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IntroductionThe COVID-19 pandemic has resulted in a dramatic unexplained decline in hospital admissions due to acute coronary syndromes and stroke. Several theories have emerged aiming to explain this decline, mostly revolving around the fear of contracting the disease and thus avoiding hospital visits.AimsIn this study, we aim to examine the impact of the COVID-19 pandemic on stroke admissions to a tertiary care centre in Qatar.MethodsThe Hamad General Hospital stroke database was interrogated for stroke admissions between September 2019 and May 2020. The number of stroke admissions, stroke subtypes and short-term outcomes was compared between the ‘pre-COVID-19’ period (September 2019 to February 2020) and the COVID-19 pandemic period (March to May 2020).ResultsWe observed a significant decline in monthly admissions in March (157), April (128) and May (135) compared with the pre-COVID-19 6-month average (229) (p=0.024). The reduction in admissions was most evident in functional stroke mimics. The average admissions decreased from 87 to 34 per month (p=0.0001). Although there were no significant differences in admissions due to ischaemic stroke (IS), intracranial haemorrhage or transient ischaemic attacks between the two periods, we noted a relative decrease in IS due to small vessel disease and an increase in those due to large vessel atherosclerosis in March to May 2020.ConclusionsThe decline in overall stroke admissions during the COVID-19 pandemic is most likely related to concerns of contracting the infection, evidenced mainly by a decline in admissions of stroke mimics. However, a relative increase in large vessel occlusions raises suspicion of pathophysiological effects of the virus, and requires further investigation.

Background: Stroke in diabetics may delay recovery and increases the risk of early recurrence of stroke. We compared the outcomes of patients (with and without diabetes) admitted with an acute ischemic stroke (AIS) in the state of Qatar. Patients and methods: We prospectively compared the clinical presentation, complications, discharge outcome, and stroke recurrence at 90 days in patients with and without diabetes. Results: Five thousand two hundred twenty-eight stroke patients were admitted between January 2014 and December 2017. Two thousand nine hundred sixty-one had confirmed AIS, 1695 (57.2%) had diabetes, 429 (14.5%) had prediabetes and 873 (29.5%) had no diabetes. Comparing diabetic patients to prediabetic and nondiabetics, they were significantly older (58.5 ± 11.9 versus 54.0 ± 12.9 versus 49.5 ± 13.8, P = .0001), had higher rates of hypertension (80.8% versus 67.4% versus 59.2%), previous stroke (18.0% versus 5.4% versus 6.2%), and coronary artery disease (12.9% versus 5.6% versus 5.0%; P = .001 for all). The percentage of patients with modified Rankin scale 3-6 at discharge (39.7% versus 32.6% versus 30.2%; P = .0001) and 90 days (26.7% versus 18.8% versus 21.4%, P = .001); 90-day mortality (6.2% versus 2.2% versus 5.2%; P = .03) and stroke recurrence (4.2% versus .7% versus 2.2%; P = .005) was significantly higher in diabetic patients. Conclusions: Patients with diabetes and AIS have more in-hospital complications, worse discharge outcomes, higher mortality and stroke recurrence at 90 days, compared to prediabetes and no diabetes.

Background Atrial fibrillation is an important risk factor for stroke but there are limited data on atrial fibrillation-related stroke from the Middle East. Methods We interrogated the Qatar Stroke Database to establish the occurrence, clinical features, and outcomes of atrial fibrillation-related stroke at Hamad General Hospital, the sole provider of acute stroke care in Qatar. Results A total of 4079 patients (81.4% male, mean age 55.4 ± 13.3 years) were enrolled in the stroke database between January 2014 and 21 October 2017. Atrial fibrillation was present in 260 (6.4%) patients, of whom 106 (2.6%) had newly diagnosed atrial fibrillation. The National Institute of Health Stroke Scale (NIHSS) was significantly higher (7.9 + 7.0 (median 6; IQR 11) vs. 5.9 + 6.4 (median 4; IQR 6), P Conclusion We demonstrate a low rate of atrial fibrillation and stroke in Qatar, perhaps reflecting the relatively young age of these patients. Atrial fibrillation-related strokes had higher admission NIHSS, greater disability, and higher mortality at 90 days when compared to non-atrial fibrillation strokes.

ObjectivesCorneal nerve damage may be a surrogate marker for the risk of ischemic stroke. This study was undertaken to determine if there is greater corneal nerve damage in patients with recurrent ischemic stroke.MethodsCorneal confocal microscopy (CCM) was used to quantify corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL) and corneal nerve fiber tortuosity (CNFT) in 31 patients with recurrent ischemic stroke, 165 patients with a first acute ischemic stroke and 23 healthy control subjects.ResultsTriglycerides (P = 0.004, P = 0.017), systolic BP (P = 0.000, P = 0.000), diastolic BP (P = 0.000, P = 0.000) and HbA1c (P = 0.000, P = 0.000) were significantly higher in patients with first and recurrent stroke compared to controls. There was no difference in age, BMI, HbA1c, total cholesterol, triglycerides, LDL, HDL, systolic and diastolic BP between patients with a first and recurrent ischemic stroke. However, CNFD was significantly lower (24.98±7.31 vs 29.07±7.58 vs 37.91±7.13, PConclusionsCorneal confocal microscopy identified greater corneal nerve fibre loss in patients with recurrent stroke compared to patients with first stroke, despite comparable risk factors. Longitudinal studies are required to determine the prognostic utility of corneal nerve fiber loss in identifying patients at risk of recurrent ischemic stroke.

Stroke in air travelers is being increasingly recognized. We report on stroke among passengers arriving at or transiting through a busy air travel hub.The stroke database of the sole tertiary care center for stroke in a large busy international hub was interrogated. Demographic data of transit passengers, their stroke risk factors, stroke severity, National Institutes of Health Stroke Scale (NIHSS), acute stroke interventions, discharge status and outcome utilizing the Modified Raking scale (mRS) were retrieved and compared between passengers and non-passenger controls.Forty-three flight-related stroke patients were compared to 2564 non-passenger stroke patients. The mean age in the flight-related stroke group was 59.53±10.83 years, 30/43 (69.8%) were males. The stroke subtypes were ischemic in 30 (69.8%) patients, hemorrhagic in 9 (20.9%), and transient ischemic attack in 3 (7.0%), with one cerebral sinus venous thrombosis (2.3%). The mean NIHSS score was 7.79±6.44 in passengers, demonstrating moderate severity. Ten patients (23.3%) received thrombolysis, one (2.3%) received thrombectomy, and one (2.3%) received both thrombolysis and thrombectomy. Outcomes, 54.8% had a good outcome (mRS 0-2), and 45.2% had dependence/death (mRS 3-6).Air passengers with stroke were found to be older with more severe strokes and a higher probability of receiving acute stroke treatment compared to non-passengers. Increased awareness with appropriate and timely recognition and triaging of transit passengers with stroke is warranted.

Endothelial dysfunction and damage underlie cerebrovascular disease and ischemic stroke. We undertook corneal confocal microscopy (CCM) to quantify corneal endothelial cell and nerve morphology in 146 patients with an acute ischemic stroke and 18 age-matched healthy control participants. Corneal endothelial cell density was lower (P P P P P P = 0.001) were lower in patients with acute ischemic stroke compared to controls. Corneal endothelial cell density, cell area and cell perimeter correlated with corneal nerve fiber density (P = 0.033, P = 0.014, P = 0.011) and length (P = 0.017, P = 0.013, P = 0.008), respectively. Multiple linear regression analysis showed a significant independent association between corneal endothelial cell density, area and perimeter with acute ischemic stroke and triglycerides. CCM is a rapid non-invasive ophthalmic imaging technique, which could be used to identify patients at risk of acute ischemic stroke.

