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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.

Abstract Background Cerebrovascular disease is the second commonest cause of death, and over a third of stroke deaths occur in developing countries. To fulfil the current gap on data, this systematic review is focused on the frequency of stroke, risk factors, stroke types and mortality in Iran. Methods Thirteen relevant articles were identified by keyword searching of PubMed, Iranmedex, Iranian University index Libraries and the official national data on burden of diseases. Results The publication dates ranged from 1990 to 2008. The annual stroke incidence of various ages ranged from 23 to 103 per 100,000 population. This is comparable to the figures from Arab Countries, higher than sub-Saharan Africa, but lower than developed countries, India, the Caribbean, Latin America, and China. Similarly to other countries, ischaemic stroke was the commonest subtype. Likewise, the most common related risk factor is hypertension in adults, but cardiac causes in young stroke. The 28-day case fatality rate is reported at 19-31%. Conclusions Data on the epidemiology of stroke, its pattern and risk factors from Iran is scarce, but the available data highlights relatively low incidence of stroke. This may reflect a similarity towards the neighbouring nations, and a contrast with the West.

Background: Previous literatures have shown a transient ischemic attack (TIA) mimic rate of 9-31%. We aimed to ascertain the proportion of stroke mimics amongst suspected TIA patients. Methods: A prospective observational study was performed in Ghaem Hospital, Mashhad, Iran during 2012-2013. Consecutive TIA patients were identified in a stroke center. The initial diagnosis of TIA was made by the resident of neurology and final diagnosis of true TIA versus TIA mimics was made after 3 months follow-up by stroke subspecialist. Results: A total of 310 patients were assessed during a 3- month period of which 182 (58.7%) subjects were male and 128 (41.3%) were female. Ten percent of the patients was categorized as a TIA mimic. The presence of hypertension, aphasia, duration of symptoms, and increased age was the strongest predictor of a true TIA. Migraine was the most common etiology of stroke mimic in our study. Conclusion: It seems that many signs and symptoms have low diagnostic usefulness for discrimination of true TIA from non-cerebrovascular events and predictive usefulness of any sign or symptom should be interpreted by a stroke neurologist. [ABSTRACT FROM AUTHOR]

Background: Intravenous Valproate (IVVP) has been used in the treatment of migraine in some studies; however, it is far better known in the management of status epilepticus.Methods: Consecutive patients with migraine in our Headache Clinic were enrolled in this prospective, randomized clinical trial in 2011. The patients were randomized into two therapeutic groups, one receiving 900 mg IVVP (Orifil) and the other 16 mg IV Dexamethasone (IVDEX) diluted in 150 CC normal saline and infused for 10 minutes. Worst severity of pain before treatment and least severity at 3 hours after the infusion using a 0-10 point numeric rating scale were recorded. An interview with the patient was performed 72 hours after treatment to detect a possible relapse of headache. Results: Thirty-one migraine status patients, comprising 28 women and 3 men at a mean±SD age of 33.355±12.373 SD, were investigated. Differences in the therapeutic effects of IVVP (Orifil) and IVDEX on pain score were not significant between the two groups (t=0.933, df=29; P=0.358). Relapse of headache occurred in 68.42% of the IVVP (Orifil) group and 66.67% of the IVDEX group. Distribution of relapse was not significantly different between the two therapeutic groups of patients (P=0.870). Conclusion: IVVP (Orifil) was similar in efficacy to IVDEX as abortive therapy in patients with migraine status. IVVP (Orifil) appears to offer a safe and well-tolerated abortive treatment. Trial Registration Number: IRCT13891146234N2 [ABSTRACT FROM AUTHOR]

