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BackgroundThere is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19.MethodsThis multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes.ResultsA total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054).ConclusionIV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.

Background: Myasthenia gravis (MG) is a rare neuromuscular disorder resulting from the destruction of acetylcholine receptors at the neuromuscular junction by IgG antibodies. Although dysphagia is a common symptom in generalized form of MG, it is rarely reported as a sole manifestation of the disease, specifically in younger patients. Herein, we report a middle-aged adult patient with dysphagia as the sole manifestation of MG.Case presentation: A 49-year-old male complaining of severe dysphagia underwent an extensive clinical and paraclinical examination. Oropharyngeal dysphagia was confirmed by an experienced speech-language pathologist using the water swallowing test. Unilateral right paresis of the soft palate and vocal fold was confirmed using laryngeal video stroboscopy. Chest computerized tomography (CT) scan, brain Magnetic resonance imaging (MRI), and routine blood, urine, and thyroid tests were normal. In electromyography, slow repetitive nerve stimulation (RNS) showed a decremental response in the right nasalis muscle. The diagnostic neostigmine test with 1.5 mg of intramuscular neostigmine led to significant recovery of laryngeal and pharyngeal motor dysfunction and dysphagia within 12 hours, so the MG diagnosis was confirmed. The patient was treated with plasmapheresis, pyridostigmine, and prednisolone, which followed an improving course and led to better swallowing of solid and liquid foods.Conclusion: MG should be considered as a diagnosis in middle-aged adults with complaints of dysphagia.

Natascha Schurz,1,* Lydia Sariaslani,1,* Patrick Altmann,1 Fritz Leutmezer,1 Christoph Mitsch,2 Berthold Pemp,2 Paulus Rommer,1 Tobias Zrzavy,1 Thomas Berger,1 Gabriel Bsteh1 1Department of Neurology, Medical University of Vienna, Vienna, Austria; 2Department of Ophthalmology, Medical University of Vienna, Vienna, Austria*These authors contributed equally to this workCorrespondence: Gabriel BstehMedical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, AustriaTel +43 1 40400 31450Email gabriel.bsteh@meduniwien.ac.atPurpose: Retinal layer thickness parameters measured by optical coherence tomography (OCT) are emerging biomarkers of neuroaxonal degeneration and inflammation in multiple sclerosis (MS). We aimed to evaluate the value of retinal layer thickness for prediction of disability worsening and relapse in a real-world MS cohort.Patients and Methods: For this longitudinal observational study, we included MS patients with spectral-domain OCT scans available and ≥ 1 year of clinical follow-up. The value of peripapillary retinal nerve fiber layer (pRNFL), macular ganglion-cell-and-inner-plexiform-layer (GCIPL) and inner nuclear layer (INL) thickness for prediction of disability worsening and relapse during the observation period was tested by multivariate models.Results: We analyzed 60 MS patients during a mean observation period of 2.9 years (SD 1.8). Lower baseline thickness of GCIPL (cut-off < 77μm; HR 4.1, p=0.001) and pRNFL (cut-off ≤ 88μm; HR 3.1, p=0.019) were associated with an increased risk of disability worsening. Longitudinally, mean thinning rates were − 0.8μm/year (SD 1.6) for GCIPL, − 0.6μm/year (SD 3.5) for pRNFL. GCIPL thinning ≥ 1.0μm/year and pRNFL > 1.5μm/year is associated with higher likelihood of disability worsening (HR 5.7, p=0.009 and HR 6.8, p=0.003, respectively). INL thickened in patients with relapse by a mean 0.9μm while thinning by 0.3μm in patients without relapse (p=0.04). In multivariate analyses, INL thickening was associated with an increased probability of relapse (OR 17.8, p=0.023).Conclusion: Cross-sectional and longitudinal measurement of GCIPL and pRNFL thinning is reliable as a biomarker of disability worsening in a real-world setting. Change of INL thickness is a promising marker of relapse, i.e. inflammatory activity.Keywords: multiple sclerosis, biomarker, optical coherence tomography, retinal thinning, progression, relapse

