Egyptian adaptation and validation of the Edinburgh Cognitive and Behavioral Amyotrophic Lateral Sclerosis Screen (ECAS-EG)

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is the most common, fatal adult neuromuscular disease. It is a multi-system disorder characterized primarily by motor manifestations, but there is established evidence for cognitive and behavioral impairment, which is associated with poor prognosis, hence, the importance of tools for its assessment. The Edinburgh Cognitive and Behavioral Assessment Screen (ECAS) is an invaluable assessment tool for cognition in ALS-front temporal spectrum dementia (FTSD), as it accommodates physical challenges that usually confound traditional neuropsychological testing in those patients.

OBJECTIVE AND METHODS

To validate the Egyptian Arabic version of ECAS (ECAS-EG) based on the original English scale. This is a prospective study. The ECAS was adapted and administered to 62 Egyptian ALS patients and 60 healthy controls. Patients were recruited from the Neuromuscular Unit, Ain Shams University Hospital. The ECAS was adapted to Egyptian Arabic after being translated using the back translation method. Internal consistency of the test, inter-rater reliability, and construct validity were assessed.

RESULTS

The Egyptian Arabic version of ECAS (ECAS-EG) showed good internal consistency using Cronbach's alpha of 0.84. Inter-rater reliability was tested, values for all variables were compared, and no statistically significant differences were found (ICC = .997). ECAS-EG discriminated significantly between the patients from the control subjects (p-value of 0.001). There was a strong positive correlation between the ECAS-EG total score and the MoCA total score with a p-value of 0.001, thus indicating convergent validity. The test showed that 63% of Egyptian ALS patients were cognitively affected; most affected domains were executive functions and verbal fluency.

CONCLUSION

The current study proves that the Egyptian version of the ECAS (ECAS-EG) is valid and reliable among Egyptian ALS patients and it would be applicable to the general Arabic-speaking population.

Lateralized readiness potentials can identify hemisphere of recovery in stroke patients

Highlights • In healthy adults, the lateralized readiness potential (LRP) is localized to the hemisphere contralateral to a moving limb. • In stroke, the LRP can lateralize contra-, or ipsilateral to the paretic limb depending on the stage of recovery. • Identification of hemisphere of recovery can guide further measures for enhancing brain plasticity. Background: Event related cortical potentials related to motor action are referred to as movement related cortical potentials. The late component of which is the readiness potential (RP) and its polarity is more negative in the hemisphere responsible for planning of motor action. This lateralized nature of RP during unilateral hand movement is studied as lateralized readiness potential (LRP) by calculating the contralateral-minus-ipsilateral difference wave for each hand. Objective: The aim was to identify the hemisphere contributing to motor recovery in acute and chronic stroke patients through recording LRPs. Methods: Twenty-nine cases with cerebrovascular stroke (15 acute and 14 chronic) were included in the study. EEG was recorded in response to self-cued button presses by the paretic side to obtain the averaged LRP amplitude. The hemisphere with greater negativity was considered the side of recovery. Functional recovery was assessed by Fugl Meyer test. Results: In acute cases, recovery was more related to LRP activity in the contralesional hemisphere (73% ), whereas lateralization was equal in chronic cases; 50% in either group. LRP amplitude was higher in the contralesional hemisphere (p = 0.02). Functional recovery assessed by the Fugl Meyer test (FM) was similar whether recovery was ipsi- or contralesional. Conclusions: Early after stroke, motor recovery is more likely to involve compensatory activity in the contralesional hemisphere, while in the chronic phase, the ipsilesional hemisphere may recover its function and become more active. Further research is needed to verify if the technique mentioned in our study could be used to guide customized NIBS protocols tailoring the optimal site and parameters for each patient.

Assessment of diagnostic potential of some circulating microRNAs in Amyotrophic Lateral Sclerosis Patients, an Egyptian study

OBJECTIVE

Numerous studies have been carried out to identify the role of microRNA (miRNA) as potential biomarkers for many diseases including amyotrophic lateral sclerosis (ALS). The aim of this study was to explore the circulating levels of some miRNAs in cohort of Egyptian ALS patients in an attempt to correlate the selected miRNA profiles with disease progression.

METHODS

Thirty ALS patients and 20 age and sex matched healthy controls were enrolled. Circulating miRNA levels were determined in venous blood samples, collected on EDTA, from all the study subjects. The selection of miRNA species (miR-206, miR-142-3p, miR-143-3p, miR-181a-5p, miR-106b-3p, miR-4516 and Let7f-5p) was based on their involvement in the pathophysiology of ALS and was further confirmed by data mining of specific miRNA databases (miRBase and miRDB).