BACKGROUND: Assessing the risk of recurrent ischemic events in patients with transient ischemic attack (TIA) and minor ischemic stroke (MIS) is of a great importance in clinical practice. METHODS: Consecutive patients with TIA or MIS who were visited in Ghaem Hospital, (Mashhad, Iran) were enrolled in a prospective cohort study during 2010 to 2011. Diagnosis of TIA or MIS was accomplished by a stroke neurologist. Only those who presented within 24 hours from the onset of symptoms were recruited. MIS was considered as an ischemic stroke with National Institutes of Health Stroke Scale (NIHSS) < 4. The endpoint of the study was a new ischemic cerebrovascular event or vascular death in 90 days and additionally in 3 days. The decision to admit and type of treatment in each case was left to the discretion of the stroke neurologist. The association between 20 potential factors with recurrent ischemic events in 3 and 90 days was investigated using univariate and multivariate analysis (MVA). RESULTS: 393 TIA patients (238 males and 155 females) and 118 MIS patients (77 males and 41 females) were enrolled in the study. Stroke occurred in 117 (23.2%) patients, TIA in 99 (19.6%), and there was 11 (2.2%) vascular deaths within 3 months in the total 511 patients with minor ischemic events. Crescendo TIAs and multiple TIAs were associated with greater risk of stroke in 3 days in a univariate analysis (OR = 5.12, P < 0.001) and (OR = 3.98, P = 0.003), respectively. Patients with index stroke had 11.5% lower risk of recurrent stroke in 3 days than patients with index TIA in multivariate analysis (OR = 0.115, P = 0.039). Diabetes was independently associated with 3 months stroke recurrence in the patients with minor ischemic events (OR = 2.65, P = 0.039). CONCLUSION: Multiple and crescendo TIAs are the main predictors of stroke recurrence, derived from the univariate analysis of the patients with minor ischemic events. [ABSTRACT FROM AUTHOR]

Background: Gender distribution of acute stroke patients varies considerably among stroke registries throughout the world, but factors responsible for this phenomenon remained vastly unknown. Materials and Methods: Using data from prospective hospital‑based stroke registries in China (n=752 acute stroke patients), Germany (n = 96054), India (n=1500), and Iran (n=1392), this descriptive study explored gender distribution of stroke patients and its determinants. In addition, the proportions of males and females to be expected in fictive study populations were calculated, and differences in gender distribution between stroke databases throughout the world were described. Results: In the German dataset, a maximum male preponderance was found for patients aged between 55 and 64 years (proportion of male patients 0.67 [95% CI: 0.66-0.67]), whereas patients older than 84 years revealed a strong overbalance of females (0.27 [0.26-0.28]). In Germany, age‑specific gender distribution of stroke patients is well explained by the numbers of females and males in the general population and by gender‑specific stroke incidence rates. Both in China and India, a strong preponderance of male stroke patients was found for the majority of age categories with a maximum proportion of male patients of 0.82 in the 35-44 years age group. In contrast, the Iranian stroke register revealed an overbalance of females (0.13 [0.11-0.14]) in nearly all age categories. A total of 1392 Iranian ischemic stroke patients (738 female, 654 male) were investigated. Conclusion: Gender distribution of acute stroke patients is highly variable. Gender distribution varied considerably between countries. Apart from demographic factors reflecting gender ratio in the general population and gender‑specific stroke incidence rates, sociocultural peculiarities may also play an important role in this context. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study tried to develop an Asian Stroke Disability Scale (ASDS) and compared its interrater reliability with modified Rankin Scale (mRS) and Barthel Index (BI). METHODS: Three items including self-care, mobility, and daily activities were selected as variables for development of the ASDS. The variables were provisionally graded on a 2- to 4- point scale based on the importance of each item. Each of the variables was categorized into 3 categories. Afterward, 125 rater-patient assessments for each scale (mRS, BI, and ASDS) were performed on 25 stroke patients by 5 raters. For categorization of functional impairment as minor or major, the scores of mRS, BI and ASDS were categorized as ≤ 2 and > 2, < 90 and ≥ 90, and < 3 and ≥ 3, respectively. 125 rater-patient assessments for each of the mRS, BI, and ASDS were performed on 25 stroke patients by five raters. RESULTS: The quantitative variability of BI, mRS, and ASDS scores was not significant (P = 0.379; P = 0.780; and P = 0.835, respectively). Interrater variability of mRS, BI, and ASDS scores based on qualitative categorization was not significant (P = 1.000; P = 0.978; and P = 0.901, respectively). Paired interrater variability of mRS, BI, and ASDS scores based on qualitative categorization was not significant (P > 0.05). CONCLUSION: The ASDS is easy to use, requires less than 1 minute to complete and is as valid as mRS and BI in assessment of functional impairment of patients with stroke. [ABSTRACT FROM AUTHOR]