Introduction: Reperfusion and neuroprotection are 2 main treatment strategies exist for management of patients with ischemic stroke. This study aimed to assess the 3-month outcome of patients who underwent thrombolytic therapy following ischemic stroke. Methods: In the present prospective cohort study, the 3-month outcome of patients (mortality, disability) with acute ischemic stroke admitted to neurology department an educational hospital, Kermanshah, Iran, from 2016 to 2019, who had received thrombolytic therapy was assessed. National Institute of Health Stroke Scale (NIHSS) and Modified Rankin Score (MRS) were used for measuring the degree of disability (on admission, at the time of discharge and 3 months after thrombolytic therapy). Results: 217 patients with the mean age of 66.40 ± 13.37 (27 – 97) years were studied (55.3% male). There was no significant correlation between decrease in NIHSS score and age (p = 0.44), sex (p = 0.082), time interval between initiation of symptoms (p = 0.104), and blood pressure on admission (p = 0.156). However, patients with blood sugar lower than 144 had better 3-month outcome (p = 0.045). Additionally, there was no significant correlation between the rate of decrease in MRS score and age (p = 0.813), sex (p = 0.875), time interval between initiation of symptoms (p = 0.495), and blood pressure on admission (p = 0.264). However, patients with blood sugar lower than 144 had better 3-month outcome (p = 0.022). 47 (21.7%) patient died and 170 (78.3%) were discharged. Mean age of the patients who died (73.70 ± 11.85 versus 64.39 ± 13.09 years; p < 0.0001) and their NIHSS score on admission (13.22 ± 6.01 versus 11.28 ± 5.70; p = 0.045) were significantly higher. In other words, the odds of mortality was 3.19 times in patients over 60 years of age (95% confidence interval (CI): 1.18 – 8.62) and 1.83 times in patients with NIHSS score over 12 (95% CI: 0.92 – 3.61). Conclusion: There was no significant correlation between 3-month disabilities of stroke patients underwent thrombolytic therapy and age, sex, time from initiation of symptoms, or vital signs on admission. Patients with a blood sugar lower than 144 had better 3-month outcome.

Background and Purpose: Several risk factors of symptomatic intracerebral hemorrhage (SICH) following intravenous thrombolysis for acute ischaemic stroke have been established. However, potential predictors of good functional outcome post-SICH have been less studied., Methods: Patient data registered in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) from 2005 to 2021 were used. Acute ischaemic stroke patients who developed post intravenous thrombolysis SICH according to the SITS Monitoring Study definition were analyzed to identify predictors of functional outcomes., Results: A total of 1679 patients with reported SICH were included, out of which only 2.8% achieved good functional outcome (modified Rankin Scale scores of 0-2), whilst 80.9% died at 3 months. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score and 24-h ΔNIHSS score were independently associated with a lower likelihood of achieving both good and excellent functional outcomes at 3 months. Baseline NIHSS and hematoma location (presence of both SICHs, defined as remote and local SICH concurrently; n = 478) were predictors of early mortality within 24 h. Independent predictors of 3-month mortality were age, baseline NIHSS, 24-h ΔNIHSS, admission serum glucose values and hematoma location (both SICHs). Age, baseline NIHSS score, 24-h ΔNIHSS, hyperlipidemia, prior stroke/transient ischaemic attack, antiplatelet treatment, diastolic blood pressure at admission, glucose values on admission and SICH location (both SICHs) were associated with reduced disability at 3 months (≥1-point reduction across all modified Rankin Scale scores). Patients with remote SICH (n = 219) and local SICH (n = 964) had comparable clinical outcomes, both before and after propensity score matching., Conclusions: Symptomatic intracerebral hemorrhage presents an alarmingly high prevalence of adverse clinical outcomes, with no difference in clinical outcomes between remote and local SICH., (© 2023 European Academy of Neurology.)

Background: Rates of intracranial hemorrhage (ICH) after intravenous thrombolysis (IVT) differ depending on ethnicity, one reason that few Eastern countries have approved a lower dose of alteplase. Data in this regard are scarce in the Middle Eastern region. Methods: The present retrospective study was performed on data extracted from the Safe Implementation of Treatments in Stroke (SITS) registry. Computed tomography (CT) image analysis was based on the SITS-Monitoring Study (SITS-MOST) definition for symptomatic ICH (SICH). Functional outcome at 3 months was assessed using the modified Rankin Scale (mRS). Multivariate logistic regression including adjusted analysis was used for comparison between groups. Results: Of 6615 patients, 1055 were enrolled. A total of 86% (n = 906) received a standard dose and 14% (n = 149) received a low dose of alteplase. Favorable 3-month outcome was achieved in 481 (53%) patients in the standard group and 71 (48%) patients in the low-dose group [adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI): 0.87-1.75, P = 0.218]. SICH occurred in 14 (1.5%) patients in the standard group and 3 (2%) patients in the low-dose group [odds ratio (OR) = 2.77, 95% CI: 0.36-21.04, P = 0.120]. At 3 months, mortality occurred in 145 (16.0%) patients in the standard group and 29 (19.4%) patients in the low-dose group (OR = 1.22, 95% CI: 0.78-1.91, P = 0.346). Conclusion: Low-dose compared to standard-dose alteplase for patients with acute ischemic stroke (AIS) was not associated with fewer hemorrhagic events and there was no significant difference in the favorable 3-month outcome (mRS: 0-2) or mortality rate., (Copyright © 2021 Iranian Neurological Association, and Tehran University of Medical Sciences.)

Introduction: Visual sleep-stage scoring is a time-consuming technique that cannot extract the nonlinear characteristics of electroencephalogram (EEG). This article presents a novel method for sleep-stage differentiation based on sonification of sleep-EEG signals using wavelet transform and recurrent neural network (RNN)., Methods: Two RNNs were designed and trained separately based on a database of classical guitar pieces and Kurdish tanbur Makams using a long short-term memory model. Moreover, discrete wavelet transform and wavelet packet decomposition were used to determine the association between the EEG signals and musical pitches. Continuous wavelet transform was applied to extract musical beat-based features from the EEG. Then, the pretrained RNN was used to generate music. To test the proposed model, 11 sleep EEGs were mapped onto the guitar and tanbur frequency intervals and presented to the pretrained RNN. Next, the generated music was randomly presented to 2 neurologists., Results: The proposed model classified the sleep stages with an accuracy of >81% for tanbur and more than 93% for guitar musical pieces. The inter-rater reliability measured by Cohen's kappa coefficient (κ) revealed good reliability for both tanbur (κ = 0.64, p < 0.001) and guitar musical pieces (κ = 0.85, p < 0.001)., Conclusion: The present EEG sonification method leads to valid sleep staging by clinicians. The method could be used on various EEG databases for classification, differentiation, diagnosis, and treatment purposes. Real-time EEG sonification can be used as a feedback tool for replanning of neurophysiological functions for the management of many neurological and psychiatric disorders in the future., (© 2020 S. Karger AG, Basel.)

Background: (i) Cluster analysis and partitioning samples based on cardio-cerebrovascular histories and length of stay (LOS); (ii) Determining related demographic and medical factors in individual clusters; and (iii) Comparing clusters based on 12-month health outcomes., Methods: The statistical population of the study included 2,293 stroke patients hospitalized in Imam Reza hospital of Kermanshah city from January 1, 2015, to December 31, 2016. After a one-year follow-up, the data collection window was closed on December 31, 2017. The patients' data were extracted from the electronic hospital information system (HIS). Two-step cluster analysis (TSCA), chi-square, Fisher exact, Kruskal-Wallis, and Mann-Whitney U tests, as well as multinomial logistic regression analysis were the analysis methods., Results: This model suggested five distinct clusters: the patients (i) without any cardio-cerebrovascular history and LOS = 5 days (36.2%); (ii) without any cardio-cerebrovascular history and LOS = 6 days (21.6%); (iii) with cerebrovascular history and LOS = 6 days (18.6%); (iv) with cardiovascular history and LOS = 6 days (16.1%); and (v) with cardio-cerebrovascular history and LOS = 6 days (7.5%). Hypertension, diabetes, and smoking were respectively the most significant modifiable risk factors, while sex, cerebrovascular diseases in the family, and age were respectively the most significant non-modifiable risk factors in high-risk clusters and LOS = 6 days. Compared to Cluster 1 (reference), during a one-year follow-up, a larger number of members in Clusters 3 and 5 were readmitted and/or expired., Conclusion: Considering the modifiable risk factors identified in the current study, providing programs for preventing readmission and potential death caused by stroke for Clusters 3 and 5 seems essential., (© 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

A significant portion of the various communities, especially developing countries, is involved in drug abuse and receive formal drug treatments. Although the benefits of available therapeutics such as methadone maintenance treatment (MMT) for controlling infectious diseases have been confirmed, treatment failure has been seen in a large range of the patients. This review addresses the importance of a less attentive behavioural approach in reducing treatment withdrawal. The executive protocol, the outcomes and challenges, and the benefits of this approach are debatable., Competing Interests: Conflict of Interest None.

