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Abstract Background Differentiating unipolar depression from bipolar depression is clinically important. The identification of biomarkers that characterize the pathophysiology of each disorder may provide biological targets for treatment. The objective of the study was to demonstrate a relationship between CRP level and the severity of depressive symptoms and see if C-reactive protein (CRP) levels can be used as a biomarker to distinguish between unipolar and bipolar depression. A convenience sample of 90 individuals was consecutively recruited from the psychiatry outpatient clinic at Beni-Suef University Hospital, Egypt. They were divided into three equal groups: patients with major depressive disorder (MDD) (group 1), bipolar depression (group 2), and a healthy volunteer group (group 3). Patient groups were assessed using semi-structured interviews, and CRP levels were measured. Results Patients with bipolar depression and MDD showed a significantly higher score on the Beck Depression Inventory scale than the control group (32.97 ± 2.4 vs. 31.93 ± 2.3 vs. 8.00 ± 2.3 in all groups respectively) (P-value

BackgroundThe prevalence of autism spectrum disorder (ASD) has been increasing steadily in Egypt and worldwide. Detecting risk factors for ASD could help initiate screening and risk prevention approaches. Herein, this study aimed to detect several maternal and neonatal risk factors for ASD in Egypt.MethodsIn this case-control study, mothers of children with ASD who were visiting Beni-Suef University Hospital in Egypt (n = 268) were compared to mothers of children without ASD attending one primary school with a kindergarten (n = 504) regarding their preconception, conception, and postconception characteristics. Data were collected using a self-administered questionnaire. The odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to investigate the possible associations between the collected data and the odds of ASD.ResultsIn the multivariable-adjusted models, urban residence: OR (95% CI) = 2.33 (1.60-3.38), relative father: 2.63 (1.74-3.96), history of diabetes: 5.98 (1.99-17.97), previous abortion: 2.47 (1.20-13.38), assisted fertility: 4.01 (1.20-13.38), family history of ASD: 7.24 (2.00-26.24), multiple pregnancy: 11.60 (2.54-53.07), exposure to passive smoking during pregnancy: 2.95 (1.86-4.68), vaginal bleeding during pregnancy: 3.10 (1.44-6.67), hypertension with pregnancy: 3.64 (1.06-12.51), preterm labor: 2.64 (1.26-5.57), neonatal convulsions: 14.88 (5.01-44.20), and admission to neonatal intensive care unit 2.13: (1.21-3.74) were associated with the increased odds of ASD. On the other hand, the intake of vitamins during pregnancy: 0.09 (0.06-0.16) and C-section: 0.44 (0.27-0.70) were associated with the decreased odds of ASD.ConclusionThis study detected several maternal and neonatal risk factors for ASD in Egyptian children.

Background: Spine surgery needs a special consideration as regards minimizing the movement during intubation to avoid the hazards to spinal cord. The present study aims to highlight the preferable technique for cervical intubation. The Intubating Laryngeal Mask Airway (ILMA, Fastrach™ laryngeal mask company, Henle-on-Thomes, U.K.) is a supraglottic device specially designed to be an effective ventilator device and blind intubation guide in patient with normal and abnormal airways. Methods: 40 patients were involved and randomly assigned to two equal groups according to the used technique of endotracheal intubation: (Group 1): Intubating Laryngeal Mask technique and (Group 2): Direct laryngoscopy technique. Anesthesia was induced using a combination of 1 μg/kg fentanyl, 5 mg/kg thiopental sodium (sleeping dose) and atracurium 0.5 mg/kg (Intubating laryngeal Mask or the Macintosh blade) was used to secure the airway according to the patient group. Meanwhile a continuous videofluoroscopy was recorded. The radiographs were analyzed for movements in the cervical segments C1/2 and C2/3. A reference line was drawn following the dorsal alignment of C2. Another two lines, one connecting the anterior and posterior arch of C1, and one through the basal plate of C3, were drawn to transect the above mentioned reference line. Results: The mean cervical spine extension at C1/C2 was 77.2 ± 3.5 before intubation, 74.8 ± 4.3 during intubation, and 75.9 ± 4.2 after intubation for group 1, while it was 74.95 ± 4 before, 65.9 ± 4.4 during, and 68.75 ± 3.9 after intubation for group 2 there was statistically significant difference between LMA group (group 1) and direct laryngoscopy group (group 2) in the motion of cervical spine extension at C1/C2 during and after intubation where the p-value was

