Ketogenic Diet Provides Neuroprotective Effects against Ischemic Stroke Neuronal Damages

Ischemic stroke is a leading cause of death and disability in the world. Many mechanisms contribute in cell death in ischemic stroke. Ketogenic diet which has been successfully used in the drug-resistant epilepsy has been shown to be effective in many other neurologic disorders. The mechanisms underlying of its effects are not well studied, but it seems that its neuroprotective ability is mediated at least through alleviation of excitotoxicity, oxidative stress and apoptosis events. On the basis of these mechanisms, it is postulated that ketogenic diet could provide benefits to treatment of cerebral ischemic injuries.

Long-Term Endovascular Treatment Outcome of 46 Patients with Cavernous Sinus Dural Arteriovenous Fistulas Presenting with Ophthalmic Symptoms. A Non-Controlled Trial with Clinical and Angiographic Follow-up

Ocular symptoms are regularly observed in patients with cavernous sinus dural arteriovenous fistulas (cDAVF). We aimed to evaluate the long-term efficacy and safety of endovascular approaches in patients with cDAVF presenting with different ocular symptoms. In a prospective study between June 2008 and March 2013, 46 patients with ocular symptoms due to cDAVF who were not eligible for conservative therapy, met the inclusion criteria and underwent endovascular treatment. They underwent a transarterial approach with histoacryl glue injections or transvenous coil embolization, all in one session. They were followed up for a mean period of 17.3 months (range 7 to 30 months) clinically and using angiography. The mean age of patients was 36.8 years (18-60) and 65% of them were male. All patients showed venous drainage into the superior and inferior orbital veins. Access to the cavernous sinus was transvenous in ten patients, transarterial in 26 patients, and mixed in ten patients. Initial symptoms were improved in 97.8% of patients and did not recur during the study follow-up. The procedural complications included: blurred vision, transient sixth nerve palsy and exacerbation of chemoproptosis in two, one and two patients respectively that completely resolved in initial weeks with no recurrence. No patient worsened or developed new symptoms suggestive of a recurrent fistula during the follow-up period. One patient experienced intracranial dissection of the internal carotid artery and ischemic stroke with an unfinished procedure. The relief of early presentation was durable in long-term follow-up and the cured lesions were stable in angiographic controls. Favorable and durable outcomes could be obtained following endovascular approaches for cDAVF presenting with different ocular symptoms.

Allopurinol as a preventive contrivance after acute ischemic stroke in patients with a high level of serum uric acid: a randomized, controlled trial

OBJECTIVES

To assess the clinical relevance (functional outcome) of a 3-month allopurinol regimen in patients with high serum uric acid (SUA) levels and acute ischemic stroke without considering the changes in SUA levels.

MATERIALS AND METHODS

In a randomized, double-blind, controlled study, 70 patients (45 females, 25 males) with acute ischemic stroke who had elevated levels of SUA were included. They were divided in two 35-patient groups to investigate the effect of 3 months of an allopurinol (200 mg/day) regimen versus placebo on their functional outcome, which was evaluated using a modified Rankin scale.

RESULTS

The overall mean age was 68.9 ± 11.33 years (range 27-89). The final favorable functional status (mRS = 0-2) was 23 (65.7%) and 14 (40.0%) in the treated and placebo groups, respectively, which was strongly associated with allopurinol consumption (OR = 4.646, p = 0.014) and age ≤70 years (OR = 0.139, p = 0.005) in patients with ischemic stroke after adjusting for confounders. There was no significant difference in death between allopurinol-treated cases (3; 8.6%) and placebo-treated ones (6; 17.2%; p = 0.278).

CONCLUSION

Allopurinol treatment was well tolerated and improved the 3-month functional status of patients with acute ischemic stroke who had high levels of SUA without considering the decreasing effect of allopurinol on SUA.

