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Carotid angioplasty and stenting (CAS) could be considered for preventing stroke in patients with carotid artery stenosis. This study aimed to determine the incidence and the risk factors of the early and mid-term complications associated with CAS.This is a retrospective cohort study conducted at Shiraz University of Medical Sciences from March 2011 to March 2019. Patients at high risk and standard risk for carotid endarterectomy were included. The primary composite outcome was defined as stroke, myocardial infarction (MI), and death in the first 30 days after CAS. All-cause mortality, vascular mortality, and stroke were investigated during mid-term follow-up.A total of 579 patients (618 CAS) were recruited (mean age: 71.52 years). Overall, 394 (68.40%), 211 (36.63%), 179 (31.07%), and 96 (16.72%) patients had hypertension, dyslipidemia, diabetes mellitus, or were cigarette smokers, respectively. Primary composite outcomes were observed in 2.59% of patients (1.55% stroke, 0.69% MI, and 1.72% death). Atrial fibrillation was a predictor of primary composite outcome in multivariate logistic regression (p = .048). The presence of total occlusion in the contralateral carotid artery was significantly associated with the risk of stroke in univariate logistic regression (p = .041). The patients were followed for a period ranging from 1 to 83 months. The overall survival rate for all-cause mortality was 93.48% at 1 year, 77.24% at 5 years, and 52.92% at 8 years. All-cause mortality was significantly higher among patients with symptomatic carotid stenosis (p = .014).CAS provides acceptable short-term and mid-term outcomes in a unique population of high- and standard-surgical-risk, symptomatic and asymptomatic, octogenarian, and nonoctogenarian patients.

Objectives: There are several reports of the association between SARS-CoV-2 infection (COVID-19) and cerebral venous sinus thrombosis (CVST). In this study, we aimed to compare the hospitalization rate of CVST before and during the COVID-19 pandemic (before vaccination program). Materials and methods: In this retrospective cohort study, the hospitalization rate of adult CVST patients in Namazi hospital, a tertiary referral center in the south of Iran, was compared in two periods of time. We defined March 2018 to March 2019 as the pre-COVID-19 period and March 2020 to March 2021 as the COVID-19 period. Results: 50 and 77 adult CVST patients were hospitalized in the pre-COVID-19 and COVID-19 periods, respectively. The crude CVST hospitalization rate increased from 14.33 in the pre-COVID-19 period to 21.7 per million in the COVID-19 era (P = 0.021). However, after age and sex adjustment, the incremental trend in hospitalization rate was not significant (95% CrI: -2.2, 5.14). Patients > 50-year-old were more often hospitalized in the COVID-19 period (P = 0.042). SARS-CoV-2 PCR test was done in 49.3% out of all COVID-19 period patients, which were positive in 6.5%. Modified Rankin Scale (mRS) score ≥3 at three-month follow-up was associated with age (P = 0.015) and malignancy (P = 0.014) in pre-COVID period; and was associated with age (P = 0.025), altered mental status on admission time (P

Background and purpose. – Identifying multiple sclerosis (MS) lesions is cornerstone in the diagnosis and prognosis of the disease activity. Application of contrast-enhanced magnetic resonance imaging (CE-MRI) is vital but the alternative use of diffusion-weighted imaging (DWI) and biomarkers is most appropriate when the injection of contrast agents is contraindicated. The present study investigated the possible substitution of CE-MRI with DWI and determined a vitamin D3 cutoff point for MS patients with positive MRI.Materials and Methods. – 5 ml of peripheral venous blood was collected from all patients and DWI and post-contrast T1-weighted MRI were performed on 85 patients with acute attacks of MS from April 2018 to November 2019. Contrast-enhanced lesions were considered the gold standard of activity in MRI in evaluating the relation between CE-MRI and DWI.Results. – The accuracy of CE-MRI was higher (63.5%) compared to DWI (27.1%). Majority of patients (54) showed positive results in CE-MRI. The difference between patients with and without positive CE-MRI was statistically significant in terms of vitamin D3 deficiency (P=0.001). The optimal cutoff of vitamin D3 for CE-MRI positive patients was 23.33 ng/ml with 83.33% sensitivity and 61.29% specificity. Conclusions. – Combination of CE-MRI and DWI yields more positive imaging results; DWI sequence alone, without using T1 with contrast in MRI, is not enough to assess brain lesion activity in patients with MS. Furthermore, vitamin D3 levels of

The aim of the current study was to inquire the questions and concerns of people with epilepsy (PWE) about COVID-19 vaccines in order to provide a more realistic list of their frequently asked questions (FAQs).We surveyed all the consecutive PWE or their care-givers who were referred to our neurology clinics (Shiraz University of Medical Sciences) during January-February 2022. We collected their questions and concerns in relation to COVID vaccines based on a predesigned brief questionnaire. Informed consent to participate in the study was obtained from the participants.In total, 452 people participated in the study; 291 people (64.4%) did not have any questions or concerns with regard to the COVID-19 vaccination. Having any questions or concerns about COVID-19 vaccination was significantly associated with not being vaccinated. Questions and concerns about the adverse effects of COVID-19 vaccines [seizure worsening, general adverse effects, long-term effects (e.g., infertility, cognitive dysfunction)] were by far the most common questions by people with epilepsy and their carers.Our findings may be used by policy-makers to prepare appropriate educational materials to provide the best targeted and tailored information to people with epilepsy and their carers to convince them of the necessity and safety of COVID-19 vaccination. Such an educational material must include enough information on the associated adverse effects of COVID-19 vaccines and should also discuss some other important issues such as indications of these vaccines in special populations and drug-vaccine interactions.