Background: Laryngotracheal stenosis is a life-threatening restriction in pulmonary ventilation. It is an umbrella term, including luminal compromise at the level of the larynx, subglottis, or trachea. Etiology of laryngotracheal stenosis is multi- factorial. In adults and adolescents it is mostly acquired, where in children it may be acquired or congenital. Acquired laryngotracheal stenosis can result from previous intubation or tracheostomy, systemic disease, trauma, infection, or idiopathic causes. Historically, infectious etiology was common. Currently, laryngotracheal stenosis most frequently results from prolonged intubation or trauma from intubation itself. Objective: To evaluate the effectiveness of topical Mitomycin C as an adjuvant treatment with the endoscopic management of laryngotreacheal stenosis. Patients and Methods: The total number of patients in all the included studies was 454, 379 patients in MMC group and 75 patients in non-MMC group. Results: This meta-analysis study showed that resolution (success) rate in MMC group was (68.7%) and there was a significant increase in resolution (success) rate in MMC compared to non- MMC group (p = 0.011) with the odds of being 5 times higher in MMC group (OR = 5.04). The Complications rate in MMC using patients was (4%). The result of this meta-analysis study showed that Mitomycin C is an effective and safe adjuvant in the endoscopic treatment of laryngotracheal stenosis. However, this study included limitations. We recommend the need of more high quality prospective randomized controlled trials, two armed studies and further studies in the future to achieve stronger results. Conclusion: We suggest that that Mitomycin C is an effective and safe adjuvant in the endoscopic treatment of laryngotracheal stenosis. However, this study included limitations. We recommend the need of more high quality prospective randomized controlled trials, two armed studies and further studies in the future to achieve stronger results. [ABSTRACT FROM AUTHOR]

ImportanceStroke-to-recanalization time is a strong predictor of outcomes in anterior circulation large-vessel occlusion (LVO). The authors aimed to evaluate functional outcomes in early (

BackgroundThe first pass effect has been shown to improve clinical outcomes in patients with middle cerebral artery (MCA) M1 occlusions.ObjectiveTo determine the rates of first pass effect in MCA M1 occlusions and determine if proximal or distal location of occlusion modified clinical outcomes.MethodsPatients with recanalized MCA M1 occlusions who underwent endovascular thrombectomy (EVT) were reviewed to determine the effect of first pass effect (FPE) and location of occlusion on clinical outcomes. MCA occlusions were classified as proximal if they included the first two thirds of the MCA and involved the lenticulostriate vessels, or distal if they did not.ResultsWe included 261 patients of which 27% achieved FPE. Of the cohort, there were 91 (35%) proximal MCA occlusions and 170 (65%) distal MCA occlusions. Baseline demographics and treatment time metrics were comparable across both groups. There was a trend toward good clinical outcome in patients with or without a FPE (60 vs. 46%; p = 0.06), however a higher rate of excellent clinical outcome was noted in patients with FPE (46 vs. 30%; p = 0.02). When compared by location, patients with distal MCA occlusions had a higher rate of excellent clinical outcome (40 vs. 25%; p = 0.02). Multivariable analysis showed that distal MCA occlusion was the strongest predictor of an excellent clinical outcome and first pass effect.ConclusionPatients with MCA M1 occlusions with FPE have a higher rate of excellent clinical outcomes compared to those who did not. Location of MCA occlusion appears to modify rates of first pass effect and excellent clinical outcomes.

