Shima Shahjouei

Safety of Intravenous Thrombolysis among Stroke Patients Taking New Oral Anticoagulants—Case Series and Systematic Review of Reported Cases

BACKGROUND Current guidelines do not recommend the administration of intravenous tissue plasminogen activator (IV-tPA) to patients with acute ischemic stroke (AIS) who take new oral anticoagulants (NOACs). We present a multicenter case series of IV-tPA use while the patients are on NOACs, as well as a systematic review of the literature. METHODS We reviewed the medical records of consecutive patients on NOACs who received IV-tPA for symptoms of AIS at four participating stroke centers in the United States and Europe. Safety endpoints were post-thrombolysis symptomatic intracranial hemorrhage (sICH) or other serious systemic bleeding. RESULTS Between October 2010 and October 2014, 6 patients received IV-tPA for possible AIS while taking dabigatran. None of the patients had sICH or any other hemorrhagic complication. Literature review resulted in a total of 26 patients receiving IV-tPA while on NOACs (dabigatran: 15, rivaroxaban: 10, apixaban: 1). Among them, two patients experienced sICH and died. None of the patients experienced major extracranial hemorrhage; however, minor and asymptomatic hemorrhagic complications were described in 7 patients. Pooled analysis indicates an sICH rate of 6.45% (95% CI by the adjusted Wald method: .8-21.7%). The mean interval between the last dose of NOAC and IV thrombolysis was 12 ± 7.8 [4-28.3] hours. CONCLUSIONS Although the safety of IV-tPA cannot be definitively confirmed in a small series, consideration of stroke severity and management of hemorrhage risk with general precautions with post-tPA management protocols can justify treatment in the absence of coagulopathy.

White Matter Changes Correlates of Peripheral Neuroinflammation in Patients with Parkinson’s Disease

Neuroinflammatory pathology has long been identified to contribute to the pathology of Parkinson disease. Early microstructural changes in white matter tracts might give a clue for earlier detection of PD. We investigated through diffusion MRI connectometry the structural correlates of white matter tracts of 81 patients with PD with whole blood neutrophil-to-lymphocyte ratio (NLR), controlling for age and sex. Diffusion data were reconstructed in the MNI space using q-space diffeomorphic reconstruction to obtain the spin distribution function. The spin distribution function (SDF) values were used in DMRI connectometry analysis. The connectometry analyses identified white matter QA of the following fibers to be correlated with NLR score after adjustment for age and sex: bilateral cingulum, body and left crus of fornix, bilateral corticospinal tract (CST), and body and splenium of corpus callosum (CC) and superior cerebellar peduncle with decreased connectivity related to NLR (FDR = 0.04542). Keeping with emerging evidence on the role of neuroinflammation in PD pathology, these results with functional relevance to prodromal Parkinson disease, bring new insights to pivotal role of peripheral inflammation in CNS neurodegeneration.

Cranial Dermal Sinus: Presentation, Complications and Management

Objective: Cranial dermal sinus is a very rare anomaly mostly found in the midline occipital area, presenting with diverse clinical features from asymptomatic dermal sinus to symptomatic situations including meningitis, dermoid tumor or abscess. Methods: Medical records of 18 patients with 19 cranial dermal sinuses operated at the Children’s Hospital Medical Center in Tehran from 1999 to 2011 were retrospectively studied. Their presentations, accompanying anomalies, radiological and surgical findings were evaluated. Results: Patients were aged 1 month to 6 years and were followed for 2–12 years. Most sinuses were located in the midline occipital region. Infection was the most common reason for referral (50%) followed by skin dimple (33.3%). Creamy white discharge was found in 50% of patients. Posterior fossa abscess, hydrocephalus and meningitis were observed in 38.9, 38.9 and 22.2% of children, respectively. All sinus tracts with associated dermoid tumors or abscesses were removed en bloc to decrease the risk of recurrence. Conclusion: The sinus tracts are a portal of entry for pathogens which result in serious complications of meningitis or abscess. In this series, 67% of children presented with serious symptoms; therefore, we recommend prophylactic surgery in all cranial dermal sinuses. The exact time of surgery is not obvious as the natural course of the disease is unknown. If any symptom is observed surgery should be done as soon as possible. For asymptomatic sinuses identified by the pediatrician during a regular visit prophylactic surgery is recommended as soon as the child can tolerate operation.