Introduction: Although several animal studies have indicated the antiepileptic effect for curcumin, there are reports stating the null antiepileptic effect of this substance. This inconsistency might be due to the low bioavailability of curcumin. Therefore, the current study aimed to assess the effect of oral bovine serum albumin (BSA)-based nanocurcumin on seizure caused by pentylenetetrazol (PTZ) in mice. Furthermore, due to the suggested involvement of JNK signaling in seizure pathology, the hippocampal pattern of JNK phosphorylation (activation) was evaluated. Methods: BSA based nanocurcumin was administered at doses of 50 and 100mg/kg oral gavage to male NMRI mice, one hour before PTZ administration. Intravenous PTZ paradigm was used to determine the threshold dose of PTZ to induce clonic seizures, while the intraperitoneal PTZ paradigm was applied to evaluate the latency for appearance of generalized clonus. Upon completion of intraperitoneal PTZ paradigm experiments, the hippocampi were removed and Western blot analysis was performed to determine the phosphorylated and total forms of JNK. Results: The results indicated that BSA-based nanocurcumin at the doses of 50 and 100mg/kg could significantly increase the threshold and latency of clonic seizure, which was a significant superior effect compared to natural curcumin. PTZ significantly increased the level of hippocampal JNK phosphorylation, but pretreatment of nanocurcumin did not modify this effect. Conclusion: The present study shows that converting curcumin to BSA-based nanocurcumin can increase its antiepileptic effect. Furthermore, the antiepileptic effect of nanocurcumin was not associated with a modification in PTZ-induced hippocampal JNK hyper activation.

Background Aneurysm formation of internal carotid arteries (ICA) in patients with mucormycosis is a scarce phenomenon. However, the prevalence of rhino-cerebral mucormycosis has been reported to increase after the coronavirus disease 2019 (COVID-19) pandemic. Methods Three patients with stroke and subarachnoid hemorrhage due to ICA aneurysm after the involvement of adjacent paranasal sinuses with mucormycosis were presented. All patients were recruited from Namazi and Khalili hospitals affiliated with Shiraz University of Medical Sciences in Iran from April 2021 to May 2021. Results They had a history of diabetes and corticosteroid use. Also, one of them was treated with imatinib. Two out of three patients were infected with SARS-CoV-2 infection before developing mucormycosis. Two patients had diagnostic angiography before endovascular intervention. One patient did not undergo any therapeutic intervention due to total artery occlusion, whereas the other patient experienced a successful parent artery occlusion by coiling, and only this patient survived. Although all patients received antifungal treatment and surgical debridement, two of them died. Conclusions In the patients with rhino-cerebral mucormycosis evolving of aneurysm should be promptly and meticulously investigated by magnetic resonance angiography (MRA) and computed tomography angiography (CTA). As this type of aneurysms was very fast-growing, as soon as the involvement of sphenoid sinus was detected, the possibility of ICA aneurysm formation should always be kept in mind. If the patient developed an aneurysm, prompt intensive antifungal therapy and therapeutic endovascular interventions such as stenting, coiling, or sacrificing should be considered as soon as possible to optimize outcomes.

The loss of cholinergic neurons has been a major issue in researches on Alzheimer's disease (AD) for about 40 years. Therefore, the scopolamine model of amnesia has been widely used in AD researches. Recently, it was reported that the early stage amnesia of AD is related to memory retrieval deficit. Curcumin, as the main ingredient of turmeric, has been suggested to decrease the prevalence of AD in human population. This study was conducted to assess if curcumin prevents retrieval deficit induced by scopolamine in passive avoidance task. Moreover, according to the proposed link between cholinergic system and Akt/GSK-3β (Glycogen synthase kinase 3 beta) signaling, the hippocampal contents of these proteins were determined. Male NMRI mice (20–25 g body weight) were treated with 50 or 100 mg/kg/po curcumin or its vehicle for 10 days. On day 10, the animals were trained in passive avoidance apparatus. The retention trial was performed 24 h later. Scopolamine (1 mg/kg/i.p.) or its vehicle was administered 30 min before retention test. At the completion of behavioral studies, the hippocampi were removed and western blot analysis was performed to determine hippocampal phosphorylated and total Akt and GSK-3β and beta actin contents. The results showed that curcumin treatment at 50 and 100 mg/kg doses prevented scopolamine-induced memory retrieval deficit and restored Akt and GSK dephosphorylation caused by scopolamine. Overall, these findings showed that pre-test scopolamine administration disrupts memory retrieval along with the diminished Akt and GSK-3β phosphorylation in hippocampus while curcumin administration prevented those changes.

Background: Multiple sclerosis (MS) is the most disabling neurological disease and has been studied for decades, but there are still many unproven treatments. Cinnamon (Cinnamomum zeylanicum) is a well-known herb and has many therapeutic applications. Objectives: This study aimed to evaluate the effect of cinnamon on inflammatory factors, pain, and anthropometric indices in patients with progressive-relapsing MS. Methods: In this randomized controlled trial, 60 patients suffering from progressive-relapsing MS were randomly recruited from Shiraz MS Center. Four capsules of cinnamon were taken every day for eight weeks by each participant in the intervention group (500 mg in each capsule) and four capsules of wheat flour by the control group (500 mg in each capsule). A 3-day 24-h food recall and physical activity questionnaire was filled out by interviewing before and after the intervention. Pain level was evaluated by using a Visual Analog scale (VAS). Interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) were measured in blood samples before and after the intervention. Participants underwent anthropometric measurements, including body weight, height, and waist and hip circumference. Results: Thirty-six (87.80%) participants were female, and twenty-six patients were married (63.41%). IL-6 and hs-CRP levels decreased significantly in the intervention group compared to the control group (P < 0.05). According to the VAS results, the pain level also decreased significantly (P = 0.003) in the intervention group in comparison to the control group. Conclusions: Multiple sclerosis is a debilitating inflammatory disease, and cinnamon may help improve inflammatory markers and pain in MS patients.