Objective Approximately 30% of individuals who initially present with stroke are found to be stroke mimics (SM), with functional/psychological SM (FSM) accounting for up to 6.4% of all stroke presentations. Middle Eastern countries may have higher rates of somatization of emotional distress. The aim of this study was to evaluate the incidence and characteristics of FSM at a large general hospital in the Middle East. Methods All patients presenting with an initial diagnosis of stroke from June 2015 to September 2016 were eligible for this study. Clinical and sociodemographic data were obtained from the hospital's stroke database. All SM and strokes were diagnosed by Joint Commission International-certified stroke program neurologists. SM was defined as any discharge diagnosis (other than acute stroke) for symptoms that prompted initial admission for suspected stroke. FSM were compared with medical stroke mimics (MSM) and strokes (ischemic, hemorrhagic, and transient ischemic attacks). Results A total of 1961 patients were identified; 161 FSM (8.2%), 390 MSM (19.9%), and 1410 strokes (71.9%) (985 ischemic strokes, 196 transient ischemic attacks, 229 intracerebral hemorrhages). Admission with FSM was related to patients' nationality, with the highest frequency in Arabic (15.6%) and African (16.8%) patients. FSM patients were younger, more often female, and had fewer cardiovascular risk factors except for smoking compared with the strokes. FSM patients presented with more left-sided weakness and had more magnetic resonance imagings than the stroke and MSM groups. A total of 9.9% of FSM patients received thrombolysis versus only 0.5% of the MSM and 16.4% of ischemic strokes. Conclusions FSM frequencies varied by nationality, with Arab and African nationals being twice as prevalent. Stress, vulnerable status as expats, sociopolitical instability, and exposure to trauma are proposed as potential factors contributing to FSM.

Identification of factors in malignant middle cerebral artery (MMCA) stroke patients that may be useful in selecting patients for DHC. This study was a retrospective multicenter study of patients referred for DHC based on the criteria of the randomized control trials of DHC in MMCA stroke. Demographic, clinical, and radiology data were analyzed. Patients who underwent DHC were compared to those who survived without surgery. Two hundred three patients with MMCA strokes were identified: 137 underwent DHC, 47 survived without DHC, and 19 refused surgery and died. Multivariate analysis identified the following factors determining DHC in MMCA stroke: age 55 years (OR 8.5, 95% CI 3.3-22.1, P 0.001), MCA with involvement of additional vascular territories (anterior cerebral artery, posterior cerebral artery (OR 4.8, 95% CI 1.5-14.9, P = 0.007), septum pellucidum displacement ≥ 7.5 mm (OR 4.8, 95% CI 1.9-11.7, P = 0.001), diabetes (OR 3.7, 95% CI 1.3-10.6, P = 0.012), infarct growth rate (IGR) ml/h (OR 1.11, 95% CI 1.02-1.2, P = 0.015), and temporal lobe involvement (OR 2.5, 95% CI 1.01-6.1, P = 0.048). The internal validation of the multivariate logistic regression model using bootstrapping analysis showed marginal bias. Among patients with MMCA infarctions, an increased possibility of DHC is associated with younger age, MCA with additional infarction, septum pellucidum deviation of 7.5 mm, diabetes, IGR, and temporal lobe involvement. The presence of these risk factors identifies those MMCA stroke patients who may require DHC. Bootstrapping analysis indicated the model is good enough to predict the outcome in general population.

Asymptomatic small vessel disease (SVD), including white matter hyperintensities (WMHIs), periventricular hyperintensities (PVHIs), silent stroke (SS), and cerebral microbleeds (CMBs), increases the risk of stroke. There are limited studies of SVD in subjects from the Middle East and Southeast Asia (SA). All patients admitted to stroke service between 2014 and 2015 were reviewed for presence of “pre-existing” SVD. Stroke mimics with no previous history of stroke were used as controls. There were 1727 patients admitted with stroke. Analysis was done on 988 subjects (914 strokes and 74 controls) who had MRI scan done. Pre-existing SVD was seen in 642 (64.9%) patients (WMHIs 19.6%, PVHIs 33.2%, SS 51.4%, and CMBs 22%). Silent strokes were significantly more common with ischemic stroke (IS) compared to intracranial hemorrhage (ICH) (62.0 vs 34.3%, p

Background and Purpose— Corneal confocal microscopy can identify corneal nerve damage in patients with peripheral and central neurodegeneration. However, the use of corneal confocal microscopy in patients presenting with acute ischemic stroke is unknown. Methods— One hundred thirty patients (57 without diabetes mellitus [normal glucose tolerance], 32 with impaired glucose tolerance, and 41 with type 2 diabetes mellitus) admitted with acute ischemic stroke, and 28 age-matched healthy control participants underwent corneal confocal microscopy to quantify corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length. Results— There was a significant reduction in corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length in stroke patients with normal glucose tolerance ( P P P P =0.004, P P =0.002), and type 2 diabetes mellitus ( P P P r =−0.187, P =0.03; r =−0.229 P =0.01), corneal nerve fiber length ( r =−0.228, P =0.009; r =−0.285; P =0.001), and corneal nerve branch density ( r =−0.187, P =0.033; r =−0.229, P =0.01). Multiple linear regression showed no independent associations between corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length and relevant risk factors for stroke. Conclusions— Corneal confocal microscopy is a rapid noninvasive ophthalmic imaging technique that identifies corneal nerve fiber loss in patients with acute ischemic stroke.

Mimics comprise a third of patients presenting with an acute stroke. There is limited information on their natural history.We evaluate long term major cardiovascular events (MACE) in stroke mimics in a prospective database from Qatar.Between Feb 2014 and Jan 2019, 481 patients (male: 238; female: 243) mean age 57.5 years (±18.0), with 399 (83%) medical mimics and 82 (17%) functional mimics were evaluated. Imaging revealed previous old stroke in 26.6% and small vessel disease in 5%. MACE occurred in 57 (11.9%) and there were 31 deaths (6.4%) with majority of deaths (5.6%) from cardiovascular causes. MACE was significantly higher in patients with previous stroke, p 0.0001), coronary artery disease, p = 0.002), diabetic, p = 0.01), and hypertensive on admission, p 0.0001. MACE were also significantly higher in patients where imaging showed a previous stroke, p = 0.006).The occurrence of MACE during follow-up suggests that patients with existing vascular disease require aggressive management of vascular risk factors.

Background: There are gender differences in the short-term prognosis following acute stroke suggesting that outcome is less favorable in women. Factors contributing to this poor outcome include preexisting morbidity, stroke severity and higher age. Most previous studies have looked at short-term prognosis. PURPOSE: We investigated whether gender differences have a differential impact on incidence of short-term outcome and long-term major adverse cardiovascular events (MACE) including stroke, myocardial infarction, unstable angina, coronary revascularization procedure, and death in patients with suspected acute stroke. Methods: The study used a prospective cohort of Qatari patients with suspected acute stroke between January 2014 and February 2019. We calculated the modified Rankin score (mRS) at discharge and 90-days (short-term) and MACE (long-term) outcomes in both genders. To determine the independent predictor for MACE, the Cox proportional hazards regression analysis was used and summarized as hazard ratio and 95% confidential interval. Results: A total of 1372 patients identified. At 90-days, women found to have significantly poorer outcome (34.0% vs 23.4%, p Conclusion: Our results show that despite higher mortality and poor outcome at 90-days, the long-term outcome in women did not show any significant difference from men in this cohort. This may be related to older age and presence of cardiovascular risk factors.

Background: Stroke mimics (SM) is a stroke-like clinical picture due to a disease other than cerebrovascular diseases. The causes of SM are diverse. Distinguishing SM from stroke is important to avoid unnecessary acute treatment and secondary prevention. PURPOSE: We hypothesized to evaluate short and long-term outcomes in terms of major adverse cardiovascular events (MACE) in patients who presented with SM. Methods: We evaluated a prospective cohort of Qatari patients with confirmed diagnosis of SM who presented to our hospital as suspected acute stroke between January 2014 and February 2019. We investigated the associated risk factors, short- and long-term risk of MACE in these patients. We calculated the modified Rankin score (mRS) at discharge and 90-days (short-term) and MACE (long-term) outcomes. To determine the independent predictor for MACE, the Cox proportional hazards regression analysis was used and summarized as hazard ratio and 95% confidential interval. Results: A total of 481 Qatari patients (mean age 57.5 ±18.0; 56.3% male) with diagnosis of SM were identified, of whom 126 (26.2%) patients were found to have MACE during follow up (36.7 months (95% CI 35.5-37.8). Patients who develop MACE were older (62.4 ±17.5 vs 55.7 ±17.9, p Conclusions: Stroke mimics if associated with cardiovascular risk factors carry a poorer short and long-term prognosis after the first presentation. More aggressive reduction of cardiovascular risk may help in preventing such major cardiovascular events.

