon confirmation of genetic diagnosis, further neurologic and genetic evaluation of all family members was done.

RESULTS

A mutation in ABCD1 was identified in 35 affected individuals (out 96 pedigree members). The c. 253dup, in exon 1, leads to a frame shift and a premature stop codon at amino acid position 194 (p.Arg85Profs*110). Surprisingly, affected individuals in our cohort show some variability in phenotype, including childhood cerebral ALD, adrenomyeloneuropathy, and addison-only disease phenotypes, expanding the phenotype of X-ALD with p.Arg85Profs*110.

CONCLUSION

This report characterizes the clinical spectrum of an expanded Iranian pedigree with X-ALD due to an ABCD1 mutation. Given a high frequency of carriers in this region, we expect the prevalence of X-ALD to be higher, underscoring the importance of genetic counseling through reliable identification of heterozygous as well as homozygote females in consanguineous communities.

Is the serum ferritin level a considerable predictor for hemorrhagic transformation of ischemic stroke?

BACKGROUND

Hemorrhagic Transformation (HT) of Ischemic Stroke (IS) is a detrimental complication. This study investigated the association between serum ferritin level and HT in patients with massive IS of middle cerebral artery.

METHODS

Thirty patients with massive IS of middle cerebral artery were enrolled in this prospective cohort study. They were divided into two groups based on the serum ferritin level, lower or greater than 164.1ng/ml at the first 24 hours after admission. To investigate the incidence of HT in the two groups, we observed them for two weeks.

RESULTS

During the two- week observation, the incidence of HT was two persons (13.3%) in the group with the serum ferritin level of lower than 164.1ng/ml, and eight persons (53.3%) in the other group. This difference was statistically significant between the two groups (p=0.02). The relative risk of HT was 4 (95% CI: 1.012- 15.8) in the patients with massive IS of middle cerebral artery and the serum ferritin level greater than 164.1ng/ml.

CONCLUSION

This study revealed that the serum ferritin level greater than 164.1ng/ml in the first 24 hours after admission is a reasonably important predictor for HT of IS. Conducting studies on factors affecting the serum ferritin level are suggested.

Diagnostic value of median nerve ultrasonography for screening of carpal tunnel syndrome in hypothyroid patients: A cross-sectional study

BACKGROUND

Carpal tunnel syndrome (CTS) is a common peripheral entrapment neuropathy in patients with hypothyroid. The diagnosis of CTS is usually clinical and confirmed by electrodiagnostic (EDX) procedures. This study aimed to describe the diagnostic accuracy of high-resolution ultrasonography (US) as an alternative method to nerve conduction study (NCS) for the diagnosis of subclinical CTS in patients with hypothyroidism.

METHODS

Between April 2013 and November 2014, from the patients with the diagnosis of hypothyroidism referring to the institute of endocrinology and metabolism of Firoozgar Hospital, Tehran, Iran, those who met our inclusion criteria entered this cross-sectional study. The patients divided into two groups of subclinical CTS with the age- and gender-matched control group. US measurements of the median nerve cross-sectional area (CSA) in the CT inlet were compared with the NCS results as the gold standard diagnostic test.

RESULTS

A total number of 152 wrists of 76 hypothyroid patients were examined in this study. The mean of median nerve CSA at the tunnel inlet was 9.96 ± 2.20 mm(2) for the CTS group and 7.08 ± 1.38 mm(2) for the control group (P < 0.05). 31 wrists (20.4%) were diagnosed as CTS using NCS while US diagnosed 19 wrists (12.5%) as CTS. Using receiver-operating-characteristics analysis, the sensitivity and specificity of US at the diagnosis of CTS were 45.0 and 95.8%, respectively, with a median nerve CSA cutoff point of 9.8 mm(2). Positive and negative predictive values of US were 87.2 and 85.5%, respectively, with a test accuracy of 85.5%.

CONCLUSION

According to our findings, US has an acceptable diagnostic value to confirm CTS in hypothyroid patients. However, it may not replace NCS due to low sensitivity.

Oral consumption of α-linolenic acid increases serum BDNF levels in healthy adult humans

Background aims

Dietary omega-6 and omega-3 fatty acids have remarkable impacts on the levels of DHA in the brain and retina. Low levels of DHA in plasma and blood hamper visual and neural development in children and cause dementia and cognitive decline in adults. The level of brain-derived neurotrophic factors (BDNF) changes with dietary omega-3 fatty acid intake. BDNF is known for its effects on promoting neurogenesis and neuronal survival.

Methods

In this study, we examined the effect of the oral consumption of α-Linolenic acid (ALA) on blood levels of BDNF and Malondialdehyde (MDA) in healthy adult humans. 30 healthy volunteers, 15 men and 15 women, were selected randomly. Each individual served as his or her own control. Before consuming the Flaxseed oil capsules, 5cc blood from each individual was sampled in order to measure the plasma levels of BDNF and MDA as baseline controls. During the experiment, each individual was given 3 oral capsules of flaxseed oil, containing 500mg of alpha linolenic acid, daily for one week. Then, plasma levels of BDNF and MDA were tested.

Results

The plasma levels of BDNF and MDA significantly (P < 0.05) increased in individuals who received the oral capsules of ALA. Plasma levels of BDNF increased more in the women in comparison with the men.

Conclusion

ALA treatment could be a feasible approach to reduce size of infarcts in stroke patients. Thus, ALA could be used in adjunction with routine stroke therapies to minimize brain lesions caused by stroke.

Clinical assessment of fear of falling after stroke: validity, reliability and responsiveness of the Persian version of the Fall Efficacy Scale-International

BACKGROUND

Fear of falling may be related to falling during stroke onset. The Fall Efficacy ScaleInternational (FES-I) with excellent psychometric properties, is an instrument developed to assess patients' concerns about fallings. The aim of this study was to determine validation of this scale in Iranian patients with stroke.

METHODS

The "forward-backward" procedure was applied to translate the FES-I from English to Persian. One hundred-twenty patients who had suffered stroke, aged 40 to 80 years (55% male) completed the Persian FES-I, Geriatric Depression Scale-15 (GDS-15), General Health Questionnaire-28 (GHQ-28), Berg Balance Scale (BBS) and Timed up and Go (TUG) questionnaires. The interval time for the test-retest of the Persian scale was 7-14 days.

RESULTS

The test-retest and inter-rater reliabilities of the Persian FES-I were excellent (ICC2,1=0.98, p<0.001) and the internal consistency was high (Cronbach's alpha=0.78). Factor analysis of the 16 items in the Persian scale showed only one significant factor. The total Persian FES-I score had a significantly negative correlation (p<0.001) with the BBS, but it had significantly positive correlation with the TUG, GHQ-28, and GDS-15. The difference in responsiveness scores across fallers and non-fallers yielded a large effect size (0.46), which indicated a good discriminating validity.

CONCLUSION

The Persian FES-I proved to be an effective and valuable measurement tool to assess stroke patients' fear of falling in practice and research setting.