Background Metabolic syndrome (MetS) represents a collection of metabolic risk factors such as obesity, dyslipidemia, hyperglycemia, and hypertension. Medications can increase the incidence rate of MetS and insulin resistance (IR). Objective This study aims to evaluate the effects of Carbamazepine (CBZ) or Valproate (VPA) as monotherapy on the development of MetS and IR in the adult Iranian epileptic patients. Methods In this observational analytic case-control study, 80 epileptic patients were treated with VPA (40 patients) or CBZ (40 patients) monotherapies for more than 6 months and 45 age and sex matched controls were included. MetS was assessed based on International Diabetes Federation (IDF) and National Cholesterol Education Program (NCEP) criteria. Results In the multiple regression analysis, in VPA-treated patients the risk of MetS (by IDF criteria) was increased 19 times higher than controls (OR = 19.20; 95% CI = 2.62-140.23, P = 0. 004) and risk of IR (by HOMA and QUICKI) was increased 15 and 9 times more than controls (OR = 14.83; 95% CI = 3.03–72.56, P = 0.001) and (OR = 9.13; 95% CI = 2.55–32.65, P = 0.001) respectively. Increase in waist, DBP, and insulin level were also showed as important factors in risk of MetS. In CBZ therapy, the risk of MetS (by IDF) depressed by 17% less than controls and the risk of IR (by HOMA) increased 7 times more than controls. Conclusion Treatment with VPA can increase the likelihood of developing MetS and IR while, CBZ therapy could decrease the risk of MetS and increase risk of IR in the epileptic patients in Iran compared to the general population.

Background: Rituximab is a monoclonal antibody against CD20 antigen present on mature B lymphocytes. It is commonly used in some hematologic, rheumatologic as well as neurologic disorders, including multiple sclerosis (MS) and neuromyelitis optica (NMO). Although there are some data about the safety of rituximab in patients with MS and NMO, there are few experiences regarding its safety in the Iranian population with MS, and known complications are often related to the studies conducted on the patients in other countries or with other autoimmune diseases and malignancies that are different from the population of patients with MS in terms of the underlying disease status and the concomitant medications or previous medications used. Objectives: The aim of this study was to investigate the infusion related, short-term and delayed side effects of rituximab on patients with MS and NMO in the population of the south of Iran. Methods: This was a longitudinal study on patients with MS and neuromyelitis optica who were referred to the health centers affiliated to Shiraz University of Medical Sciences from September 2018 to February 2019 and received Rituximab. They were observed for side effects from the first infusion of the drug to at least 6 months later. A checklist prepared by the researcher was used to collect the data. Independent t-test and chi-square test were used for data analysis. The significance level was considered 0.05 in this study. Results: In this study, 37% of the patients had at least one side effect during the first infusion. The most common side effect was chills (shivering). Short-term side effects occurred in 15.5% of the patients. The most common type was skin manifestations. These side effects led to hospitalization in two patients. Delayed side effect was developed in 20.7% of the patients. The most common delayed side effect was skin manifestations. Conclusions: Overall, there was no unexpected side effect in patients under the study and the side effects developed were comparable to previous studies as well as those conducted on patients other than patients with MS and neuromyelitis optica. Side effects were often mild, with only two cases leading to hospitalization, both of which were self-limiting as well, and there were no serious life-threatening side effects, except for one case with bradycardia.

Curcumin has been suggested as a candidate for the prevention of Alzheimer’s disease. Recently, a human study has revealed that curcumin enhances cognition in non-demented aged population. Although the neuroprotective effect of curcumin has been shown in some animal models of amnesia, no study has showed its memory improving effect in intact adult animals. This study aimed to assess the effect of curcumin on passive avoidance memory in adult young mice. Additionally, the hippocampal contents of MMP-2, MMP-9 and Akt/GSK3β were determined. Male mice weighing 20–25 g were trained in passive avoidance apparatus. Curcumin 50 or 100 mg/kg/po (according to our initial tests) or its vehicle was administered for 10 days. On day 10 the training was done and the retention trial was performed 24 h later. At the complement of behavioral studies, the hippocampal tissue was isolated and western blot analysis was performed for MMP-2, MMP-9 and Akt/GSK3β. The results indicated that curcumin improved passive avoidance memory. Moreover, it elevated hippocampal MMP-2,9 and p-Akt/t-Akt while it decreased the activated form of GSK-3β. According to these findings, it seems that curcumin improves memory and affects hippocampal MMP-2, MMP-9 and Akt/GSK3β signaling molecules in young adult animals.

This is a case study of a 34-year-old woman who was admitted to hospital with a history of severe orthostatic headache. She was diagnosed as having spontaneous intracranial hypotension (SIH) by undetectable cerebrospinal fluid (CSF) pressure at lumbar puncture, and with evidence of diffuse dural enhancement of the brain detected by magnetic resonance imaging (MRI). However, the contrast-enhanced MRI of the spinal cord did not show a CSF leak site and she was treated conservatively. After a few days, the patient’s recurrence of headache with continuous duration and progressive worsening led to further investigations by contrast-enhanced MRI, magnetic resonance venography (MRV) and computed tomography venography (CTV) that showed an extensive thrombosis in the superior sagittal sinus, left sigmoid sinus and both transverse sinuses. Then, the patient was treated successfully with heparin and oral anticoagulant. She had no neurological deficit after six months. SIH with concomitant intracranial cerebral venous thrombosis is a rare condition. We hypothesize that SIH may change cerebral blood-flow velocity and viscosity and can cause intracranial cerebral venous thrombosis.