Remote ischemic perconditioning (RIPerC) results in collateral enhancement and a reduction in middle cerebral artery occlusion (MCAO) induced ischemia. RIPerC likely activates multiple metabolic protective mechanisms, including effects on matrix metalloproteinases (MMPs) and protein kinases. Here we explore if RIPerC improves neuroprotection and collateral flow by modifying the activities of MMP-9 and AMPK/e-NOS. Age matched adult male Sprague Dawley rats were subjected to MCAO followed one hour later by RIPerC (3 cycles of 15 min ischemia). Animals were euthanized 24 h post-MCAO. Haematoxylin and Eosin (HE) staining 24 h post-MCAO revealed a significant (p 0.02) reduction in the infarction volume in RIPerC treated animals (24.9 ± 5.4%) relative to MCAO controls (42.5 ± 4.2, %). TUNEL staining showed a 42.6% reduction in the apoptotic cells with RIPerC treatment (p 0.01). Immunoblotting in congruence with RT-PCR and Zymography showed that RIPerC significantly reduced MMP-9 expression and activity in RIPerC + MCAO group compared to MCAO group (218.3 ± 19.1% vs. 148.9 ± 12.05% (p 0.01). Immunoblotting revealed that RIPerC was associated with a significant 2.5-fold increase in activation of p-AMPK compared to the MCAO group (p 0.01) which was also associated with a significant increase in the e-NOS activity (p 0.01). RIPerC resulted in reduction of infarction volume, decreased apoptotic cell death and attenuated MMP-9 activity. This together with the increased activity of p-AMPK and increase in p-eNOS may, in part explain the neuroprotection and sustained increase in blood flow observed with RIPerC following acute stroke.

Background and purposePatients with acute stroke and mild or rapidly improving symptoms frequently show progression. The role of reperfusion treatment in such patients is not clear. We hypothesized that progression was most likely in patients with cortical localization and such patients may benefit from thrombolysis.Material and methodsWe interrogated Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Evaluation was based on localization (lacunar or cortical), multi-model imaging abnormalities and whether they received rt-PA. The 90-day mRS was used to determine outcome.ResultsDuring study period 6381 patients were admitted with acute stroke. Mild stroke within 4 hours was diagnosed in 506 [no thrombolysis: 381(lacunar: 213; cortical: 168), thrombolysis: 125 (lacunar: 45; cortical: 80)]. The rt-PA treated patients had significantly higher NIHSS (2.94±3.9 versus 1.28±2.46, pConclusionsThe outcome in patients with mild stroke depends on lesion location (lacunar versus cortical) and severity of symptoms. Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of hospital complication, explaining the poor outcome in such subjects.

There is ambiguity regarding the role of left ventricle wall motion abnormalities (LVWMAs) as a potential cardioembolic source in patients, who satisfy embolic stroke of undetermined source (ESUS) criteria.We analyzed prospectively collected data in 345 acute stroke patients, 185 (53.6%) stroke with atrial fibrillation (SwAF), and 160 (46.4%) stroke with LVWMA. LVWMA were younger (P = .003), had significantly higher frequency of stroke risk factors and lower ejection fraction (P.001). No significant difference was found between the stroke pattern in SwAF and LVWMA except focal cortical, cortical-subcortical lesions were more frequent in LVWMA (P = .002). Mean wall motion score index (WMSI) was 1.523 (range 1.05-2.71) without any correlation between the severity of WMSI and multiple strokes (P = .976). In subgroup analyses vertical basal WMSI (P = .030) and vertical mid cavity WMSI (P = .010) was significantly related to branch arterial stroke. LVWMA 94 (65%) patients were on antiplatelet/anticoagulation compared to 47 (52.4%) with atrial fibrillation (AF), with no significant difference in stroke recurrence during 4 years follow-up (P = .15).Patients with LVWMA who satisfy ESUS criteria, have stroke pattern on diffusion-weighted magnetic resonance imaging and risk of stroke recurrence similar to AF-related stroke despite being on appropriate antiplatelet medications. Further studies with anticoagulation therapy may be required in this group of patients to improve the high risk of recurrent stroke.

With the advent of machine learning techniques, creation and utilization of prediction models for different medical procedures including prediction of diagnosis, treatment and recovery of different medical conditions has become the norm. Recent studies focus on the automation of infarction volume growth rate prediction by the utilization of machine learning techniques. These techniques when effectively applied, could significantly help in reducing the time needed to attend to stroke patients. We propose, in this proposal, a Fuzzy Inference System that can determine when a stroke patient should undergo Decompressive Hemicraniectomy. The second infarction volume growth rate and the decision whether a patient needs to undergo this procedure, both predicted outputs of two trained models, act as inputs to this system. While the initial prediction model, that which predictsthesecondinfarctionvolumegrowthrateisadoptedfromanearliermodel,weproposethelatermodelin this paper. Three Machine Learning techniques - Support Vector Machine, Artificial Neural Network and Adaptive Neuro Fuzzy Inference System with and without the feature reduction technique of Principle Component Analysis were modelled and evaluated, the best of which was selected to model the proposed prediction model. We also defined the structure of Fuzzy Inference System along with its rules and obtained an overall accuracy of 95.7% with a precision of 1 showing promising results from the use of fuzzy logic. - Universiti Tun Hussein Onn M alay sia Publisher's Office. Scopus

Objective We analysed the Qatar stroke registry for ethnic variations in patients admitted with cerebrovascular disease at Hamad General Hospital, Qatar. Methods Patients admitted with acute stroke from January 2014 to December 2015, enrolled in the registry were included in the study. We evaluated the clinical presentation, risk factors, and outcome at discharge and 90 days post-discharge in relation to the patient’s ethnic background. Results A total of 1727 patients were enrolled in the Hamad General Hospital stroke registry (Middle Eastern 594 (34.4%), South East Asian 924 (53.5%) and Far Eastern 209 (12.1%)). There were significant differences in risk factors, clinical presentation and prognosis. Compared to Middle Eastern patients, Far Eastern patients were younger (62.8 ± 13.7 vs. 48.9 ± 9.1 years; p Conclusion The early age at presentation and the poor control of risk factors, especially in patients from South East Asia and the Far East requires attention.

Introduction: Cerebral small vessel disease (SVD) confers an increased risk of stroke, dementia and death. Corneal confocal microscopy (CCM) and Optical Coherence Tomography (OCT) are ophthalmic instruments which can detect neuronal loss non-invasively and may be useful surrogate markers for white matter disease (WMD). Hypothesis: To determine whether corneal and retinal nerve pathology identified using CCM and OCT, respectively, are associated with cerebral SVD in patients with acute ischemic stroke. Methods: 248 patients admitted with acute ischemic stroke underwent CCM to quantify corneal nerve fiber density (CNFD), corneal nerve fiber length (CNFL), corneal nerve branch density (CNBD) and OCT to quantify central foveal ganglion cell complex (CF-GCC). SVD was graded in periventricular (PV) and deep white matter (DWM) regions according to the Fazekas scale and white matter hyperintensities (WMH) were quantified. Statistical analysis was performed using ANOVA and multiple regression. Results: DWMSVD and PVSVD were absent (50%,40%) or present with mild (37%,37%), moderate (9%,16%) and severe (4%,7%) severity in patients with acute ischemic stroke. CNFD was significantly lower in patients with mild PVSVD (P=0.02) and severe PVSVD (P=0.004) and DWMSVD (P=0.026) compared to no SVD. CNBD was significantly lower in patients with severe PVSVD (P=0.020) compared to no PVSVD. CF-GCC was significantly lower in patients with moderate PVSVD (P=0.012) and DWMSVD (P=0.044) and severe PVSVD (P=0.012) compared to no SVD. Comparing patients with and without WMH, CF-GCC was significantly lower (P=0.045), but there was no difference for CCM. Multiple regression analysis showed an association between CNFD and PVSVD severity (β= –1.416, P=0.014) and triglyerides (β=1.146, P=0.016). There was no correlation between DWSVD and PVSVD with age, cholestrol, HbA 1c or blood pressure. Conclusions: Corneal confocal microscopy and optical coherence tomography allow rapid non-invasive identification of corneal and retinal nerve pathology in patients with moderate and severe SVD. Furthermore, corneal nerve fibre density correlates with the severity of PVSVD and triglycerides.