Potential Roles of Adropin in Central Nervous System: Review of Current Literature

Adropin is a 4.9 kDa peptide that is important for maintenance of metabolic and non-metabolic homeostasis. It regulates glucose and fatty acid metabolism and is involved in endothelial cell function and endothelial nitric oxide (NO) synthase bioactivity as well as physical activity and motor coordination. Adropin is expressed in many tissues and organs including central nervous system (CNS). This peptide plays a crucial role in the development of various CNS disorders such as stroke, schizophrenia, bipolar disorder as well as Alzheimers, Parkinsons, and Huntingtons diseases. In this comprehensive review, the potential roles of adropin in cellular signaling pathways that lead to pathogenesis and/or treatment of CNS disorders will be discussed.

Sacrococcygeal teratoma with intradural extension: case report

Intradural sacrococcygeal teratoma (SCT) is a rare entity that has been reported in only a few cases previously. The authors present the case of a 2-week-old, otherwise healthy neonate with a mass in the buttock. The imaging findings and the high level of serum alpha-fetoprotein were highly suggestive of SCT. On operation the authors found intradural extension of the teratoma. The lesion was managed successfully without any remaining sequelae. The authors briefly review the currently proposed etiology regarding teratoma formation and the intradural extension of SCT.

Randomized clinical trial of acetazolamide administration and/or prone positioning in mitigating wound complications following untethering surgeries

OBJECTIVE No evidence-based guideline has been approved for the postoperative management of pediatric patients with tethered cord syndrome (TCS). The purpose of this randomized clinical trial was to evaluate the effectiveness of prone positioning and acetazolamide administration on complication rates following spinal cord untethering surgeries. METHODS From October 2012 to February 2015, patients with a primary diagnosis of TCS who were admitted to the Childrens Medical Center Hospital of Iran were randomly allocated to 1 of 4 intervention modality groups postoperatively: 1) Group A, acetazolamide administration for 10 days; 2) Group B, prone positioning for 10 days; 3) Group C, acetazolamide administration and prone positioning for 10 days; and 4) Group D, no intervention. CSF leakage, CSF collection, wound dehiscence, operative site infection, and secondary surgical wound repair were considered failure. RESULTS A total of 161 patients were enrolled in this study (Group A, n = 39 [24.2%]; Group B, n = 41 [25.5%]; Group C, n = 39 [24.2%]; and Group D, n = 42 [26.1%]). The overall failure rate was 12.42% (20 patients). Complication rates through pooled analyses were as follows: CSF leakage (n = 9, 5.6%), CSF collection (n = 12, 7.5%), wound dehiscence (n = 2, 1.2%), and infection of operation site (n = 3, 1.9%). Two patients (1.2%) required surgical secondary wound repair due to complications. CSF leakage and collection rates were significantly lower in patients who underwent prone positioning (p = 0.042 and 0.036, respectively). The administration of acetazolamide, either isolated or in combination with prone positioning, not only could not significantly lower the complication rates, but also added the burden of side effects. CONCLUSIONS The current study demonstrates the possible role of prone positioning in mitigating the complication rates subsequent to untethering surgeries. Clinical trial registration no.: NCT01867268 ( clinicaltrials.gov ).

Exophytic glioma of the medulla: presentation, management and outcome.

Objective: Exophytic gliomas of the medulla are rare childhood tumors that mostly are pilocytic astrocytomas. Here we report our experience in 11 ‑children with this rare tumor. Methods: A retrospective study was performed using the records of children with exophytic gliomas of the medulla at Childrens Hospital Medical Center in Tehran, Iran, from 2002 through 2013. The general, clinical, and radiological data and follow-up of all patients were reviewed. Results: The patients mostly were male aged from 11 months to 7 years. Swallowing problems, failure to thrive and nausea and vomiting were the most common symptoms. The time span between the onset of symptoms and the diagnosis was 2-24 months. Gross total resection of tumor was possible in 8 patients. Most tumors were pilocytic astrocytomas. Patients were followed for 2 months to 11 years (mean = 3.6 years). There was no intraoperative mortality. Recurrence occurred in 1 child with fibrillary astrocytoma. Conclusion: Gross total resection of symptomatic dorsal exophytic medullary glioma is recommended. Most tumors are pilocytic astrocytomas. The attachment of these tumors to important brainstem structures usually inhibits total resection. Electrophysiological monitoring of sensorimotor pathways and cranial nerves can be helpful to preserve surrounding neural tissue during tumor resection and to minimize complications. Regular follow-up of patients with clinical examination and brain MRI is mandatory. Repeated surgery, radiation therapy and chemotherapy are suggested in cases with tumor recurrence or progression.

