Letter and Category Fluency: Normative Data for Lebanese Older Adults.

BACKGROUND: Verbal fluency tasks are frequently used for neuropsychological assessment in clinical practice and research. It consists of two tasks namely category and letter fluency tests. OBJECTIVE: To determine normative values in category (animals, vegetables, fruits) and letter fluency [Mim () "M", Alif () "A", Baa () "B"] tasks in Arabic language in 60 s. METHODS: This study was a cross-sectional national survey and included 859 community-dwelling, cognitively intact Lebanese residents aged ≥55 years. Norms were presented according to age (55-64 years, 65-74 years, ≥75 years), sex and level of education (illiterate, no diploma, primary certificate, baccalaureate or higher). RESULTS: Level of education had the most significant positive effect on verbal fluency tasks performance amongst Lebanese older adults. The negative effect of older age was more prominent in the category fluency task compared to the letter fluency task. Women outperformed men in vegetables and fruits categories. CONCLUSION: This study provides clinicians with normative scores of category and letter fluency tests, which can be used for neuropsychological assessment of older Lebanese patients being evaluated for cognitive disorders.

An adapted Arabic version of the Test of Nine Images for the illiterate Lebanese population: Validation and preliminary normative data.

OBJECTIVES: In the absence of a simple validated instrument to screen for cognitive impairment among illiterate Lebanese older adults, the aims of this study were to validate an Arabic version of the Test of Nine Images (A-TNI93) adapted by the Working Group on Dementia at Saint Joseph University: Groupe de Travail sur les Démences de l'Univesité Saint Joseph (GTD-USJ) for illiterate older Lebanese and to establish normative data. METHOD: A national population-based sample of 332 community-dwelling illiterate Lebanese aged 55 years and older was administered the A-TNI93 (GTD-USJ) scoring free and overall recall. The sample is part of a larger national sample (1342 participants) used to validate an Arabic version of the Mini-Mental State Examination already reported. Reproducibility, sensitivity, specificity, and area under the curve of the A-TNI93 (GTD-USJ) scoring to detect cognitive impairment according to Clinical Dementia Rating (CDR) as the gold standard were measured. Normative data were established among 188 cognitively normal participants. RESULTS: A threshold score of six on free recall (FR) provided a sensitivity of 66.7% and a specificity of 90.5%. The area under the curve was 0.93. By taking either scores, that is, a FR ≤ 6 or a total recall ≤ 8, the A-TNI93 (GTD-USJ) slightly improved dementia case detection with a sensitivity of 70.8% and a specificity of 88%. Normative data illustrate the distribution of cognitive performance among illiterate older adults. CONCLUSIONS: Compared to the CDR requiring physician's competence, the A-TNI93 (GTD-USJ) is a valid Arabic adaptation to screen for cognitive impairment among illiterate Lebanese older adults.

Economic evaluation of cladribine tablets in high disease activity (HDA) relapsing multiple sclerosis (RMS) patients in Lebanon.

BACKGROUND: Cladribine tablets are a newly launched short course oral treatment approved for high disease activity (HDA) relapsing multiple sclerosis (RMS). The current analysis assessed the cost-utility and budgetary impact of introducing cladribine tablets in HDA-RMS patients compared with other HDA-RMS therapies in Lebanon. METHODS: The global cost-utility and budget impact models were adapted from Lebanese National Social Security Fund (NSSF) perspective. The data for the models' adaptation were retrieved from the literature and validated by Lebanese experts. The comparators considered in the cost-utility model were alemtuzumab, fingolimod, and natalizumab while budget impact analysis additionally considered dimethyl fumarate. A sensitivity analysis was also performed to assess the uncertainty in the analysis. RESULTS: The cost-utility results showed that cladribine tablets are an economically dominant therapeutic strategy (i.e., less costly and better quality-adjusted life year [QALY]) compared to all comparators. The cost saving was driven by drug acquisition, administration, and monitoring costs; while incremental QALY gain was driven by differences in delayed Expanded Disability Status Scale progression. Sensitivity analysis showed that cladribine tablets have a high probability (99.3-100%) of being dominant at a threshold of 22,000 United States Dollars (approximately three times of gross domestic product) per QALY gained against different comparators. The budget impact analysis showed that the introduction of cladribine tablets would result in 5.0% to 21.5% savings in the overall budget over a period of five years. CONCLUSIONS: Cladribine tablets are a cost-effective and a budget-saving treatment option for the treatment of HDA-RMS patients in Lebanon from the NSSF perspective.