Background and Purpose: Embolic stroke of undetermined source (ESUS) is an important contributor to stroke worldwide. Little is known about ESUS in developing parts of the world such as South Asia, West Asia and North Africa despite the high stroke burden in these areas. The purpose of the study was to characterize the prevalence, demographic, risk factor and clinical aspects of ESUS in patients from South Asia, West Asia and North Africa residing in Qatar. Methods: Data were retrospectively collected on 3103 stoke patients. Risk factors and clinical features of the ESUS group were compared to all other strokes using Chi–square or student's t–tests. Logistic regression was used to identify factors associated with ESUS. ESUS patients were compared based on ethnicity using Chi-square or one-way ANOVA. Results: 634 patients (30·9%, 95% CI (28·9%-32·9%) met the ESUS criteria. Mean age was 56·3 years ± 13·7 and South Asian ESUS patients were younger than West Asians or North Africans (67·1 ± 13·5 versus 52·1 ± 10·8 versus 53·5 ± 14·2, P = .001). Smoking, diastolic function, prior antiplatelets and wall motion abnormalities were more common in ESUS. Logistic regression showed that South Asian ethnicity (OR 1·50, CI 1·14-1·97, P = ·003), diastolic dysfunction (OR 1·47, CI 1·23-1·75, P = ·005), global (OR 1·79, CI 1·41-2·26, P = ·001) and focal (OR 5·48, CI 3·79-7·92, P = ·001) wall motion abnormalities, predicted ESUS. Conclusions: ESUS is a major cause of stroke in patients from West Asia, South Asia and North Africa residing in Qatar. The clinical profile and risk factors for ESUS vary based on ethnicity. In South Asians, ESUS occurs at a younger age and is most likely cardiogenic in origin.

An important aspect of Smart healthcare involves the development of innovative non-intrusive procedures for early detection and diagnosis of specific illnesses. Essentially, diseases for which very complicated and invasive clinical and pathological tests are required could benefit from such innovations. Neuropathy or nerve loss is a characteristic of several commonly occurring long-term or terminal illnesses such as Diabetes, Multiple Sclerosis, Parkinson's disease, and Alzheimer. The detection of a degree of neuropathy is usually done through biopsy-type procedures in which tissue samples are collected from the body for further tests and visualization. In this paper, an innovative approach is presented by using one of the neuronal-representative organ in the body, the eye, to detect nerve loss. Specifically, small nerves are affected in the eye as the disease progresses. While this is currently a clinical practice in neurology and ophthalmology, it is still highly subjective and depends upon the clinician's perspective and experiences. The presented technique in this paper, attempts to make this procedure highly objective through translating human knowledge of neuropathy grading into a data-centric classification system using the corneal images through Confocal microscope. Clinicians use this common, non-invasive procedure for detecting a variety of anomalies in the eye. However, using the nerve-level resolution of the microscope, the corneal nerve canvas can be visualized and accordingly segmented and classified for possible neuropathy grading, which in turn, give the insight into the disease progression. The technique used in this paper is Adaptive Neuro Fuzzy Inference System (ANFIS) that translates the human understanding of the underlying pathology into numerical decisions that can be utilized as a tool into predicting and early diagnosis of the disease. - 2019 IEEE. This paper was made possible by National Priorities Research Program (NPRP) grant No. 7-234-2-109 from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the authors. Scopus

Stroke is one of the leading causes of death in the world today. Treatment of stroke using a procedure called Decompressive Hemicraniectomy requires the patient to undergo multiple CT scans in order to determine the size of the stroke affected area, also known as the infarction volume. Recent studies have focused on the automation of infarction growth rate prediction by the utilization of machine learning techniques. These, when applied correctly significantly reduce the amount of time required to determine the infarction volume in stroke patients. In this paper, we propose a system that is able to predict the infarction volume growth rate based on only one CT scan and several clinical measurements. The proposed technique uses a combination of Principal Component Analysis (PCA) and Adaptive Neuro-Fuzzy Inference System (ANFIS) and has shown to perform better in predicting the infarction volume. Dimensionality reduction in clinical data is first performed by reducing the number of features in the given stroke dataset. Then the target infarction volume growth rate is predicted using Adaptive Neuro-Fuzzy Inference System. The dataset used had 122 instances with 15 features. The obtained prediction from our proposed system consisting of a combination of PCA and ANFIS had a root mean square error of 0.196, cosine distance of 0.464 and outperformed that obtained by prediction with Adaptive Neuro-Fuzzy Inference System alone which had an error of 0.439 and a cosine distance of 0.616. This paper was made possible by National Priorities Research Program (NPRP) grant No. 7342109 from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the authors. Scopus

Cerebral microbleeds (CMBs) are very frequent diagnoses with MRI imaging in the elderly or in patients with cerebral infarction, intracranial hemorrhage (ICH), and dementia. The mechanisms for CMBs are not fully understood but may be secondary to injury to the vascular wall from long-standing hypertension or amyloid deposition in the tissue. The presence of CMB increases the risk for stroke, dementia, and death. The increasing number of CMBs is also associated with a higher risk of hemorrhagic complications with the long-term use of anticoagulants in atrial fibrillation and in patients requiring thrombolysis for acute stroke. The presence of CMBs is however not a contraindication for anticoagulation or thrombolysis as was recently shown from the results of the CROMIS-2 study. This review will summarize our current understanding of the natural history of CMBs and offer suggestions on the best management in common clinical settings.

Introduction: Many acute stroke patients present with mild symptoms, make it difficult to determine whether they should be treated with reperfusion strategies or not. The symptoms of such patients may frequently show progression. We hypothesized that localization based on clinical examination and multi-model imaging will be very helpful in determining patients most likely to have a bad outcome. Methods: We interrogated the Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Patients were evaluated based on the localization (lacunar or cortical), abnormalities on multi-model imaging and whether they were treated with rt-PA or not. The 90-day mRS was used to determine outcome. Results: During the study period 4016 patients were admitted with acute stroke. Mild stroke with arrival within 4 hours was diagnosed in 365 patients [no thrombolysis: 269 (lacunar: 155; cortical: 114), thrombolysis: 96 (lacunar: 38; cortical: 58)]. The rt-PA treated patients had significantly higher NIHSS (4.8±1.2 versus 2.3±1.6, p Conclusions: The prognosis in patients with mild stroke depends on location of the lesion (lacunar versus cortical). Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of complications that may explain the poor prognosis in such subjects.

