Clinical pharmacist's contribution to treatment adherence and quality of life in patients with stroke.

PRIMARY OBJECTIVE: The optimal treatment adherence rate among patients with stroke is low. This study aims to determine the effect of clinical pharmacists' intervention on treatment adherence and quality of life (QOL) in patients with first-ever stroke. RESEARCH DESIGN: This open, controlled, prospective and interventional study was conducted sequentially at two different university hospitals for 3 months. Patients in the intervention group (IG) were provided with clinical pharmacist-led education whereas the control group (CG) only received routine care. METHODS AND PROCEDURES: Treatment adherence and QOL were assessed on discharge day, and in months 1 and 3 after discharge. Morisky Green Levine Adherence Scale and Stroke Specific Quality of Life Scale were employed to evaluate treatment adherence and QOL, respectively. MAIN OUTCOMES AND RESULTS: Changes in treatment adherence score were higher between discharge day, 1st and 3rd months after discharge in IG than CG (p < 0.001). Regarding 'energy' and 'work/productivity' domains, patients' scores in IG were higher than those from CG at months 1 and 3 after discharge (p < 0.05). CONCLUSION: Clinical pharmacist-led education improves treatment adherence in patients with first-ever stroke. The clinical pharmacist might be integrated into the multidisciplinary team to improve QOL and treatment adherence.

Evaluation of retinal vessel density and choriocapillaris flow in migraine patients with and without aura.

PURPOSE: Migraine is thought to be a neurovascular disorder and increases the likelyhood to develop ischemic complications. Studies have shown that vascular disorders such as ischemic optic neuropathy, retinal artery and vein obstructions are more common in patients with migraine. This study aimed to evaluate the differences between retinal and optic disc microvasculature between migraine patients with and without aura and healthy controls using optical coherence tomography angiography (OCTA) imaging. METHODS: Thirty-three patients with migraine and 28 healthy subjects were included in this prospective cross sectional study. Optical coherence tomography angiography imaging was performed for the macula and optic disc. Vessel densities (VD) and choriocapillaris flow values were compared between three groups: control group, migraine with aura (MWA), and migraine without aura (MWOA). RESULTS: There was no difference between the three groups for the VDs of the foveal, perifoveal, parafoveal, and the whole area. The choriocapillaris flow of patients with MWA was significantly less than that of the MWOA and control groups. The VDs of the optic disc revealed no significant difference between the three groups. CONCLUSION: A lack of choriocapillaris autoregulatory mechanisms may be a possible cause of the decrease in choriocapillaris flow in patients with MWA.

Determinants of preventable stroke-Ankara ACROSS stroke preventability study.

BACKGROUND: Unhealthy lifestyle and inadequate control of vascular risk factors are the major contributors of stroke burden. Failure in achieving the target levels in control of these factors, not only designate missed opportunities contributing to the preventability of an incident stroke, but also set the post-stroke treatment goals in a case wise basis. In this study, we analyzed pre-event clinical features that play a role in stroke preventability, and determined the cumulative burden of risk factors that necessitate optimization following the ischemic insult. METHODS: Information about the pre-stroke optimal control of seven major modifiable risk factors (Life's Simple 7: hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, diet, and physical activity) was prospectively collected in ischemic stroke patients admitted to three tertiary academic centers in Ankara. Stroke preventability was evaluated by the overall number of factors requiring optimization with patients ≥4 risk factor conditions categorized as those suffering from a preventable stroke. Bivariate and multivariate analyzes were performed to uncover predictors of stroke preventability. RESULTS: Among 787 patients, 386 (49.0%) had ≥4 risk factor conditions requiring optimization. Preventable stroke was more common in younger patients, and patients with small artery occlusion. Multivariate analyses taking into account the pre-stroke antithrombotic treatment regimen, have highlighted age (OR: 0.99, 95%CI 0.98-1.00), female gender (1.59, 95%CI 1.17-2.16), coronary artery disease (1.54, 95%CI 1.10-2.14), small artery occlusion (1.90, 95%CI 1.13-3.18), and cardio-aortic embolism (0.53, 95%CI 0.35-0.82) as significant factors associated with preventability. CONCLUSIONS: Approximately half of the ischemic stroke patients have preventable stroke from the perspective of risk factor control. Extra care should be given to strategies directed to risk factor control and lifestyle interventions in certain high-risk groups for the prevention of future complications.

