Pre- and in-hospital delays in the use of thrombolytic therapy for patients with acute ischemic stroke in rural and urban Egypt.

Background: Reducing pre- and in-hospital delays plays an important role in increasing the rate of intravenous thrombolysis (IVT) in patients with acute ischemic stroke. In Egypt, the IVT rate has increased steadily but is still far away from an ideal rate. Aim: The study aimed to investigate the factors associated with pre- and in-hospital delays of IVT among patients with acute ischemic stroke coming from urban and rural communities. Methods: This prospective, multicenter, observational cohort study was conducted from January 2018 to January 2019. Patients with acute ischemic stroke, who did not receive IVT, were included in the study. Patients were recruited from three large university stroke centers in Egypt, Assiut (south of Egypt), Tanta (north of Egypt), both serving urban and rural patients, and the University Hospital in Cairo (capital city), only serving an urban community. All participants underwent the National Institutes of Health Stroke Scale and full neurological assessment, urgent laboratory investigations, and computed tomography or magnetic resonance imaging to confirm the stroke diagnosis. The patients were subjected to a structured questionnaire that was designed to determine the parameters and time metrics for the pre- and in-hospital delays among patients from rural and urban regions. Results: A total of 618 patients were included in the study, of which 364 patients (58.9%) lived in rural regions and 254 (41.1%) in urban regions. General demographic characteristics were similar between both groups. Approximately 73.3% of patients who arrived within the therapeutic time window were urban patients. The time from symptom onset till hospital arrival (onset to door time, ODT) was significantly longer among rural patients (738 ± 690 min) than urban patients (360 ± 342 min). Delayed onset to alarm time (OAT), initial misdiagnosis, and presentation to non-stroke-ready hospitals were the most common causes of pre-hospital delay and were significantly higher in rural patients. For patients arriving within the time window, the most common causes of in-hospital delays were prolonged laboratory investigations and imaging duration. Conclusion: The limited availability of stroke-ready hospitals in rural Egypt leads to delays in stroke management, with subsequent treatment inequality of rural patients with acute stroke.

Evaluation of optical coherence tomography angiography findings in patients with multiple sclerosis.

Purpose: To evaluate optical coherence tomography angiography findings in patients with multiple sclerosis (MS). Methods: This prospective noninterventional study was conducted on 30 eyes of relapsing-remitting MS patients. Group (1) included 10 eyes with a history of optic neuritis (ON), group (2) included 10 eyes without any history of optic neuritis (MS-ON), and group (3) included 10 eyes of normal age/sex/refraction matched participants. Optical coherence tomography (OCT) and OCT-A (ZEISS Cirrus™ HD-OCT Model 4000 (Carl Zeiss-Meditec, Dublin, CA) of the optic disc were done for all patients. Results: The best-corrected visual acuity was diminished in MS cases, especially in patients with ON with P value <0.001. The retinal nerve fiber layer (RNFL) thickness showed a significant decrease in the average thickness and in all quadrants, notably the temporal quadrant in group 1 (P < 0.001). Ganglion cell layer thickness was diminished in average thickness and in all quadrants in both groups of MS, but only the first group showed statistical significance with P value <0.001). In respect to optic disc perfusion, Average, superficial, and deep vascular density index (AVDI, VDI 1, VDI 2) were statistically significantly lower in groups 1, 2 with (P-value < 0.001). Conclusion: Decreased vascular perfusion of the optic nerve in MS patients, especially in those with ON is strongly correlated with the damage of RNFL and ganglion cell layer detected by OCT.

Thrombomodulin, alarmin signaling, and copeptin: cross-talk between obesity and acute ischemic stroke initiation and severity in Egyptians.

Acute ischemic stroke (AIS) is followed by a strong inflammatory response contributing to brain damage and making early diagnosis and treatment inevitable. Hence, obesity is a state of chronic inflammation with amplified oxidative stress; this study aimed to assess the role played by thrombomodulin (TM)/alarmin signaling pathway and copeptin in AIS initiation and severity in addition to the implication of abnormal body weight. The study was conducted on 50 participants; 30 were patients with AIS (15 overweight/obese and 15 normal weight), 10 were overweight/obese, and 10 were normal weight. Plasma TM, copeptin, high mobility group box1 (HMGB1), and lipocalin 2 (LCN2) levels were immunoassayed. Toll-like receptor 4 (TLR4) mRNA expression was evaluated by real-time PCR, National Institutes of Health Stroke Scale (NIHSS), carotid intima media thickness; atherogenic index and glycemic status were also assessed. TM, copeptin, HMGB1, and LCN2 levels were significantly increased in overweight/obese AIS patients and in AIS patients with NIHSS score ≥ 7 when compared to other groups (p value=, ˂ 0.001*). Receiver operating characteristic (ROC) curve elaborated HMGB-1 and LCN2 as the best biomarker for diagnosis and prediction of AIS severity, respectively. Regression analysis avails LCN2 and TM as best biomarker for AIS severity predication. In conclusion, these results highlighted detrimental role of alarmin signaling with increased adaptive response to block this pathway through TM in addition to increased copeptin level as an acute damage marker and their tight relation to WC not to BMI in AIS which clarify the implication of central adiposity.

Public stroke knowledge, awareness, and response to acute stroke: Multi-center study from 4 Egyptian governorates.

BACKGROUND AND PURPOSE: Acute stroke treatment has significantly improved over the years in Egypt. However, there is often notable delay in pre-hospital and in-hospital management of acute stroke patients. The delay may be largely attributed to poor stroke knowledge and awareness of the general public and this study was aimed at the evaluation of the abovementioned factors. METHODS: Descriptive cross-sectional study involving 1154 participants from 4 governorates using a questionnaire in Arabic, collecting sociodemographic data, participants' risk factors, and knowledge and stroke awareness (risk factors, symptoms, prevention, treatment and prognosis, action in response to acute stroke). Data were collected during the World stroke day October 29, 2015. RESULTS: Study participants were found to have a low level of awareness of stroke with median percent score of 35.7% and interquartile range (IQR) of 17.86. Higher income, level of education, having risk factors and knowing someone with stroke were significant predictors of a higher level of stroke awareness. CONCLUSION: In general, low public stroke awareness has been detected among Egyptians, and this is a call for healthcare authorities to invest in public education programmes among the Egyptian population.