Background: Intracerebral hemorrhage (ICH) accounts for 10 to 30 % of all strokes. However, the clinical outcome is worse than ischemic stroke with 50 % mortality rate at 30 days follow up. Qatar has a unique multi-cultural demography which may make the etiology and mechanism of ICH different from the west. There are no reports on the epidemiology of ICH from Qatar. Our study thus aims to evaluate the main risk factors and etiology based on the age and race of our current population. Method: Using our stroke database a retrospective analysis of prospectively collected data of patients with suspected stroke was undertaken . Our study sample included all ICH’s based on head CT imaging and clinical presentation. The etiology of ICH was based on age, risk factors and neurovascular imaging findings. Etiology was classified as: hypertension, CAA, vascular malformation, drug related and others (eg: vasculitis). Baseline characteristics of ICH population were assessed using univariate analysis (χ 2 test, ANOVA & student t test). Multiple logistic regression analysis was performed to define predictors of ICH using SPSS 23 and P value of 0.05 was considered significant. Result: Out of 2525 strokes, 518 (20.5%) were ICH. Patients with ICH were younger with a mean age of 51.72±13.1 compared to ischemic strokes 56.12±13.38. (P value 0.68) Due to the population distribution of races, ICH was more common in the South Asians 201/518 (38.8%) followed by Filipino and Far East [FFE] 96/518 (18.5%), then Nepali 76/518 (14.7%) then Qatari and Arabic population 12% and 9.8% (P < 0.001). The main risk factors for ICH were FFE and Nepali race followed by hypertension, obesity and diabetes. Hypertensive ICH remained the main mechanism across the different races. In the multiple logistic regression analysis, the main predictors of ICH were the FFE race (adjOR: 2.297, CI: 1.77-2.97, P-Value: 0.00) and hypertension (adj OR: 1.85 CI: 1.46-2.36, P-Value: 0.00, NIHSS (adjOR: 1.15 CI: 1.13-1.17, P-value: 0.00) and age (adjOR: 0.9, CI: 0.96-0.98, P-value: 0.00) Conclusion: The rate of ICH in Qatar is similar to the west. It is substantially low in the Qatari’s compared to the Far Eastern and South Asian population. Across all races the main risk factor and etiology remains uncontrolled hypertension.

The author names "Dr. Pablo Garcia Bermejo" and "Dr. Muhammad Faisal Wadiwala" needed to be added as the 6th and 7th authors, respectively. The authors regret this error.

In patients with malignant middle cerebral artery (MMCA) stroke, a vital clinically relevant question is determination of the speed with which infarction evolves to select the time for decompressive hemicraniectomy [DHC]. A retrospective, multicenter cross-sectional study of patients referred for DHC, based on the criteria of randomized controlled trials, was undertaken to identify factors for selecting the timing of DHC in MMCA stroke, stratified by time [ 48, 48-72, 72 h]. Infarction volume and infarct growth rate [IGR] were measured on all CT scans. One hundred eighty-two patients [135 underwent DHC and 47 survived without DHC] were included in the analysis. After multivariate adjustment, factors showing the strongest independent association with DHC were patients 55 years of age, septum pellucidum deviation, temporal lobe involvement, MCA with additional infarcts, and IGR on second CT. Of the five factors identified, different combinations of determining factors were observed in each subgroup. Both first and second IGRs were highest in the 48, 48- 72, and 72 h [p 0.001]. Patients who survived without surgery had the slowest IGRs. There was no association between time to DHC and infarct volume, although infarct volume was lower in patients who survived without DHC compared to the DHC subgroups. We identify the major risk factors associated with DHC in time-stratified subgroups of patients with MMCA. Evaluation of IGRs between the first and second scan and when possible second and third scan can help in selecting the timing of hemicraniectomy.

Purpose To evaluate whether corneal confocal microscopy (CCM) detects axonal degeneration and whether this is associated with retinal nerve fiber degeneration and clinical disability in patients with multiple sclerosis (MS). Methods Twenty-five patients with MS and 25 healthy control subjects underwent CCM, optical coherence tomography (OCT), and assessment of neurological disability using the expanded disability status scale (EDSS) and MS severity score (MSSS). Results In patients with MS compared with controls, there was a significant reduction in corneal nerve fiber density (CNFD), branch density (CNBD), and length (CNFL). There was no significant difference in CCM parameters between patients with optic neuritis (MS-ON) and without (MS-NON), or between relapsing-remitting (RRMS) and secondary-progressive MS (SPMS). There was significant thinning of the retinal nerve fiber layer (RNFL) in the global, temporal, temporal superior, and temporal inferior quadrants, with no difference between MS-ON and MS-NON. Patients with SPMS compared with RRMS had a significantly lower global, temporal superior, temporal inferior, nasal, and nasal superior RNFL. The EDSS and MSSS correlated significantly with CNBD, nasal, nasal superior, and nasal inferior RNFL and with CNBD and nasal inferior RNFL, respectively. Conclusions CCM and OCT detect significant corneal and retinal nerve degeneration which relates to the severity of neurological deficits in patients with mild MS.

The prediction of infarction volume after stroke onset depends on the shape of the growth dynamics of the infarction. To understand growth patterns that predict lesion volume changes, we studied currently available models described in literature and compared the models with Adaptive Neuro-Fuzzy Inference System [ANFIS], a method previously unused in the prediction of infarction growth and infarction volume (IV). We included 67 patients with malignant middle cerebral artery [MMCA] stroke who underwent decompressive hemicraniectomy. All patients had at least three cranial CT scans prior to the surgery. The rate of growth and volume of infarction measured on the third CT was predicted with ANFIS without statistically significant difference compared to the ground truth [P = 0.489]. This was not possible with linear, logarithmic or exponential methods. ANFIS was able to predict infarction volume [IV3] over a wide range of volume [163.7–600 cm3] and time [22–110 hours]. The cross correlation [CRR] indicated similarity between the ANFIS-predicted IV3 and original data of 82% for ANFIS, followed by logarithmic 70%, exponential 63% and linear 48% respectively. Our study shows that ANFIS is superior to previously defined methods in the prediction of infarction growth rate (IGR) with reasonable accuracy, over wide time and volume range.

BACKGROUND The Arabian Gulf region is rapidly developing, with major changes in lifestyle that can increase the risk of cardiovascular diseases, including TIA and stroke. Stroke constitutes a major cause of morbidity and mortality in Qatar. Cerebral auto-regulation is an intrinsic protective mechanism guaranteeinghemodynamic integrity of cerebral circulation. It modulates cerebral blood flow(CBF) in order to meet regional perfusion demands despite variations in arterial blood pressure. Impaired cerebral auto-regulation is associated with poor functional and prognostic outcomes in patients with ischemic stroke. OBJECTIVES The study has two arms; one arm is a health improvement project conducted in Qatar with the aim of developing, establishing and maintaining an acute stroke database (registry) in Qatar. The second arm is an applied research project with the aim to correlate CBF and cerebral auto-regulation and microalbuminuria in TIA patients, and to assess the prognostic significance of such a correlation. Thus far, no physiologic or biochemical biomarker has been proven as an effective predictor of poor outcome in TIA patients. DESIGN / METHODS Fifty-six patients (35 men, mean age, 53.2 yrs) with acute TIAs or small strokes (TIAs with tissue evidence of infarction) were enrolled last year and evaluated with bilateral, simultaneous TCD studies of their MCAs CBF within 72 hrs of the indexed event. On best medical therapy, the patients were followed up at one year for outcomes measures of death, stroke and recurrent TIAs in an attempt to correlate them with the TCD parameters. RESULTS Fifteen healthy volunteers (mean age 30 years) were studied using voluntary breath-holding technique to provide the hypercapnia stimulus to effect cerebral auto regulation of CBF in their MCAs. Fifty TIA patients (mean age 53.7 yrs) had complete TCD studies and 48 were followed up to one year. Seven experienced symptoms or signs of a new cerebrovascular event (3 strokes and 3 recurrent TIAs) for an annual rate for cerebrovascular events of 14%. The average BHI for the respective groups were 0.9 ± 0.78 for the controls, 0.62 ± 1.1 for the TIA patients and 0.31 ± 0.85 for those who had cerebrovascular events on follow up. MCA TCD studies with BHIs in the TIA patient group with stroke or recurrent TIA at follow up showed a tendency towards abnormality as compared to healthy controls (p>0.05) CONCLUSION Preliminary results indicate the feasibility of TCD and BHI in acute evaluation of TIA patients for the purpose of prognosis and functional outcome. Further studies are necessary to confirm their clinical value. Calculating BHI has potential of a strong prognostic predictor of future cerebrovascular events. It could be used as an inexpensive non-invasive tool for the acute evaluation of TIA patients. Together with other neuroimaging studies it brings a real time neurophysiologic dimension to the assessment and possible prevention of stroke.

