Stroke services in the Middle East and adjacent region: A survey of 34 hospital-based stroke services

Background

Acute stroke care is complex and requires multidisciplinary networking. There are insufficient data on stroke care in the Middle East and adjacent regions in Asia and Africa.

Objective

Evaluate the state of readiness of stroke programs in the Middle East North Africa and surrounding regions (MENA+) to treat acute stroke.

Method

Online questionnaire survey on the evaluation of stroke care across hospitals of MENA+ region between April 2021 and January 2022.

Results

The survey was completed by 34/50 (68%) hospitals. The median population serviced by participating hospitals was 2 million. The median admission of patients with stroke/year was 600 (250–1,100). The median length of stay at the stroke units was 5 days. 34/34 (100%) of these hospitals have 24/7 CT head available. 17/34 (50%) have emergency guidelines for prehospital acute stroke care. Mechanical thrombectomy with/without IVT was available in 24/34 (70.6%). 51% was the median (IQR; 15–75%) of patients treated with IVT within 60 min from arrival. Thirty-five minutes were the median time to reverse warfarin-associated ICH.

Conclusion

This is the first large study on the availability of resources for the management of acute stroke in the MENA+ region. We noted the disparity in stroke care between high-income and low-income countries. Concerted efforts are required to improve stroke care in low-income countries. Accreditation of stroke programs in the region will be helpful.

Comparison of COVID-19 patients who underwent thrombectomy with those in the pre-pandemic period in terms of etiology and prognosis

OBJECTIVE

We aimed at determining the effectiveness of mechanical thrombectomy (MT) in patients with major vessel occlusion and infected with COVID-19, evaluating its clinical outcome and comparing it with non-COVID patients.

PATIENTS AND METHODS

During the pandemic, 729 patients who underwent MT in stroke centers due to Acute Ischemic Stroke (AIS) with large vessel occlusion were evaluated. This study included 40 patients with a confirmed COVID-19 diagnosis by a positive PCR test between March 11, 2020, and December 31, 2020. These patients were compared to 409 patients who underwent MT due to major vessel occlusion between March 11, 2019, and December 31, 2019.

RESULTS

Of the patients with AIS who are infected with COVID-19, 62.5% were males, and all patients have a median age of 63.5 ± 14.4 years. The median NIHSS score of the COVID-19 group was significantly higher than that of the non-COVID-19 groups. Dissection was significantly more in the COVID-19 group. The mortality rates at 3 months were higher in the COVID-19 groups compared to non-COVID-19 groups.

CONCLUSIONS

This study revealed an increased frequency of dissection in patients with COVID-19. COVID-19-related ischemic strokes are associated with worse functional outcomes and higher mortality rates than non-COVID-19 ischemic strokes.

How does the use of antiplatelet and anticoagulants affect the success of mechanical thrombectomy in acute ischemic stroke cases?

BACKGROUND AND PURPOSE

In this study, we wanted to investigate the effect of antiplatelet and anticoagulant use on the success of mechanical thrombectomy in acute ischemic stroke cases.

METHODS

174 patients who were brought to the Stroke Center of Gaziantep University Şahinbey Research and Practice Hospital between January 2018 and February 2019 due to acute ischemic stroke and who underwent mechanical thrombectomy were retrospectively analyzed. The demographic characteristics, antiplatelet/anticoagulant use before the stroke and mTICI (modified-Throm-bolysis-In-Cerebral-Infarction) scores used for reperfusion in mechanical thrombectomy were evaluated. The findings were analyzed statistically (p<0.05).

RESULTS

The mean age was 63.3 ± 13.5 in 174 patients who underwent mechanical thrombectomy. 23/174 (13.2%) patients were using anticoagulant therapy (warfarin-OAC or new generation oral anticoagulant-NOAC) and 28/174 (16.1%) were using antiplatelet therapy. A history of atrial fibrillation (AF) was significantly higher in patients receiving anticoagulant therapy before acute ischemic stroke (p=0.001). Patients with a history of hyper tension (HT), diabetes mellitus (DM) and coronary artery disease (CAD) before acute ischemic stroke were receiving antiplatelet therapy in higher rates (respectively; p=0.003, p=0.037, p=0.005). Successful recanalization (mTICI ≥ 2b) was higher in patients with a history of anticoagulant use and who underwent mechanical thrombectomy (p=0.025).

CONCLUSION

Our study showed that the use of anti-platelet or anticoagulants before mechanical thrombec-tomy may have an indirect positive effect on the success of the procedure.

Predictors of Symptomatic Hemorrhage After Endovascular Treatment for Anterior Circulation Occlusions: Turkish Endovascular Stroke Registry

We evaluated the predictive factors of symptomatic intracranial hemorrhage (SICH) in endovascular treatment of stroke. We included 975 ischemic stroke patients with anterior circulation occlusion. Patients that had hemorrhage and an increase of ≥4 points in their National Institutes of Health Stroke Scale (NIHSS) after the treatment were considered as SICH. The mean age of patients was 65.2±13.1 years and 469 (48.1%) were women. The median NIHSS was 16 (13-18) and Alberta Stroke Program Early CT 9 (8-10). In 420 patients (43.1%), modified Rankin Scale was favorable (0-2) and mortality was observed in 234 (24%) patients at the end of the third month. Patients with high diastolic blood pressure (P<.05) had significantly higher SICH. SICH was significantly higher in those with high NIHSS scores (P<.001), high blood glucose (P<.001), and leukocyte count at admission (P<.05). Diabetes mellitus (DM) (OR 1.90; P<.001), NIHSS (OR 1.07; P<.05), adjuvant intra-arterial thrombolytic therapy (IA-rtPA) (OR, 1.60; P<.05), and puncture-recanalization time (OR 1.01; P<.05) were independent factors of SICH. Higher baseline NIHSS score, longer procedure time, multiple thrombectomy maneuvers, administration of IA-rtPA, and the history of DM are independent predictors of SICH in anterior circulation occlusion.