Episodic Oculomotor Nerve Palsy with Intracranial Hypertension and Carcinomatous Meningitis.

The classically affected cranial nerve from intracranial hypertension is the sixth nerve. Carcinomatous meningitis can cause persistent or progressive cranial nerve palsies by infiltrating them in the subarachnoid space. Here we present a rare case of episodic, short-lasting, and unilateral oculomotor nerve palsy associated with carcinomatous meningitis and intracranial hypertension in a 44-year-old woman diagnosed with metastatic lung adenocarcinoma. As the survival rates enhance for metastatic cancers, neurologists should expect more perplexing neurologic presentations and consider leptomeningeal metastasis and intracranial hypertension in patients who have cancer and present with short episodes of diplopia and unilateral third nerve palsy.

The Significance and Reliability of Imaging Findings in Pseudotumor Cerebri.

The objective of our study was to provide a comparative assessment of previously reported magnetic resonance imaging (MRI) parameters in primary and secondary pseudotumor cerebri (PTC) patients, to examine their diagnostic contribution, and to evaluate their association with symptoms, neuro-ophthalmological findings, laboratory results, and cerebrospinal fluid characteristics. Twenty-eight consecutive patients with PTC were included in the study. Age- and sex-matched 20 individuals with normal neurologic examination served as the control group. Modified Dandy Criteria were used for the diagnosis of PTC. Orbital and cranial MRI and MR venography of all patients and controls were assessed by three radiologists. According to our study, posterior flattening of the globe (64% sensitive, 100% specific), optic nerve sheath distention (46% sensitive, 100% specific), vertical tortuosity of the optic nerve (30% sensitive, 95% specific), and partial empty sella (43% sensitive, 100% specific) emerged as particularly valuable markers for a diagnosis of PTC.

Oculomotor Nerve Palsy Presented with Isolated Unilateral Ptosis and Minimal Upgaze Palsy.

This case with unilateral complete blepharoptosis and slight limitation of upgaze as ocular findings due to midbrain infarction represents an unusual form of intra-axial oculomotor nerve involvement. A 65-year-old man was admitted with acute unilateral ptosis of the left eyelid and gait ataxia. He had chronic hypertension in the medical history. The neurologic examination revealed that he had a complete ptosis of the left eyelid, slight limitation of elevation in the left eye, bilateral dysmetria, and gait ataxia. Magnetic resonance imaging showed acute infarction in the central part of midbrain tegmentum. Previous models for arrangement of oculomotor fascicle in the midbrain suggest that a lesion involving the most caudal fibres for levator palpebrae and superior rectus without affecting other extraocular muscles and pupillomotor fibres is the most likely aetiology.

Etiologic Subtypes of Watershed Infarcts.

BACKGROUND: Two types of watershed infarcts (WI) are recognized. Internal WI are usually attributed to either severe stenosis in large arteries or acute hypotensive events, whereas external WI are thought to be caused by embolism. The aim of this study was to determine the etiologic background and prognosis of external and internal WI in our patients. METHODS: We reviewed the medical records and diffusion-weighted images of the patients who were admitted to our stroke unit with acute ischemic stroke between January 2012 and November 2014. The demographics, clinical features, radiologic investigations, and other etiologic tests of the patients with internal or external WI were recorded. We determined etiologic stroke subtypes according to the automated Causative Classification System. RESULTS: Fifty-three patients with WI were detected in our registry. Twenty-two (41.5%) of them were women. The mean age was 69 ± 12.8 (33-98) years. Twenty-one (39.6%) patients had external WI: 7 (33.3%) of them had large-artery atherosclerosis (LAA), 8 (38.1%) patients had cardioembolism, 3 (14.3%) patients had stroke due to other causes (vasculitis; n = 3), and etiologic subtype was undetermined in 3 patients (14.3%). Thirty-two (60.4%) patients had internal WI: 21 (65.6.%) of them had LAA, 5 (15.6%) patients had cardioembolism, 3 (9.4%) patients had stroke due to other causes (aneurysm; n = 1, hypercoagulability due to chronic myeloid leukemia; n = 1, vasculitis; n = 1), and etiologic subtype of 3 (9.4%) patients remained cryptogenic. LAA was significantly associated with internal WI (P = .024). Hypertension was more common in patients with internal WI (P = .035). CONCLUSIONS: In this series, cardioembolism was the most common etiologic subtype in the patients with external WI, whereas internal WI were significantly associated with LAA. Uncommon causes should also be investigated in cryptogenic patients.