Background: There is limited information on evolution of temporal lesion volumetric changes in acute ischemia. Though infarct evolves in natural logarithmic or linear pattern in acute phase [24 hrs] both fail to predict the lesion volume in later phase [48,96,200 hours]. Maximum infarct volume [MIV] measured by these methods don’t reach a plateau at the infinite point in time, not true in clinical medicine. Instead of probability based statistical methods we used Adaptive Neuro-Fuzzy Inference System [ANFIS]. ANFIS utilizes features of human brain fundamental to the learning process, pattern modeling and perceptive inference. The purpose is to identify the best method to predict stroke volume at various time intervals. Methods: We used pooled hemicraniectomy database to select patients with three CT scans. Measurement of the infarct volume [IV] was done using ABC/2 method. Maximum infarct volume [MIV] was calculated using last CT before DHC. Time was measured from stroke onset to CT. Mean measured MIV was used as standard to compare the outcome by various methods. A Pseudo-Monte-Carlo scheme was utilized in improving the accuracy of the classification. Results: There were 66 patients with 3 CT-scans. We used MATLAB-2015 with Fuzzy Logic Toolbox functions to determine the pattern of infarct growth [Linear, Logarithmic, Exponential and ANFIS] and to determine the best predictive method at various time intervals. Of the measured IV on CT 1 and 2, 40 patients [60%] data set was used for training the ANFIS system while remaining 26 [40%] was used for testing. Mean measured MIV was 332±112.21 cm 3 [min 112.86 cm 3 , max 650 cm 3 ] at mean time 67.75±67.39 hour [min 21.30 hours, max 350 hours]. Mean MIV measured by ANFIS 319.05±94.58 cm 3 [p=0.32], Linear 251.77±154.46 cm 3 [p=0.01], Logarithmic 259.68±88.76 cm 3 [p=0.00], and Exponential 157.80±84.05 cm 3 Conclusion: ANFIS predicted the third infarct volume with high degree of accuracy across various time intervals. ANFIS method can provide an excellent model for forecasting infarct volume and growth rate, characterizing the evolution of lesion and pathological stages for mechanistic studies and therapeutic interventions of stroke disease.

Objective: The purpose of this multi-institutional pooled data analyses from three countries was to determine the impact of DHC timing on the functional outcomes in patients operated beyond 48 hours in comparison with DHC under 48 hours. In addition factors leading to early or late DHC were also identified. Methods: Retrospective, multicenter cross-sectional study to measure outcome following DHC 48 hours using the modified Rankin Scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4, at three months. Results: In total 137 patients underwent DHC. There was no significant difference in the functional outcome [P=0.140] and mortality [P=0.975] but with a trend towards better outcome in patients operated over 48 hours. Multivariate analysis showed age ≥ 55, MCA with additional infarction, septum pellucidum deviation ≥1cm, and uncal herniation was independent predictor of poor functional outcome at three months. In the ‘‘best’’ multivariate model IGR >7.5ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] [DHC48 hours, 7.1 ± 5.03ml/hr] [P 48 hours 7.15 ±6.23 ml/hr [P Conclusions: There was no significant difference in the functional outcome and mortality in patients operated >48 hours of stroke onset compared to early [

Purpose: Thrombolysis in acute stroke is time limited. Onset time is unknown in a large number of patients. We wanted to classify acute stroke patients with unknown time of onset into less than or more than 4.5 hours onset, using CT scan and National Institute of Health Stroke Scale(NIHSS). Methods: Acute stroke patients with NIHSS ≥8 and CT within 24 hours of onset were included. The control group included 100 normal CT. Two reviewers blinded to clinical information independently reviewed all images. CT was graded as 0-normal, grade-I poorly-demarcated hypodensity and grade-II well-demarcated hypodensity. Hounsfield unit (HU) calculated in the area of interest using 0.5-1 cm area and compared with the contralateral side (n=44). The diagnosis was confirmed from follow-up scans. Results: A total 120 CT-scans were reviewed. There were 65% males, age ranged from 39-90 years. < 4.5 hour group : Sixty-nine CT were graded as 4.5 hours category. Both observers were incorrect on same eight CT-scans. Five of the false negative (assigned to >4.5-hours) were in 2.30-3.0 hours range with average NIHSS of 13. Four patients under two hours developed hypodensity, assigned to >4.5 hour category with average NIHSS of 21. Average NIHSS of the group was 15. > 4.5 hours group: Fifty-one CT were over 4.5 hours. Forty-four (86%) were correctly graded as >4.5-hours (p4.5-hour group was 14. Eleven incorrectly categorized scans [false negative (n=5) and positive (n=6)] tend to fall in the 2.45-4.10 hours range. Twenty-five (21%) CT scans were normal, all under three hours except one with NIHSS ≥8 at seven hours. HU were measured in 44 patients. Average HU of patients in 4.5 hour category (n=24) was 7.5. Conclusion: Acute stroke with unknown time of onset, NIHSS >8 and CT scan changes of grade 0-I indicate 4.5 hours onset (false negative).

Objective: The randomized trials and pooled analysis showed improved outcome and reduced mortality in malignant middle cerebral artery [MMCA] undergoing decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. This could be due to highly selective patient population in trials, not reflecting real world practice. Furthermore, with ischemic stroke being so common in the South Asian and Middle Eastern population, there still exists very little published data on DHC in MMCA stroke patients. Methods: Retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4, at three months. Results: In total 137 patients underwent DHC. At 90 days, mortality was 16.8%, 61.3% of patients survived with an mRS ≤4 and 38.7% had an mRS of >4. Age (55 years), diabetes [p=0.004], hypertension [p=0.021], pupillary abnormality [p=0.048], uncal herniation [p=0.007], temporal lobe involvement [p=0.016], additional infarction [MCA + ACA, PCA] [P=0.001], and infarction growth rates [P=0.025] was significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation >1cm and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome [p=0.109]. Conclusions: Similar to the effects observed in the studies from the West, DHC improves functional outcome in predominantly South Asian patients with MMCA stroke. Increasing age, MCA with additional infarctions, septum pellucidum deviation 1cm and uncal herniation were significant predictors of disability and poor functional outcomes. Time to surgery had no impact on functional outcome.

Background The randomized trials showed improved outcome and reduced mortality in malignant middle cerebral artery (MMCA) undergoing Decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. Despite high prevalence of stroke, especially in younger individuals, high and short-term mortality from stroke in South Asian and Middle East, there is little published data on DHC in patients with MMCA stroke. Methods This is a retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale (mRS) and dichotomized as favorable (mRS ≤ 4) or unfavorable (mRS > 4), at 3 months. Results In total, 137 patients underwent DHC. At 90 days, mortality was 16.8%; 61.3% of patients survived with an mRS of 4 or less and 38.7% had an mRS greater than 4. Age (55 years), diabetes (P = .004), hypertension (P = .021), pupillary abnormality (P = .048), uncal herniation (P = .007), temporal lobe involvement (P = .016), additional infarction (MCA + anterior cerebral artery, posterior cerebral artery) (P = .001), and infarction growth rates (P = .025) were significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation greater than 1 cm, and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome (P = .109). Conclusions Similar to the results of the studies from the West, DHC Improves functional outcome in predominantly South Asian patients with MMCA Stroke.