Juvenile ischemic stroke secondary to cardiogenic embolism: a rare case report

Myxomas, the most common primary cardiac tumors, are known as a source of cardiogenic emboli. The possibility of their early detection has made them of great importance for emergency medicines. Detection of the disease is probable at early stages using echocardiography and associate complications such as syncope, cerebral embolic ischemic strokes, and sudden death. We report experience of a rare case of juvenile acute stroke in a patient with cardiac myxoma affecting all cardiac chambers presenting to the emergency department. In young stroke patients with signs and symptoms compatible with cardiovascular involvement, cardiogenic emboli should be taken into consideration; early echocardiographic studies are highly recommended. Prompt myxoma resection is required in both asymptomatic and stroke patients in whom intravenous thrombolysis course has not been implemented due to any limitations.

Early and intermediate prognosis of intravenous thrombolytic therapy in acute ischemic stroke subtypes according to the causative classification of stroke system

Objectives: Intravenous thrombolytic therapy has established acceptable results in treating ischemic stroke. However, there is little information on treatment outcome especially in different subtypes. The aim of current study was to evaluate early and intermediate prognosis in intravenous thrombolytic therapy for acute ischemic stroke subtypes.

Methodology: Forty eligible patients (57.5% male with mean age of 63.18±13.49 years) with definite ischemic stroke who were admitted to emergency department of Imam Reza University Hospital, in the first 180 minutes after occurrence received recombinant tissue plasminogen activator. All investigation findings were recorded and stroke subtypes were determined according to the Causative Classification of Stroke System. Stroke severity forms including modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores were recorded for all patients in first, seven and 90 days after stroke and disease outcome was evaluated.

Results: The etiology of stroke was large artery atherosclerosis in 20%, cardio-aortic embolism in 45%, small artery occlusion in 17.5% and undetermined causes in 17.5%. NIHSS and mRS scores were significantly improved during time (P < 0.001 in both cases). Three months mortality rate was 25%. Among the etiologies, patients with small artery occlusion and then cardio-aortic embolism had lower NIHSS score at arrival (P = 0.04). Caplan-meier analysis showed that age, sex and symptom to needle time could predict disease outcome.

Conclusion: Intravenous thrombolytic therapy is accompanied by good early and intermediate outcome in most patients with ischemic stroke. Small artery occlusion subtype had less disease severity and higher improvement.

Is there a correlation between hs-CRP levels and functional outcome of Ischemic Stroke?

Objective: C-reactive protein, a well known marker of inflammation is being investigated as a probable marker of predicting acute cardiovascular events and its severity. The aim of the present study was to assess the possible role of highly-sensitivity C-reactive protein (hs-CRP) in predicting short-term functional outcome of ischemic stroke.

Methodology: A prospective study was conducted on subjects admitted with first attack of confirmed ischemic stroke. It included 50 male and 52 female. Serum hs-CRP was measured in the 2^nd (CRP-D2) and 5^th days (CRP-D5) post-stroke. Modified Rankin scale (MRS) was measured in all subjects in the 2^nd (MRS-D2), 5^th days (MRS-D5) and also 3 month (MRS-M3) after stroke to assess the short-term functional outcome and mortality of subjects.

Results: The mean age of the patients was 71.75±11.44 years. The mortality rate was 47.1% in the third months after stroke. There was no significant correlation between CRP-D2 and MRS-M3 and also between CRP-D5 and MRS-M3 (P>0.05). However there was a significant association between high CRP-D2 (CRP>3) and MRS-M3 and also between high CRP-D5 and MRS-M3 (P<0.005).

Conclusion: This study showed that the value of CRP by itself could not predict the severity of short-term functional disability and it might not be useful as a clinical tool for predicting outcome.

A Comparison of Stent Implant versus Medical Treatment for Severe Symptomatic Intracranial Stenosis: A Controlled Clinical Trial

Background

Atherosclerotic stenosis of the major intracranial arteries is the most common cause of ischemic stroke. There are limited treatments for severe intracranial stenosis, and stent placement versus medical treatment remains controversial. The aim of this study was to compare functional outcomes of these two modalities in patients with severe symptomatic intracranial stenosis.

