An assessment on the use of infra-scanner for the diagnosis of the brain hematoma in head trauma.

PURPOSE: Timely identification and treatment of intracranial hematomas in patients with brain injury is essential for successful treatment. This study evaluates Infra-scanner as a handy medical screening tool for diagnosing, on-site, cerebral hematomas in patients with head injury. MATERIALS AND METHODS: Patients referred to the emergency department of university hospitals with mild to moderate brain trauma, up to 12 h from injury were included. NIR sensors of infra-scan device were placed on the right and left frontal, temporal, peritoneal and occipital parts of the head and light absorption was recorded. Positive or negative cerebral hemorrhage cases were compared with contrast-enhanced CT scan results as the gold standard. Diagnostic parameters of the device and cases related to bleeding were analyzed and reported. RESULTS: A total of 300 patients were studied. Sensitivity of the infrasound scanner in the Iranian study population was 94.8 (95% CI: 88% -100) and its specificity was 86.9 (95% CI: 79% -99% 99). Negative predictive value (NPV) was 90.3% and positive predictive value (PPV) was 92.9%. Sensitivity in men (95.7%) (95%CI, 90% -1) was more than women (95% CI, 81% -99%)90%. At the ages of less than 36 years, sensitivity (95.3%) and specificity (87.1%) were more than sensitivity (94.4%) and specificity (86.5%) over 36 years old. If the test had been performed in less than / equal to two hours from trauma, the sensitivity (94.9%) and the specificity (92%) were greater than the sensitivity (94.6%) and the specificity (75%) during when the scan had been performed in more than two hours from trauma. In general, in extra-axial bleeding including EDH, SAH, SDH, the sensitivity was 95.1% and the specificity was 84.5%, while in intra-axial bleeding, including ICH and IVH, the sensitivity was lower (93.9%) and the specificity was 91.7. The sensitivity of the device in detecting bleeding in the occipital lobe (95.8%) was higher than other brain lobes. CONCLUSION: This study shows that Infra-scanner is useful in initial examination and screening of patients with head injury and can be used as an adjunct to a CT scan or when not available and may allow earlier treatment which reduce the secondary damage to the hematoma.

Carotid intima-media thickness measurements in patients with multiple sclerosis.

OBJECTIVES: The goal of this study was to evaluate the mean carotid intima-media thickness (CIMT) in patients with Multiple Sclerosis (MS). METHODS: In this cross-sectional study, 100 patients with MS were enrolled. Carotid intima-media thickness was measured by Doppler Ultrasonography. The mean CIMT was then compared between different groups of sex, age, body mass index (BMI), medications, and site of the MS plaques in the brain and cervical MRI. In addition, disease duration, annual relapse rate, and Expanded Disability Status Scale (EDSS) were compared between high and normal CIMT groups. RESULTS: Among 100 patients, Sixty-two percent of the patients were female. The mean age was 35.95 ± 9.32 years. Mean CIMT was 0.38 ± 0.2 mm, and 22% of the patients had abnormal CIMT measures. CIMT was significantly associated with higher age (P = 0.01) and prolonged disease duration (P < 0.001). CIMT was not associated with other disease factors or types of the disease-modifying drug (P > 0.05). CONCLUSION: Multiple Sclerosis might be associated with carotid atherosclerotic vascular disease.

Rituximab and risk of COVID-19 infection and its severity in patients with MS and NMOSD.

BACKGROUND: Choosing a safe disease modifying therapy during the COVID-19 pandemic is challenging. This case series study was conducted to determine the incidence rate and the course of Covid-19 infection in MS/NMOSD patients treated with Rituximab. METHODS: In this study, we designed a web-based questionnaire. Baseline information such as patient- reported walking disability, total number of Rituximab infusions received, delayed injections, occurrence of any relapse, and the use of corticosteroids during the pandemic were collected. Also, information regarding the Covid-19 pandemic such as adherence to self-isolation, any recent exposure to an infected individual and the presence of suggestive symptoms were collected. In case of positive test results, patients were grouped into 2 categories; mild to moderate and seriously ill and outcomes were evaluated as favorable (improved/ discharged) and unfavorable (expired). RESULTS: Two hundred fifty-eight patients with Multiple Sclerosis were enrolled in this study, 9 of the subjects (3.4%) were confirmed positive for Covid-19, five of which required hospitalizations (55.5%), two patients required ICU admission (22.2%) and 2 two patients died (22.2%). None of these patients ever mentioned using corticosteroids during the pandemic. In comparison to MS patients who were not receiving disease modifying therapy (DMT), our study indicated a higher incidence of Covid-19 infection, higher ratio of serious illness and a higher fatality ratio. CONCLUSIONS: Rituximab seems not to be safe enough during the pandemic.