The abstract not available.

Purpose We investigated the prevalence of attention-deficit hyperactivity disorder (ADHD) in adult people with epilepsy (PWE). We hypothesized that ADHD is common among adult PWE and, some clinical factors may be associated with ADHD. Methods In this cross-sectional study, 200 adult PWE referred to our neurology clinic at Shiraz, Iran were recruited (consecutively sampled). Validated Persian versions of Adult ADHD Self-Report Scale (ASRS v1.1) and Addenbrooke's Cognitive Examination-Revised (ACE-R) tests were used. We performed univariate analyses and also a logistic regression analysis. Results Eighty-two patients (41%) were male, and 118 (59%) were female. Seventy patients (35%) had a positive screen for ADHD. There was a significant association between cognitive function and the prevalence of positive screening for ADHD in the whole group; 19 (18%) of the patients with a normal cognition, 23 (42%) of those with mild impairment, and 28 (70%) of those with severe cognitive impairment screened positive for ADHD (p = 0.0001). One hundred and five patients had normal cognition and were studied separately. Nineteen patients (18%) had screened positive for ADHD. Attention-deficit hyperactivity disorder was not associated with any of the tested variables in these patients. Conclusion About one-fifth of adults with epilepsy and normal cognitive function may have a positive screen for ADHD. Routine screening of all PWE for early detection and appropriate management of ADHD would be a reasonable approach.

Background: Restless leg syndrome (RLS), fatigue and daytime sleepiness are three known co-morbidities in patients with multiple sclerosis (MS). The aim of this study was to evaluate the frequency of RLS in patients with MS and its effect on the frequency of fatigue and daytime sleepiness in these patients. Material and Methods: One hundred twenty patients who referred to the Inpatients Neurology Ward of Chamran hospital, affiliated with the Shiraz University of Medical Sciences, from June 2014 to March 2015, were selected as the study participants. The patients with clinically definite MS, according to the 2010 Revised Mc-Donald criteria, and expanded disability status scale (EDSS) ≤5.5 were included. RLS, fatigue and daytime sleepiness were assessed by the criteria of the International RLS study group (IRLSSG), fatigue severity scale (FSS) and Epworth sleepiness scale (ESS) respectively and the related statistical analyzes were conducted. Results: Seventy eight patients (65%) met all the four IRLSSG criteria, 77 patients (64.1%) suffered from fatigue and only 36 patients (30%) had excessive daytime sleepiness. RLS was not significantly linked to mean age, sex, MS duration, and daytime sleepiness of the studied MS patients, but fatigue was more frequent in MS patients with RLS, which was statistically significant (P=0.018). Conclusion: The main result of this study is that RLS is a common comorbidity in MS and the patients with MS, who also suffer from RLS. They have frequently experienced higher fatigue symptoms than those without RLS. Therefore, the appropriate diagnosis and management of RLS may improve both RLS and fatigue in these patients. [GMJ. 2016;5(1):7-12]

Background: Diagnosis of psychogenic non-epileptic seizures (PNES) particularly in patients with epilepsy poses a challenge to physicians to care. This study is aimed at determining the frequency of depression and anxiety among Iranian patients with PNES. Materials and Methods: Sixty patients with PNES and one hundred age-and-sex matching healthy controls were enrolled in this study from January 2010 to January 2011. Patients had at least one psychogenic non-epileptic seizure recorded during video-EEG monitoring in an epilepsy care unit of Namazi Hospital, Shiraz, Iran. Demographic data were collected and Iranian validated versions of Beck Depression and Anxiety Inventory-2 questionnaires were used. Statistical analysis was conducted using Mann-Whitney U-test, Pearson’s chi-square test and independent T test. P < 0.05 was considered statistically significant. Results: Of 60 PNES patients, 37 (61.7%) were female and 23 (38.3%) were male (P=0.767) and mean of the patients’ age was 24.9 ± 6.6 years (P=0.674). Among controls, 64 (64%) persons were female and 36 (36%) were male; mean age was 24.4 ± 2.1 years. Forty two patients (70%) and 36 controls (36%) had moderate to severe depression (P=0.001). Thirty eight patients (63.4%) and 10 controls (10%) had medium to high levels of anxiety (P=0.001). Conclusion: Frequency of depression and anxiety among patients with PNES is much higher than general population. Prompt diagnosis of these two common coexisting psychiatric disorders may help physicians for better evaluation and appropriate management of PNES patients. [GMJ. 2014;3(4):202-6]

Background Epilepsy surgery has been proved to be feasible and cost-effective in developing countries. In the current paper, we discussed the outcome of patients with mesial temporal lobe epilepsy (MTLE) and medically-refractory seizures who had surgery at our center in Shiraz, Iran. Methods Patients aged 18 years and older with refractory MTLE and mesial temporal sclerosis operated at Namazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran from May 2009 through December 2011 were enrolled. Presurgical evaluation included clinical history, neurological examination, 2-hour video-EEG recording, and 1.5-T MRI. All patients were submitted to standard temporal lobectomy at the side determined by MRI and video-EEG. Results Twenty-two patients (12 women and 10 men) underwent surgery between May 2009 and December 2011. All patients were followed postoperatively for at least 12 months (mean=24.8±7.7 months; minimum=12 months; maximum=36 months). At the last follow-up visit, 18 patients (81.8%) had a good outcome (15 patients [68.2%] had Engel class 1 and three others had Engel class 2). The total cost of presurgical evaluation and epilepsy surgery at our center was less than $500. Conclusions Resources are limited for the vast majority of medically-refractory patients with epilepsy who live in the developing countries. However, it is feasible to select good surgical candidates for anterior temporal lobectomy relying on the clinical history and examination, MRI and interictal EEG. Broader application of epilepsy surgery should be encouraged in countries with limited financial resources.