RESULTS

As compared to the control group, significant consistent upregulation was found in the levels of miR-206, miR-143-3p and to a lesser extent in miR-142-3p. An elevation trend, although not significant, was also found in the levels of miR-181a-5p, miR-106b-3p, and miR-4516. Interestingly, we found that the levels of miR-142-3p were elevated in familial cases, while that of miR-4516 were significantly increased in sporadic cases. Furthermore, the levels of Let7f-5p, although were generally lowered in ALS patients but were also decreased in familial cases as well as in spinal onset ALS as compared to bulbar onset.

CONCLUSION

This is the first study investigating miRNA profiles in Egyptian ALS patients. We found that some miRNAs are significantly altered in ALS patients, and some may be used to distinguish familial and sporadic cases and bulbar and spinal onset. Larger study is needed, in which we will conduct a correlation of miRNA levels against variations in disease onset, progression as well as systemic inflammatory responses and the extent of neuromuscular involvement in Egyptian ALS patients in an attempt to identify environmental/occupational risk factors.

Imaging the Cellular Biology of the Carotid Plaque

Carotid atherosclerotic disease is a significant preventable cause of stroke. Clinical decision-making in current practice is based primarily on detection of the severity of luminal stenosis, as determined by ultrasound or conventional angiographic imaging modalities. New insights in the biology of atherosclerosis now suggests that the morphological characteristics of the carotid plaque as well as the molecular and cellular processes occurring within it may be more important markers of plaque vulnerability and stroke risk. This review summarizes emerging applications in the molecular imaging of atherosclerosis and detection of the vulnerable carotid plaque. We discuss how advances in imaging platforms and biochemical technology (e.g. targeted contrast agents) have driven some exciting and promising novel diagnostic imaging approaches from bench to bedside.

Restless legs syndrome in Egyptian medical students using a validated Arabic version of the Restless Legs Syndrome Rating Scale

OBJECTIVE

Restless legs syndrome (RLS) is a common movement disorder that has a variable prevalence and impact reported from different countries and specific populations. The current study validated an Arabic version of the International Restless Legs Syndrome Study Group (IRLSSG) rating scale (IRLS) and investigated the prevalence and impact of RLS in medical students at Ain Shams University in Cairo.

METHODS

Translation of IRLS was done according to standard recognized guidelines provided by the publisher. A total of 389 medical students (217 female and 172 male) participated in the study and answered four questions to detect RLS as proposed by the IRLSSG. Subjects who answered positively the first three questions were recruited for face-to-face interview to exclude RLS mimics and to answer the IRLS.

RESULTS

A total of 46 subjects (11.8%; 27 female and 19 male) met the four criteria for RLS. Of these, 39 subjects (10%) had idiopathic RLS. Five subjects (1.3%) and two subjects (0.5%) reported association with history of anemia and diabetes mellitus respectively. Their mean total IRLS score was 16.33 ± 5.3, with moderate severity (11.62 ± 3.9) and low impact (3.1 ± 1.8). The prevalence of individuals who had two or more episodes of RLS of at least moderate severity per week was 5.9%.

CONCLUSION

In this specific population of Egyptian medical students, a within-average prevalence of RLS was found with low impact on quality of life similar to worldwide reported populations. RLS sufferers were of high prevalence among this cohort. The Arabic version of IRLS is reliable and valid for further research in Arabic countries.

Diffusion and perfusion correlates of the 18F-MISO PET lesion in acute stroke: pilot study

PURPOSE

Mapping the ischaemic penumbra in acute stroke is of considerable clinical interest. For this purpose, mapping tissue hypoxia with (18)F-misonidazole (FMISO) PET is attractive, and is straightforward compared to (15)O PET. Given the current emphasis on penumbra imaging using diffusion/perfusion MR or CT perfusion, investigating the relationships between FMISO uptake and abnormalities with these modalities is important.

METHODS

According to a prospective design, three patients (age 54-81 years; admission NIH stroke scale scores 16-22) with an anterior circulation stroke and extensive penumbra on CT- or MR-based perfusion imaging successfully completed FMISO PET, diffusion-weighted imaging and MR angiography 6-26 h after stroke onset, and follow-up FLAIR to map the final infarction. All had persistent proximal occlusion and a poor outcome despite thrombolysis. Significant FMISO trapping was defined voxel-wise relative to ten age-matched controls and mapped onto coregistered maps of the penumbra and irreversibly damaged ischaemic core.

RESULTS

FMISO trapping was present in all patients (volume range 18-119 ml) and overlapped mainly with the penumbra but also with the core in each patient. There was a significant (p ≤ 0.001) correlation in the expected direction between FMISO uptake and perfusion, with a sharp FMISO uptake bend around the expected penumbra threshold.

