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Introduction: In the current study, we are going to look at different factors responsible for the diagnostic delay of ALS patients among the sample of Egyptian patients. Method/patients: This is a cohort study. ALS patients were recruited from December 2018 to January 2020 from the ALS clinic at the international medical center (IMC) (Cairo, Egypt). We analyzed the site of onset, the time from symptom onset to diagnosis, age and sex differences among these ALS patients. Results: Thirty patients were included in the study. Seventy percent of the patients had limb onset ALS with a mean age of onset of 50 ± 12.1 vs 58.6 ± 2.1 years for the patients with bulbar onset (p = 0.02). Bulbar-onset patients were diagnosed earlier than limb onset patients (mean lag of 8.2 ± 2.57 months vs 22.95 ± 17.6 months respectively, p < 0.05). The average diagnosis time for women was slightly longer than that of men with a mean lag of 20.7 ± 21.1 vs. 17.6 ± 13.6 months, respectively, p > 0.05. Diagnostic delay and age at onset of symptoms were negatively correlated, however, this was not statistically significant. Discussion: To our knowledge, this the first population-based study from Egypt about predicting factors of diagnostic delay among Egyptian patients. Limb onset, female gender and young age are correlated with increased mean time to diagnosis. Statistically insignificant results could be attributed to a small sample. Larger population-based studies are needed from Egypt. [ABSTRACT FROM AUTHOR]

Introduction: Amyotrophic lateral sclerosis (ALS) diagnosis could be challenging in some cases and a thorough workup should be done to rule out ALS mimics. Thus, diagnosis should be made by an experienced neurologist and should be regularly reviewed. Objectives: Review challenging cases from the ALS clinic that were misdiagnosed as ALS. Method/patients: This is a descriptive study. We registered data of all patients coming for evaluation in the period between December 2018 and January 2020 at the international medical center (IMC) where the ALS specialized clinic is located. All patients underwent thorough clinical assessment according to the EFNS guidelines on the Clinical Management of Amyotrophic Lateral Sclerosis (MALS), and the diagnosis of ALS was made based on El Escorial revised criteria. Results: The records of 30 patients were available for review. Twenty-four patients out of 30 patients (80%) were diagnosed with ALS, and 6 patients (20%) were diagnosed with other disorders (ALS mimics). In the ALS group (24 patients), there are 18 males and 6 females (male to female ratio is 3:1); mean age of onset of ALS patients is 49.2 years ± SD 15.1 years; 18 patients (75%) had limb onset ALS and 6 patients (25%) had bulbar onset ALS. In the ALS mimics group (6 patients), there were 3 patients with multifocal motor neuropathy (MMN); 1 patient with celiac disease, 1 patient with mesothelioma, and 1 patient with cervical myelopathy. Discussion: The percentage of ALS mimics in our study is higher than that reported in previous studies. This could be due to the small sample size and the deficiency of specialized ALS centers across the country. MMN was the most common ALS mimic syndrome. Factors leading to change the diagnosis from ALS to another ALS mimic disorder were the adherence to El Escorial revised criteria for the diagnosis of ALS, following EFNS guidelines for management, and looking for demyelinating features in electrophysiological studies according to the EFNS criteria. [ABSTRACT FROM AUTHOR]

Background: Sleep disorders and epilepsy commonly exist and affect each other. Patients with epilepsy often complain of poor sleep and on the other hand, poor sleep makes epilepsy control difficult. Objectives: We aimed at comparing the sleep disturbances in a group of patients with medically controlled epilepsy versus another group with medically refractory epilepsy, from the electrophysiological standpoint. Subjects and methods: Sixty epilepsy patients were included; half of them with controlled epilepsy were assigned as group I, and the other half with refractory epilepsy was assigned as group II. All patients had an overnight polysomnogram and sleep EEG done. We excluded any patient with abnormal general or neurological clinical examination. Results: Patients in group II, had significantly delayed sleep onset latency and REM latency. However, higher arousal index, insomnia, and periodic limb movement index were found to be significantly higher in group I. Respiratory events; as light sleep durations, were observed to be higher in Group II, in addition to apnea-hypopnea index that was significantly higher in this group. Conclusion: Epilepsy affects sleep architecture and sleep-related events. Patients with refractory epilepsy suffer from more disturbance in sleep patterns. Moreover, antiepileptic drugs can have a diverse effect on sleep architecture and quality in epileptic patients. [ABSTRACT FROM AUTHOR]

