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Repulsive guidance molecule-a (RGMa) inhibits angiogenesis and increases inflammation. Animal models of cerebral ischemia have shown that an increased expression of RGMa leads to larger infarction and its inhibition attenuates effects of ischemia. We report on the relationship of RGMa to stroke types and severity. This is a prospective study in patients admitted to the stroke service in Qatar. We collected the clinical determinants, including NIHSS at admission, imaging and outcome at discharge and 90-days. RGMa levels were determined by measuring mRNA levels extracted from peripheral blood mononuclear cells (PBMCs) within 24 h of onset and at 5 days. There were 90 patients (lacunar: 64, cortical: 26) and 35 age-matched controls. RGMa mRNA levels were significantly higher in the stroke patients: day 1: 1.007 ± 0.13 versus 2.152 ± 0.19 [p

Background: Visual rating of medial temporal lobe atrophy (MTA) is an accepted structural neuroimaging marker of Alzheimer’s disease. Corneal confocal microscopy (CCM) is a non-invasive ophthalmic technique that detects neuronal loss in peripheral and central neurodegenerative disorders. Objective: To determine the diagnostic accuracy of CCM for mild cognitive impairment (MCI) and dementia compared to medial temporal lobe atrophy (MTA) rating on MRI. Methods: Subjects aged 60–85 with no cognitive impairment (NCI), MCI, and dementia based on the ICD-10 criteria were recruited. Subjects underwent cognitive screening, CCM, and MTA rating on MRI. Results: 182 subjects with NCI (n = 36), MCI (n = 80), and dementia (n = 66), including AD (n = 19, 28.8%), VaD (n = 13, 19.7%), and mixed AD (n = 34, 51.5%) were studied. CCM showed a progressive reduction in corneal nerve fiber density (CNFD, fibers/mm2) (32.0±7.5 versus 24.5±9.6 and 20.8±9.3, p

Neurodevelopmental and neurodegenerative pathology occur in Schizophrenia. This study compared the utility of corneal confocal microscopy (CCM), an ophthalmic imaging technique with MRI brain volumetry in quantifying neuronal pathology and its relationship to cognitive dysfunction and symptom severity in schizophrenia. Thirty-six subjects with schizophrenia and 26 controls underwent assessment of cognitive function, symptom severity, CCM and MRI brain volumetry. Subjects with schizophrenia had lower cognitive function (P ≤ 0.01), corneal nerve fiber density (CNFD), length (CNFL), branch density (CNBD), CNBD:CNFD ratio (P

Axonal loss is the main determinant of disease progression in multiple sclerosis (MS). This study aimed to assess the utility of corneal confocal microscopy (CCM) in detecting corneal axonal loss in different courses of MS. The results were confirmed by two independent segmentation methods. 72 subjects (144 eyes) [(clinically isolated syndrome (n = 9); relapsing–remitting MS (n = 20); secondary-progressive MS (n = 22); and age-matched, healthy controls (n = 21)] underwent CCM and assessment of their disability status. Two independent algorithms (ACCMetrics; and Voxeleron deepNerve) were used to quantify corneal nerve fiber density (CNFD) (ACCMetrics only), corneal nerve fiber length (CNFL) and corneal nerve fractal dimension (CNFrD). Data are expressed as mean ± standard deviation with 95% confidence interval (CI). Compared to controls, patients with MS had significantly lower CNFD (34.76 ± 5.57 vs. 19.85 ± 6.75 fibers/mm2, 95% CI − 18.24 to − 11.59, P 2, 95% CI − 8.94 to − 5.77, P 2, 95% CI − 9.55 to − 5.6, P P P