CONCLUSION

FMISO uptake had the expected overlap with the penumbra and relationship with local perfusion. However, consistent with recent animal data, our study suggests FMISO trapping may not be specific to the penumbra. If confirmed in larger samples, this preliminary finding would have potential implications for the clinical application of FMISO PET in acute ischaemic stroke.

Watershed Infarcts in Transient Ischemic Attack/Minor Stroke With ≥50% Carotid Stenosis

Background and Purpose— Watershed ischemia is a significant cause of stroke in severe carotid disease, but its pathophysiology is unsettled. Although hemodynamic compromise has long been regarded as the main mechanism—particularly with deep watershed infarction—there is some contradictory evidence from clinical and pathological studies for a role of microembolism, thought to result from plaque inflammation. However, no study so far has directly addressed these conflicting scenarios.

Methods— In 16 consecutive patients with recent transient ischemic attack/minor stroke and ipsilateral 50% to 99% carotid stenosis, we prospectively obtained (1) plaque inflammation mapping with 18 F fluorodeoxyglucose positron emission tomography; (2) brain MRI and perfusion MR; and (3) transcranial Doppler detection of microembolic signals (MES). Patients were excluded if on dual antiplatelets or with a potential cardiac source of emboli or contralateral MES.

Results— We found the expected significant relationship between (1) degree of stenosis and severity of distal hemodynamic impairment in the watershed areas; and (2) degree of in vivo plaque inflammation and rate of MES/hr. Deep watershed infarcts were present in 8 patients and MES in 8 (3 with both). There was no systematic association between the presence of deep watershed infarcts and either hemodynamic impairment or MES, but deep watershed infarcts were present only when either hemodynamic impairment or MES was present ( P =0.01).

Conclusion— This pilot study supports the idea that in symptomatic carotid disease, deep watershed infarcts result either from hemodynamic impairment secondary to severe lumen stenosis or from microembolism secondary to plaque inflammation. There was no direct evidence that both mechanisms act in synergy.

Repetitive transcranial magnetic stimulation at 1Hz and 5Hz produces sustained improvement in motor function and disability after ischaemic stroke

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a simple and non-invasive method of augmenting motor recovery after stroke, probably mediated by restoring inter-hemispheric activation balance. This placebo-controlled pilot study examined the possible benefit of stimulating the lesioned hemisphere (5-Hz rTMS) or inhibiting the contra-lesional hemisphere (1-Hz rTMS) on clinical recovery of motor function in patients with ischaemic stroke and assessed the sustainability of the response.

METHODS

Sixty patients with ischaemic stroke (>1 month from onset) with mild-to-moderate hemiparesis were randomized to receive 10 daily sessions of either sham rTMS, 5-Hz ipsi-lesional rTMS or 1-Hz contra-lesional rTMS, in addition to a standard physical therapy protocol. Serial assessments were made over a period of 12 weeks by the thumb-index finger tapping test (FT), Activity Index (AI) score and the modified Rankin Scale (mRS).

RESULTS

In contrast to control patients, those receiving active rTMS as ipsi-lesional 5-Hz stimulation or 1-Hz contra-lesional stimulation showed statistically significant improvement on the FT test, AI scores and mRS score at 2 weeks, and the effect was sustained over the 12-week observation period. No significant adverse events were observed during treatment in either group.

CONCLUSIONS

Repetitive TMS has beneficial effects on motor recovery that can be translated to clinically meaningful improvement in disability in patients with post-stroke hemiparesis, with a well-sustained effect. The similarity of inhibitory and stimulatory rTMS in producing these effects supports the inter-hemispheric balance hypothesis and encourages further research into their use in long-term neurorehabilitation programmes of patients with stroke.

T2*-weighted MRI versus oxygen extraction fraction PET in acute stroke

BACKGROUND

Mapping high oxygen extraction fraction (OEF) in acute stroke is of considerable interest to depict the at-risk tissue. Being sensitive to deoxyhemoglobin, T2*-weighted MRI has been suggested as a potential marker of high OEF.

METHODS

We compared T2*-weighted images from pre-contrast arrival perfusion scans against quantitative positron emission tomography in 5 patients studied 7-21 h after onset of carotid territory stroke. OEF and T2* signal were obtained in the voxels with significantly high OEF.

RESULTS

All patients showed increased OEF. No significant relationship between OEF and T2*-weighted signal was found either within or between subjects.

CONCLUSION

We found no indication that T2*-weighted MRI in the way implemented in this investigation was sensitive to high OEF in acute stroke.