A 20-year Clinical and Genetic Neuromuscular Cohort Analysis in Lebanon: An International Effort.

BACKGROUND: Clinical and molecular data on the occurrence and frequency of inherited neuromuscular disorders (NMD) in the Lebanese population is scarce. OBJECTIVE: This study aims to provide a retrospective overview of hereditary NMDs based on our clinical consultations in Lebanon. METHODS: Clinical and molecular data of patients referred to a multi-disciplinary consultation for neuromuscular disorders over a 20-year period (1999-2019) was reviewed. RESULTS: A total of 506 patients were diagnosed with 62 different disorders encompassing 10 classes of NMDs. 103 variants in 49 genes were identified. In this cohort, 81.4% of patients were diagnosed with motor neuron diseases and muscular dystrophies, with almost half of these described with spinal muscular atrophy (SMA) (40.3% of patients). We estimate a high SMA incidence of 1 in 7,500 births in Lebanon. Duchenne and Becker muscular dystrophy were the second most frequently diagnosed NMDs (17% of patients). These disorders were associated with the highest number of variants (39) identified in this study. A highly heterogeneous presentation of Limb Girdle Muscular Dystrophy and Charcot-Marie-Tooth disease was notably identified. The least common disorders (5.5% of patients) involved congenital, metabolic, and mitochondrial myopathies, congenital myasthenic syndromes, and myotonic dystrophies. A review of the literature for selected NMDs in Lebanon is provided. CONCLUSIONS: Our study indicates a high prevalence and underreporting of heterogeneous forms of NMDs in Lebanon- a major challenge with many novel NMD treatments in the pipeline. This report calls for a regional NMD patient registry.

Evaluation of corneal sensitivity in multiple sclerosis patients.

PURPOSE: To measure the corneal sensitivity in patients with multiple sclerosis (MS), to compare it with normal values and to study its correlation with different disease characteristics. METHODS: Corneal sensitivity of 28 MS patients was compared to corneal sensitivity of 28 age- and gender-matched normal controls. Corneal sensitivity was measured using the Cochet-Bonnet esthesiometer and was correlated to the duration, type and severity indexes of the disease. RESULTS: Corneal sensitivity was comparable between both groups (P = 0.79). No statistically significant correlation was found between corneal sensitivity and the duration of MS (P = 0.55) nor the severity indexes of MS (expanded disability status scale [EDSS] P = 0.52, global multiple sclerosis severity score [MSSS] P = 0.64). Following subgroup analysis, only the primary progressive (PPMS) form of MS had a reduced corneal sensitivity with P = 0.023, while remittent-recurrent (RRMS), secondary progressive (SPMS), and clinically isolated (CIS) forms of MS did not have any reduction in the corneal sensitivity. "ROC curve analysis" showed an area under the curve of 0.48. CONCLUSION: In the exception of PPMS subtype, MS patients have similar corneal sensitivity in comparison to controls. Cochet-Bonnet esthesiometer does not seem to be a good diagnostic tool or a disease severity marker for patients with MS.

Real-world retrospective study of effectiveness and safety of FINgOlimod in relapsing remitting multiple sclerosis in the Middle East and North Africa (FINOMENA).