Background Prehospital triage scores aim to identify large vessel occlusions (LVOs) in the field; however, their real‐world performance and accuracy across a 24‐hour period remains unknown. In this study, we compare the positive predictive value of the prehospital Rapid Arterial occlusion Evaluation (RACE) score for the detection of LVO during working hours and nonworking hours. Methods We performed a retrospective review of all patients presenting with a RACE score of ≥5 at one comprehensive and one thrombectomy‐capable hospital between July 2015 and December 2019. Patients were dichotomized to those presenting during “working hours” (7:00 am to 6:00 pm on weekdays) or “nonworking hours” (6:01 pm to 6:59 am on weekdays or anytime during weekends). The primary outcome was diagnosis of LVO. Secondary outcomes included diagnosis of acute neurovascular syndromes, door‐to‐treatment time metrics, and a modified Rankin Scale of ≤2 in those undergoing mechanical thrombectomy. Results Of the 701 patients with RACE score ≥5, 687 patients were included (355 nonworking hours and 332 working‐hours cohorts). Mean age was 71 and 72 years in the nonworking hours and working hours groups, respectively (P=0.13). Median National Institutes of Health Stroke Scale and baseline demographics were comparable between the 2 groups. There was no significant difference in the diagnosis of LVO (36.3% versus 34.6%; P=0.69) or final discharge diagnosis. The positive predictive value of the RACE score for the detection of an acute neurovascular syndrome (transient ischemic attack and stroke) was improved during nonworking hours (76.3% versus 67.8%; P=0.01). In patients undergoing mechanical thrombectomy, rates of good clinical outcome were similar (44.7% versus 48%; P=0.76), despite the shorter door‐to‐groin‐puncture and revascularization times during working hours. Conclusions The RACE score shows a consistent positive predictive value in determining LVO during working and nonworking hours. However, it is more accurate in determining acute neurovascular syndromes during nonworking hours, which is driven by a decrease in stroke mimics during this time.

Background and Purpose: Cerebral microbleeds (CMB) are reported to be frequent in moyamoya disease (MMD) and moyamoya syndrome (MMS) in the Asian population. It is associated with an increased risk of intracerebral hemorrhage. The significance of CMB in MMD/MMS in non-Asian populations has not been well established. Our study aimed to investigate the prevalence of CMB in MMD/MMS in a moymoya cohort with a majority of non-Asians and to identify risk factors for developing a CMB and its predictive value for subsequent vascular events. Methods: The moyamoya database was compiled by screening for MMD/MMS among patients admitted to the Zale-Lipshy University Hospital at the University of Texas Southwestern Medical Center. We identified and analyzed data of 67 patients with MMD or MMS. Patients were characterized as CMB+ or CMB– based on MRI findings. In CMB+ patients, the total number and location of CMB were identified. Univariate and multivariate logistic regression were used to identify risk factors for developing CMB and whether CMB are associated with the development of subsequent vascular events. Results: Out of a total of 67 patients, 11 (16%) had CMB. Males had significantly higher odds of having CMB as compared to females (OR 1.76; 95% CI 1.40–24.3, p = 0.021). The incidence of CMB was also associated with age at diagnosis (mean age of CMB+ patients vs. CMB– patients: 44 vs. 34 years, respectively, p = 0.024), smoking (p = 0.006), and hemorrhagic stroke at presentation (p = 0.034). Logistic regression with multivariate analysis found that gender and age at diagnosis remained statistically significant. New ischemic events occurred in 2 (20%) out of 10 CMB+ patients and 13 (23%) out of 55 CMB– patients, respectively (p = 0.79). While 2 (3%) CMB– patients had a new cerebral hemorrhage during follow-up, none of the CMB+ patients did. Conclusions: CMB are less prevalent in MMD/MMS in the USA than in Asia. An older age at diagnosis and male gender were associated with CMB. The presence of CMB was not associated with an increased risk of a subsequent ischemic or hemorrhagic stroke.

Background: Neurointerventional procedures in acute ischemic stroke often require immediate antiplatelet therapy in the cases of acute stenting and occasionally re-occluding vessels. Intravenous cangrelor is a P2Y12 receptor antagonist with short onset and quick offset. The study objective was to evaluate the safety and efficacy of intravenous cangrelor in patients with acute ischemic stroke requiring urgent antiplatelet effect.Methods: Patients who received intravenous cangrelor intra-procedurally during acute ischemic stroke treatment were identified from a prospectively collected database. Cangrelor was administered as a bolus of 15 mcg/kg, followed by an infusion rate of 2 mcg/kg/min. A historical control group consisting of anterior circulation tandem occlusions was used to compare to patients with similar lesions who received intravenous cangrelor. Outcomes of interest included in-stent thrombosis, thromboembolic complications, intracranial hemorrhage, and functional outcomes at 90 days.Results: Twelve patients received intravenous cangrelor for acute ischemic stroke between October 2018 and April 2020 at a comprehensive stroke center. Eleven patients had intra or extracranial stenting performed, which included two posterior circulation lesions. No cases of symptomatic intracranial hemorrhage were reported. At 90 day follow-up, two patients had died and 10 had a good functional outcome. Patients with anterior circulation tandem occlusions who received cangrelor and those who received dual antiplatelets orally had similar radiographic and clinical outcomes.Conclusion: Low dose intravenous cangrelor is similar in safety and efficacy to oral antiplatelets in acute ischemic stroke in a small case series. Larger prospective studies on the efficacy, safety, and effect on procedure times of intravenous cangrelor in neurointervention are warranted.