Background: Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after carotid angioplasty and stenting.Methods and Material: This is a prospective study conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing carotid angioplasty and stenting were enrolled. Both standard risk and high risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. 30-day stroke, myocardial infarction, and/or death were considered as the composite primary outcome of the study.Results: two hundred and fifty one patients were recruited (mean age: 71.1+ 9.6 years, male: 65.3%). One hundred and seventy eight (70.9%) patients were symptomatic; 73 (29.1%), 129 (51.4%), 165 (65.7%) and 62 (24.7%) patients were diabetic, hyperlipidemic, hypertensive and smoker respectively. CAS performed for left ICA in 113 (45.4%) patients. 14 (5.6%) patients had Sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 +13.8 %. Embolic protection device was used in 203 (96.2%) patients. Predilation and post-dilation were performed in 39 (18.5%) and 182 (86.3%) patients respectively. Composite outcome was observed in 3.6% (3.2% stroke, 0% myocardial infarction and 1.2% death). Left sided lesions and presence of DM was significantly associated with poor short term outcome. (P value: 0.025 and 0.020, respectively)Conclusion: There was a higher risk of short term major complications in diabetic patients and left carotid artery intervention.

Background: Status epilepticus (SE) is one of the most common neurological emergencies with high mortality and morbidity. This study aims to determine the most common causes and outcomes of SE in adult patients from Fars Province in southern Iran. Materials and Methods: 134 patients with SE (either convulsive or non-convulsive), admitted to Namazi Hospital, were enrolled from January 2006 to February 2012. We designed a questionnaire to collect the patients' demographics and disease characteristics and their outcomes according to Glasgow Outcome Scale (GOS). Statistical analyses were performed using SPSS software version 15. P-value

We aimed to compare cerebral artery velocity and relevant clinical factors in patients with β-thalassemia intermedia (β-TI), β-thalassemia major (β-TM), and healthy individuals. For this study, 60 patients with β-TM and 64 with β-TI were randomly selected. Sixty healthy adults comprised the control group. Time average maximum mean velocity (TAMMV) was measured in large cerebral arteries with transcranial Doppler (TCD) ultrasonography. In all arteries, TAMMV was significantly higher in the β-TI group than that of β-TM or controls ( P < .001). Patients with β-TM had significantly higher TAMMV than controls in most arteries evaluated ( P < .001). Overall, the lack of regular blood transfusions, splenectomy, and lower age (to a lesser extent) was found to be independent influencing factors contributing to high cerebral artery velocities. Further detailed longitudinal studies are needed to confirm these results and to determine the risk of silent infarction and stroke in patients with thalassemia and abnormal TCD, with particular focus on patients with β-TI.

The present study was performed to investigate the effects of dimethylfumarate (DMF) and methylhydrogen fumarate (MHF) on the cytokine pattern of peripheral blood mononuclear cells (PBMCs) of multiple sclerosis (MS) patients. The PBMCs from patients and healthy controls were stimulated with myelin basic protein (MBP) or phytohemagglutinin (PHA) and cultured in the presence of DMF and MHF. The percentage of CD4+IL-4+ and CD4+IFN-γ+ cells was determined by means of intracellular cytokine staining. CD4+IL-4+ cells were significantly increased in the presence of DMF and MHF when PBMCs were stimulated by MBP (P < 0.003). The same significant result was obtained by PHA stimulation (P < 0.049). In terms of CD4+IFN-γ+ cells, the percentage of cells did not significantly differ between the cultures stimulated with MBP or PHA in the presence and absence of the drugs. Results of MBP stimulation in control group also showed a significant increase in CD4+IL-4+ cells in the presence of DMF and MHF. In comparison between patient and control groups, no statistically significant changes were observed. In conclusion, both DMF and MHF effectively increased IL-4 production, whereas they did not significantly change IFN-γ level, indicating the role of these drugs in increasing the production of beneficial cytokines such as IL-4.

Introduction: The coexistence of myasthenia gravis and Lambert-Eaton myasthenic syndrome (LEMS) is very rare. Case report: Herein we report an 82 year old man a known case of adenocarcinoma of bladder who came with ptosis in left eye, diplopia, and dysphagia, weakness of both lower extremities and autonomic dysfunction. According to history, physical examination and para clinical work ups coexisting of myasthenia gravis and LEMS was diagnosed. Discussion: our patient is the first patient with Overlap myasthenic syndrome on the base of adenocarcinoma of bladder. The purpose of this case report is to emphasize on this fact that a patient with LEMS should be evaluate carefully for detecting underlying malignancies. Although in the most cases the origin is lung, extra pulmonary origin such as urinary system should be evaluate carefully too.

This study investigated effects of applying cognitive-behavioral group therapy on recurrent headaches. Among Shiraz University female students complaining of headaches, 20 patients, each reporting either migraine or tension-type headaches and who met the 1988 International Headache Society diagnosis criteria for migraine and tension-type headaches, formed two groups. Analysis showed cognitive-behavioral group therapy decreased headache index significantly. Therapeutic response patterns on dependent variables were similar for patients with migraines and those with tension-type headaches.