Determinants of in-hospital muscle loss in acute ischemic stroke - Results of the Muscle Assessment in Stroke Study (MASS).

BACKGROUND & AIMS: There is a change in the mass and composition of paretic and non-paretic skeletal muscles in the chronic phase of stroke. The multi-center, prospective, and observational Muscle Assessment in Stroke Study (MASS) was performed to evaluate the degree of muscle loss during the in-hospital acute stroke setting and determine factors contributing to this loss. METHODS: Acute dysphagic ischemic stroke patients (n = 107) admitted to neuro-intensive care units were evaluated by computed tomography on days 1 and 14 after admission to determine the cross-sectional muscle area (CSMA) at the level of the mid-humerus, mid-thigh, and third lumbar vertebra. The percentage change in CSMA and variables associated with this change were evaluated by univariate and multivariate analyses. RESULTS: There were significant reductions in CSMA in all the muscle groups analyzed; the most prominent change was observed in the arms (both: 14.2 ± 10.7%; paretic: 17.7 ± 11.6%; non-paretic: 10.1 ± 12.5%), followed by the muscles in the legs (both: 12.4 ± 8.7%; paretic: 12.9 ± 9.9%; non-paretic: 12.0 ± 9.3%) and L3-vertebra level (5.6 ± 9.8%) (P < 0.001 for all). Higher calorie (r = -0.378, P < 0.001) or protein (r = -0.352, P < 0.001) intake was negatively associated with the decrease in CSMA of upper extremities. A substantial protein (≥0.4 g/kg/d) or calorie (≥5 kcal/kg/d) gap between targeted or actual intake was related to a larger decrease in CSMA in all the anatomic regions (P ≤ 0.05 for all). Other significant predictors of muscle loss included history of diabetes mellitus, male sex, higher BMI, in-hospital infections, and the necessity for invasive mechanical ventilation. CONCLUSIONS: There is a considerable degree of loss in the global muscle mass in acute ischemic stroke patients over a two-week period. Along with several factors, falling significantly behind the daily protein or calorie targets was related to the decrease in the muscle area. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov identifier NCT03825419.

Dark Side of the COVID-19 Pandemic; 'Long COVID'.

Objective: Besides its morbidity and mortality all over the world, SARS-CoV-2 infection maintains its importance with prolonged symptoms after acute disease. The post-infectious period including a heterogeneous group of symptoms is named 'long COVID'. This study aimed to describe persisting symptoms three months after COVID-19 and risk factors associated with 'long COVID'. Materials and Methods: This cross-sectional retrospective study included COVID-19 patients diagnosed with SARS-CoV-2 PCR positivity in the first 18 months of the COVID-19 pandemic, between March 2020 and September 2021. We conducted a survey in 2022 to inquire about the participants' symptoms that lasted three months or more after their own COVID-19 period. All patients were employees of one of the biggest national banks in Turkey. Participants answered a total of 31 questions over the phone. The presence of one or more symptoms persisting ≥3 months was defined as 'long COVID'. The risk factors associated with 'long COVID' were determined. Results: A total of 1301 patients were included in our study. The median age of patients was 40 (22-57), and 558 (42.9%) were women. 257 (19.8%) patients had 'long COVID' symptoms. The most prevalent symptoms were myalgia (14.3%), arthralgia (14.1%), and back pain (13.8%). Female gender ( p=0.000, OR=2.19 [95% CI=1.655-2.904]) and diabetes mellitus ( p=0.016, OR=2.43 [95% CI=1.177-5.017]) were found as independent risk factors for 'long COVID' by multivariant logistic regression analysis. Conclusion: Female gender and diabetes mellitus are risk factors for 'long COVID'. Detecting patients with a high risk for developing 'long COVID' is crucial for their management during the COVID and post-COVID periods.