OBJECTIVES: Evidence on the effectiveness and safety of fingolimod in real-world clinical practice in the Middle East and North African (MENA) region is limited. This study aimed to evaluate the effectiveness and safety of fingolimod in patients with relapsing-remitting multiple sclerosis (RRMS) in real-world setting in the MENA region. PATIENTS AND METHODS: RRMS patients who had been treated with fingolimod for at least 12 months were retrospectively identified from the databases of 34 centers across the MENA region. Study outcomes included the annualized relapse rate (ARR), relapse-free rate (RFR), time to first and second relapses, mean change in Expanded Disability Status Scale (EDSS), proportion of patients with Magnetic Resonance Imaging (MRI) activity and no evidence of disease activity (NEDA)-3, retention of patients on treatment, as well as all safety measures. RESULTS: A total of 806 patients were included: 66.34 % female; mean age 32.97 ± 9.62 years; mean disease duration 4.92 ± 4.66 years; mean fingolimod use 37.2 ± 16.7 months. Most patients had received previous disease-modifying therapy (79.65 %). Compared to the year preceding fingolimod initiation, RFR improved (33.00%-86.35%; p < 0.001), ARR decreased (0.84 ± 0.73 to 0.16 ± 0.45; p = 0.005), EDSS decreased (2.69 ± 1.74-2.01 ± 1.66; p < 0.001), and the proportion of patients with Gadolinium-enhancing T1 lesions decreased (57.84 % to 12.93 %; p < 0.001), after 12 months of fingolimod treatment. NEDA-3 was achieved in 41.3 % of patients. Median time to first and second relapses was not reached since 86.35 % and 98.39 % of patients had not experienced relapses for the first time and second time, respectively. Eight-hundred one (99.38 %) patients continued fingolimod treatment beyond 12 months. One-hundred thirty patients (16.13 %) experienced adverse events, mainly lymphopenia (5.46 %) and leukopenia (2.11 %), while 13 patients (1.61 %) experienced serious adverse events. CONCLUSION: This study confirms the effectiveness and safety profile of fingolimod in real-world setting in the Middle East and North African (MENA) region.

Urodynamics in patients with multiple sclerosis: is it necessary? A randomized-controlled trial.

BACKGROUND: The need for complete urodynamic evaluation in Multiple Sclerosis (MS) patients with Lower Urinary Tract Symptoms (LUTS) is not fully established in the literature. The objective was to evaluate the effect of urodynamics in MS patients with LUTS on treatment outcomes. METHODS: MS patients with LUTS were recruited. On their first visit, urinary symptoms, symptom bother and urologic quality-of-life were evaluated using standardized questionnaires. On their second visit, patients were randomized into two groups: Group A underwent uroflowmetry, and Group B underwent a urodynamic study. Patients received treatment based on the whole evaluation and then were evaluated at 1, 3 and 6 months. RESULTS: Fifty MS patients with LUTS were randomized to 25 patients in each group. All scores decreased significantly after 6 months of treatment in both groups (p < 0.05). However, no differences were found between the two groups at baseline and at 1, 3 and 6 months of treatment (p > 0.05) concerning treatment outcomes. CONCLUSION: A detailed clinical and non-invasive evaluation of MS patients with LUTS seems to be sufficient for prescribing an effective treatment. A urodynamic study does not influence the response to the prescribed treatment in terms of LUTS severity, bother or urologic quality-of-life.

Immune Reconstitution Therapy or Continuous Immunosuppression for the Management of Active Relapsing-Remitting Multiple Sclerosis Patients? A Narrative Review.

The majority of disease-modifying drugs (DMDs) available for the management of active relapsing-remitting multiple sclerosis (RMS) depend on continuous drug intake for maintained efficacy, with escalation to a more active drug when an unacceptable level of disease activity returns. Among continuously applied regimens, interferons and glatiramer acetate act as immunomodulators, while dimethyl fumarate, fingolimod, ocrelizumab, natalizumab and teriflunomide are associated with continuous immunosuppression. By contrast, immune reconstitution therapy (IRT) provides efficacy that outlasts a short course of treatment. Autologous hemopoietic stem cell transplantation is perhaps the classic example of IRT, but this invasive and intensive therapy has challenging side-effects. A short treatment course of a pharmacologic agent hypothesized to act as an IRT, such as Cladribine Tablets 3.5 mg/kg or alemtuzumab, can provide long-term suppression of MS disease activity, without need for continuous treatment (the anti-CD20 mechanism of ocrelizumab has the potential to act as an IRT, but is administered continuously, at 6-monthly intervals). Cladribine Tablets 3.5 mg/kg shows some selectivity in targeting adaptive immunity with a lesser effect on innate immunity. The introduction of IRT-like disease-modifying drugs (DMDs) challenges the traditional maintenance/escalation mode of treatment and raises new questions about how disease activity is measured. In this review, we consider a modern classification of DMDs for MS and its implications for the care of patients in the IRT era.