Methods

At a single center, between 2008 and 2011, patients with angiographically demonstrated severe (70–90%) symptomatic intracranial atherosclerosis were divided into two groups: group A, which received only medical treatment, and group B, which underwent endovascular stent implant treatment. The severity and location of the stenosis was determined by digital subtraction angiography and the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial criteria in all patients. The exclusion criteria were: specific causes other than atherosclerosis, such as artery dissection, fibromuscular dysplasia, vasculitis, radiation and intracranial hemorrhage, focal neurological deficit that did not correlate to internal carotid artery or middle cerebral artery stenosis. All procedures were done under light anesthesia. Technical success was defined as the reduction of stenosis to <30% with complete enveloping of the lesion after the procedure. Early and late adverse events and functional outcomes were compared between the groups using the modified Rankin Scale (mRS).

Results

Overall, 63 patients (29 in group A and 34 in group B) were evaluated and followed for a mean period of 15.22 months (range 6–25). The technical success rate was 97% in a total of 34 stents in 34 patients. There was no difference between the early (within 30 days) adverse event rates of the two groups. The median follow-up duration for the stent implant patients was 15 months (range 6–25), and for the medically treated cohort it was 14 months (range 8–25). The re-stenosis rate was 5.8% and the total number of late (>30 days) adverse events, including stroke, myocardial infarction and death, was 1 (2.9%) and 6 (20.7%) in the stent implant and medical groups, respectively (p = 0.042). The stent implant group had significantly better favorable functional outcomes according to the mRS than the medical group (93.9 vs. 63.0%). The cumulative secondary adverse event-free survival was significantly lower in the stent implant group.

Conclusion

Stent implants can be considered more durable and safe for patients with symptomatic severe stenosis of the internal carotid artery or middle cerebral artery, despite optimal medical therapy. Randomized, multicenter trials are required to confirm these results.

Treatment of progressive cerebral sinuses thrombosis with local thrombolysis

Cerebral venous thrombosis (CVT) is a potentially serious disease, with nonspecific clinical symptoms and an unpredictable outcome. Despite adequate anticoagulation, a patient's clinical condition can rapidly deteriorate. The aim of this study was to evaluate the efficacy of local thrombolysis in these patients. Consecutive patients with progressive cerebral venous thrombosis between October 2008 and January 2011 were enrolled prospectively. Progressive CVT was defined as the persistence of neurologic findings (headache, blurred vision, and visual field defects) despite at least four days (or 48 hours in patients with involvement of more than one sinus) on full anticoagulation therapy with heparin and development of focal neurologic deficits or cortical hemorrhage. We excluded patients with large hematomas and predisposing malignancies like leukemia. All patients underwent local thrombolysis with 30 mg recombinant tissue plasminogen activator (rtPA). Overall, 26 patients were enrolled with a mean age of 35.5 years (range 18 to 56 years). Six patients (23%) were male and twenty patients (77%) were female. The most common presenting feature was headache and the most common neurologic finding was papilledema, which was present in all patients. Eighty-five percent of women had a history of oral contraceptive pill consumption. Successful recanalization was achieved in all patients except one (96.2%). Neurological examinations and follow-up assessments were based on a modified Rankin scale (mRS). Favorable outcome and recovery was defined as a mRS score of 0-1. Follow-up assessments at the third week showed that 25 out of 26 recovered, with 18 having a mRS score of 0 and 7 with a mRS score of 1. There were no procedure-related neurological complications. Our results show that local thrombolysis is a safe and effective treatment modality for patients suffering from progressive CVT.