Call-Fleming syndrome associated with subarachnoid haemorrhage: three new cases

The Call-Fleming syndrome (CFS) comprises acute severe recurrent (thunderclap) headaches, occasional transient or fluctuating neurological abnormalities and reversible segmental cerebral vasoconstriction. It is a benign condition with an excellent prognosis, yet because it is often clinically and radiologically similar to a number of commonly encountered conditions, diagnostic difficulties may arise, leading to inappropriate, and even potentially harmful, investigative and therapeutic approaches. Three personal cases are presented to highlight the occurrence of subarachnoid haemorrhage (SAH) as part of CFS. In two patients with a positive CT head, SAH involved the sulci in the upper cerebral convexity, an unusual location in aneurysmal SAH. SAH is not an uncommon feature of CFS, occurring in approximately 25% of reported cases, and may pose a diagnostic challenge. CFS has a relatively characteristic spectrum of features, allowing a confident diagnosis in most cases, even when atypical features such as SAH are present. Recognising the spectrum of abnormalities seen in CFS, including particularly SAH, allows a sound approach to a safe diagnosis.

Call-Fleming syndrome associated with subarachnoid haemorrhage: three new cases

BACKGROUND

The Call-Fleming syndrome (CFS) comprises acute severe recurrent (thunderclap) headaches, occasional transient or fluctuating neurological abnormalities and reversible segmental cerebral vasoconstriction. It is a benign condition with an excellent prognosis, yet because it is often clinically and radiologically similar to a number of commonly encountered conditions, diagnostic difficulties may arise, leading to inappropriate, and even potentially harmful, investigative and therapeutic approaches.

CASES

Three personal cases are presented to highlight the occurrence of subarachnoid haemorrhage (SAH) as part of CFS. In two patients with a positive CT head, SAH involved the sulci in the upper cerebral convexity, an unusual location in aneurysmal SAH.

RESULTS

SAH is not an uncommon feature of CFS, occurring in approximately 25% of reported cases, and may pose a diagnostic challenge. CFS has a relatively characteristic spectrum of features, allowing a confident diagnosis in most cases, even when atypical features such as SAH are present.

CONCLUSIONS

Recognising the spectrum of abnormalities seen in CFS, including particularly SAH, allows a sound approach to a safe diagnosis.

Combined PET-FDG and USPIO-enhanced MR imaging in patients with symptomatic moderate carotid artery stenosis

INTRODUCTION

PET-FDG and USPIO-enhanced MRI are increasingly being used in depicting carotid atheroma inflammation--a risk factor for the high risk plaque. Their combined use has not been previously reported.

REPORT

Two patients presenting with stroke and identified with 50% carotid stenosis on duplex ultrasonography, underwent PET FDG and USPIO-enhanced MR imaging. Results were concordant and complementary suggesting that both techniques reflect similar metabolic processes.

DISCUSSION

The selection of patients for carotid revascularisation has largely been based on the severity of luminal stenosis alone. The two imaging modalities, which identify inflammatory activity, may be potential surrogate risk markers in the selection of patients eligible for carotid surgery, if plaque inflammation can be correlated with risk of developing clinical symptoms.

Imaging the penumbra in acute stroke

Imaging continues to have a huge impact on the understanding of the ischemic penumbra and the management of acute stroke. Determinants of penumbral tissue fate, such as age, hyperglycemia, hematocrit, and oxygen concentration, are increasingly being recognized using neuroimaging. The significance of the penumbra in the white matter and in posterior circulation stroke is also becoming clearer. Neuroimaging is also making invaluable contributions to clinical decision making in acute stroke, especially in relation to reperfusion therapies in the 3- to 6-hour time window. Despite ongoing questions over the choice of parameters to identify the penumbra and their respective clinical usefulness, imaging is gaining widespread use in acute stroke management. However, definitive evidence of its benefit is still lacking. This review explores the recent progress and controversies relating to imaging of the penumbra.

Stroke Attributable to a Calcific Embolus From the Brachiocephalic Trunk

Background and Purpose— Calcific brain embolization is a rare event that is usually secondary to cardiac valve calcification. We present a case of stroke caused by embolization of calcific material from the brachiocephalic trunk, probably induced by radiotherapy.

Summary of Case— A 56-year-old right-handed female developed left-sided hemiparesis, hemihypesthesia, and sensory inattention. She had a history of right breast carcinoma that was excised 8 years previously followed by radiotherapy. She had no other history of note. Computed tomography of the head and magnetic resonance imaging confirmed a calcific embolus in right middle cerebral artery and an acute infarction in the corresponding territory. Plain chest radiography, carotid ultrasonography, transthoracic and transoesophageal echocardiography failed to demonstrate the source of calcific embolism. Computed tomography of the thorax revealed heavy calcification of the brachiocephalic trunk and the origin of the right common carotid artery.

Conclusions— Undertaking a vigilant systematic search for the source in cases of calcific embolization is necessary. The aorta and its main branches are possible, yet unusual, sources of calcific emboli that merit investigation.