An Arabic Version of the Mini-Mental State Examination for the Lebanese Population: Reliability, Validity, and Normative Data.

BACKGROUND: The Mini-Mental State Examination (MMSE) has not been validated in the Lebanese population and no normative data exist at the national level. OBJECTIVE: To evaluate the reliability and validity of an Arabic version of MMSE developed by the "Groupe de Travail sur les Démences de l'Université Saint Joseph" (A-MMSE(GTD-USJ)) and to provide normative data by gender, age, and education in adults over 55. METHODS: Study design: national cross-sectional survey. STUDY POPULATION: 1,010 literate community-dwelling Lebanese residents aged 55 and above. OUTCOMES: reproducibility, internal consistency, sensitivity, specificity, predictive values, and area under the curve of the A-MMSE(GTD-USJ) for the detection of cognitive impairment using the Clinical Dementia Rating (CDR) as the gold standard. Normative data were established from 720 healthy adults. A-MMSE(GTD-USJ) scores corresponding to the 5th, 10th, 15th, and 50th percentiles were identified according to gender, age, and education. RESULTS: Intra-rater and inter-rater test-retest score correlations were 0.89 and 0.72, respectively. Cronbach alpha coefficient for internal consistency of the A-MMSE(GTD-USJ) was 0.71. A threshold value of 23 provided a sensitivity of 80% and a specificity of 89.4%. The area under the curve was 0.92. A-MMSE(GTD-USJ) scores increased with education and decreased with age. Women had significantly lower scores than men. Normative data for A-MMSE(GTD-USJ) stratified by gender, age, and education were generated. CONCLUSION: In reference to the CDR, the A-MMSE(GTD-USJ) is a valid tool to assess cognitive status among Lebanese subjects aged 55 and above. Normative data will help clinicians in detecting cognitive impairment in this population.

Loss of Cajal bodies in motor neurons from patients with novel mutations in VRK1.

Distal hereditary motor neuropathies (dHMNs) are a heterogeneous group of diseases, resembling Charcot-Marie-Tooth syndromes, but characterized by an exclusive involvement of the motor part of the peripheral nervous system. Here, we describe two new compound heterozygous mutations in VRK1, the vaccinia-related kinase 1 gene, in two siblings from a Lebanese family, affected with dHMN associated with upper motor neurons (MNs) signs. The mutations lead to severely reduced levels of VRK1 by impairing its stability, and to a shift of nuclear VRK1 to cytoplasm. Depletion of VRK1 from the nucleus alters the dynamics of coilin, a phosphorylation target of VRK1, by reducing its stability through increased proteasomal degradation. In human-induced pluripotent stem cell-derived MNs from patients, we demonstrate that this drop in VRK1 levels leads to Cajal bodies (CBs) disassembly and to defects in neurite outgrowth and branching. Mutations in VRK1 have been previously reported in several neurological diseases affecting lower or both upper and lower MNs. Here, we describe a new phenotype linked to VRK1 mutations, presenting as a classical slowly progressive motor neuropathy, beginning in the second decade of life, with associated upper MN signs. We provide, for the first time, evidence for a role of VRK1 in regulating CB assembly in MNs. The observed MN defects are consistent with a length dependent axonopathy affecting lower and upper MNs, and we propose that diseases due to mutations in VRK1 should be grouped under a unique entity named `VRK1-related motor neuron disease'.

Linking multiple pathogenic pathways in Alzheimer's disease.