Rationale and Objectives In brain MRI of multiple sclerosis (MS) patients, enhancement of the lesions is usually evaluated in early contrast-enhanced T1-weighted images (CE-T1WI). The objective of this study is to determine the sensitivity of contrast-enhanced fluid-attenuated-inversion-recovery (CE-FLAIR) and delayed contrast-enhanced MRI in evaluation of MS brain lesions. Materials and Methods Brain MRI examination including early and delayed CE-T1WI and early and delayed CE-FLAIR images was performed for 46 patients with clinically definite MS disease. Number, size, location, degree, and pattern of enhancement of the enhanced lesions in each sequence were recorded separately. Results A total number of 87 enhanced lesions was detected in 30 patients. Early CE-T1WI could detect only 63 lesions (72.4% of total) in 24 patients, while delayed CE-T1WI and early and delayed CE-FLAIR images showed 85 (97.7%), 84 (96.6%), and 81 (93.1%) lesions in 28, 28, and 26 patients, respectively. A greater degree of enhancement and larger lesion size were observed in the additional sequences compared with the early CE-T1WI. Conclusions The sensitivity of early CE-T1WI for the detection of enhanced MS lesions is significantly lower than that for other additional sequences. Delayed CE-FLAIR images could not add significant information to other sequences. Therefore, early CE-FLAIR and delayed CE-T1WI brain MRI can be considered as part of the evaluation of MS patients, especially if, despite clinically suspected active disease, no enhanced lesion is found in the routine CE-T1WI.

Background: Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after CAS. Materials and Methods: This is a prospective study that was conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing CAS were enrolled. Both standard- and high-risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. Thirty-day stroke, myocardial infarction, and/or death were considered as the composite primary outcomes of the study. Results: A total of 251 patients were recruited (mean age: 71.1 ± 9.6 years; male: 65.3%). Of these, 178 (70.9%) were symptomatic, 73 (29.1%) were diabetic, 129 (51.4%) were hyperlipidemic, 165 (65.7%) were hypertensive, and 62 (24.7%) patients were smokers. CAS was performed for left internal carotid artery (ICA) in 113 (45.4%) patients. Fourteen (5.6%) patients had sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 ± 13.8%. An embolic protection device was used in 203 (96.2%) patients. Pre- and postdilation were performed in 39 (18.5%) and 182 (86.3%) patients, respectively. Composite outcomes were observed in 3.6% of patients (3.2% stroke, 0% myocardial infarction, and 1.2% death). Left-sided lesions and the presence of diabetes mellitus were significantly associated with poor short-term outcome (p = 0.025 and p = 0.020, respectively). Conclusion: There was a higher risk of short-term major complications in diabetic patients and for left carotid artery intervention.

Behcet's disease is a multisystem vasculitis. Its neurologic complications include different syndromes. The purpose of this investigation was to study the prevalence of neurologic manifestations among patients with Behcet's disease and to determine the frequency of different symptoms, signs, and syndromes in neuro-Behcet's disease. Ninety-six consecutive patients who were referred to the Behcet's Disease Clinic in Shiraz (southern Iran) were interviewed and thoroughly examined. Psychiatric evaluation, CSF analysis, electroencephalography, electrodiagnostic studies, and neuroradiologic imaging (preferably MRI) were performed in appropriate cases. Six patients (6.3%) had definite neuro-Behcet's disease. They were 4 males and 2 females (mean age 37.5 years). In 2 patients Behcet's disease had not been diagnosed before. The most frequent symptoms of neuro-Behcet's disease were headache (83.3%), paresthesia (83.3%), unsteadiness (66.7%), diplopia (66.7%), and weakness (50%). The most frequent signs were gait abnormalities (66.7%), sensory abnormalities (66.7%), ophthalmoplegia (50%), cerebellar ataxia (50%), and hemiplegia (50%). The most common syndrome was brain-stem+ type (50%). Subacute onset and relapsing-remitting course were the most common temporal patterns. Neurological manifestation is a relatively less frequent complication of Behcet's disease but it produces severe disabilities. It must be considered in differential diagnosis of multiple sclerosis.

Objective To describe a patient with a rare presentation of neuro-Behcet disease. Methods and results A 42-year-old patient with definite Behcet disease was referred to Nemazee Hospital, affiliated to Shiraz University of Medical Sciences, Shiraz, South of Iran, with headache, biparesis, left central facial palsy, and urinary dysfunction. Brain magnetic resonance imaging revealed a hypo/hypersignal lesion in T1-/T2-weighted images in the right cerebral peduncle extending to the right basal ganglia. Cervical magnetic resonance imaging showed a lesion in the parenchyma of the spinal cord extending from C2 to T1 which was iso-hyperintense in T1-/T2-weighted images. Initial cerebrospinal fluid analysis revealed significant pleocytosis, hypoglycorrhachia and increased protein content. The patient had an incomplete response to treatment with corticosteroids and cyclophosphamide. Conclusions An acute disseminated encephalomyelitis (ADEM)-like presentation is a rare manifestation of neuro-Behcet disease.

Purpose We present our experience with corpus callosotomy (CC) in a developing country with limited resources in patients with Lennox–Gastaut syndrome (LGS) and medically refractory seizures. Methods All patients with LGS who underwent CC for medically refractory epilepsy at Namazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran from May 2009 through March 2012 were reviewed in a retrospective study. Presurgical evaluation included clinical history, neurological examination, a 2-hour video-EEG recording, and 1.5-T MRI. Outcome was evaluated at 6, 12, and 24 months postoperatively. We considered the outcome as a success if the patients were either seizure-free or had more than 85% reduction in seizure frequency compared to their preoperative status. Results Eighteen patients (14 males and 4 females) had surgery. Overall, seizures in 11 patients (61.1%) responded favorably one year after surgery; this figure was 6 out of 9 patients (66.6%) two years after surgery. Seven patients (38.8%) were free of disabling seizures one year after CC; this figure was three out of nine patients (33.3%) two years after CC. Three patients (16.6%) were free of all seizure types one year after surgery. Ten patients (55.5%) had no postoperative complications of any kind. Conclusion Corpus callosotomy is an effective palliative surgical procedure for patients with LGS with intractable seizures whose seizures are not amenable to focal resection. This is a feasible treatment option for patients, even for those in developing countries with limited resources.