Background: Sex differences may determine presentation, utility of treatment, rehabilitation, and occurrences of major adverse cardiovascular events (MACEs) in acute stroke (AS). Objective:The purpose of the study was to evaluate the short-term prognosis and long-term outcomes in MACEs in Qatari nationals admitted with AS. Methods: All AS patients admitted between January 2014 and February 2019 were included. We evaluated the preadmission modified Rankin scale (mRS) score, etiology and severity of symptoms, complications, and functional recovery at discharge and 90 days. MACEs were recorded for 5 years. Results: There were 891 admissions for AS (mean age 64.0 ± 14.2 years) (male, n = 519 [mean age ± SD 62.9 ± 14.1 years]; female, n = 372 [mean age ± SD 65.6 ± 14.2 years] p = 0.005). There were no differences in the preadmission mRS and severity of symptoms as measured on National Institute of Stroke Scale. At discharge, the outcome was better (mRS 0–2) in men (57.8 vs. 46.0%), p = 0.0001. This difference persisted at the 90-day follow-up (mRS 0–2, male 69.4% vs. female 53.2%, p = 0.0001). At the 90-day follow-up, more women died (total deaths 70; women 38 [10.2%] versus men 32 [6.2%], p = 0.03). MACEs occurred in 25.6% (133/519) males and 30.9% (115/372) females over the 5-year follow-up period (odds ratio 0.77, 95% confidence interval 0.57–1.0, p = 0.83). Conclusions: Female patients have a poor short-term outcome following an AS when corrected for age and comorbidities. While our study cannot explain the reasons for the discrepancies, higher poststroke depression and social isolation in women may be important contributory factors, and requires further studies are required to confirm these findings.

Background The association of cardiac wall motion abnormalities (CWMAs) in patients with stroke who have major adverse cardiovascular events (MACE) remains unclear. The purpose of this study was to estimate the 50‐month risk of MACE, including stroke recurrence, acute coronary events, and vascular death in patients with stroke who have CWMAs. Methods and Results We performed a retrospective analysis of prospectively collected acute stroke data (acute stroke and transient ischemic attack) over 50 months by electronic medical records. Data included demographic and clinical information, vascular imaging, and echocardiography data including CWMAs and MACE. Of a total of 2653 patients with acute stroke/transient ischemic attack, CWMA was observed in 355 (13.4%). In patients with CWMAs, the embolic stroke of undetermined source (50.7%) was the most frequent index stroke subtype and stroke recurrences (P=0.001). In multivariate Cox regression after adjustment for demographics, traditional risk, and confounding factors, CWMA was independently associated with a higher risk of MACE (adjusted hazard ratio [HR], 1.74; 95% CI, 1.37–2.21 [P=0.001]). Similarly, CWMA independently conferred an increased risk for ischemic stroke recurrence (adjusted HR, 1.50; 95% CI, 1.01–2.17 [P=0.04]), risk of acute coronary events (aHR, 2.50; 95% CI, 1.83–3.40 [P=0.001]) and vascular death (adjusted HR, 1.57; 95% CI, 1.04–2.40 [P=0.03]), in comparison to the patients with stroke without CWMA. Conclusions In a multiethnic cohort of ischemic stroke with CWMA, CWMA was associated with 1.7‐fold higher risks of MACE independent of established risk factors. Embolic stroke of undetermined source was the most common stroke association with CWMA. Patients with stroke should be screened for CWMA to identify those at higher risk of MACE.

Stroke in air travelers is being increasingly recognized. We report on stroke among passengers arriving at or transiting through a busy air travel hub.The stroke database of the sole tertiary care center for stroke in a large busy international hub was interrogated. Demographic data of transit passengers, their stroke risk factors, stroke severity, National Institutes of Health Stroke Scale (NIHSS), acute stroke interventions, discharge status and outcome utilizing the Modified Raking scale (mRS) were retrieved and compared between passengers and non-passenger controls.Forty-three flight-related stroke patients were compared to 2564 non-passenger stroke patients. The mean age in the flight-related stroke group was 59.53±10.83 years, 30/43 (69.8%) were males. The stroke subtypes were ischemic in 30 (69.8%) patients, hemorrhagic in 9 (20.9%), and transient ischemic attack in 3 (7.0%), with one cerebral sinus venous thrombosis (2.3%). The mean NIHSS score was 7.79±6.44 in passengers, demonstrating moderate severity. Ten patients (23.3%) received thrombolysis, one (2.3%) received thrombectomy, and one (2.3%) received both thrombolysis and thrombectomy. Outcomes, 54.8% had a good outcome (mRS 0-2), and 45.2% had dependence/death (mRS 3-6).Air passengers with stroke were found to be older with more severe strokes and a higher probability of receiving acute stroke treatment compared to non-passengers. Increased awareness with appropriate and timely recognition and triaging of transit passengers with stroke is warranted.

The severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) pandemic, became rapidly recognised by variable phonotypic expressions that involve most major body organs. Neurological complications of severe acute respiratory syndrome coronavirus disease are increasingly encountered in patients with COVID-19 infection, more frequently in patients with severe infection, and develop as a consequence of the neurotropic potential of this virus, secondary cytokine storm and acquired syndrome of COVID-19 coagulopathy. Spinal cord involvement after COVID-19 more commonly includes infectious transverse myelitis, para and post infection myelopathy and, rarely, spinal cord ischaemia related to increased coagulopathy with thromboembolic consequences. We herein report a COVID-19-positive patient with increased coagulopathy and vertebral artery thrombosis leading to posterior circulation and subsequent spinal cord infarction.

We are reporting the imaging findings of the rare entity of critical illness-associated cerebral microbleeds in a COVID-19-positive 66-year-old woman with hypoxic respiratory failure, who was eventually intubated and ventilated. Multiple scattered cerebral microhaemorrhages diffusely distributed in the juxtacortical white matter and internal capsule region, sparing the deep and periventricular white matter, basal ganglia, thalami and cortex were seen, which is a unique imaging finding in critically ill patients with respiratory failure and hypoxemia requiring mechanical ventilation. The mechanism underlying these microhaemorrhages relates to the endpoint of critical illness, rather than a specific underlying disease.

Mimics comprise a third of patients presenting with an acute stroke. There is limited information on their natural history.We evaluate long term major cardiovascular events (MACE) in stroke mimics in a prospective database from Qatar.Between Feb 2014 and Jan 2019, 481 patients (male: 238; female: 243) mean age 57.5 years (±18.0), with 399 (83%) medical mimics and 82 (17%) functional mimics were evaluated. Imaging revealed previous old stroke in 26.6% and small vessel disease in 5%. MACE occurred in 57 (11.9%) and there were 31 deaths (6.4%) with majority of deaths (5.6%) from cardiovascular causes. MACE was significantly higher in patients with previous stroke, p 0.0001), coronary artery disease, p = 0.002), diabetic, p = 0.01), and hypertensive on admission, p 0.0001. MACE were also significantly higher in patients where imaging showed a previous stroke, p = 0.006).The occurrence of MACE during follow-up suggests that patients with existing vascular disease require aggressive management of vascular risk factors.

Functional magnetic resonance imaging (MRI) of tumors of the head and neck usually encompasses diffusion-weighted imaging (DWI) and intravenous (IV) contrast T1 dynamic perfusion imaging (DCE-MRI or PWI). Both techniques can characterize different tissues by probing into their microstructure, providing a novel approach in oncological imaging. In this pictorial review, we will cover the important technical aspects of DWI and PWI, the pathophysiological background and the current applications and potential of these functional MRI techniques in the imaging of head and neck cancer.

Asymptomatic small vessel disease (SVD), including white matter hyperintensities (WMHIs), periventricular hyperintensities (PVHIs), silent stroke (SS), and cerebral microbleeds (CMBs), increases the risk of stroke. There are limited studies of SVD in subjects from the Middle East and Southeast Asia (SA). All patients admitted to stroke service between 2014 and 2015 were reviewed for presence of “pre-existing” SVD. Stroke mimics with no previous history of stroke were used as controls. There were 1727 patients admitted with stroke. Analysis was done on 988 subjects (914 strokes and 74 controls) who had MRI scan done. Pre-existing SVD was seen in 642 (64.9%) patients (WMHIs 19.6%, PVHIs 33.2%, SS 51.4%, and CMBs 22%). Silent strokes were significantly more common with ischemic stroke (IS) compared to intracranial hemorrhage (ICH) (62.0 vs 34.3%, p