Alzheimer's disease (AD) is a chronic neurodegenerative disorder presenting as progressive cognitive decline with dementia that does not, to this day, benefit from any disease-modifying drug. Multiple etiologic pathways have been explored and demonstrate promising solutions. For example, iron ion chelators, such as deferoxamine, are a potential therapeutic solution around which future studies are being directed. Another promising domain is related to thrombin inhibitors. In this minireview, a common pathophysiological pathway is suggested for the pathogenesis of AD to prove that all these mechanisms converge onto the same cascade of neuroinflammatory events. This common pathway is initiated by the presence of vascular risk factors that induce brain tissue hypoxia, which leads to endothelial cell activation. However, the ensuing hypoxia stimulates the production and release of reactive oxygen species and pro-inflammatory proteins. Furthermore, the endothelial activation may become excessive and dysfunctional in predisposed individuals, leading to thrombin activation and iron ion decompartmentalization. The oxidative stress that results from these modifications in the neurovascular unit will eventually lead to neuronal and glial cell death, ultimately leading to the development of AD. Hence, future research in this field should focus on conducting trials with combinations of potentially efficient treatments, such as the combination of intranasal deferoxamine and direct thrombin inhibitors.

Morvan Syndrome Secondary to Thymic Carcinoma in a Patient with Systemic Lupus Erythematosus.

Morvan syndrome (MoS) is a rare paraneoplastic autoimmune disorder characterized by peripheral nerve hyperexcitability, autonomic dysfunction, and sleep disorders. Systemic lupus erythmatosus (SLE) cooccurs in 6-10% of patients with thymoma. It may occur before, concurrently with, or after thymoma diagnosis. This paper reports the first case of cooccurrence of SLE, thymic carcinoma, and MoS. The cooccurrence of SLE, thymoma, and MoS delineates the generalized autoimmunity process. Symptoms of both MoS and SLE abated upon tumor resection.

Natalizumab treatment for multiple sclerosis: Middle East and North Africa regional recommendations for patient selection and monitoring.

BACKGROUND: Natalizumab, a highly specific α4-integrin antagonist, , has recently been registered across the Middle East and North Africa region. It improves clinical and magnetic resonance imaging (MRI) outcomes and reduces the rate of relapse and disability progression in relapsing-remitting multiple sclerosis (MS). Natalizumab is recommended for patients who fail first-line disease-modifying therapy or who have very active disease. Progressive multifocal leukoencephalopathy is a rare, serious adverse event associated with natalizumab. We aim to develop regional recommendations for the selection and monitoring of MS patients to be treated with natalizumab in order to guide local neurological societies. METHODS: After a review of available literature, a group of neurologists with expertise in the management of MS met to discuss the evidence and develop regional recommendations to guide appropriate use of natalizumab in the region. RESULTS: Disease breakthrough is defined as either clinical (relapse or disability progression) or radiological activity (new T2 lesion or gadolinium-enhancing lesions on MRI), or a combination of both. Natalizumab is recommended as an escalation therapy in patients with breakthrough disease based on its established efficacy in Phase III studies. Several factors including prior immunosuppressant therapy, anti-John Cunningham virus (JCV) antibody status and patient choice will affect the selection of natalizumab. In highly active MS, natalizumab is considered as a first-line therapy for naive patients with disabling relapses in association with MRI activity. The anti-JCV antibody test is used to assess anti-JCV antibody status and identify the risk of PML. While seronegative patients should continue treatment with natalizumab, anti-JCV antibody testing every 6 months and annual MRI scans are recommended as part of patient monitoring. In seropositive patients, the expected benefits of natalizumab treatment have to be weighed against the risks of PML. Clinical vigilance and follow-up MRI scans remain the cornerstone of monitoring. After 2 years of natalizumab therapy, monitoring should include more frequent MRI scans (every 3-4 months) for seropositive patients, and the risk-benefit ratio should be reassessed and discussed with patients. CONCLUSIONS: Recommendations have been developed to guide neurologists in the Middle East and North Africa on patient selection for natalizumab treatment and monitoring.