Objectives: Octogenarians account for a third of ischemic stroke (IS) patients and applying endovascular carotid artery stenting (CAS), as a secondary prevention, in these patients is challenging. The aim of this study was to evaluate peri-procedural and long term clinical and angiographic impact of CAS on octogenarians., Patients and Methods: In a prospective study, 102 patients aged over 80 years old with symptomatic internal carotid artery (ICA) stenosis presenting by non-disabling IS or transient ischemic attack and having undergone CAS were evaluated prospectively from January 2012 to July 2016. All patients received standard stroke care during the study follow up period. Peri-procedural complication, cerebrovascular accidents, restenosis in target vessel and mortality rate were recorded and the collected data were analyzed to evaluate safety and durability of CAS in octogenarians., Results: 48 (47.06%) males and 54 (52.9%) females with the mean age of 83.39 ± 2.53 (range, 80-88) years were followed in a mean period of 24.5 ± 14.1 months (6-50 months). Success rate of CAS was 100%; whereas, the peri-procedural complication rate was 5.8% (only one patient experienced acute ischemic stroke during the procedure). Restenosis and recurrent cerebrovascular accidents were observed in 3.9% and 9.8% of the cases, respectively. Recurrent cerebrovascular accident leading to death was seen in 2.9% of the cases. The median patient event-free survival was 20 months., Conclusion: Endovascular CAS seems to be a safe and durable method for secondary prevention in ischemic stroke following symptomatic carotid artery stenosis in octogenarians., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To investigate the clinical effectiveness and safety of fingolimod in the western Iranian population., Methods: This study was performed as a prospective observational study between March 2014 and October 2015. Sixty patients with relapsing remitting multiple sclerosis (RRMS) who were referred to the MS clinic of Imam Reza Hospital, which is affiliated with Kermanshah University of Medical Sciences, Iran, were treated with 0.5 mg oral fingolimod capsules once daily for 12 months. The outcomes were clinical and included the annualized relapse rate, expanded disability status scale (EDSS) change, proportion of relapse-free patient, and side effects., Results: An 85% reduction in the annualized relapse rate compared with the baseline (from 1.8+/-1.35 to 0.27+/-0.58, p=0.001) was observed, and 76.66% of patients were free from relapse after the 12-month intervention. In addition, a significant reduction of EDSS was measured from 3.32 at baseline to 2.97 (p=0.001). The overall adverse events in our study were similar to those in previous studies., Conclusion: The present study confirms the effectiveness of fingolimod as a second-line therapy in western Iranian RRMS patients. Fingolimod side effects were generally mild and tolerable.

Objective: To compare the efficacy and safety of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in the treatment of patients with cerebral venous sinus thrombosis (CVST), and to provide an appropriate treatment option in these patients., Methods: This is a randomized double blind clinical trial conducted between December 2013 and December 2014. The subjects were selected among patients referred to Neurology Department, Imam Reza Hospital; affiliated to Kermanshah University of Medical Sciences, Kermanshah, Iran. Fifty-two cases of CVST were included in this study and randomly divided into 2 groups. Twenty-six cases received LMWH and the other 26 cases received UFH. The primary outcomes include hospital mortality rate and neurologic deficits as assessed by the National Institutes of Health Stroke Scale (NIHSS). The secondary end point was disability as measured by the Modified Rankin Scale (MRS)., Results: We observed the rate of mortality and neurological deficits and disability based on NIHSS, and the MRS did not differ between the 2 groups., Conclusion: The efficacy of LMWH and UFH in reduction of neurologic deficit and functional disability in patients with CVST are similar.

Introduction: Stroke is the second leading cause of death in the world. However, there is still no approved neuroprotective drug for acute ischaemic stroke. To clarify the neuroprotective efficacy and safety of dextromethorphan in stroke, the following study was carried out., Material and Methods: Forty patients with acute stroke causing moderate deficit were randomized to be treated with either dextromethorphan 300 mg per day or placebo for 5 days. Plasma level of dextromethorphan and its active metabolite was not evaluated in this study. The NIHSS score was calculated on day 5 and the Barthel activities of daily living index and Rankin score were checked after 3 months by a blinded investigator. Collected data were analysed using the t-test and χ(2) test., Results: In the dextromethorphan-treated group, the mean NIHSS score was 16.8 ±3.9 at baseline, and was 14.2 ±4.8 for the placebo-treated group (p = 0.069). At day 5, there was also no significant difference regarding NIHSS score (p = 0.167). At the 3-month follow-up, there was no significant difference regarding Barthel scale and Rankin score between the dextromethorphan and placebo groups., Conclusions: The results of our study suggest that although low-dose and short-term oral administration of dextromethorphan seems to be not neuroprotective, it does not worsen either patients' condition or NIHSS score. Moreover, patients treated with dextromethorphan showed a significant reduction in seizures (complication after stroke), but had increased chance of MI and renal failure by almost 5% when compared to the placebo-treated groups. More prolonged studies with a higher number of cases are recommended.

When evaluating a patient with amyotrophic lateral sclerosis (ALS), a number of other motor neuron disorders and related motor syndromes should be considered. Herein, we describe a 55-year-old Persian man with typical presentation of ALS in whom based on further finding of elevated level of antiphospholipid antibodies, final diagnosis of ALS with laboratory abnormalities of uncertain significance (ALS-LAUS) was made. With respect to persistent increased titre of antiphospholipid antibodies, he was treated with plasma exchange and prednisolone. After 3 months of treatment, the symptoms improved and antiphospholipid antibody titres decreased. To the best of our knowledge, this is the first case of ALS-LAUS accompanied by high titre of antiphospholipid antibodies with response to plasma exchange and corticosteroids.