The diagnostic values of UCH-L1 in traumatic brain injury: A meta-analysis

ABSTRACT Traumatic brain injury (TBI) is a major health concern. The purpose of this study is to identify the diagnostic accuracy of ubiquitin C-terminal hydrolase-L1 (UCH-L1)—a protein biomarker—in comparison with CT-scan findings post-TBI. Accordingly, we conducted a systematic review of eligible studies and assessed the risk of bias according to the QUADAS-2 checklist. A total of 13 reports from 10 original studies were included. Based on our analysis, serum UCH-L1 has a high accuracy in predicting CT findings in mild to moderate TBI. Based on the QUADAS-2 checklist, this result has a high risk of bias affecting its applicability. The plasma level of UCH-L1 has moderate accuracy in predicting CT findings when assessed in all GCS levels. This result has a low risk of bias and low concerns regarding applicability. Pooled analysis suggests that the plasma/serum UCH-L1 level has high accuracy in predicting CT findings in a wide range of GCS in patients with TBI. This result has a high risk of bias and high concern about its applicability. The heterogeneity in approaching TBI biomarker interferes with drawing a definitive conclusion. Therefore, although UCH-L1 is a promising blood-based diagnostic biomarker for TBI, but due to differences in reported diagnostic accuracy, further studies are needed to recommend UCH-L1 as an alternative to CT scanning.

Abstract 4: Safety of Intravenous Thrombolysis Among Patients Taking Direct Oral Anticoagulants: A Systematic Review and Meta-analysis

INTRODUCTION Direct oral anticoagulants (DOACs) are increasingly being administered for atrial fibrillation and stroke prevention. The risk of symptomatic hemorrhagic transformation (sHT) following intravenous thrombolysis (IVT) among stroke patients who take DOACs is not clear. METHODS We conducted a systematic review of literature through six different resources-PubMed, Scopus, Embase, Clinicaltrial.gov, ICTRP and Cochrane library. The control groups included patients who took warfarin with INR<1.7 and patients without prior anticoagulation use. The heterogeneity between studies was assessed by χ2 test for heterogeneity. Meta-analysis was conducted by assuming the random-effect models. RESULTS A total of 12606 search results were retrieved. After reduction of the duplication, screening the title and abstracts and review of the candidate manuscripts, 44877 stroke patients were enrolled in this study-DOACs: 369 patients, warfarin: 1997 patients and 42511 patients without prior anticoagulation use. Pretreatment use of DOACs was not associated with increased risk of sHT compared to those who received warfarin (OR: 0.62; 95% CI: 0.23-1.71; P=0.74) or patients without prior anticoagulation use (OR: 0.89; 95% CI: 0.31- 2.56; P=0.98). Similarly, by restricting the results to last DOACs-IVT interval of 48 hours, DOACs was not associated with increased risk of sICH; neither in comparison with warfarin (OR: 0.63; 95% CI: 0.39- 1.02; P=0.82), nor with patients without prior anticoagulation use (OR: 0.89; 95% CI: 0.53- 1.48; P=0.36). CONCLUSION Pretreatment use of DOACs appears not to be associated with increased risk of sHT among patients who presented with stroke symptoms and treated with IVT.

Iatrogenic Acute Ascending Aortic Dissection with Intramural Hematoma during Coronary Artery Stenting: A Case Report

Background Iatrogenic acute ascending aortic dissection during percutaneous coronary intervention (PCI) is an exceptionally rare and life-threatening sequel that requires early and accurate diagnosis along with rapid management. No guidelines have yet been established to direct decisions on the different treatment options that can be employed in the setting of acute aortic dissections caused by PCI. However, similar cases have been treated either by intracoronary stenting and conservative management as in localized aortocoronary dissections or by surgical intervention in cases of extensive aortic dissections. Case summary Hereby, we present a rare case of a female patient who developed “full-blown” acute ascending aortic dissection (Stanford type A—DeBakey type II dissection) with intramural hematoma during an elective percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) and left circumflex artery (LCA). Accordingly, emergent surgical repair of the dissected aorta was performed including grafting of supracoronary ascending aortic tube, along with coronary artery bypass graft placement and septal myomectomy for severely hypertrophied cardiac septum. The patient recovered successfully without any documented postoperative complications. Conclusion It is pivotal to avoid aggressive use of instrumentation during PTCA in order to prevent the potential development of catheter-induced aortic dissection.