Cerebral vein thrombosis as an exceptional cause of transient ischemic attack.

We present a case of transient ischemic attack (TIA) as an extremely rare presentation of cerebral vein thrombosis. A 41-year-old man presented with a headache and episodes of hypoesthesia on his left side lasting approximately 30 minutes. Several vascular risk factors were remarkable in his medical history. The neurologic examination was normal. TIA of arterial origin was excluded by detailed investigations. Magnetic resonance imaging revealed acute thrombosis of the right superficial middle cerebral vein and the vein of Trolard. TIA-like episodes stopped with anticoagulation. Head trauma a few days earlier was the most likely mechanism of venous thrombosis. We suggest that the patients with TIA and headache should be carefully investigated in terms of cerebral venous thrombosis.

The Relationship Between Renal Function and Imaging Markers and Total Burden of Cerebral Small Vessel Disease.

BACKGROUND: Previous studies demonstrating the association between renal functions and cerebral small vessel diseases have usually focused on white matter hyperintensity in the general population or lacunar stroke patients. This study aimed to investigate the effects of renal function on imaging markers of cerebral small vessel disease and etiologic subtypes of stroke in patients with acute ischemic stroke or transient ischemic attack. MATERIALS AND METHODS: A total of 356 consecutive patients with acute ischemic stroke or transient ischemic attack who were admitted to the Stroke Unit and underwent brain magnetic resonance imaging were evaluated. Demographic data, vascular risk factors, stroke etiology, estimated glomerular filtration rate and severity of cerebral small vessel disease markers, and total cerebral small vessel disease burden were evaluated. RESULTS: There was a significant inverse correlation between estimated glomerular filtration rate and total number of lacunes, periventricular and deep subcortical Fazekas scores, grade of enlarged perivascular spaces in the centrum semiovale, lobar and total cerebral microbleeds, and total cerebral small vessel disease burden. Impaired renal function was an independent risk factor for the presence of lacunes, deep cerebral microbleeds, and increased total burden. Renal function impairment and periventricular white matter hyperintensities were significantly associated with the etiologic subgroup of small vessel occlusion. The results were still significant after the exclusion of patients below 50 years of age. CONCLUSION: Our results indicate that there is a relationship between renal function impairment and increased total burden, as well as acute ischemic stroke/transient ischemic attack due to small vessel occlusion.

Assessment of safety and feasibility of non-invasive vagus nerve stimulation for treatment of acute stroke.

BACKGROUND: Non-invasive vagus nerve stimulation (nVNS) using a hand-held stimulator placed on the neck is an FDA-approved treatment for primary headache disorders. The safety of nVNS is unknown in stroke patients. OBJECTIVE: To assess the safety and feasibility of nVNS for the acute treatment of stroke. METHODS: TR-VENUS (clinicaltrials.gov identifier NCT03733431) was a randomized, sham-controlled, open-label, multicenter trial conducted in patients with acute ischemic stroke (IS) or intracerebral hemorrhage (ICH). Patients were randomly assigned to standard-dose nVNS, high-dose nVNS, or sham stimulation. The primary endpoint was a composite safety outcome defined as bradycardia or reduction in mean arterial blood pressure during treatment or progression of neurological or death within 24 h of treatment. The feasibility endpoints were the proportion of eligible subjects receiving nVNS within 6 h of symptom onset and the proportion completing all pre-specified treatment doses. Efficacy assessments included infarct growth from baseline to 24 h after treatment. RESULTS: Sixty-nine patients (61 IS, 8 ICH) completed the study. The composite safety outcome was achieved in 32.0% in sham and 47.7% in nVNS group (p = 0.203). Treatment was initiated in all but two randomized patients. All dosed subjects received 100% of prespecified stimulations. A non-significant reduction in infarct growth was observed in the high-dose nVNS group (184.2% in sham vs. 63.3% in high-dose nVNS; p = 0.109). CONCLUSIONS: The results of this study suggest that nVNS may be safe and feasible in the setting of acute stroke. These findings support further development of nVNS as a potential treatment for acute ischemic stroke.