ALSFRS-R is 12-item scale used to assess disability and to measure disease progression in ALS patients. The objective is to validate the Arabic version of ALSFRS-R based on the original English version. Methods and patients: This is a cross sectional study. ALSFRS-R was administered to 162 Egyptian patients with ALS after being translated in Arabic, and reapplied after 1 week. Patients were recruited from 2 centers: Neuromuscular unit, Ain Shams University hospitals and the specialized ALS clinic which is located at the international medical center (IMC). Results: No significant differences were found between the application and reapplication of the scale (p = 0.5). The linear regression and internal consistency that were measured by Pearson correlation and alpha Conbrach respectively were significant. Discussion: The Arabic version of the ALSFRS-R proposed by the current was proven to be reproducible and valid among Egyptian ALS patients. Thus, it will provide a useful tool for professionals to evaluate Arabic speaking patients in clinical practice and research. [ABSTRACT FROM AUTHOR]

Background D-dimer, a marker of plasmin-mediated fibrin degradation, is cross-linked to fibrin degradation products and indicates vessel occlusion. Objectives The purpose of this study was to evaluate the role of D-dimer serum level as a serological marker in the diagnosis and prognosis of acute ischemic stroke in Egyptian population. Patients and methods This prospective observational case-control study was conducted on 50 patients with acute ischemic stroke. Ten healthy age-matched and sex-matched individuals were taken as controls. The patient and control groups were subjected to detailed history taking, examination, and D-dimer level assessment. Neurologic examination using the National Institutes of Health Stroke Scale was carried out at admission and on discharge after treatment. Serum D-dimer level was evaluated within the first 24 h of admission. The outcome of the patients was graded using the modified Rankin scale on admission and 1 month of treatment. Results The mean D-dimer level was significantly higher in the patient group than in the control group (P < 0.001). There was a positive correlation between the levels of D-dimer and the National Institutes of Health Stroke Scale scores (P = 0.002) and the initial infarct volume in MRI of the brain (P = 0.000). The mean D-dimer level was significantly higher in patients with unfavorable outcome than in patients with favorable outcome, measured using the modified Rankin scale (P = 0.029). Conclusion Plasma D-dimer levels were significantly higher in patients with acute ischemic stroke than in controls. D-dimer levels increased with increasing severity of stroke and with increasing infarction volume. Moreover, D-dimer level could predict stroke outcome. [ABSTRACT FROM AUTHOR]

Background: Intravenous thrombolytic therapy remains the guideline-recommended treatment to improve outcomes after acute ischemic stroke. However, the functional outcome among patients with acute ischemic stroke after receiving intravenous thrombolytic therapy is influenced by huge variety of factors, and this was the aim of our study to evaluate the outcome predictors of intravenous thrombolytic therapy in a sample of Egyptian patients with acute ischemic stroke. Methods: We enrolled 183 acute ischemic stroke patients who were treated with intravenous recombinant tissue plasminogen activator (IV rtPA) according to the last updated guidelines of American Heart Association and American Stroke Association (AHA/ASA) from February 2018 to February 2020; however, only 150 patients of them completed our study plan till the end. Data of study variables were collected, analyzed statistically and correlated with the functional outcome 3 months after receiving IV rtPA using the modified Rankin Scale (mRS). Results: Good functional outcome was seen in 98 (65.3%) patients and poor functional outcome was seen in 52 (34.7%) patients. Multivariate analysis of the study variables was done to detect the significant independent predictors of the functional outcome. Atrial fibrillation (AF) (P value < 0.001*OR 6.28* (95% C.I)), hypertension (P value 0.001*OR 3.65*(95% C.I)), diabetes mellitus (DM) (P value 0.009*OR 2.805*(95% C.I)), increased National Institute of Health Stroke Scale (NIHSS) score 24 h after receiving IV rtPA (P value 0.003* OR 8.039* (95% C.I)), increased pulsatility index (PI) value in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of poor functional outcome. On the other hand decreased NIHSS score 24 h after receiving IV rtPA (P value 0.003* OR 0.124*(95% C.I)), Normal value of PI in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of good functional outcome. Conclusion: Intravenous thrombolytic therapy improves the functional outcome of acute ischemic stroke patients. Also, AF, hypertension, DM, NIHSS 24 h after receiving IV rtPA and PI could be used as independent predictors of the functional outcome. [ABSTRACT FROM AUTHOR]

Background: Intravenous thrombolysis (IVT) with alteplase is the first-line therapy for acute ischemic anterior and posterior circulation strokes (ACS and PCS). Knowledge about safety and efficacy of IVT in posterior circulation stroke is deficient as most of the Egyptian studies either assessed IVT outcome in comparison to conservative therapy or its outcome in anterior circulation stroke only. Therefore, our aim was to compare the relative frequency and outcome after intravenous thrombolysis in anterior versus posterior circulation stroke patients presenting to stroke centers of Ain Shams University hospitals (ASUH). Results: A total of 238 anterior circulation stroke and 61 posterior circulation strokes were enrolled, onset-to-door and door-to-needle time were statistically insignificant. NIHSS showed comparable difference at all time points despite higher scores along anterior circulation stroke; 90-day modified Rankin Scale (mRS) showed significant improvement in both groups from mRS >2 to =2 with a better percentage along posterior circulation stroke patients. There was insignificant difference for either incidence of death or intracranial hemorrhage (ICH) between the two groups. Conclusion: IVT significantly reduced NIHSS for both anterior and posterior circulation stroke along different studied time points. Meanwhile, a higher percentage of patients with posterior circulation stroke had a better mRS outcome at 90 days. [ABSTRACT FROM AUTHOR]

Background: The anatomical location of white matter hyperintense lesions in small vessel disease are apparently similar to those of borderzone infarction. The objective of this study is to find clinical and radiological points of differentiation between the two vascular disorders in a sample of Egyptian patients which might have an impact on primary and secondary prevention.Methods: Ischemic stroke patients with white matter lesions were categorized into two groups: small vessel disease and borderzone infarctions. NIHSS was done on admission. Risk factor profile was reported, and investigations done including: HbA1C, lipid profile, CRP, ECG, echocardiography, carotid duplex, brain MRI, MRA and MR perfusion study.Results: 46 patients completed the study, 29 with SVD and 17 with BZI. Smoking, hypertension and recurrent stroke were more common in borderzone infarctions, but only diabetes was significantly higher (p = 0.047). Limb shaking was more observed in borderzone infarctions (p = 0.049). Radiologically: lacunar pattern was observed more in small vessel disease, while rosary pattern was more in borderzone infarctions (p = 0.04). FLAIR symmetrical lesions and microbleeds were more significant in small vessel disease (p = <0.001; 0.048, respectively). Perfusion study time to peak denoted evidence of significant hypoperfusion in all regions of interest in borderzone infarctions.Conclusion: Limb shaking, retinal claudication or syncope, with MRI showing rosary pattern of white matter hyperintensity, few microbleeds and markedly impaired perfusion favor the diagnosis of borderzone infarctions. On the other hand, presence of lacunae, FLAIR showing symmetrical WMH and microbleeds with minimal or no perfusion deficit suggests the diagnosis of small vessel disease. [ABSTRACT FROM AUTHOR]

Background The rate of alteplase (tPA) thrombolysis utilization in acute stroke in Egypt is <1%. We report on the causes of this low rate of reperfusion therapies and take corrective action to improve it. Methods Two prospective observational studies were conducted at Ain Shams University hospitals. The first included 269 acute stroke patients admitted to the hospital over a six-month period. Obstacles to reperfusion therapy were identified, and based on the results, a corrective action plan was implemented including making alteplase(tPA) available, training, and establishing a standardized local protocol for reperfusion therapy. A second study was then conducted that included 284 acute ischemic stroke patients over another six-month period. Results In the first study, 53/269 patients (19.7%) arrived at hospital within 4.5 h and were eligible for reperfusion therapy. Of those, seven (13.2%) received alteplase(tPA), representing 2.6% of the total ischemic stroke patients admitted. The main causes for not giving thrombolytic therapy was unavailability of alteplase(tPA) (56.5%), wrong treatment decision (17.4%), missed window while performing brain imaging (15%), and unavailability of intermediate care bed (10.9%). The second study showed that out of 284 cases admitted with acute ischemic stroke, 37 were eligible for thrombolysis and 35 received alteplase(tPA) (94.3%), representing 12.3% of the total ischemic stroke admissions. Conclusion A comprehensive action plan that centers around making the drug available and training resulted in a significant improvement of reperfusion therapy utilization in Egypt. [ABSTRACT FROM AUTHOR]

Background Optical coherence tomography (OCT) is a promising tool for detecting subclinical changes in retinal nerve fiber layer (RNFL) and macular volume in multiple sclerosis (MS). Objectives The aim of the study was to assess the relationship of retinal changes in different MS subtypes with and without optic neuritis (ON) with clinical disability, duration of illness, and MRI results. Methods Twenty-four patients with relapsing-remitting subtype and 12 patients with secondary progressive subtype, of age range 16-55 years, with and without ON, and 16 age-matched and sex-matched healthy controls were enrolled in this study; in total, there were 15 male and 37 female participants. Patients were subjected to history, clinical evaluation, Extended Disability Status Score for disease severity, MRI brain with contrast, and OCT to assess the RNFL and macular volume of the optic nerve. The control group underwent OCT. Results RNFL thinning was highly correlated in both subtypes with and without ON in all field quadrants compared with the healthy controls. In addition, retinal and macular thickness inversely correlated with Extended Disability Status Score and disease duration in the progressive group than in the relapsing-remitting type. MRI with contrast inversely correlated with both macular and RNFL thickness in the progressive type. Conclusion Retinal axonal loss is more prominent in advanced stages of disease with proportionally greater thinning in eyes previously affected by clinically evident ON. In the absence of clinically evident ON, OCT is a promising potential biomarker of retinal pathology in MS subtypes. [ABSTRACT FROM AUTHOR]