Global Impact of COVID-19 on Stroke Care and IV Thrombolysis

OBJECTIVE

To measure the global impact of COVID-19 pandemic on volumes of IV thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with 2 control 4-month periods.

METHODS

We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases.

RESULTS

There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95% confidence interval [CI] -11.7 to -11.3, p < 0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95% CI -13.8 to -12.7, p < 0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95% CI -13.7 to -10.3, p = 0.001). Recovery of stroke hospitalization volume (9.5%, 95% CI 9.2-9.8, p < 0.0001) was noted over the 2 later (May, June) vs the 2 earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was noted in 3.3% (1,722/52,026) of all stroke admissions.

CONCLUSIONS

The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID-19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months.

Favorable first-pass recanalization rates with NeVa™ thrombectomy device in acute stroke patients: Initial clinical experience

BACKGROUND

The NeVa™ thrombectomy device (Vesalio LLC, Nashville, USA) has been reported to succeed in large vessel occlusion thrombectomy in animal, in-vitro, and clinical studies. Designed with Drop Zone technology, a closed distal tip, and strong expansive radial force, the device demonstrated particular efficiency in resistant "white" thrombi in preclinical research. Our goal is to determine the safety and performance of this novel stent retriever on first-pass rates and overall recanalization.

METHODS

The Interventional Neurology Database is a prospectively maintained database of anterior and posterior circulation stroke thrombectomy cases. We retrospectively analyzed cases where the NeVa™ thrombectomy device was used as the first-line treatment strategy. Data collection occurred between January 2019 and January 2020. First-pass recanalization, final recanalization, 90-day functional outcome, complication, and bleeding rates are reported.

RESULTS

One hundred eighteen patients were treated with the NeVa™ thrombectomy device. The mean patient age was 69 ± 14 years, the median baseline National Institutes of Health Stroke Scale was 14, and the median initial Alberta Stroke Program Early Computed Tomography score was 8. The median time from groin puncture to successful recanalization was 29 min (interquartile range (IQR): 20-40). First-pass recanalization rates were 56.8% (modified treatment in cerebral infarction (mTICI) 2b/3) and 44.9% (mTICI 2c/3). Final successful recanalization rate was 95.8% (thrombolysis in cerebral infarction 2b/3). Favorable functional outcome (modified Rankin Scale 0-2) was 53% in the "first-pass" subgroup and 42.4% in the total patient population. The median number of passes to achieve the final recanalization score was 1 (IQR 1-2). The rate of embolization into new territory was 1.7%. Four patients (3.3%) had symptomatic hemorrhage.

CONCLUSIONS

In our experience, the NeVa™ device demonstrated high first-pass and overall recanalization rates along with a good safety profile.

Distance to Thrombus in Endovascular Treatment of Middle Cerebral Artery M1 Occlusion Predicts Recanalization Success and Clinical Outcome

BACKGROUND

The occlusion site of the cerebral artery can help to determine recanalization success, treatment and prognosis in acute stroke patients. In current studies, different measurement techniques and different length values have been considered. We aimed to determine the relationship between the location of occlusion and recanalization success following endovascular therapy of acute middle cerebral artery (MCA) M1 occlusion.

METHODS

This study was conducted from January 2015 to March 2019. The "M1 distance-to-thrombus length" was determined on curve-linear reformat reconstruction of the MCA, and measured from the center of internal carotid artery (ICA) bifurcation to the beginning of the thrombus on digital subtraction angiography (DSA). A successful recanalization was defined as ≥ modified thrombolysis in cerebral infarction (mTICI) 2b and full recanalization as mTICI 3. Evaluation of patients at the end of the third month was carried out with modified Rankin Scale (mRS) and mortality.

RESULTS

We eventually included 95 patients treated with endovascular therapy. The patients with distance to thrombus (DT) ≤13.2 mm showed significantly higher rates of full recanalization (AUC = 0.639 ± 0.06; P=0.014, 95% confidence interval [CI]). Additionally, DT could predict successful recanalization with an AUC of 0.639. The possibility to distinguish unsuccessful recanalization cases after the endovascular treatment by considering DT had 85.7% sensitivity (95% CI). Of the 82 (86.3%) patients who were treated with successful recanalization (≥mTICI 2b), 46 (48.4%) achieved mRS (0-3) and 38 (40%) expired at the end of the 3 months.

CONCLUSION

Shorter DT was associated with higher rate of full recanalization (mTICI 3) after endovascular therapy. Having a longer DT reduces the chance of successful recanalization without distal embolism. However, there was no statistically significant effect for DT on a favorable outcome at third months or mortality with endovascular treatment of MCA M1 occlusions.

The relationship between first pass recanalization of stent-retriever-based thrombectomy and neutrophil to lymphocyte ratio in middle cerebral artery occlusions

BACKGROUND

Inflammatory response plays an important role in the process of ischemic stroke. Rapid, sustained and complete reperfusion is the most important modifiable prognostic factor for a favorable clinical outcome in patients receiving endovascular treatment (EVT). The studies related to the clot contents regarding the high level of leukocyte clots that are difficult to recanalize are quite remarkable. We aimed to investigate the relationship between Neutrophil to lymphocyte ratio and recanalization at the first pass thrombectomy.

METHODS

Study was conducted from February 2015 to December 2018. Patients with stroke were treated with mechanical thrombectomy. The normality of distribution of continuous variables was tested by Shapiro-Wilk test. The Mann-Whitney U test and Chi-square test was used to assess relations between variables. ROC curve analysis was performed to determine the cut-off value for NLR.

RESULTS

There were 84 patients included the study, the mean age 62.8 ± 12.9; 61.9% (52/84) that were female; median (IQR 25-75) NIHSS 16 (14-19) treated with stent-retriever-based thrombectomy. The distribution of NLR was skewed (p value for 1-sample Kolmogorov-Smirnov test: <0.001). In terms of recanalization outcomes, the patients with NLR < 3.51 showed a significantly higher rates of successful recanalization (AUC = 0.671 ± 0.06; p = 0.005).

CONCLUSION

This study demonstrates that higher admission NLR values are independent predictors of unsuccessful recanalization first pass in MCA M1 occlusion of stroke patients treated with mechanical stent-retriever-based thrombectomy. Future large cohort and structural analysis of thrombi studies are needed to further explore the role of NLR as a prognostic neuroinflammatory biomarker for successful recanalization in EVT of stroke.

Direct Common Carotid Artery Puncture: Rescue Mechanical Thrombectomy Strategy in Acute Ischemic Stroke

PURPOSE

In a minority of cases, the transfemoral approach cannot be performed due to unfavorable anatomical barriers. In such cases, direct common carotid artery puncture (DCCAP) is an important alternative for rescue mechanical thrombectomy. The purpose of this study was to evaluate the efficacy and safety of DCCAP in patients with an unaccessible femoral route for mechanical thrombectomy.

MATERIALS AND METHODS

This is a retrospective study using data in the Turkish Interventional Neurology Database recorded between January 2015 and April 2019. Twenty-five acute stroke patients treated with DCCAP were analyzed in this study. Among 25 cases with carotid puncture, 4 cases were excluded due to an aborted thrombectomy attempt resulting from unsuccessful sheath placement.

RESULTS

Patients had a mean age of 69±12 years. The average National Institutes of Health Stroke Scale score was 16±4. Successful revascularization (modified Thrombolysis In Cerebral Infarction 2b-3) rate was 86% (18/21), and 90-day good functional outcome rate (modified Rankin Scale 0-2) was 38% (8/21).

CONCLUSION

DCCAP is a rescue alternative for patients with unfavorable access via the transfemoral route. Timely switching to DCCAP is crucial in these cases.

Parathyroid Hormone and Ischemic Cerebrovascular Event

BACKGROUND

Increased parathyroid hormone (PTH) level is associated with coronary artery disease, hypertension and left ventricular hypertrophy which are all predisposing factors for the ischemic cerebrovascular event (ICVE). Carotid intima-media thickness (CIMT) and aortic distensibility are the two early, subclinical predictors of atherosclerosis. The relation of PTH with CIMT and aortic distensibility in patients with ICVE has not been previously studied.

OBJECTIVE

Our aim was to study the relationship of PTH levels with aortic distensibility and CIMT in patients with ICVE.

METHODS

Sixty-four ICVE patients and 50 control group were enrolled in the study. PTH levels, aortic distensibility and CIMT were measured in all individuals.

RESULTS

PTH levels were significantly higher in ICVE patients than in the controls (60.1±21.6 vs. 52.3±6.2 pg/ml) (p=0. 008). PTH levels were found to be inversely correlated with aortic distensibility (r= -0. 420, p=0.001) and positively correlated with CIMT (r:0, 285, p=0,002).

CONCLUSION

The present study shows that PTH levels are increased in patients with acute ischemic cerebrovascular event compared to the control group. It also demonstrates that PTH levels are inversely related to aortic distensibility of ascending aorta and positively associated with CIMT.

Mean Platelet Volume, C-Reactive Protein, and Prognosis in Patients with Acute Ischemic Stroke Following Intravenous Thrombolytic Treatment

BACKGROUND The aim of this study was to investigate the association between mean platelet volume (MPV), C-reactive protein (CRP), and prognosis in patients with acute ischemic stroke (AIS) following intravenous (IV) thrombolytic treatment. MATERIAL AND METHODS A retrospective clinical study included 129 patients within 4.5 hours from the onset of AIS, who received IV thrombolytic treatment. Clinical data were retrieved from electronic medical records. MPV, CRP, and National Institutes of Health (NIH) Stroke Scale and the modified Rankin Scale (MRS) scores for physical disability were recorded. RESULTS Of the 129 patients, 65.9% were men, and more than half received IV thrombolytic treatment within between 3-4.5 hours. The NIH Stroke Scale scores at 24 hours and at three months after hospital admission were compared with the NIH Stroke Scale scores on hospital admission. A significant correlation was found between the MPV values at 24 hours (r=0.221; p=0.012) and at three months after hospital admission (r=196; p=0.026). There was a significant correlation between CRP values at 24 hours (r=0.224; p=0.021), the difference in NIH Stroke Scale score between 24 hours and three months (r=0.249; p=0.005), and the MPV score at three months (r=0.186; p=0.035). CONCLUSIONS MPV and CRP values were significantly associated with improvement in the NIH Stroke Scale and MRS scores in AIS when patients were treated with IV thrombolytic therapy within 4.5 hours of the onset of symptoms.

Carotid artery stenting without using any embolic protective device A single Centre experience

INTRODUCTION

Despite the use of embolic protective devices in the majority of cases applied with carotid stenting to prevent embolic neurological complications related to the carotid stenting procedure, this procedure is applied to some cases without protection. The aim of this study was to present the clinical outcomes of carotid artery stent application without a cerebral embolism protective device.

MATERIAL AND METHOD

A retrospective examination was made of a total of 171 patients applied with a stent between 2014 and 2017. The patients included in the study were applied with a stent because they were symptomatic and determined with >50% narrowing in the carotid artery on angiography or asymptomatic with >60% narrowing. The degree of carotid artery narrowing was determined with Doppler ultrasonography before angiographic examination and with the North American symptomatic carotid endarterectomy trial measurement criteria during angiography. After stenting the carotid artery, patients were observed at the hospital for 24 hours RESULTS: In 10 (5.8%) patients, there was a mid cerebral artery branch infarct ipsilateral to the stent. No reperfusion bleeding was observed in any patient. In 5 (2.9%) patients, encephalopathy and agitation not exceeding 24 hours was observed. Hypotension was determined in 8 (4.6%) patients and headache lasting <24 hours in 53 (31%) patients. 1 (0.5%) patient, rectus abdominis bleeding developed one week after the procedure and within 24 hours, the patient was exitus.

CONCLUSION

Revascularisation interventions to be able to prevent the development of stroke are evaluated as important treatment options in patients with symptomatic or severe carotid stenosis. With careful patient selection in experienced centres and a multi-disciplinary approach both before and after the procedure, pleasing results can be obtained without the use of embolic protective devices.

KEY WORDS

Carotid artery stenting, Embolic protective device, Stroke.

Analyses of the Turkish National Intravenous Thrombolysis Registry

BACKGROUND

The relatively late approval of use of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke in Turkey has resulted in obvious underuse of this treatment. Here we present the analyses of the nationwide registry, which was created to prompt wider use of intravenous thrombolysis, as well as to monitor safe implementation of the treatment in our country.

METHODS

Patients were registered prospectively in our database between 2006 and 2013. Admission and 24-hour National Institutes of Health Stroke Scale and 3-month modified Rankin Scale scores were recorded. A "high-volume center" was defined as a center treating 10 or more patients with rt-PA per year.

RESULTS

A total of 1133 patients were enrolled into the registry by 38 centers in 18 cities. A nearly 4-fold increase in the study population and in the number of participating centers was observed over the 6 years of the study. The mean baseline NIHSS score was 14.5 ± 5.7, and the prevalence of symptomatic hemorrhage was 4.9%. Mortality at 3 months decreased from 22% to 11% in the 6 years of enrollment, and 65% of cases were functionally independent. Age older than 70 years, an NIHSS score higher than 14 upon hospital admission, and intracranial hemorrhage were independently associated with mortality, and being treated in a high-volume center was related to good outcome.

CONCLUSIONS

We observed a decreasing trend in mortality and an acceptable prevalence of symptomatic hemorrhage over 6 years with continuous addition of new centers to the registry. The first results of this prospective study are encouraging and will stimulate our efforts at increasing the use of intravenous thrombolysis in Turkey.

Hypertension alters phosphorylation of VASP in brain endothelial cells

Hypertension impairs cerebral vascular function. Vasodilator-stimulated phosphoprotein (VASP) mediates active reorganization of the cytoskeleton via membrane ruffling, aggregation and tethering of actin filaments. VASP regulation of endothelial barrier function has been demonstrated by studies using VASP(-/-) animals under conditions associated with tissue hypoxia. We hypothesize that hypertension regulates VASP expression and/or phosphorylation in endothelial cells, thereby contributing to dysfunction in the cerebral vasculature. Because exercise has direct and indirect salutary effects on vascular systems that have been damaged by hypertension, we also investigated the effect of exercise on maintenance of VASP expression and/or phosphorylation. We used immunohistochemistry, Western blotting and immunocytochemistry to examine the effect of hypertension on VASP expression and phosphorylation in brain endothelial cells in normotensive [Wistar-Kyoto (WKY)] and spontaneously hypertensive (SH) rats under normal and exercise conditions. In addition, we analyzed VASP regulation in normoxia- and hypoxia-induced endothelial cells. Brain endothelial cells exhibited significantly lower VASP immunoreactivity and phosphorylation at the Ser157 residue in SHR versus WKY rats. Exercise reversed hypertension-induced alterations in VASP phosphorylation. Western blotting and immunocytochemistry indicated reduction in VASP phosphorylation in hypoxic versus normoxic endothelial cells. These results suggest that diminished VASP expression and/or Ser157 phosphorylation mediates endothelial changes associated with hypertension and exercise may normalize these changes, at least in part, by restoring VASP phosphorylation.

Therapeutic Plasma Exchange in Neurologic Diseases: An Experience with 91 Patients in Seven Years

INTRODUCTION

In this study, we report the results of our experience of therapeutic plasma exchange (TPE) for neuroimmunologic disorders performed at our hospital over a seven-year period.

METHODS

We retrospectively reviewed the medical records of 91 patients (53 male, 38 female) who had been treated at our center with TPE.

RESULTS

60 patients with Guillain-Barrè syndrome (GBS), 23 with myasthenia gravis (MG), 4 with chronic inflammatory demyelinating polyneuropathy (CIDP) and 1 patient each with polymyositis, septic encephalopathy, acute disseminated encephalomyelitis (ADEM) and Opsoclonus-Myoclonus syndrome (OMS) received TPE. 26.7% of GBS patient's made complete recovery, 61.7% had partial recovery and 11.7% patients died due to respiratory failure. Despite our best efforts and effective TPE treatments, 13.4% of MG patients deceased, however, 78% had full recovery. Three patients with CIDP were discharged with full and 1 patient with partial recovery. The patient with ADEM had partial recovery with TPE at first, but deceased 2 months later due to pneumonia-related respiratory insufficiency. While, patient with polymyositis had slight-partial recovery, we obtained full recovery with TPE in septic encephalopathy and OMS patients. The side effects and complications of treatments with TPE, which included hypotension, hypocalcaemia and anemia, were mild and manageable.

CONCLUSION

The improvement rates were encouraging and we concluded that significant benefit can be achieved with TPE for the treatment of neuroimmunological disorders.

CKD is associated with recurrent ischemia but not with hemorrhagic transformation in acute ischemic stroke patients

BACKGROUND

We investigated the associations of Recurrent Ischemic Stroke (RIS) and Hemorrhagic Transformation (HT) with CKD in acute ischemic stroke patients.

METHOD

The subjects were 160 patients, divided into two groups: with eGFR <60 mL/min/1.73 m2 (CKD), with eGFR ≥60 mL/min/1.73 m2 (without CKD).

RESULTS

Subjects having DM (p = 0.018), CKD (p = 0.025) and treated with ACEI/ARB (p = 0.039) revealed association with RIS. Regression analysis disclosed only CKD (p = 0.04). Carotid artery stenosis (p = 0.030) and serum calcium levels (p = 0.013) showed significant association with HT.

CONCLUSION

Our results disclosed that CKD could be a risk factor for RIS. There is no relation between CKD and HT.

Impact of early versus late enteral nutrition on cell mediated immunity and its relationship with glucagon like peptide-1 in intensive care unit patients: a prospective study

Introduction

Glucagon-like peptide-1 (GLP-1) originates from the gastrointestinal system in response to the presence of nutrition in the intestinal lumen and potentiates postprandial insulin secretion. Also, it acts as an immune-modulator which has influences on cell-mediated immunity.

The aim of this study was to determine the impact of early enteral nutrition versus late enteral nutrition on plasma GLP-1 levels and the relationship between GLP-1 changes and cell-mediated immunity.

Materials and methods

The study was designed as a prospective, single-blinded study and carried out in the neurology intensive care unit (ICU) of a university hospital. Twenty-four naive patients with acute thromboembolic cerebrovascular events, with National Institute of Health (NIH) stroke scores between 12 and 16, were included. Any condition interfering with GLP-1 and immunity was regarded as exclusion criterion. Two patients died, and two dropped out of the study due to complicating conditions.

Patients were randomly subjected to early enteral feeding within the first 24 hours (Group 1), or late enteral feeding, beginning 48 hours after admission (Group 2) via a nasogastric tube. Calculated daily energy requirement was supplemented with parenteral nutrition, starting on the first study day for both groups. Blood samples were obtained before, and at 5, 15, 30, 60 and 120 minutes after the first enteral feeding for GLP-1 assays; this procedure was repeated on the third day. Before and 24 hours after the first enteral feeding, samples were also taken for immunological analysis. Clinical observations were recorded.

Pre- and post-feeding plasma GLP-1 changes between the two groups and within groups were evaluated. Lymphocyte subgroup changes before and 24 hours after the first enteral feeding in relation to GLP-1 changes were sought as well.

Results

Group 1 and Group 2 exhibited similar GLP-1 levels in the pre-feeding and post-feeding periods for both the first time and the third day of enteral feeding. Also, no significant change in pre-/post-feeding GLP-1 levels was observed within groups. T-helper and T-regulatory cells increased, T-cytotoxic cells decreased significantly in Group 1 (P = 0.02; P = 0.036; P = 0.0019), but remained the same in Group 2 after enteral feeding. Positive but statistically insignificant clinical effects in terms of predisposition to infections (10% vs 40%) and median time of ICU stay (10 vs 15 days) were observed in Group 1.

Conclusions

Depending on our findings, we propose that early enteral feeding may cause amelioration in cell-mediated immunity via factors other than GLP-1 in ICU patients with acute thromboembolic stroke. However, the possible deleterious effects of parenteral nutrition cannot be ruled out.

Pre- and perioperative risk factors predicting neurologic outcomes after coronary artery bypass surgery in patients with pre-existing neurologic events

BACKGROUND

A neurologic event (NE) after coronary artery bypass graft (CABG) surgery is a principal complication affecting morbidity and mortality. We investigated the risk factors predicting postoperative NEs and survival in patients with pre-existing NE undergoing CABG.

METHODS

Between 2001 and 2012, 3137 patients underwent isolated primary CABG. The data were stored in a computerized database and retrospectively evaluated. Patients were divided into 2 groups based on the existence of preoperative NE (study group; n=126) and without NE (n=3011). Uni- and multivariate logistic regression analyses were performed to evaluate the possible predictors of postoperative NEs. Survival was determined using Kaplan-Meier survival analyses of the study group and propensity score-matched control group.

RESULTS

The mean age of the 3137 patients was 60±9 years, and 28% (n=885) were female. Postoperative NE was seen in 4 (3.2%) patients with pre-existing NE and in 16 (0.5%) without pre-existing NE. Preoperative NE (odds ratio 4.47; 95% confidence interval 1.32-15.18; P=.01) and age (≥70 years; odds ratio 2.98; 95% confidence interval 1.21-7.33; P=.01) showed strong multivariate associations with postoperative NE. Median CHA2DS2-VASc scores were 4.5 (interquartile range 3-5) and 3 (range 0-4) in patients in the pre-existing and without NE groups, respectively (P=.01). The overall mean follow-up was 4.6±3 years. Overall survival rates (88.1% and 94%, respectively) were different between the 2 groups (P=.02).

CONCLUSIONS

Preoperative neurologic events and advanced age are significant risk factors predicting postoperative neurologic events. Meticulous management of the ascending aorta and carotid artery are important in diminishing postoperative neurologic events. A pre-existing neurologic event is also predictive for decreased overall survival.

Recurrent ischemic stroke as an initial manifestation of an concealed pancreatic adenocarcinoma: Trousseau's syndrome

In rare instances, stroke may precede a diagnosis of cancer and be the first clinical evidence of an underlying malignancy.Cerebral infarction mostly complicates lymphomas, carcinomas, and solid tumors. Malignancy-related thromboembolism can present as acute cerebral infarction, nonbacterial thrombotic endocarditis and migratory thrombophlebitis. It is generally attributed to a cancer-related hypercoagulable period, chronic disseminated intravascular coagulopathy (DIC), or tumor embolism. We reported a case of malignancy-related thromboembolism from an undiagnosed pancreatic adenocarcinoma in a 54-year-old man, who presented with recurrent ischemic stroke due to chronic DIC. He died of the underlying malignancy despite the appropriate institution of anticoagulation therapy.This case emphasizes that cerebral infarction may be the first manifestation of an undiagnosed cancer. If there is laboratory or clinical evidence associated with DIC, patients with a cerebral infarct of an unknown etiology should be investigated for a malignant process. The optimal method of anticoagulation in cancer patients with thromboembolic disease (TED) remains unclear.

A controlled study of psychiatric manifestations and electroencephalography findings in chronic kidney disease patients with Sagliker syndrome

Sagliker syndrome (SS) is a novel syndrome that was described in 2004 in patients with chronic kidney disease (CKD). The aim of this study was to assess psychiatric evaluations and electroencephalography (EEG) findings of patients with CKD and SS to compare them with patients with CKD having characteristics similar to that of the study group, in terms of age and gender. The study group comprised 13 patients with CKD and SS. The control group included 13 patients with CKD. Psychiatric diseases were diagnosed using the Structure Clinical Interview. Beck Depression Inventory, Beck Anxiety Inventory, Social Comparison Scale, Hopelessness Scale, and Mini Mental State Examination (MMSE) were administered to the groups. Moreover, EEG recording for all the patients was performed. According to the results obtained from the Structure Clinical Interview, 69.2% of patients with CKD and SS were diagnosed with a mental disease, as compared with only 3 (23.1%) patients with CKD. There was a significant difference between the study and the control group (P < .001). As compared with the control group, patients with CKD and SS had significantly higher scores on the Beck Depression Inventory, the Beck Anxiety Inventory, and the Hopelessness Scale. However, patients with CKD and SS had significantly lower scores on the Social Comparison Scale. The MMSE scores were not significantly different between the 2 groups. When the 2 groups were evaluated separately, no significant differences were found between the EEG abnormalities and psychiatric diagnosis of both the groups. However, an evaluation of EEG abnormalities in all cases with CKD suggested a statistically significant difference between them. In the EEG recordings, electrical seizures activity was not enrolled in any of the cases. In the present study, psychiatric morbidity for patients with CKD and SS was worse than for patients with only CKD. These results indicate a need to develop an effective psychologic strategy for dealing with psychiatric disorders among patients with CKD and SS.

A very rare case of encephalopathy in a patient with end-stage renal disease: contrast agent, ioversol

Contrast agents are associated with a number of adverse effects, including central nervous system effects. These agents are primarily filtered and excreted by the kidney. Contrast-associated encephalopathy is a rare complication. We report the case of a 55-year-old male on chronic hemodialysis who developed confusion and agitation after receiving ioversol during abdominal angiography. Although hemodialysis was performed his healing took 15 days. Patients with end-stage renal disease may be at an increased risk of adverse effects of contrast agents.

Health-related quality of life of patients with epilepsy in Turkey

The aim of this study was to measure the health related quality of life (HRQOL) of epilepsy patients and to compare it with that of a healthy control group. The evaluation included the effects of the type of seizure, duration of seizure and medical treatment on the quality of life of the patients. The group studied consisted of 221 participants (121 epilepsy patients and 100 healthy control individuals) who completed a sociodemographic data form and who were administered the World Health Organization Quality of Life (WHOQOL-100) scale. The epilepsy patients had statistically lower physical health, psychological well-being, level of independence and global HRQOL than participants in the control group (p<0.05). The analysis of variance showed that the partial epilepsy subgroup had significantly lower averages for all the quality-of-life subfields except for the social relationship dimension. On regression analysis, being married, having a generalized type of seizure and being treated with fewer medications were all related to higher scores on the HRQOL. Epilepsy is a disease that has neurological, psychiatric and psychosocial dimensions that should be evaluated using a multidisciplinary approach.

Spontaneous primary intraventricular hemorrhage in adults: clinical data, etiology and outcome

AIM

Primary intraventricular hemorrhage (PIVH), bleeding in the ventricular system without a recognizable parenchymal component, is a rare neurological disorder. The purpose of this study was to identify clinical features, risk factors, etiology and outcome of patients with PIVH.

MATERIAL AND METHODS

We retrospectively reviewed the clinical data, complementary examinations, outcome and computed tomography (CT) IVH score of 24 patients in our hospital from 2004 to 2008. We identified 24 patients with the inclusion criteria of non-traumatic PIVH. Their mean age was 60.6+/-17.4 years (range 38-79). Fourteen patients were male and 10 were female.

RESULTS

The major symptoms included headache (n=24), loss of consciousness (n=6), confusion and disorientation (n=14), nausea/vomiting (n=10). Angiography revealed vascular malformations in five patients (21%). Other possible causative factors were hypertension in 12 patients (50%) and clotting disorder in one. The aetiology remained unknown in six patients. Most PIVH patients had associated hydrocephalus (58%) and 37% of the patients required ventricular drainage. In-hospital mortality was high (41%) and a FOUR score <or=10, GCS <or=8 and early hydrocephalus were independent predictors of mortality.

CONCLUSION

Hypertension is the most common associated risk factor for PIVH followed by vascular malformation. Spontaneous resorption and rebleeding may be seen. The neurological status of the patients and an early developing hydrocephalus are the most important risk factors.

Partial Recovery from Cortical Blindness Following Monoxide Intoxication

Patients with carbon monoxide (CO) intoxication may show neurological signs such as headache, seizures, extrapyramidal findings, and coma. However, cortical blindness is rare in these cases. This study describes a woman exhibiting confusion and axial rigidity after CO intoxication. Ten days after intoxication, her pupils were isonormocoric and reactive to light. A fundoscopic examination was normal, but visual acuity was light-perception in both eyes. There were diffuse EEG slow waves. Magnetic resonance imaging (MRI) demonstrated bilateral hyperintensity in the basal ganglia. The P100 latencies of visual evoked potentials (VEP) were increased and dispersed. One year later, the patient's visual acuity was almost normal and VEPs showed mild dispersion in P100 latencies. The authors found this case of interest because cortical blindness due to CO intoxication is only rarely seen with a relatively good outcome.

PERSONALITY, DEPRESSION, AND ANXIETY AS RISK FACTORS FOR CHRONIC MIGRAINE

This article evaluated risk factors such as personality, depression, and anxiety in relation to migraine transformation in Turkish patients. Thirty-seven patients with chronic migraine and 50 patients with episodic migraine were investigated The scores for hysteria, hypochondriasis, psychasthenia, depression, and social introversion were all significantly higher in the chronic-migraine group than the episodic-migraine group. Seventy-four percent of the chronic-migraine group and 26% of the episodic-migraine group had depression. Eighty percent of the chronic-migraine group and 36% of the episodic-migraine group had anxiety. The results suggest that depression, anxiety, and personality characteristics such as hysteria, hypochondriasis, psychasthenia, depression, and social introversion may be associated with chronic migraine in Turkish patients.

Hypertensive encephalopathy with atypical MRI leukoencephalopathy affecting brain stem and cerebellum

Reversible posterior leukoencephalopathy syndrome associated with hypertension rarely presents with predominant involvement of the brainstem and sparing of the supratentorial regions. In this study, the clinical and neuroimaging features of a 39-year-old woman with hypertensive encephalopathy and magnetic resonance imaging (MRI) findings localized to pons and bilateral middle cerebellar peduncles were described. Reversible posterior leukoencephalopathy syndrome associated with hypertension rarely shows isolated brainstem and cerebellum involvement, and it is important to be familiar with the lack of correlation between the severity of the radiological abnormality and the clinical status.

Parkinsonian syndrome associated with subacute subdural haematoma and its effective surgical treatment: a case report

There have been several reports of parkinsonian syndrome arising from a mass effect from subdural haematomas. In this study, we present a case of parkinsonian syndrome caused by a subacute subdural haematoma. Evacuation of the haematoma resulted in the disappearance of parkinsonian symptoms in this case. Parkinsonism is not common complication of subdural haematoma; surgical treatment of those cases is associated with favourable outcome, without the need for antiparkinsonian medication.

[Pseudoaneurysm of the internal carotid artery following a tonsil biopsy: endovascular repair with covered stent]

Evaluation and management of peritonsillar masses require specific attention because of their relationship to vital neighboring anatomical structures. A 57-year-old woman developed pseudoaneurysm of the internal carotid artery following a biopsy taken at another center from a mass in the left tonsillar region. She was treated by a multidisciplinary approach and an endovascular covered stent was implanted under local anesthesia in the left internal carotid artery. No recurrence was detected in the neck and the patient was asymptomatic in the postoperative second year.

Spinal segmental myoclonus related to pregnancy

A 33-year-old pregnant woman (gestational age, 39 weeks and 2 days) presented with a one-day history of abdominal rhythmic myoclonus. Gynecological examination revealed that the cervix was unfavorable with irregular contractions that were ineffective. Electroencephalography, MRI of the dorsal spine and blood biochemical, examinations were normal. Electrophysiological recordings from the rectus abdominis muscles with surface electrodes showed 2 Hz rhythmic myoclonic activity bursts. On the same day, the delivery was induced and the frequency and severity of involuntary contractions decreased and disappeared in two days. This is the first case of abdominal myoclonus developed as a complication of pregnancy or delivery.

Neurologic manifestations in Sagliker syndrome: uglifying human face appearance in severe and late secondary hyperparathyroidism in chronic renal failure patients

Patients with chronic renal failure (CRF) often have signs and symptoms related to fluid and electrolyte disturbances, anemia, malnutrition, bone disease, and gastrointestinal problems. Vascular and neurologic impairment in particular remain an important source of morbidity and mortality in this vulnerable patient population. Sagliker syndrome is a novel syndrome that was recently described in 2004 in patients with CRF and severe and late secondary hyperparathyroidism who suffered from severe skull and facial bone changes, particularly from uglifying human face appearances and neuropsychiatric disorders. The goal of this study was to assess neuropsychiatric manifestations occurring in CRF patients with Sagliker syndrome. Four female and 8 male patients with CRF on regular dialysis at the hemodialysis units of the Internal Medicine Departments around southern Turkey participated in the study. All patients underwent a clinical neurologic examination performed by the same neurologist. Neuropsychiatric signs and symptoms were found in all cases. The results showed that the most frequent neurologic manifestations in CRF patients with Sagliker syndrome were headache, polyneuropathy, cranial neuropathy, fatigue, and psychiatric disorders.

[Endovascular treatment of vertebral artery origin stenosis in high risk patients]

PURPOSE

Atherosclerotic stenosis of the vertebrobasilar system most commonly occurs at the vertebral artery origin. Stenting of these stenotic lesions in combination with antithrombotics with or without anticoagulants is a safe and effective treatment method. The purpose of this study is to present the results of vertebral artery origin stenting in 14 high-risk patients.

MATERIALS AND METHODS

Significant vertebral artery origin stenosis was treated with primary stenting in 14 patients, aged between 58 and 74 years (mean, 66+/-5.3 years). Eleven patients were male, and three were female. Vertebral artery stenosis was detected in eight patients prior to coronary artery surgery, and in six patients after a posterior system stroke or during evaluation of a vertebrobasilar insufficiency. All stenosis were successfully treated with stent placement. Except one patient who had a left posterior cerebral artery infarction, all patients had an uneventful procedure without any complication. Third-month and sixth-month clinical and color Doppler follow-up examinations were available in ten patients, and 12th-month control angiography performed in three patients did not show stent restenosis. None of the patients had new neurologic deficit during the follow-up.

CONCLUSION

Vertebral artery origin stenoses are one of the most common causes of vertebrobasilar stroke. In the presence of concomitant cerebral artery stenosis or systemic disorders, patients are under high risk even if they are on medical therapy. Primary stenting combined with medical treatment is a safe and effective treatment modality.

Rupture of the hydatid disease of the liver into the biliary tracts

BACKGROUND

To analyze the diagnosis and the surgical treatment of intrabiliary ruptured hydatid disease of the liver.

METHODS

Between 1990 and 1995, 263 patients with hydatid cysts of the liver underwent surgery in a university hospital. Twenty-five (9.43%) patients with intrabiliary rupture of hepatic hydatid cyst were retrospectively reviewed.

RESULTS

Diagnosis was principally made using ultrasonography and computed tomography scanning and was confirmed by the findings of other tests. In 12 patients (48%) partial cystectomy with primary closure; 5 patients (20%) partial cystectomy with drainage; 5 patients (20%) cystotomy with drainage; 3 patients (12%) left hepatic resection (atypic, segmentary or lobar) was performed. Omentoplasty was performed in 6 patients. The common bile duct was explored in all patients and it was drained by a T-tube in 22 patients, and by a choledochoduodenostomy in 3 others. The average postoperative hospitalization time was 8.3 and 22.5 days in patients treated with choledochoduodenostomy and T-tube drainage respectively. Cholecystectomy was performed in 18 patients. Complications were seen in 4 patients (16%) with 1 pleural effusion and 3 wound infections. There was only 1 death (4%) due to duodenal peptic ulcus perforation with intrabiliary ruptured hydatid cyst.

CONCLUSION

This study indicates that T-tube drainage and choledochoduodenostomy in intrabiliary ruptured hydatid cysts are effective procedures with low morbidity and mortality rates.