PurposeLumbar spinal canal stenosis and lumbar spinal foraminal stenosis are common, degenerative pathologies which can result in neurogenic claudication and have a negative impact on function and quality of life. Percutaneous interspinous devices (PIDs) are a recently-developed, minimally-invasive, alternative treatment option. This study details a 9 year single-centre experience with PIDs and examines the complementary use of spinous process augmentation (spinoplasty) to reduce failure rates.MethodsA retrospective cohort assessment of 800 consecutive patients who presented to a specialized spine hospital was performed with 688 receiving treatment. Inclusion was based on high-grade stenosis, failure of conservative management and electromyography. 256 had a PID alone while 432 had concurrent polymethyl methacrylate (PMMA) augmentation of the adjacent spinous processes. The patients were followed up at 3 and 12 months using the Zurich Claudication Questionnaire (ZCQ) and Oswestry Disability Index (ODI).ResultsBoth groups showed marked improvement in the patients’ ZCQ scores (3.2 to 1.3) and ODI scores (32 to 21), with strong satisfaction results (1.7). The symptom recurrence rate from complications for the group which received concurrent spinous process augmentation was reduced when compared with the PID alone cohort (ConclusionThis study demonstrates the efficacy of percutaneous interspinous devices in treating lumbar spinal stenosis. It also provides evidence that concurrent spinous process augmentation reduces the rate of symptom recurrence.

There is ambiguity regarding the role of left ventricle wall motion abnormalities (LVWMAs) as a potential cardioembolic source in patients, who satisfy embolic stroke of undetermined source (ESUS) criteria.We analyzed prospectively collected data in 345 acute stroke patients, 185 (53.6%) stroke with atrial fibrillation (SwAF), and 160 (46.4%) stroke with LVWMA. LVWMA were younger (P = .003), had significantly higher frequency of stroke risk factors and lower ejection fraction (P.001). No significant difference was found between the stroke pattern in SwAF and LVWMA except focal cortical, cortical-subcortical lesions were more frequent in LVWMA (P = .002). Mean wall motion score index (WMSI) was 1.523 (range 1.05-2.71) without any correlation between the severity of WMSI and multiple strokes (P = .976). In subgroup analyses vertical basal WMSI (P = .030) and vertical mid cavity WMSI (P = .010) was significantly related to branch arterial stroke. LVWMA 94 (65%) patients were on antiplatelet/anticoagulation compared to 47 (52.4%) with atrial fibrillation (AF), with no significant difference in stroke recurrence during 4 years follow-up (P = .15).Patients with LVWMA who satisfy ESUS criteria, have stroke pattern on diffusion-weighted magnetic resonance imaging and risk of stroke recurrence similar to AF-related stroke despite being on appropriate antiplatelet medications. Further studies with anticoagulation therapy may be required in this group of patients to improve the high risk of recurrent stroke.

An outbreak of corona virus disease 2019 (COVID-19) began in China in December 2019, and rapidly spread to become a worldwide pandemic. Neurological complications encountered in hospitalized patients include acute arterial ischemic cerebrovascular stroke, cerebral venous thrombosis, critical illness-associated cerebral microbleeds, hypertensive hemorrhagic posterior reversible encephalopathy, meningoencephalitis/flare up of infections, flare up of multiple sclerosis, acute disseminated encephalomyelitis, cerebral hemodynamic/hypoxic changes such as watershed ischemic changes and hypoxic ischemic encephalopathy, and spine manifestations of Guillain Barre syndrome and viral myelitis. The purpose of our study is to illustrate the different neuroimaging features in critically ill hospitalized COVID-19 positive patients in the State of Qatar.

Objectives Corneal confocal microscopy (CCM) is a noninvasive ophthalmic technique that identifies corneal nerve degeneration in a range of peripheral neuropathies and in patients with multiple sclerosis, Parkinson's disease, and amyotrophic lateral sclerosis. We sought to determine whether there is any association of corneal nerve fiber measures with cognitive function and functional independence in patients with MCI and dementia. Methods In this study, 76 nondiabetic participants with MCI (n = 30), dementia (n = 26), and healthy age‐matched controls (n = 20) underwent assessment of cognitive and physical function and CCM. Results There was a progressive reduction in corneal nerve fiber density (CNFD), branch density (CNBD), and fiber length (CNFL) (P

Background The randomized trials showed improved outcome and reduced mortality in malignant middle cerebral artery (MMCA) undergoing Decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. Despite high prevalence of stroke, especially in younger individuals, high and short-term mortality from stroke in South Asian and Middle East, there is little published data on DHC in patients with MMCA stroke. Methods This is a retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale (mRS) and dichotomized as favorable (mRS ≤ 4) or unfavorable (mRS > 4), at 3 months. Results In total, 137 patients underwent DHC. At 90 days, mortality was 16.8%; 61.3% of patients survived with an mRS of 4 or less and 38.7% had an mRS greater than 4. Age (55 years), diabetes (P = .004), hypertension (P = .021), pupillary abnormality (P = .048), uncal herniation (P = .007), temporal lobe involvement (P = .016), additional infarction (MCA + anterior cerebral artery, posterior cerebral artery) (P = .001), and infarction growth rates (P = .025) were significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation greater than 1 cm, and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome (P = .109). Conclusions Similar to the results of the studies from the West, DHC Improves functional outcome in predominantly South Asian patients with MMCA Stroke.

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.

Background: Ischaemic stroke features may show regional differences. Posterior circulation stroke (PCS) is of special interest, as symptomatology, course and outcome are usually different and complex. No significant studies or registries have reported on the characteristics and outcomes of PCS in our region. Methods: We prospectively collected data of 116 patients with PCS admitted from 2005 through 2008 in the only stroke admitting hospital in Qatar. Demographics, risk factors, clinical signs/symptoms, pattern of presentation, aetiology, imaging features, complications and outcome at discharge and follow-up were recorded. Results: Mean age was 53 years with 25% aged ≤45, 85% were males. Demographically 47% were Arabs and 51% of South-Asian origin. Mean duration from onset to presentation was 29 h. Major risk factors were obesity (66%) and hypertension (61%). Minimal or fluctuating symptoms were present in 64%, while 9% had maximal deficit at onset. Thirty nine per cent had lesions in proximal territory and 23% in multiple territories. Around 41% had no occlusion, 16% had vertebro-basilar, 16% vertebral, 8% basilar occlusion. Etiologically 53% patients had large artery disease, 16% small vessel disease, and 17% cardioembolism. Seventy per cent of patients were discharged home, while 10% expired. Modified Rankin score (mRS) at discharge was ≤2 in 53% and ≥4 in 13% patients. At 30-day follow-up, 68% had mRS of ≤2. Ninety-day survival status showed 89% alive with mRS ≤ 2 in 73%. Conclusion: The aetiology and lesion topography of PCS in this heterogeneous population differs from the pattern observed in other populations.

The purpose of this study was to evaluate the potential of transarterial embolization (TAE) for the treatment of focal nodular hyperplasia (FNH). Four women with the diagnosis of FNH underwent superselective transarterial embolization with contour particles between 2001 and 2004. The indications were progressive increase in size in three of the patients and abdominal pain in the fourth patient. No immediate or delayed postembolization complications were encountered in any of our patients. All patients presented angiographically with characteristic findings, such as feeding artery, a tumor blush, and septations. In two patients, the embolization resulted in a constant size or volume decrease in the 1-year follow-up. In the other two patients, a complete resolution of the FNH was observed in the MRI follow-up after 1 year. This group presented with a homogeneous devascularization in the immediate postembolization exam. In conclusion, transarterial embolization of focal nodular hyperplasia can be considered as a possible alternative treatment method to surgery.