BACKGROUND: The main source of studies about effects of opium consumption on heart and brain attacks originates from Iran Therefore the aim of the present study was to assess opium addiction as a probable influencing factor for ischemic heart disease and ischemic stroke. MATERIALS AND METHODS: A cross-sectional study was carried out in two Cardiology and Neurology clinics in Eastern Iran in 2011. Diagnosis of Ischemic Heart Disease (IHD) and Ischemic Stroke (IS) was made by Cardiologist and Stroke Neurologist respectively. The influence of gender, hypertension, diabetes, hyperlipidemia, cigarette smoking, oral and inhaled opium consumption on distribution of IHD and IS were evaluated. RESULTS: Five hundred fifty eight patients (307 females, 251 males) with mean age 56.2 years enrolled the study. On adjusted odds ratios of our whole 558 patients, only hypertension and diabetes had a significant influence on occurrence of IHD; (P = 0.000 and P = 0.000) respectively. Oral and inhaled routes of opium addiction did not have a significant effect on occurrence of IHD; [OR = 1.172, 95% CI = 0.624-2.203, P = 0.621] and [OR = 1.820, 95% CI = 0.811-4.085, P = 0.147] respectively. Hypertension and diabetes were significant risk factors of IS in our 558 patients at multivariate analysis; (P = 0.000, P = 0.020). Oral opium addiction was as significant protective factor of IS in our study group; OR = 0.211, 95% CI = 0.079-0.564, P = 0.002, while inhaled opium addiction did not have a significant effect on occurrence of IS in our patients at; OR = 1.760, 95% CI = 0.760-4.076, P = 0.187. CONCLUSION: Oral opium consumption is a protective factor of IS but not IHD. Inhaled opium addiction does not have a significant influence on occurrence of IS and IHD. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Alberta Stroke Program Early Computerized Tomography Score (ASPECTS) was used to detect significant early ischemic changes on brain CT of acute stroke patients. We designed the modified ASPECTS and compared it to the above system based on the inter-rater reliability. METHODS: A cross-sectional validation study was conducted based on the inter-rater reliability. The CT images were chosen from the stroke data bank of Ghaem hospital, Mashhad in 2010. The inclusion criteria were the presence of middle cerebral artery territory infarction and performance of CT within 6 hours after stroke onset. Axial CT scans were performed on a third-generation CT scanner (Siemens, ARTX, Germany). Section thickness above posterior fossa was 10 mm (130 kV, 150 mAs). Films were made at window level of 35 HU. The brain CTs were scored by four independent radiologists based on the ASPECTS and modified ASPECTS. The readers were blind to clinical information except symptom side. Cochrane Q and Kappa tests served for statistical analysis. RESULTS: 24 CT scans were available and of sufficient quality. Difference in distribution of dichotomized ?7 and >7 ASPECT scores between four raters was significant (Q=13.071, df=3, p=0.04). Distribution of dichotomized <6 and ?6 scores based on modified ASPECT system between 4 raters was not significantly different (Q=6.349, df=3, p=0.096). CONCLUSIONS: Modified ASPECT method is more reliable than ASPECTS in detecting major early ischemic changes in stroke patients candidated to tPA thrombolysis. [ABSTRACT FROM AUTHOR]

Thrombolysis for stroke is being used in some developing countries. This study was designed to evaluate the problems of thrombolysis therapy in Iran. During January-July 2008, all patients with ischemic stroke admitted to Ghaem Hospital, Mashhad, northeast Iran, were enrolled in a prospective observational study. Ghaem Hospital is a tertiary care hospital that includes infrastructure for thrombolysis with tissue plasminogen activator (tPA). The stroke onset to hospital entrance time, hospital entrance to completed investigation time, contraindications of thrombolysis, and the capability of the patients to afford the treatment costs by their own were recorded. Of the 625 patients with ischemic stroke, 50 (8%, 30 men, 20 women) arrived at hospital within a 3-hour time window. About 44% of these early arrived stroke patients remained within the 3-hour time window to complete computed tomography and laboratory tests. About 30% of these patients were capable to pay tPA cost by themselves. Contraindications of thrombolysis by tPA were found in 58% of these early arrived stroke patients. Seven patients (five men, two women) were eligible for intravenous thrombolysis. The major hurdles in implementing the treatment are the high cost of the drug and the lack of priority for triage and investigation of hyperacute stroke patients. [ABSTRACT FROM AUTHOR]

Background: Rheumatic valvular disease is a common complication of rheumatic fever in children in developing countries. Later in life, rheumatic valvular disease becomes an important modifiable risk factor of stroke. The incidence of rheumatic valvular disease and its complications are unknown in Iran. Materials and Methods: This is a prospective study of 302 consecutive patients admitted to a tertiary care hospital in Iran with a diagnosis of non-hemorrhagic stroke from June 2003 to June 2005. All patients underwent diagnostic work-up to determine stroke etiology according to clinical indications. Diagnosis and classification of stroke were made according to World Health Organization (WHO) criteria. Results: In 302 patients with stroke (mean age 66.78, SD: 14.36), 60 (20%) patients (mean age 65.61, SD: 17.48) had cardiac source of embolism (CSE). Rheumatic mitral stenosis was present in 28 (28/60; 46.6%) of these cardioembolic stroke patients. Atrial fibrillation was documented in 19 (67.8%) patients with mitral stenosis. The remaining 32 (32/60; 53.3%) cardioembolic stroke patients had other CSE. Among the latter group, 8 (25%) patients had non-valvular atrial fibrillation. In the entire group of CSE, there were a total of 30 patients who were candidates for anticoagulation, and among those, 14 (14/30; 46.6%) were anticoagulated, but only 6 (6/30; 20%) were within therapeutic range at the time of their stroke. Conclusions: Rheumatic valvular disease seems to be the most common CSE in Iran. Many patients with rheumatic or non-rheumatic CSE are not adequately managed for prevention of cardioembolic stroke. [ABSTRACT FROM AUTHOR]

Background – Stroke in young adults causes morbidity in this socioeconomically active age group. The etiologic frequency of ischemic stroke in young adults differs around the world. Methods – The study population consisted of 314,000 ‘young adult’ residents in Southern Khorasan province in Iran. All patients with stroke are routinely admitted to the Valie Asr tertiary care hospital. Data on patients demographics, clinical presentation and investigations of consecutive patients aged 15–45 years with ischemic stroke are registered in Southern Khorasan stroke data bank for the period March 2000 to March 2005. All patients underwent a standard battery of diagnostic investigations by a stroke neurologist. The etiologic classification of stroke in the patients was made based on the trial of ORG 10172 in acute stroke treatment (TOAST) criteria. Results – One hundred and twenty-four patients (60 female, 64 male) were prospectively investigated during a 5-year period. The incidence of ischemic stroke in young adults was eight cases per 100,000 people per year. Cardioembolic mechanism comprised 54% of stroke etiology in young adults. Rheumatic valvular disease was present in 32% of the patients and caused 2.5 preventable stroke cases per 100,000 ‘young adults’ per year. Conclusion – Rheumatic valvular disease is the most common cause and a preventable etiology of stroke in Persian young adults. [ABSTRACT FROM AUTHOR]

Background: Neurologic literature on therapeutic effect of subcutaneous corticosteroids in patients with migrainous chronic daily headache is scarce. The aim of this research is to assess the therapeutic effects of this management in such patients. Methods: Consecutive patients with migrainous chronic daily headache enrolled a prospective before-after therapeutic study during 2010-2013. Methylprednisolone 40 mg was divided into four subcutaneous injection doses. Two injections were administered in the right and left suboccipital area (exactly at retromastoid cervicocranial junction) and the other two injections in the lower medial frontal area (exactly at medial right and left eyebrows). A daily headache diary was filled out by the patients before and one month after the intervention. The severity of pain was classified based on a pain intensity instrument using numeric rating scale from 0-10 point scale. Paired t-test and Chi- square test were used for statistical analysis. Results: 504 patients (378 females, 126 males) with migrainous chronic daily headache were enrolled in the study. Dramatic, significant, moderate, mild, or no improvements respectively constituted 28.6%, 33.3%, 23.8%, and 14.3% of the post treatment courses. Therapeutic effect of intervention on mean pain scores was significant; t=7.38, df=20, P=0.000. Two cases developed subcutaneous fat atrophy in frontal injection site and three cases experienced syncope during injection. Conclusion: Subcutaneous corticosteroids could be used as an adjunct therapy in patients with migrainous chronic daily headache. [ABSTRACT FROM AUTHOR]

Background and purpose: Stroke is one of major causes of disability and self-care. Therefore, it is important to introduce and develop new treatment approaches in order to improve and enhance post stroke recovery process for medical, social and economical purposes. The aim of this study was to determine the effect of mirror therapy on self-care of patients with stroke. Materials and methods: This study is a randomized controlled-trial conducted on 50 patients with stroke hospitalized randomly; allocated in two groups of control (25 patients) and mirror therapy (25 patients). In the experimental group, twenty 30 --minute sessions were done daily or every other day. The patients did range of motion of their healthy upper and lower extremities in front of the mirror and only observed its mirror image. In addition to mirror therapy in both groups, the routine program (physiotherapy and neuromuscular stimulation) was performed. The ability of self-care was assessed before the 5th, the 10th, the 15th and last sessions of intervention using Barthel Index scale. Finally, the data were analyzed in different phases by t-test and repeated measure. Results: Two groups showed no significant difference in terms of ability of self-care and confounding variables before intervention. The 5th, the 10th and the 15th sessions were significantly different (P<0.05) but the last session of intervention in mirror therapy group did not significantly improve in comparison with control group after intervention (P>0.05). Repeated measures showed significantly independent effect on the group and the self-care of patients with stroke (P<0.05), however, this effect was not interactional (P>0.05). Conclusion: Mirror therapy can improve the self-care of patients with stroke as a simple, inexpensive and patient-oriented treatment. [ABSTRACT FROM AUTHOR]

Background and Purpose: Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in patients with transient ischaemic attack (TIA) or minor ischaemic stroke (MIS)., Material and Methods: Consecutive patients with TIA or MIS referring to Ghaem Hospital, Mashhad presenting within 24 hours from the onset of symptoms were recruited to the prospective cohort study between 2010 and 2011. MIS was defined as an ischaemic stroke with National Institutes of Health Stroke Scale (NIHSS) score < 4. The end-point of the study was a new ischaemic cerebrovascular event or vascular death at 90 days and, additionally, at 3 days after the index TIA or MIS. The decision to admit and of method of treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD2 scoring system for recurrent stroke or TIA was quantified by the area under the curve (AUC), using the c-statistics., Results: The study included 393 patients with TIA (238 males, 155 females) and 118 patients with MIS (77 males, 41 females). Among 511 patients with minor ischaemic events, 117 strokes (23.2%), 99 TIAs (19.6%), and 11 vascular deaths (2.2%) occurred within 3 months after the index event. The ABCD2 score had a weak predictive value for 3-month and 3-day recurrent stroke in patients with TIA (AUC = 0.599 and 0.591, respectively), but a high predictive value for 3-month and 3-day recurrent stroke in patients with MIS (AUC = 0.727 and 0.728, respectively)., Conclusion: The ABCD2 score is highly predictive for short-term recurrent stroke in patients with MIS but not in patients with TIA, although it was originally designed for patients with TIA.