Saadat Kamran

Corneal Confocal Microscopy: An Imaging Endpoint for Axonal Degeneration in Multiple Sclerosis

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.

Downbeat nystagmus following classical heat stroke.

Cerebellar syndrome following classical heat stroke is rare. We report a case of a 39-year-old man who presented with a cerebellar syndrome including downbeat nystagmus. MRI taken after 3 days of admission was normal. The downbeat nystagmus lasted for 6 days and than gradually disappeared. The ataxia and dysmetria improved gradually over 2 months. A brain CT scan performed 3 months later revealed no cerebellar atrophy. This case is unique as there were no predisposing factors (e.g. hypomagnesemia) and follow-up revealed complete reversibility of the ophthalmological abnormality. It reveals that the vestibulocerebellum is particularly vulnerable to thermal injury.

Prolonged Stay of Stroke Patients in the Emergency Department May Lead to an Increased Risk of Complications, Poor Recovery, and Increased Mortality

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.

Beneficial Effects of Implementing Stroke Protocols Require Establishment of a Geographically Distinct Unit

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.

Neurological manifestation of recreational fatal and near-fatal diethylene glycol poisonings: case series and review of literature.

AbstractDiethylene glycol is a common industrial solvent which is responsible for accidental and epidemic poisoning as early as the 1930s. Due to the unavailability and unaffordability of ethanol, people in Qatar among the low income group are consuming household chemicals, some of which contain diethylene glycol, for recreational purposes.The history of ingestion is usually not volunteered and the initial clinical presentation is usually nonspecific, making it difficult to diagnose from the clinical presentation. Moreover, the biochemical profile varies with time, making the diagnosis more difficult. The neurological course and toxicity is less well characterized than its renal counterpart. Moreover, reports in the literature of such recreational poisoning is lacking particularly in the region.Three cases of recreational diethylene glycol poisoning seen in Hamad General Hospital, Doha, Qatar from 2009 to 2012 are detailed here.These illustrate the clinical course with emphasis on the neurological sequelae that include encephalopathy and multiple cranial and peripheral neuropathies with fatal and near-fatal outcomes. Neuroimaging in 2 were initially normal, but follow-up imaging showed brain atrophy. The third patient’s neuroimaging showed diffuse brain edema with evidence of transtentorial herniation. Nerve conduction studies were performed in 2 of the 3 cases and showed evidence of mixed sensorimotor neuropathy. The outcomes were death in 1 and severe neurological morbidity and disability in 2 cases.Diethylene glycol is a dangerous substance when ingested and can result in mortality and severe morbidity, particularly from the renal and neurological manifestations. Whereas the mechanism of damage is less well known, the damage is likely dose related. The typical clinical pattern of evolution of the poisoning in the absence of cost-effective ways to detect it in the serum can help clinicians in making the diagnosis.Neurological manifestations may include encephalopathy and multiple cranial and peripheral neuropathies with subsequent brain atrophy. Public awareness of the danger of such recreational use should be raised.

Segmental left ventricular wall motion abnormalities are associated with lacunar ischemic stroke

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.

Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate

Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 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. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [P = 0.140] and mortality [P = 0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/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] and second infarct growth rate [IGR2] were nearly double [P < 0.001] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery.

Corneal Confocal Microscopy Detects Corneal Nerve Damage in Patients Admitted With Acute Ischemic Stroke

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<0.001, P<0.001, P<0.001), impaired glucose tolerance (P=0.004, P<0.001, P=0.002), and type 2 diabetes mellitus (P<0.001, P<0.001, P<0.001) compared with controls. HbA1c and triglycerides correlated with corneal nerve fiber density (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.

Ethnic variation in acute cerebrovascular disease: Analysis from the Qatar stroke registry

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 < 0.001). Diabetes and hypertension were significantly more common in Middle Eastern patients (358 (60.3%), 458 (77.1%)) compared to South East Asian patients (420 (45.5%), 596 (64.5%)) and Far Eastern patients (57 (27.3%), 154 (73.7%)), respectively (p < 0.001). Stroke was more severe in the Far Eastern group (median (interquartile range) – 5.0 (2–11.5)) compared to the Middle Eastern group (median (interquartile range) – 4.0 (1–8)) and South East Asian (median (interquartile range) – 4.0 (2–9)), p = 0.011. Mortality at 90 days was highest in patients from the Far East (15/209 (8.2%)) compared to the Middle East (35/594 (6.5%)) and South East Asia (33/924 (4.0)), p = 0.028. Patients from the Far East had significantly higher rates of intracranial hemorrhage compared to the Middle East and South East Asia (70/209 (33.5%), 77/594 (13.0%), and 169/924 (18.3%)), respectively (p < 0.001). 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.

Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke

OBJECTIVE 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. PATIENTS AND METHODS 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. FINDINGS 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. CONCLUSION 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.