Migration in two directions.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG), the modality of choice for long-term enteral access, is generally a safe procedure but can be associated with many potential complications. OBJECTIVES: Report two different and late complications of PEG in two patients fed at home, leading them to the emergency department. CASE REPORT: A 75-year-old man and a 14-year-old young man with PEG presented to the emergency department with two different complications related to the gastrostomy tube. The first patient developed fever and deterioration in mental status due to parietal abscess which developed secondary to the migration of the internal button of the gastrostomy tube in the abdominal wall. He was treated with antibiotics and the gastrostomy tube was extracted. The second one presented upper gastrointestinal bleeding due to intestinal perforation at the level of the internal button of the gastrostomy tube. Bleeding and perforation were treated conservatively and he had a good evolution. CONCLUSION: Persons taking care of patients with PEG tube must be aware of potential complications. The position and the permeability of the tube must be systematically checked before feeding and medical advice should immediately be asked for in case of doubt or in the presence of any alarming sign.

C1 arch regeneration, tight cisterna magna, and cervical syringomyelia following foramen magnum surgery.

BACKGROUND: Although bone regrowth following craniocervical decompression has been rarely reported to cause late recurrence of Chiari symptoms, syringomyelia has not been observed in such cases. We report a unique case of cervical syringomyelia resulting from spontaneous regeneration of the posterior C1 arch after foramen magnum decompression. CASE DESCRIPTION: A 38-year-old male patient underwent resection of a symptomatic foramen magnum meningioma. Three years later, he developed neuropathic pain in his left upper extremity with worsening dysphagia and dysphonia. MRI revealed regeneration of the posterior arch of C1 with tight tonsillar impaction of the foramen magnum and extensive cervical syringomyelia. Surgical exploration was undertaken. Neo-ossification of the posterior arch of C1 and thick arachnoid adhesions were found to obstruct cerebrospinal fluid flow through the foramen of Magendie. Foramen magnum decompression, arachnoid dissection, and duraplasty were thus performed and cerebrospinal fluid flow was reestablished through the foramen of Magendie. Postoperatively, patient's symptoms improved dramatically and repeat MRI showed complete resolution of the syrinx cavity. CONCLUSION: Spontaneous bone regrowth and arachnoid scarring may lead to the development of cervical syringomyelia several years after foramen magnum surgery. Neurosurgeons should be aware of this rare complication whose management is similar to that of Chiari malformations, namely craniocervical decompression and establishment of a patent foramen of Magendie.

[Neurological manifestations of Behcet's disease: 22 cases among 170 patients]. / Etude de 22 observations de neuroBehçet dans une série de 170 maladies de Behçet.

OBJECTIVES: To present neurological involvement in Behçet's disease, its prognosis and treatment. METHODS: Our study was retrospective and was done at Hotel-Dieu Hospital of Beirut between 1980 and 2005. All these patients fulfilled the International Study Group criteria for diagnosis of Behçet's disease. RESULTS: Neurological involvement was observed in 13% (22/170) of our patients and was more frequent in men (sex-ratio: 1,75). The mean age of onset for Behçet's disease and NeuroBehçet's syndrome was 26+/-6 and 30+/-8 years respectively. Central nervous system involvement was found in 21 patients and peripheral nervous system involvement in one. Meningoencephalitis and/or transverse myelitis were found in 57% (12/21) of cases (in association with brainstem syndrome in 2 of these cases), brainstem syndrome without meningoencephalitis in 5 cases, tumor-like syndrome in 2 cases, repetitive ischemic attacks in 1 case and cerebral venous thrombosis in one. Focal deficits were the major presenting signs (16 cases) and external oculomotor nerve paralysis was observed in 4 patients. In meningoencephalitis, the cerebrospinal fluid findings were lymphocytic pleocytosis and elevated protein level. CT Scan, performed in 6 patients, was normal in 33% of cases. MRI, performed in 9 patients, was abnormal in 6 and showed abnormal signals distributed over the brainstem and the thalamus in 4, a tumor-like lesion and thrombosis of the left lateral sinus one each. Corticosteroids were usually efficacious but, when used alone, relapse was observed in 31% of patients. One patient who had brainstem syndrome died within 18 months because of a delayed corticosteroid treatment. CONCLUSION: Within central neurological involvement in Behçet's disease, we can individualize 4 clinical aspects: meningoencephalitis (and/or myelitis), brainstem syndrome, tumor-like features and cerebral venous thrombosis. Abnormalities, observed on CT Scan and MRI, by their brainstem localization and their multiplicity, should evoke the diagnosis. Corticosteroids, when prescribed early, are useful and are associated with better prognosis; their association to immunosuppressant agents should be considered in the parenchymatous forms.