Risk Factors, Biomarkers, Etiology, Outcome and Prognosis of Ischemic Stroke in Cancer Patients

Introduction: Cerebrovascular disease is the second most common complication in individuals with tumours. The aim of this study was to investigate risk factors, biomarkers, etiology and prognosis of ischemic stroke in cancer patients (ISCPs). Methods: The medical records of 619 consecutive patients who were admitted with acute ischemic stroke from January 2012 to November 2014 were retrospectively evaluated. The patients were divided into two groups (group 1, patients with an active cancer prior to the onset of ischemic stroke; group 2, patients without an active cancer history). The demographic data, risk factors, NIHSS scores, thrombocyte count, D-dimer, fibrinogen and C reactive protein (CRP) level at admission, modified Rankin Scale (mRS) scores in the follow-up period and location of lesions on DWI were recorded. The Mann-Whitney U test, chi-squared test and logistic regression was used for analyzing data, p<0.05 being considered statistically significant. Results: A total of 46 (7.4%) ISCPs were included. Hyperlipidemia was significantly lower in the ISCP group (p=0.001). Elevated thrombocyte counts, D-dimer, fibrinogen and CRP levels at admission, acute multiple ischemic lesions, other causes, mortality in hospital and worse outcome were significantly related to ISCP (p<0.05). On logistic regression analysis, follow up mRS>3, acute multiple ischemic lesions located in more than one vascular territory (AMIMCT) and other causes were significantly associated with ISCP (p<0.001). Conclusion: In our study, other causes, AMIMCT and mRS>3 were more common in the ISCP group. We consider that CCS could be more suitable for detecting other causes than TOAST. Biomarkers could be important in the ISCP group.

Pronation test: eyes closed or open?

BACKGROUND: The pronation test reveals slight paresis in the upper limbs. Patients hold their arms outstretched in front of them with the hands supinated while they keep their eyes closed. Position changes such as pronation, abduction, or drift indicate a positive pronation test. However, proprioceptive disorders also result in position changes when the eyes are closed. AIM: To evaluate the effects of vision on the pronation test and the relation of test results to electrophysiological findings. METHODS: Sixteen patients with slight unilateral paresis due to recent stroke were included in the study. Two pronation tests, one while the patients' eyes were open and the other while the eyes were closed (in randomized order), were performed in all patients and recorded with a video camera. Two neurologists double-blinded to the position of the patients' eyes then assessed the position changes in each recording. Electrophysiological examination included median sensory and motor evoked potentials in both upper limbs. Sensory and motor central conduction times (CCTs) were determined for all patients. RESULTS: Assessments of position changes by two physicians were concordant. Ten patients had position changes more evident in the pronation test with the eyes closed (group 1), while 6 patients had similar position changes in both tests (group 2). Motor CCT difference between two sides was similar in the two groups. However, sensory CCT difference longer than 1.0 ms was significantly more frequent in group 1 (p < 0.01). CONCLUSION: All patients who developed more obvious position changes during the pronation test with eyes closed had sensory CCT abnormalities. Therefore, we suggest that patients should keep their eyes open and then close them during the pronation test in order to distinguish motor or proprioceptive involvement.

Perioperative and follow-up results in carotid artery stenting with contralateral carotid occlusion.