Introduction: Multiple risk factors of mortality have been identified in patients with COVID-19. Here, we sought to determine the effect of a history of neurological disorder and development of neurological manifestations on mortality in hospitalized patients with COVID-19.Methods: From March 20 to May 20, 2020, hospitalized patients with laboratory confirmed or highly suspected COVID-19 were identified at four hospitals in Ohio. Previous history of neurological disease was classified by severity (major or minor). Neurological manifestations during disease course were also grouped into major and minor manifestations. Encephalopathy, ischemic or hemorrhagic stroke, and seizures were defined as major manifestations, whereas minor neurological manifestations included headache, anosmia, dysgeusia, dizziness or vertigo, and myalgias. Multivariate logistic regression models were used to determine significant predictors of mortality in patients with COVID-19 infection.Results: 574/626 hospitalized patients were eligible for inclusion. Mean age of the 574 patients included in the analysis was 62.8 (SD 17.6), with 298 (51.9%) women. Of the cohort, 240(41.8%) patients had a prior history of neurological disease (HND), of which 204 (35.5%) had a major history of neurological disease (HND). Mortality rates were higher in patients with a major HND (30.9 vs. 15.4%; p = 0.00002), although this was not a significant predictor of death. Major neurological manifestations were recorded in 203/574 (35.4%) patients during disease course. The mortality rate in patients who had major neurological manifestations was 37.4% compared to 11.9% (p = 2 × 10−12) in those who did not. In multivariate analysis, major neurological manifestation (OR 2.1, CI 1.3-3.4; p = 0.002) was a predictor of death.Conclusions: In this retrospective study, history of pre-existing neurological disease in hospitalized COVID-19 patients did not impact mortality; however, development of major neurological manifestations during disease course was found to be an independent predictor of death. Larger studies are needed to validate our findings.

The current coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to immense strain on healthcare systems and workers. Patients with severe symptoms of COVID-19 may also present with acute neurological emergencies such as ischemic stroke. Ischemic stroke in these patients may result from COVID-19 related complications or decompensation of previously asymptomatic cerebrovascular disorders, or concurrent ischemic stroke from common stroke risk factors in a patient with COVID-19. Acute ischemic stroke patients with large vessel occlusions require emergent triage, intensive care, and mechanical thrombectomy. Management of patients with large vessel occlusions (LVO) requires special considerations in the current pandemic. Physicians must now account for prognosis of severe COVID-19, resource utilization, and risk of infection to healthcare workers when determining eligibility for mechanical thrombectomy (MT). Here, we describe important prognostic factors including age, laboratory, and imaging findings to consider for MT selection and provide suggestions for taking care of patients with LVO and possible or confirmed COVID-19. It is recommended to perform MT in patients within the established guidelines, and consider a conservative approach in cases where there is clinical equipoise to minimize futile reperfusion. Lastly, we describe an illustrative case of a patient with ischemic stroke and COVID-19.