Atypical presentation of vitamin B12 deficiency

Vitamin B12 deficiency (B12D) has wide variety of neurological and non-neurological signs and symptoms. We describe a 61-year-old man who was admitted to Emergency Department (ED) with trouble to walk independently, suffering from weakness and a long history of dyspepsia that had worsened in the last four weeks. He had mild impairment of cognitive functions; motor strength was normal and his patellar and achilles reflexes were absent, also the plantar reflexes were abolished. All blood tests were normal except hemoglobin concentration which showed mild anemia. At further studies regarding trouble walking of this patient, he was candidated for lumbar disk surgery based on mild disk bulging seen at L3-L4 level in the lumbar spine MRI. Further examinations before the surgery due to approach to anemia showed severely decreased serum vitamin B12 level. The patient's symptoms improved after treating with intramuscular cobalamin. Being a very commonly seen disorder in the general population, B12 deficiency should be born in mind as a probable diagnosis in patients with peripheral neuropathy and no clear underlying cause presenting to the ED. Therefore, simple screening with a CBC might decrease the neurologic complications, morbidity and inappropriate workups through early diagnosis and treatment.

Comparative effects of insulin-like growth factor II (IGF-II) and IGF-II mutants specific for IGF-II/CIM6-P or IGF-I receptors on in vitro hematopoiesis

This report presents the results of studies investigating the effect of insulin-like growth factor II (IGF-II) on the proliferation and differentiation of CD34+ bone marrow cells in serum-substituted liquid cultures. Bone marrow cells were enriched for CD34+ cells and then placed in liquid cultures supplemented with either interleukin 3 (IL-3) or IL-3 and c-kit ligand with and without the addition of IGF-II. When CD34+ cells were incubated with IL-3, cellularity increased throughout four weeks of culture. Cellularity was twofold greater when cultures also contained IGF-II. IGF-II also promoted an increase in cellularity in cultures with IL-3 and c-kit ligand. In combination with IL-3 or IL-3 and c-kit ligand, IGF-II promoted an earlier differentiation of granulocytes, as well as an increase in the number of megakaryocyte lineage cells. There were approximately two-fold more colony-forming units for granulocytes and macrophages (CFU-GM) and burst-forming units for erythroid cells (BFU-E) in cultures containing both IL-3 and IGF-II than in cultures with IL-3 alone. These results demonstrate that in cytokine-supplemented media, physiological concentrations of IGF-II augmented both the proliferation and differentiation of CD34+ bone marrow cells while maintaining a greater number of progenitor cells. To identify the receptors through which IGF-II enhances in vitro hematopoiesis, IGF-II was substituted with one of the mutant forms of IGF-II that selectively interacts with either IGF-II/CIM6-P receptors or with IGF-I and insulin receptors. The results with the mutant forms of IGF-II demonstrate that IGF-II augments in vitro hematopoiesis primarily through its interaction with IGF-I and possibly insulin receptors, rather than IGF-II/CIM6-P receptors.

Influence of an autocrine multitherapy resistance factor on radiation responses of melanoma cells

An autocrine multitherapy resistance factor (MTRF) produced by a radioresistant subclone of S91 mouse melanoma (S91/I3) causes an increase in radioresistance of a radiosensitive subclone (S91/amel). MTRF has no effect on the survival of S91/I3, which is already relatively resistant to gamma-irradiation. In this study, we examined the effect of MTRF in the form of S91/I3 conditioned medium or as S91/I3 heavily-irradiated cells (I3-HRCells) on cellular responses of S91/amel cells after exposure to gamma-rays. Target S91/amel cells retained more than half of their ability to respond to rescue by MTRF on day 4 after exposure to 3 Gy. Continuous presence of MTRF during colony formation was necessary for maximum plating efficiency. Although the extent of double strand DNA breakage and repair was the same in S91/amel and S91/I3, split-dose recovery experiments with MTRF revealed previously undetected repair of sublethal damage in S91/amel cells. MTRF did not alter the extent of potentially lethal damage repair (PLDR) in S91/I3 or S91/amel. S91/amel cells were more responsive to MTRF if they had been harvested from confluent dishes, while S91/I3 cells produced a more effective factor if they had been harvested in exponential phase. These findings demonstrate that MTRF has unique properties. It does not appear to be involved in genome repair since it does not alter the extent of PLDR and it is effective when added to cells after complete split-dose recovery has occurred.