Cerebral dural sinus thrombosis following cisplatin chemotherapy.

Two patients with cerebral dural sinus thrombosis (CST) following cisplatin therapy are presented. Cisplatin is a well-recognized risk factor for coagulation disorders and thrombosis, but is not known to be associated with CST. Clinicians should be aware of the potential risk for the development of CST following cisplatin therapy.

Prediction of the survival and functional ability of severe stroke patients after ICU therapeutic intervention.

BACKGROUND: This study evaluated the benefits and impact of ICU therapeutic interventions on the survival and functional ability of severe cerebrovascular accident (CVA) patients. METHODS: Sixty-two ICU patients suffering from severe ischemic/haemorrhagic stroke were evaluated for CVA severity using APACHE II and the Glasgow coma scale (GCS). Survival was determined using Kaplan-Meier survival tables and survival prediction factors were determined by Cox multivariate analysis. Functional ability was assessed using the stroke impact scale (SIS-16) and Karnofsky score. Risk factors, life support techniques and neurosurgical interventions were recorded. One year post-CVA dependency was investigated using multivariate analysis based on linear regression. RESULTS: The study cohort constituted 6% of all CVA (37.8% haemorrhagic/62.2% ischemic) admissions. Patient mean(SD) age was 65.8(12.3) years with a 1:1 male: female ratio. During the study period 16 patients had died within the ICU and seven in the year following hospital release. The mean(SD) APACHE II score at hospital admission was 14.9(6.0) and ICU mean duration of stay was 11.2(15.4) days. Mechanical ventilation was required in 37.1% of cases. Risk ratios were; GCS at admission 0.8(0.14), (p = 0.024), APACHE II 1.11(0.11), (p = 0.05) and duration of mechanical ventilation 1.07(0.07), (p = 0.046). Linear coefficients were: type of CVA - haemorrhagic versus ischemic: -18.95(4.58) (p = 0.007), GCS at hospital admission: -6.83(1.08), (p = 0.001), and duration of hospital stay -0.38(0.14), (p = 0.40). CONCLUSION: To ensure a better prognosis CVA patients require ICU therapeutic interventions. However, as we have shown, where tests can determine the worst affected patients with a poor vital and functional outcome should treatment be withheld?

Mutations in TREM2 lead to pure early-onset dementia without bone cysts.

A genome-wide screen using 382 STR markers to localize and identify the gene implicated in early-onset dementia (EOD) without bone cysts in a Lebanese family with three affected subjects was conducted. A unique locus homozygous by descent at chromosome 6p21.2 locus was identified. Candidate genes were explored by fluorescent sequencing and the effect of the identified mutation was confirmed by qualitative and quantitative RT-PCR. The genetic analysis revealed a novel deletion, c.40+3delAGG, in the 5' consensus donor splice site in intron 1 of TREM2 gene which is known to be responsible for PLOSL (Polycystic Lipomembranous Osteodysplasia with Sclerosing Leukoencephalopathy) also designated as Nasu-Hakola disease. In silico analysis predicted a lower strength for the novel donor splice site. Qualitative RT-PCR revealed normal transcript while quantitative RT-PCR showed over twofold down-regulation of TREM2 transcripts. The expression profile of six genes SPP1, NEDD9, FSCN, BCL3, NFKBIA and CCL2 known as disrupted in TREM2-deficient samples was studied and showed same expression profile as TREM2-mutated samples except for CCL2 which was normally regulated. The significantly-reduced expression of TREM2 in our patients and the expression profiles of the six studied genes confirm a role for TREM2 in this distinct phenotype of EOD without bone cysts. To our knowledge, this is the first report of mutations in TREM2 causing a pure dementia.