Stroke patients, as well as all those patients who are bed-bound for a long period of time, are highly susceptible to preventable secondary complications such as pressure ulcers or commonly known as bedsores. Such secondary complications may lead to progression of symptoms and are an important cause of delayed hospital discharges or even fatalities. The unnecessary long occupancy of the bed causes stress on the hospital's operations as well and adds to the operational costs. Newer strategies are, therefore, urgently needed to improve detection of patients at risk and to prevent such complications. In this paper, a system has been presented for detection and quantification of patient's position as a measure of possible critical triggering scenario that can lead to the development of the pressure ulcers. This multidisciplinary work combines the clinical knowledge of physicians and scientists at the Stroke ward with the instrumentation and intelligent algorithm into an add-on system that can be easily attached to the existing beds in any typical neurological clinics as well as intensive care units (ICU). Data fusion is assessed continuously with intelligent algorithms to alert the medical staff about patient's physical condition, e.g.Turning to reduce the risk of post-stroke complications. The built device was tested with healthy volunteers and a detailed study is being conducted at the hospital to evaluate the clinical feasibility of the design. Scopus

The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke.The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC.There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P .001), and two predictive factors (P .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data.Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.

Stroke patients, as well as all those patients who are bed-bound for a long period of time are highly susceptible to deep vein thrombosis (DVT) as secondary complexity. DVT poses more dangers of a loose blood clot obstructing the blood flow to cardiac or cranial flow circuits and can cause further stroke or heart attack. As a typical clinical practice, a simple device called DVT Cuff is used on the leg which regulates the pressure using an air-pressure pump. This aids in blood circulation in extremities where most DVT happen. In this paper, A Fuzzy Inference System (FIS) has been proposed that can be used in long-term monitoring of the performance of the cuffs using human experience mapped into the logic hardware. Such monitoring applications are usually quite complicated and need large programs that might not fit into the small and limited memory of the embedded device. The proposed FIS converts heuristic knowledge of the healthcare experts, in solving this problem, into a hardware friendly matrix that has the possible input and output stored in it. A number of Flex sensors are the main sensing units that were used to detect the changes in the curvature of the surface of the DVT cuff, which accordingly provides the information related to the functionality of the cuff, i.e., if the cuff is inflated of deflated, etc?. 2016 IEEE. Scopus

BackgroundWorldwide, cerebrovascular disease (CVD) is the leading disease-related cause of chronic disability; the second most common cause of death and dementia; and a significant burden to patients, caregivers, and healthcare systems. Major risk factors for stroke include diabetes, hypertension, smoking and dyslipidemia which are highly prevalent in the gulf region. Indeed in Qatar, the incidence of cerebrovascular disease is increasing and most patients have major vascular risk factors. In data from the HMC Stroke Registry ∼71% of patients presenting with stroke had diabetes and indeed diabetes was undiagnosed at the time of presentation in 35% of patients. Current imaging techniques to detect early sub-clinical cerebral damage and hence those at risk of stroke includes computerized tomography (CT) and magnetic resonance imaging (MRI). MRI in particular can detect features of small vessel disease such as accumulating silent infarcts, cerebral microbleeds [CMB], periventricular white matter hyperintensity and perivascular spaces which all predict a higher risk of stroke. However, these abnormalities provide a measure of vascular and not neuronal integrity and it is not feasible or practical to undertake MRI simply to identify those at risk of stroke. There is therefore an unmet need for a rapid, non-invasive, sensitive, cost-effective, reproducible and easily imaging biomarker for neuronal damage in subjects at risk of stroke. We have pioneered the technique of corneal confocal microscopy (CCM). Our studies (NIH (5RO1-NS46259-03, R01DK077903-01A1 NINDS), JDRF (17-2008-1031, 8-2008-362)) have shown that corneal confocal microscopy (CCM) can quantify early axonal damage in diabetic neuropathy (1), reliably (2), with high sensitivity and specificity (3). Furthermore, we have shown that subjects with impaired glucose tolerance (IGT) and other vascular risk factors also show corneal nerve loss using CCM (4). Furthermore, these abnormalities improve with an improvement in blood pressure, lipids and HbA1c, all risk factors for stroke (5) and with change in glucose tolerance (6). We have recently published a large normative reference database (7) and developed an automated image analysis algorithm to enable rapid and objective quantification of corneal nerve morphology (8). We therefore hypothesized that CCM may identify corneal nerve loss driven by the common vascular risk factors which may lead to stroke and thereby provide a surrogate for cerebral neuronal loss. Hence, CCM may allow us to identify subjects who may be at high risk of developing stroke and enable risk stratification and targeted risk factor intervention in these individuals.AimWe undertook CCM in a cohort of patients admitted to HMC with a clinical and radiological diagnosis of stroke.Methods17 stroke patients (age: 53.13 ± 9.09, years) and 15 age-matched healthy control participants (age: 55.30 ± 8.98, years) underwent corneal nerve assessment using CCM (Heidelberg HRT III) to quantify corneal nerve fiber density (CNFD)(no./mm2), corneal nerve fiber branch density (CNFBD)(no./mm2), corneal nerve fiber nerve length (CNFL)(mm/mm2) and corneal nerve fiber tortuosity (TC) and metabolic testing. Stroke patients underwent detailed neurological assessment to define the severity of the stroke using a National Institute of Health Stroke Scale (NIHSS), 3D Carotid Doppler and 3 Tesla MRI. Stroke patients were stratified into different groups for analysis: Normoglycemia (HbA1c 10 silent infarcts (n = 4), patients with periventricular white matter hyperintensity (n = 11) v no periventricular white matter hyperintensity (n = 4).ResultsThere was significant difference in HbA1c (8.51 ± 2.35; 5.72 ± 0.36, %, p ConclusionCorneal confocal microscopy identifies greater corneal nerve fibre abnormalities in patients admitted with stroke, which is present in patients with and without dysglycemia. It may therefore reflect the consequence of vascular risk factors independent of glycemic status. However, the extent of corneal nerve fibre pathology does not differ in relation to the severity of neurological disability or extent of pathology on MRI. Larger, longitudinal follow up studies are required to determine the prognostic ability and utility of CCM as a surrogate imaging biomarker for stratifying patients at risk of stroke.References1. Petropoulos IN, Alam U, Fadavi H, Asghar O, Green P, Ponirakis G, et al. Corneal nerve loss detected with corneal confocal microscopy is symmetrical and related to the severity of diabetic polyneuropathy. Diabetes care. 2013;36(11):3646–51.2. Petropoulos IN, Manzoor T, Morgan P, Fadavi H, Asghar O, Alam U, et al. Repeatability of in vivo corneal confocal microscopy to quantify corneal nerve morphology. Cornea. 2013;32(5):e83–e9.3. Petropoulos IN, Alam U, Fadavi H, Marshall A, Asghar O, Dabbah MA, et al. Rapid automated diagnosis of diabetic peripheral neuropathy with in vivo corneal confocal microscopy. Investigative ophthalmology & visual science. 2014;55(4):2071–8.4. Asghar O, Petropoulos IN, Alam U, Jones W, Jeziorska M, Marshall A, et al. Corneal confocal microscopy detects neuropathy in subjects with impaired glucose tolerance. Diabetes care. 2014;37(9):2643–6.5. Tavakoli M, Kallinikos P, Iqbal A, Herbert A, Fadavi H, Efron N, et al. Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy. Diabetic medicine: a journal of the British Diabetic Association. 2011;28(10):1261–7.6. Azmi S, Ferdousi M, Petropoulos IN, Ponirakis G, Alam U, Fadavi H, et al. Corneal Confocal Microscopy Identifies Small-Fiber Neuropathy in Subjects With Impaired Glucose Tolerance Who Develop Type 2 Diabetes. Diabetes care. 2015;38(8):1502–8.7. Tavakoli M, Ferdousi M, Petropoulos IN, Morris J, Pritchard N, Zhivov A, et al. Normative values for corneal nerve morphology assessed using corneal confocal microscopy: A multinational normative data set. Diabetes care. 2015;38(5):838–43.8. Dabbah M, Graham J, Petropoulos I, Tavakoli M, Malik R. Automatic analysis of diabetic peripheral neuropathy using multi-scale quantitative morphology of nerve fibres in corneal confocal microscopy imaging. Medical image analysis. 2011;15(5):738–47.

Background: Multivessel cervical dissection with cortical sparing is exceptional in clinical practice. Case presentation: A 55-year-old man presented with acute-onset neck pain with associated sudden onset right-sided hemiparesis and dysphasia after chiropractic manipulation for chronic neck pain. Results and Discussion: Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded. Conclusion: Chiropractic cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.

To assess the effect of acute thrombolysis protocol on "door-to-needle time" (DTN) and improvement in outcome following acute stroke (AS).The charts of all patients receiving intravenous (IV) thrombolysis for AS between January 2008 and June 2015 were reviewed for DTN, complications, and clinical outcome. Good prognosis was defined as modified Rankin Scale (mRS) score of less than 2 at 90 days. In January 2014, a protocol for faster DTN was introduced. We reviewed the prognosis before and after the introduction of the new protocol.Up to 204 patients received IV recombinant tissue plasminogen activator (r-tPA) (mean age 52.5 ± 12.4 years). Mean door-to-CT time improved from 42.5 ± 41.1 to 27.1 ± 26.3 minutes (P .001); DTN improved from 83.26 ± 47.7 to 47.09 ± 25.7 minutes (P .001). Complications were reduced from 15.7% to 8.8% (P = .14). The mRS score of less than or equal to 2 improved from 47.1% to 73.3% at 90 days (P = .001). After implementing new protocol, thrombolysis rate increased to 11.8% in 2014 (before 3.3% in 2011, 4.9% in 2012, and 4.4% in 2013), P .0001. NIHSS (National Institutes of Health Stroke Scale) score at admission (P = .002), hypodensity on initial CT brain (P = .041), protocol implementation (P = .014), and reduced length of stay (P = .004) were associated with outcome at 90 days (mRS score ≤2).Implementation of specific protocols to reduce DTN in patients receiving IV r-tPA leads to reduction in complications and improves outcome.

Background and Aim Following an acute stroke (AS), patients are at an increased risk of developing complications that may affect prognosis. With overcrowding in the emergency department (ED), patients stay longer hours to days before transfer to a proper stroke ward. The aim of this study was to evaluate the effect of increasing length of stay (LOS) in the ED on the risk of stroke-related complications. Methods We analyzed data from our stroke registry of patients admitted with AS during 2014. Stay in ED was divided into 2 groups: less than 8 hours and more than 8 hours. Data regarding demographics, stroke type, severity of stroke, ED (LOS) in hours, total LOS in hospital, number and types of complications, and prognosis were collected. Results Mean age was 54.8 years and 78.9% were males (total n = 894). Prior to ward admission, 265 (29.5%) patients remained in the ED for less than 8 hours and 629 (70.4%) remained for more than 8 hours. There was no significant difference in comorbidities or the severity of stroke at admission between the 2 groups. An ED LOS of less than 8 hours was associated with reduced risk of complications (14.3% versus 19.2%, P = .06), reduced LOS in hospital, better prognosis at discharge (72.5% versus 57.6% had modified Rankin Scale of ≤2, P = .001) and at 90 days (89% versus 78.8%, P = .007) and lower in-hospital mortality (1.5% versus 5.4 %, P = .004). Conclusion Delays in transferring AS patients from the ED may lead to an increase in complications resulting in an increased LOS and slower recovery.

Background and Purpose— Usefulness of multidisciplinary stroke units in acute stroke patients is well established. There is extensive western literature on usefulness of stroke units in outcome, but limited evidence from the rest of the world. We aim to evaluate the impact of establishing a stroke unit on outcome in patients presenting to a tertiary care facility. Methods— This is a retrospective study of 1003 patients with acute stroke admitted to Hamad General Hospital, Qatar, between January 2014 and February 2015. Patients directly admitted to intensive care unit (132) were excluded. We compared outcomes of pre- and poststroke ward (SW) establishment and in SW patients versus those of general medical wards. Results— Before the establishment of the SW, 175 patients were admitted to the hospital. From April 2014 to February 2015, 696 patients were admitted (SW, 545; medical ward, 151). There was a significant reduction in length of stay from 14.7±27.7 to 6.2±20.2 days ( P =0.0001) and incidence of complications (23.6% versus 6.4%, P =0.0001) after implementation of stroke-specific protocols. Prognosis at discharge (modified Rankin Scale 0–2 in 56.0% versus 70.4%, P =0.001) and at 90 days (modified Rankin Scale 0–2 in 70.6% versus 95.0%, P =0.001) also significantly improved. Compared with medical ward patients, outcome was significantly better in SW patients with fewer complications (10.9% versus 5.0%, P =0.013) and shorter length of stay (8.9±30.7 versus 5.4±16.1 days, P =0.05). Conclusions— Establishing a distinct SW is essential for achieving full benefits of stroke protocols implementation. SW patients have significantly fewer complications and better prognosis when compared with patients in medical wards.

Objective: The aim of this study was to determine whether segmental left ventricular wall motion abnormalities (SLVWMA) are a potential cause of ischemic stroke. Methods: Demographics, cardiovascular risk factors and echocardiographic parameters of patients with ischemic stroke (with and without SLVWMA) were collected and compared with those of patients who had SLVWMA but without history of ischemic stroke. Results: Two hundred and fifty nine patients with ischemic stroke were identified: 187 patients without SLVWMA, and 72 with SLVWMA. The cardiac group consisted of 79 patients. Compared with the stroke patients with SLVWMA, stroke patients without SLVWMA were slightly but significantly younger (59 versus 63 years of age). Furthermore, the number of risk factors in stroke patients without SLVWMA was significantly lower compared with stroke patients with SLVWMA (2.7 versus 3.7). There was no difference in age or gender between stroke patients with SLVWMA and the cardiac patients. However, the number of risk factors was significantly higher in the cardiac patients compared with stroke patients with SLVWMA (4.4 versus 3.7). The ejection fraction was normal in both groups of stroke patients but significantly lower in the cardiac patients (37%). Significantly more lacunar ischemic strokes were observed in stroke patients with SLVWMA than in those without SLVWMA (76% versus 68%). Conclusion: Our data indicate that in ischemic stroke patients with multiple cardiovascular risk factors and SLVWMA a higher frequency of lacunar strokes can be found. The latter could be a marker of small-vessel disease and/or be a potential contributing factor, perhaps through a mechanism of cardiac microembolism, in the development of lacunar ischemic stroke. The mechanisms of the association between SLVWMA and lacunar ischemic stroke remain however unclear.

Objective: The aim of this study was to determine the prevalence of low back pain (LBP) in a primary care setting population and examine its association with the symptoms of depression and somatization. Methods: This is a cross-sectional study, utilising a survey carried out in primary health care clinics (PHCs) in Al-Ain, United Arab Emirates (UAE). A multistage stratified sampling design was used and a representative sample of 1304 UAE nationals aged 18–65 years who attended PHC clinics for any reason were included and 1103 (84.5%) subjects agreed to participate and responded to the questionnaire during a period from June 2001 to January 2002. A specially designed questionnaire with three parts was used for the data collection: socio-demographic information of the studied subjects, modified version of the Roland-Morris scale for evaluating back-related functional disability and SCL-90 R for depression and somatization subscales was used to assess depressive and somatic symptoms. Results: Of the total number of subjects surveyed (1103), 586 (53.1%) were men and 517 (46.9%) women. The mean age was 34.9 ± 13.4 years for men and 33.5 ± 11.8 years for women. The prevalence of LBP in the studied subjects was 64.7% (95% CI, 60.7–68.5] with 46.7% among men and 53.3% among women. There were a significant differences between the subjects with LBP and without LBP with respect to gender (P < 0.001), body mass index (BMI) (P < 0.001), occupational status (P < 0.001) and living environment (P = 0.016). Functional disability was higher in patients with LBP. Young patients in aged 15–34 years, patients with preparatory/secondary educational level and students showed higher depressive symptoms. A similar pattern was found in patients with somatic symptoms. Factor analysis revealed a strong association between depression and somatization in LBP patients. Conclusions: Functional disability was higher in with LBP. Furthermore, symptoms of depression and somatization are prevalent among LBP patients. Wiley Online Library