Purpose We investigated the various possible reasons for uncontrolled seizures in patients 18 years of age and older to determine the impact of pseudointractability. We also tried to investigate the various forms of pseudointractability. Methods In this cross-sectional study, all patients 18 years of age and older with their first seizure occurring at least six months prior to the referral date, taking at least one antiepileptic drug (AED) and having at least one seizure in the past three months were studied. The presumed reason for uncontrolled seizures was arbitrarily considered to be one of these five categories: Poor compliance; Wrong medication (misclassification); Wrong dose of the correct medication; Diagnosis other than epilepsy; and finally, Medically-refractory epilepsy. Statistical analyses were performed using Chi-square and Fisher's Exact tests, and a P value less than 0.05 was considered significant. Results 350 patients were referred to us due to uncontrolled seizures. One hundred ninety-one (55%) were male and 159 (45%) were female. Twelve percent of the patients had diagnoses other than epilepsy, 40% had indeed medically-refractory epilepsy; 29% were taking the wrong AEDs (misclassified epilepsy); 18% were taking suboptimal doses of AEDs; and 1% had poor drug compliance. The most common reason for uncontrolled seizures among patients with idiopathic generalized epilepsy was taking the wrong AED. However, among patients with focal epilepsy, true medically-refractory epilepsy was the most common reason. Conclusion Uncontrolled seizures are a commonly encountered problem, especially at epilepsy clinics and one should consider all possible reasons for these uncontrolled seizures. The mainstay for making a correct diagnosis is a detailed clinical history.

Background: Cerebral venous sinus thrombosis (CVST) is a frequent cause of cerebrovascular disease in Iran. Objectives: In this study, we report cumulative data of published Iranian studies in a systematic manner with critically appraisal and presenting future directions. Materials and Methods: The authors systematically searched the ISI web of knowledge, Pubmed, Scopus, EBESCO and iranmedex for keywords attributed to cerebral venous sinus thrombosis. The methodological and demographic characteristics, etiology, site of involvement and clinical manifestations of the patients with CVST were investigated. Results: Seven eligible series with 465 patients were found. Age of the patients were between 29.5-43.8 in these series. The ratio of Female to male was 2.79. The Mortality rate was 11.4%. Oral contraceptive pills the single most common risk factor in the all series(40-71% of female patients). Headache(80-97%), sensori/motor deficits(39-64%) and seizure(20-62%) were the most common clinical presentations. Hemorrhagic transformation was seen in 11-58% of the patients. All included studies have substantial shortcomings. Majority of the studies were retrospective and only one study was population based. Despite the ethnic heterogeneity in Iran, none of these studies reported ethnic information. Detailed methodology was missing in all studies. The extent of investigation for hematologicalor neoplastic disorders was not clear methods. Only one study reported a subgroup with multifactorialetiology. Neither Barthel index nor modified Rankin scale were reported in any studies. The mortality was reported only in the three studies. The analysis of prognostic factors was not done in any study. Conclusions: To overcome theses hortcomings, more well-structured epidemiologic studies should be conducted in Iran as a CVST-raising country.

Introduction. Patients withβ-thalassemia intermedia have a higher incidence of thromboembolic events compared to the general population. Previous studies have shown that patients with sickle cell disease, who are also prone to ischemic events, have higher intracranial arterial blood flow velocities measured by transcranial Doppler sonography (TCD). The aim of this study is to evaluate intracranial arterial flow velocities in patients withβ-thalassemia intermedia and compare the results with those found in healthy subjects.Methods. Sixty-four patients withβ-thalassemia intermedia and 30 healthy subjects underwent transcranial Doppler sonography.Results. Significantly higher flow velocities were found in intracranial arteries of patients compared to controls (P=0.001). Previously splenectomized patients with thrombocytosis showed higher flow velocities than nonsplenectomized patients without thrombosis.Conclusion. The increased flow velocities in patients withβ-thalassemia intermedia may point to a higher risk of ischemic events. Preventive measures such as blood transfusion or antiplatelet treatment may be beneficial in these patients.

Chronic antiepileptic therapy has been associated with metabolic bone diseases including osteomalacia and osteoporosis. The object of this study was to assess the effect of first line anticonvulsants on bone density and vitamin D levels in Iranian ambulatory patients.We conducted a cross-sectional study assessing bone density with dual energy X-ray absorptiometry at the hip and lumbar spine in 90 outpatients receiving anticonvulsants and 90 normal subjects matched for age, sex, and body mass index. Plasma total calcium, intact parathyroid hormone, total alkaline phosphatase in addition to 25 hydroxy vitamin D were also determined in both groups.The mean (+/-SD) bone density in patients treated with antiepileptic drugs was lower at the spine (T Score= -084+/-1.18 vs. -0.5+/-1.18, P0.05) and femoral neck (T Score= -0.83+/-1.11 vs. -0.46+/-1.1, P0.05), compared to the control group of subjects. In addition, serum total alkaline phosphatase was significantly higher in patients (246.5+/-127 vs. 190+/-65.3, P=0.004), but the total calcium, parathyroid hormone and 25 hydroxy vitamin D did not differ significantly between patients and controls.Our results suggest that maintenance therapy with antiepileptic drugs may decrease bone mass. These data also suggest a higher bone turnover rate in those receiving anticonvulsants.