Abstract: Objective: To evaluate the effect of general anaesthesia with either continuous i.v. opioids (G/O) or thoracic epidural analgesia (G/EP) on postoperative transient myocardial ischaemia (TMI) in type 2 diabetic patients undergoing open cholecystectomy. Methodology: This randomised controlled study was conducted on 50 patients with D.M. Patients were divided into G/O group or G/EP group. All patients had negative stress exercise test and at least two cardiac risks preoperatively. Epidural analgesia was established by 15ml of ropivacaine 0.2% with fentanyl 2μg/ml followed by 5–8ml/h of ropivacaine 0.1% with fentanyl 1μg for 24h postoperatively. Both studied groups received same general anaesthesia. Continuous i.v. fentanyl 100μg/h was given intraoperatively in group G/O followed by i.v. morphine PCA. Primary outcome measured postoperative TMI using 24h continuous ST segment analysis, endothelin-1(ET-1), troponin T, creatine kinase MB (CK-MB), and CKMB/CK preoperatively, 8h and 24h postoperatively. Second outcome measured dynamic stress (perioperative heart rate, blood pressure and postoperative pain). Results: Endothelin-1 was above cutoff level preoperatively and rose up dramatically postoperatively in both studied groups. G/EP attenuated ET-1 elevation than G/O. Troponin T and CK-MB did not rise postoperatively in both studied groups. Postoperative CK-MB/ CK ratio was higher than 10% in 12 and eight patients in group G/O and G/EP, respectively. Twelve cardiac ischaemic events were noticed in four patients in group G/O and four events in two patients in group G/EP without significant difference in total duration of ischaemia between groups. G/EP lowered HR more significantly intraoperatively and gave better pain control for 4h postoperatively. In conclusion, D.M was associated with high ET-1 level. Upper abdominal surgery increased ET-1 release. G/EP attenuated ET-1 release more than G/O and produced more stable haemodynamic parameters and less postoperative pain. No superior cardioprotective effect was noticed in G/EP over G/O. [Copyright &y& Elsevier]

Background and Purpose: The role of intra-arterial (IA) thrombolysis in modern endovascular therapy is not well-understood. Here, we surveyed neurointerventionalists to understand their current clinical practices and opinions of IA thrombolysis in the new era of mechanical thrombectomy (MT).Method: A 24-question anonymous survey was distributed via email to the members of the Society of Vascular and Interventional Neurology.Results: One hundred and four responses were included in the analysis. Most respondents were interventional neurologists (76.9%) and had ≥5-years in neuro-interventional practice (80.8%). IA thrombolytics are presently used by 60.6%. Aspiration plus stent-retriever was the most common MT approach used with IA-thrombolysis (66.0%). IA-thrombolysis was used in mainly three approaches: (1) treatment of primary distal occlusions, (2) as rescue after proximal occlusion thrombectomy, and (3) or as adjunct therapy to primary MT approach. The most frequent IA-rtPA dose was 3–10 mg, with 1 mg/min infusion rate (56.6%). 84.9% do not have a standardized protocol for administering IA-rtPA. About half (50.9%) believed there should be no time limit for administering IA lytic if there is a favorable imaging profile, while 30.2% indicated ≤6 h. Most respondents (76.5%) would consider using IA-tenecteplase in a trial setting. Only 12.9% felt there was no role for IA thrombolysis in modern endovascular practice. Respondents with ≥10-years' experience were less supportive of the future of IA lytic (98.0 vs. 76.4%, p = 0.006).Conclusion: IA-thrombolysis is currently used in clinical practice; however, there is no clear consensus on best practices or criteria for administration. Further studies are needed to define the role of IA-thrombolysis in the context of MT.

Background: Mechanical thrombectomy (MT) for ischemic stroke can be performed under local anesthesia (LA), conscious sedation (CS), or general anesthesia (GA). The need for monitoring by anesthesia providers may be resource intensive. We sought to determine differences in outcomes of MT when sedation is performed by an anesthesia team compared to sedation-trained providers.Methods: We performed a retrospective analysis on patients who were screened by a pre-hospital stroke severity screening tool and underwent MT at two stroke centers. Baseline characteristics, time metrics, sedatives, peri-procedural intubation, complications, and outcomes were recorded. Good outcome was defined as modified Rankin score of ≤2.Results: We analyzed 104 patients (sedation-trained provider = 63, anesthesia team = 41) between July 2015 and December 2017. In the sedation-trained provider group, four patients required intervention by an anesthesia team. There were no differences in patients receiving LA (sedation-trained provider 24% vs. anesthesia team 27% p = 0.82), CS (70 vs. 63%, p = 0.53), or GA (6 vs. 10%, p = 0.71) between groups. Sedation-trained providers were more likely to use only one drug during the procedure (62 vs. 34%, p = 0.009). The rate of procedural complications (9.5 vs. 4.5%, p = 0.48), good outcome (56 vs. 39%, p = 0.11), and mortality (22 vs. 24%, p = 0.82) was similar between groups. Sedation by provider type did not predict functional outcome or mortality at 3 months.Conclusions: Sedation-trained providers are capable of delivering appropriate sedation without compromising patient safety. The use of “as needed” anesthesia teams for MT may have considerable effect on resource allocation and cost.