Rivaroxaban for the treatment of cerebral venous thrombosis.

BACKGROUND: New Oral Anticoagulants (NOACs) such as Rivaroxaban are introduced as alternatives to conventional vitamin-K antagonists in the long-term treatment of thrombotic events due to their lower bleeding risk. There is a lack of evidence on the effectiveness and safety of Rivaroxaban in Cerebral venous thrombosis (CVT). This study aims to assess the effectiveness and bleeding risk of Rivaroxaban in comparison with Warfarin for the treatment of CVT. MATERIALS AND METHODS: 36 patients with diagnosis of CVT were included. Clinical and background information was assessed on admission and patients were followed for at least 12 months. Measured outcomes were modified Rankin Scale (mRS), evidence of recanalization on contrast-enhanced Brain MR venography (MRV) and major or minor bleeding. Patients were divided into two groups according to the type of oral anticoagulant (Rivaroxaban vs Warfarin). Groups were compared in terms of final outcomes and side effects. RESULT: Overall, 13 (36.11%) patients received Warfarin and 23 (63.89%) received Rivaroxaban. Optimal mRS score (0-1) was attained in 9 of 10 (90%) of patients treated with Rivaroxaban and 19 of 22 (86.36%) of patients received Warfarin. MRV showed complete or partial recanalization in 12 of 14 (85.71%) patients treated with Rivaroxaban and all patients in the Warfarin group. There was no significant difference between the two groups in terms of major and minor hemorrhage. CONCLUSION: Rivaroxaban holds promise for the treatment of CVT.

Transbulbar B-mode sonography in multiple sclerosis without optic neuritis; clinical relevance.

OBJECTIVE: Trans bulbar B-mode sonography (TBS) is a recently proposed method but there is little known about its diagnostic accuracy in patients with multiple sclerosis without acute optic neuritis. Therefore we assessed the correlation between OND, ONSD and OND/ONSD ratio with clinical/para clinical parameters. METHODS: In a comparative study, we intended to examine possible differences in optic nerve diameter (OND) and optic nerve sheath diameter (ONSD) between 60 patients with multiple sclerosis (MS) and 60 individuals as matched healthy controls. RESULTS: The OND, ONSD and OND/ONSD ratio in both eyes showed significantly lower amounts in patients compared to healthy controls (p < 0.05). There were no correlations, between either OND or ONSD and factors including gender, age, P100 amplitude, disease duration, history of optic neuritis and number of T2 lesions in MRI (P ≥ 0.05). Expanded disability status scale (EDSS) and p100 Latency were correlated with both OND and ONSD values (P < 0.05). CONCLUSIONS: TBS showed significantly lower amounts of OND, ONSD and OND/ONSD ratio in MS patients without current attack compared to their healthy controls indicating a subclinical axonal loss over time. It is suggested that TBS could be an applicable tool for early detection of optic nerve damages along with clinical and para-clinical findings.

Intravenous Immunoglobin Utilization Study in a Teaching Hospital.

BACKGROUND: Intravenous immunoglobulin (IVIG) is an immunomodulating agent that has several actions. The aim of this study was to investigate the indications of IVIG according to available evidence and the cost in our center. METHODS: This retrospective study was conducted between September 2017 and June 2018 at a teaching hospital affiliated with Iran University of Medical Sciences, Tehran, Iran. Patients' demographic data and disease, indication for IVIG use, its dosage and treatment regimen and previous and concurrent treatments were assessed. The collected data were compared with the present criteria for the pattern of IVIG usage. The last version of Lexicomp® was used as the reference for indications of the administrated drug and its dosage. RESULTS: A total of 119 patients received IVIG during the study period. The wards with the most frequent IVIG prescription were the neurology (46.2%) and neonatal intensive care unit (21%). The most common reasons of IVIG therapy were various inflammatory neurological disorders. IVIG was used in 22, 43 and 54 cases according to on-label, off- label and other indications, respectively. The total price was higher for off-label indications for IVIG ($254343.75) than on-label indications ($152625). As well, $107250 was exhausted for cases in which there was not sufficient evidence. CONCLUSION: One important aspects of this study was the use of IVIG in cases other than on-label indications. Although a number of studies support IVIG therapy in some diseases, further trials are needed to establish efficacy and safety in these fields.

A Mitochondrial Disorder in a Middle Age Iranian Patient: Report of a Rare Case.

INTRODUCTION: Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) can involve multiple systems and cause stroke-like episodes and status epilepticus. CASE PRESENTATION: A 48-year-old female with history of early fatigability, migraine-type headaches, and bilateral sensory-neural hearing loss presented 3 episodes of serial seizures. On admission she was affected by Wernicke aphasia and, then, right hemiparesis. Investigations showed elevated arterial lactate and ragged red fibers on muscle biopsy. CONCLUSION: Though more commonly diagnosed during childhood, some cases of adult-onset MELAS syndrome are reported. This syndrome should be considered in patients with stroke-like events in adults without cerebrovascular risk factors and difficult-to-treat seizures.

Prevalence and associated comorbidities of restless legs syndrome (RLS): Data from a large population-based door-to-door survey on 19176 adults in Tehran, Iran.

BACKGROUND: Discrepancies have been reported in the prevalence rate of restless legs syndrome (RLS) among different ethnic groups and geographic populations. Furthermore, there are disagreements on determinant factors and associated comorbidities of RLS. We aimed to estimate prevalence of RLS and investigate its associated comorbid conditions and risk factors in a large population-based door-to-door survey. METHODS: Following a multistage random sampling from the households lived in 22 urban districts of Tehran, Iran, 19176 participants with ≥30 years of age were recruited. Trained surveyors filled study checklist consisting of baseline characteristics, risk factors and comorbidity profile and the International RLS Study Group (IRLSSG) diagnostic criteria through face-to-face interviews. RESULTS: In total, 1580 individuals were positively screened for RLS resulting in a standardized prevalence rate of 60.0/1000. There was a gradual increase in RLS prevalence by advancing age, however, sex difference disappeared after adjustment. Parkinsonism [adjusted odds' ratio (adj-OR) = 7.4 (95% CI: 5.3-10.4)], peripheral neuropathy [adj-OR = 3.7 (95% CI: 3.3-4.1)], subjective cognitive impairment (SCI) [adj-OR = 3.1 (95% CI: 2.7-3.4)], acting out dreams [adj-OR = 2.8 (95% CI: 2.5-3.2)], hyposmia [adj-OR = 2.5 (95% CI: 2.2-2.9)], active smoking [adj-OR = 1.5 (95% CI: 1.3-1.9)] and additional number of cardiometabolic diseases associated with higher risk of RLS [adj-OR = 1.6 (95% CI: 1.2-2.3)]. CONCLUSION: Our findings showed that neuro-cognitive co-morbidities such as parkinsonism, peripheral neuropathy, SCI, acting out dreams and hyposmia as well as cardio-metabolic risk factors and diseases were independent determinants of RLS. It is recommended to screen individuals with either these comorbid conditions for RLS or the ones with RLS for the accompanying diseases.

Repeated sessions of transcranial direct current stimulation evaluation on fatigue and daytime sleepiness in Parkinson's disease.

Parkinson is a common and disabling disease that affects patient's and career's quality of life. Unfortunately, medications, such as dopaminergic and sedative-hypnotic drugs, as an effective treatment have unwilling side effects. Recently, Transcranial Direct Current Stimulation (tDCS) in conjunction with medication becomes popular as a complementary safe treatment and several studies have proved its effectiveness on controlling motor and specially non-motor aspects of Parkinson's disease. In this randomized double-blind parallel study, 23 patients with Parkinson's disease divided into two groups of real tDCS plus occupational therapy and sham tDCS plus occupational therapy and the effects of therapeutic sessions (eight sessions tDCS with 0.06 mA/cm2 current, 20 min on dorsolateral prefrontal cortex) were evaluated on fatigue and daytime sleepiness just after therapeutic course and in 3-month follow-up. tDCS had a significant effect on fatigue and no effect on daytime sleepiness reduction in patients with Parkinson's disease. tDCS is an effective and safe complementary treatment on fatigue reduction in Parkinson's disease.

Developing the Persian version of the homophone meaning generation test.

BACKGROUND: Finding the right word is a necessity in communication, and its evaluation has always been a challenging clinical issue, suggesting the need for valid and reliable measurements. The Homophone Meaning Generation Test (HMGT) can measure the ability to switch between verbal concepts, which is required in word retrieval. The purpose of this study was to adapt and validate the Persian version of the HMGT. METHODS: The first phase involved the adaptation of the HMGT to the Persian language. The second phase concerned the psychometric testing. The word-finding performance was assessed in 90 Persian-speaking healthy individuals (20-50 year old; 45 males and 45 females) through three naming tasks: Semantic Fluency, Phonemic Fluency, and Homophone Meaning Generation Test. The participants had no history of neurological or psychiatric diseases, alcohol abuse, severe depression, or history of speech, language, or learning problems. RESULTS: The internal consistency coefficient was larger than 0.8 for all the items with a total Cronbach's alpha of 0.80. Interrater and intrarater reliability were also excellent. The validity of all items was above 0.77, and the content validity index (0.99) was appropriate. The Persian HMGT had strong convergent validity with semantic and phonemic switching and adequate divergent validity with semantic and phonemic clustering. CONCLUSION: The Persian version of the Homophone Meaning Generation Test is an appropriate, valid, and reliable test to evaluate the ability to switch between verbal concepts in the assessment of word-finding performance.

X-ray radiation and the risk of multiple sclerosis: Do the site and dose of exposure matter?

BACKGROUND: The sporadic cases of radiation-activated multiple sclerosis (MS) has been previously described, with a few studies focused on the relationship between radiation and the risk of MS. The aim of our study was to evaluate the association between history of X-ray radiation and MS. METHODS: This case-control study was conducted on 150 individuals including 65 MS patients and 85 age- and sex-matched healthy controls enrolled using non-probability convenient sampling. Any history of previous Xray radiation consisted of job-related X-ray exposure, radiotherapy, radiographic evaluations including chest Xray, lumbosacral X-ray, skull X-ray, paranasal sinuses (PNS) X-ray, gastrointestinal (GI) series, foot X-ray and brain CT scanning were recorded and compared between two groups. Statistical analysis was performed using independent t test, Chi square and receiver operating characteristics (ROC) curve methods through SPSS software. RESULTS: History of both diagnostic [OR=3.06 (95% CI: 1.32-7.06)] and therapeutic [OR=7.54 (95% CI: 1.5935.76) X-ray radiations were significantly higher among MS group. Mean number of skull X-rays [0.4 (SD=0.6) vs. 0.1 (SD=0.3), p=0.004] and brain CT scanning [0.9 (SD=0.8) vs. 0.5 (SD=0.7), p=0.005] was higher in MS group as well as mean of the cumulative X-ray radiation dosage [1.84 (SD=1.70) mSv vs. 1.11 (SD=1.54) mSv; p=0.008]. CONCLUSION: Our study was one of the first to show higher history of X-ray radiation in patients with MS compared to healthy controls. A possible association was also found between the dose and the site exposed to X-ray radiation and risk of developing MS.

Amyotrophic lateral sclerosis as a paraneoplastic manifestation in the neuroendocrine tumor of stomach: a case report.

Motor neuron diseases have been reported as a rare paraneoplastic syndrome (PNS) of a systemic neoplasm. We present a patient with amyotrophic lateral sclerosis (ALS) in association with neuroendocrine tumor (NET) of stomach, which is the first case of motor neuronopathy with underlying neuroendocrine tumor. A 79-year old woman presented with a two months history of progressive dysphagia, spastic dysarthria and marked fasciculation in her atrophic tongue. Gag reflexes were diminished bilaterally. Other cranial nerves were intact. In muscle testing there was significant atrophy in thenar and hypothenar areas of both hands compatible with diffuse motor neuronopathy with active denervation. Upper GI endoscopic study showed patchy erythematous mucosa with congestion in body of stomach, Histological biopsy of stomach confirmed the neuroendocrine tumor (NET). The importance of considering a paraneoplastic syndrome in a patient with presentation of ALS, which can leads to searching for underlying neoplasm before its apparent signs and symptoms, to initiate tumor treatment so much sooner. In addition even though paraneoplastic motor neuron disease is rare, treating the underlying neoplasm may resolve neurologic signs and symptoms.

Retrosternal mass: An interesting allergic reaction to intravenous thrombolytic therapy for acute ischemic stroke.

Stroke is an important cause of disability and death worldwide, with the majority of strokes occurring in older people. Thrombolysis with recombinant tissue plasminogen activator (r-TPA) is the approved treatment for acute ischemic stroke. A major concern of physicians, who treat acute ischemic stroke with recombinant tissue plasminogen activator (r-TPA,) is the risk of intracerebral hemorrhage. However, other adverse reactions, including anaphylaxis and angioedema, can also occur. Here we report an interesting soft tissue reaction to intravenous r-TPA in an 80 year-old male who was treated for acute ischemic stroke.

Safety and feasibility of intravenous thrombolytic therapy in Iranian patients with acute ischemic stroke.

BACKGROUND: Thrombolytic therapy is the only approved treatment for acute cerebral ischemia. The hemorrhagictransformation is the greatest complication of this treatment, which may occur after recanalization of occludedartery. The aim of this study was to determine factors associated with clinical improvement and worseningin patients with acute ischemic stroke treated with intravenous thrombolysis. METHODS: Thirty seven patients who were treated with intravenous thrombolysis between August 2010 andAugust 2012 who had the inclusion criteria were studied. In this prospective study, all of the admitted patients instroke unit, monitored for at least 48 hours. We registered all patients' information in a stroke data registry andfollowed them for at least 6 months. RESULTS: Thirty seven patients with acute ischemic stroke who treated with recombinant tissue plasminogenactivator (r-TPA) were studied. There were hemorrhagic transformations in 9 (24%) patients. Seven of them(18%) revealed intracerebral hemorrhages (ICH) within the control brain CT after 24 hours without any deteriorationof neurologic symptoms (asymptomatic ICH). Although outcomes of patients with symptomatic post r-TPA hemorrhages were worse than non-hemorrhagic post r-TPA patients, there were no significant differencesbetween asymptomatic post r-TPA hemorrhages and non-hemorrhagic post r-TPA patients, according to theNational Institutes of Health Stroke Scale (NIHSS) at admission (p = 0.2), after 24 hours (p= 0.07) and after 7days (p= 0.06) post treatment. CONCLUSION: If the r-TPA protocol is followed carefully, the risk of symptomatic hemorrhage is low (about7%). Taking r-TPA was feasible and safe in our study population; thus, it can be applied for other Iranian patients.

Autologous mesenchymal stem cell therapy in progressive multiple sclerosis: an open label study.

Despite updating knowledge and a growing number of medications for multiple sclerosis (MS), no definite treatment is available yet for patients suffering from progressive forms of the disease. Autologous bone marrow derived mesenchymal stem cell (BM-MSC) transplantation is a promising method proposed as a therapy for MS. Although the safety of these cells has been confirmed in hematological, cardiac and inflammatory diseases, its efficacy in MS treatment is still under study. Patients with progressive MS (expanded disability status scale score: 4.0 -6.50) unresponsive to conventional treatments were recruited for this study. Twenty-five patients [f/m: 19/6, mean age: 34.7±7] received a single intrathecal injection of ex-vivo expanded MSCs (mean dose: 29.5×10(6) cells). We observed their therapeutic response for 12 months. Associated short-term adverse events of injection consisted of transient low-grade fever, nausea /vomiting, weakness in the lower limbs and headache. No major delayed adverse effect was reported. 3 patients left the study for personal reasons. The mean (SD) expanded disability status scale (EDSS) score of 22 patients changed from 6.1 (0.6) to 6.3 (0.4). Clinical course of the disease (measured by EDSS) improved in 4, deteriorated in 6 and had no change in 12 patients. In MRI evaluation, 15 patients showed no change, whereas 6 patients showed new T2 or gadolinium enhanced lesions (1 lost to follow-up). It seems that MSC therapy can improve/stabilize the course of the disease in progressive MS in the first year after injection with no serious adverse effects. Repeating the study with a larger sample size, booster injections and longer follow-up using a controlled study design is advised.

The effect of interferon-beta1a on relapses and progression of disability in patients with clinically isolated syndromes (CIS) suggestive of multiple sclerosis.

OBJECTIVES: In 85% of young adults with multiple sclerosis (MS), onset is a subacute clinically isolated syndrome (CIS) of the optic nerves, brain stem or spinal cord. The advent of disease-modifying treatments for MS has increased attention on early stages of the disease. Therefore, the aim of this study was to evaluate the effect of interferon on relapses and progression of disability in patients with a CIS. PATIENTS AND METHODS: This randomized, clinical trial was conducted in 25 patients who presented with a CIS indicative of MS. They were evaluated in two groups: 11 patients who were receiving interferon-beta(1a) (Rebif, Serono) subcutaneous injections three times a week (group A), and 14 patients who were not receiving disease-modifying treatment (group B). The progression of disability was determined using the Kurtzke Expanded Disability Status Scale (EDSS) and the numbers of new relapses were recorded during 21 months of follow-up. RESULTS: The mean numbers of new relapses and changes in EDSS at the end of study period were 0.68 (standard deviation [S.D.]=0.80) and -1.09 (S.D.=0.49), and 1.79 (S.D.=1.05) and -0.64 (S.D.=0.49) in groups A and B, respectively. Statistical analysis showed that disease-modifying treatment with interferon-beta(1a) may reduce relapses (P=0.007) and prevent progressive disability (P=0.034). CONCLUSION: Interferon-beta(1a) significantly delayed progression to disability and incidence of new relapses.