PURPOSE: Contralateral carotid occlusion (CCO) increases the risk of carotid endarterectomy (CEA). We determined the outcome of carotid angioplasty and stenting (CAS), an alternative to CEA, in the setting of CCO through an independent analysis of imaging and clinical outcome. MATERIALS AND METHODS: Medical records of 26 consecutive patients with CCO who underwent CAS by a single operator using the same procedural protocol (with distal protection and closed-cell stents) were retrospectively evaluated. National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) scores before and after CAS, periprocedural complications, and the restenosis rate were analyzed by independent stroke neurologists who were not involved in the care of the patients. RESULTS: The median mRS score for the 26 patients was 1 (range 0-5) before and after CAS. All of the patients underwent clinical and imaging follow-up (mean 19.5 ± 14.3 and 11.6 ± 11.2 months, respectively). Thirty-day mortality/permanent morbidity rates were 0 %. One patient had hyperperfusion syndrome and was managed medically without sequelae; however, he had stent occlusion after 30 days, resulting in a decline in his mRS from 4 (preprocedure) to 5. Otherwise, there was no decline in mRS during the post-discharge follow-up. CONCLUSION: According to an independent analysis of this single-operator series, CAS is safe and effective for the treatment of patients with CCO.

The effects of hematocrit and age on transcranial Doppler measurements in patients with recent ischemic stroke.

BACKGROUND: The effects of age and hematocrit on transcranial Doppler (TCD) velocities have not been evaluated in a large patient group with recent ischemic stroke. AIM: This study assessed the effects of age and hematocrit on TCD measurements in patients with recent ischemic stroke compared to patients with non-vascular diseases. SETTINGS AND DESIGN: University Hospital, retrospective study. MATERIALS AND METHODS: TCD records and data files of 862 consecutive patients (mean age, 57+/-16 years) with various neurological diagnoses were reviewed retrospectively. The peak systolic, end diastolic and mean flow velocities (FV), systolic/diastolic ratios and pulsatility indices (PI) in the middle cerebral arteries were averaged and the effect of age and hematocrit values on these TCD values was studied. Independent samples t test, Pearson's coefficients of correlation, and linear regression test were used for statistical analysis. RESULTS: Among 862 patients, 413 were women (mean age, 53+/-17 years) and 449 were men (mean age, 60+/-13 years). Peak systolic and mean FV were higher and hematocrit concentration was lower in women compared to men (P< 0.001). The relation of TCD velocities with age and hematocrit was more remarkable in the group of patients with non-vascular neurological disorders. PI values demonstrated a significant correlation to age (r=+0.47) (P< 0.001), but did not change significantly with hematocrit level. CONCLUSIONS: It should be remembered that blood FV measured by TCD may be significantly affected by age and hematocrit level. However, there seems to be no significant association between TCD velocities and hematocrit in patients with a recent ischemic stroke.

Behçet's Disease and Intracardiac Thrombosis: A Report of Three Cases.

We present three patients with Behçet's disease associated with intracardiac thrombus and pulmonary vascular involvement. One of these patients had also Budd-Chiari syndrome. All patients were treated with corticosteroid plus monthly intravenous cyclophosphamide as first line treatment and with no recurrences. Immunosuppressive therapy was successful in the treatment of intracardiac thrombus and also in the regression of pulmonary vascular thromboses in these patients. Intracardiac thrombus in Behçet's disease is rarely seen. Behçet's disease should be remembered in the differential diagnosis of the patients with intracardiac mass, especially in patients from the Mediterranean and Middle East populations.

A case of bilateral uveitis and optic disc swelling with Chiari I malformation.

We report a case of bilateral uveitis and optic disc swelling with Chiari I malformation. A 16-year-old girl was admitted to our clinic due to conjunctival hyperaemia and blurred vision in her right eye. Ophthalmologic and systemic examinations were performed. Visual acuity was 0.7 (OD) and 1.0 (OS). Bilateral optic disc swelling was observed. Fluorescein angiography demonstrated bilateral retinal vasculitis as well as optic disc hyperflourescence due to leakage. Laboratory examinations were within normal limits. Cranial magnetic resonance venography imaging revealed neither cranial mass nor cerebral venous thrombosis but a Chiari I malformation. The patient was started oral cetazolamid, topical and oral corticosteroids. After six months follow-up, bilateral optic disc swelling was resolved completely and visual acuity was 1.0 in both eyes. Optic disc swelling may be associated with intraocular inflammation; however, patients with bilateral optic disc swelling should be suspected of having an accompanying intracranial pathology.