Cerebral venous sinus thrombosis (CVST) is a disease with potentially serious consequences and usually affecting young to middle aged people. This study was designed to investigate the clinical features, and predisposing and prognostic factors of CVST in a prospective series of 61 patients.This prospective study comprised 61 consecutive patients with confirmed diagnosis of CVST who were hospitalized in Namazi Hospital in Shiraz, south of Iran, between January 2000 and August 2003. The diagnosis was confirmed using conventional MRI or cerebral angiography.The male to female ratio was 1/3.1. The mean age of patients was 35.6 +/- 12.1 years. Headache was seen in 91.8% of the patients. The most frequent risk factor was oral contraceptive consumption (62.2%). Elevation of ESR and CRP titer were seen in 37.7%, and 36.1% of patients, respectively. Involvement of superior sagittal sinus and lateral sinus was 80.3% and 41%, respectively. The final diagnosis was neurobechet in 5 ppatients (8.2%). The fatality rate was 14.7% and an altered consciousness was associated with poor prognosis.CVST presents with a wide spectrum of symptoms and signs. Headache was the most frequent symptom. Women who used OCP were especially at risk. Because of moderate to high mortality rate, patients at increased risk of death, specially comatose patients, should be closely monitored.

To determine the prevalence, clinical manifestations, and laboratory features of Neuro-Behçet's disease.This prospective study was carried out in the Behçet's Research Clinic in Shiraz (south-west Iran) and included the patients referred from 1990-1999. The patients' clinical records, images, CSF analyses, and electrodiagnostic studies were reviewed.Eighteen (15 males and 3 females) out of 690 Behcet s patients (2.6%, 95% CI = 1.4-3.8%) were found to have neurological involvement. The mean +/- standard deviation age of these patients was 34.7 +/- 8.6 years. All fulfilled the criteria of the International Study Group of Behcet s Disease. Central nervous system involvement was more common than peripheral nervous system manifestations. Headache, weakness, tingling, and numbness were the most common symptoms. Hyperreflexia, upward plantar reflex, and somatosensory findings were the most frequent signs. Hemispheral and brainstem stroke-like syndromes and cerebral venous thrombosis were the major neurologic presentations. There were also cases of myelitic, pure meningoencephalitic, amyotrophic lateral sclerosis-like, multiple sclerosis-like, and Guillain Barre syndromes.Neuro-Behçet's disease must be considered in the differential diagnosis of stroke in young adults, chronic meningitis, intracranial hypertension, multiple sclerosis, myelopathies, and peripheral neuropathies.

Abstract 3335 Introduction: Patients with β-thalassemia, especially β-thalassemia intermedia (β-TI), are prone to hypercoagulable state and subsequently cerebral thromboembolic events. In this study we aimed to determine cerebral artery velocity as a determinant of stroke risk in patients with β-TI compared to β-thalassemia major (β-TM) and healthy subjects. Method: Sixty patients with β-TM and 64 β-TI were randomly selected in this cross sectional study. Sixty healthy adults comprised as a control group. The Time average Maximum Mean Velocity (TAMMV) was measured in large cerebral arteries using Transcranial Doppler (TCD) Ultrasonography. The TAMMVs in different arteries were compared between the patients with β-TI, β-TM and controls. Results: TAMMV in all arteries was significantly higher in β-TI patients than β-TM patients and controls (P< 0.001). Also β-TM patients had significantly higher TAMMVs than controls in all arteries except for the left and right posterior cerebral arteries (P< 0.001). In univariate analysis we found that the lack of transfusion, thrombocytosis, splenectomy, higher platelet counts and lower age could contribute to increase TAMMV (P< 0.05). However, in the multiple linear regression models the only important factors influencing TAMMV were the lack of transfusion in all evaluated arteries following with age only in some investigated arteries. Conclusion: We showed that patients with β-TI has a higher TAMMV in comparison with the healthy subjects as well as with the β-TM patients probably due to the lack of transfusion and chronic anemia. In addition, β-TI patients are more prone to thromboembolic events and subsequently cerebral infarction due to hypercoagulable state. We recommend MRI screening in β-TI patients for detection of silent lesions, in the presence of asymptomatic lesions, TCD would be beneficial. In patients with high cerebral artery velocity and silent lesion further evaluation, close observation and prophylactic treatment including regular blood transfusion and antiplatelet therapy should be considered. However further prospective studies are suggested to confirm the correlation between the stroke risk and high cerebral velocity as well as the protective effect of regular transfusion in β-TI patients. Disclosures: No relevant conflicts of interest to declare.

The aim of the current study was to investigate the rates of stress, anxiety, and depression among people in south Iran (a group from the general population without a history of any chronic medical problems, and cohorts of patients were recruited from epilepsy, diabetes, and cardiac disease clinics). We surveyed a sample of people during September 2020: a group of the general population without a history of any chronic medical problems, people with epilepsy, people with diabetes mellitus (DM), and people with cardiac problems. The survey included four general questions and two COVID-19 specific questions [contracting COVID-19, relatives with COVID-19]. Furthermore, the survey included the DASS (Depression-Anxiety-Stress Scale)-21 questionnaire. 487 people were surveyed (154 people with epilepsy, 127 patients with DM, 98 people with cardiac problems, and 108 healthy individuals). Among people without a history of any chronic medical illnesses, 14% had any psychological problems. The highest rates of depression and anxiety were observed among patients with DM (52% and 57%, respectively), and the highest rate of increased stress was observed among people with cardiac problems (40%). The existence of any underlying medical problem was significantly associated with higher rates of depression, anxiety, and stress among the participants. While many patients with underlying chronic medical conditions suffer from depression, anxiety, and stress during the COVID-19 pandemic, we cannot establish a cause and effect relationship between the COVID-19 pandemic and increased psychological problems among these patients. Copyright of Acta Medica Iranica is the property of Tehran University of Medical Sciences and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract.