Creutzfeldt-Jakob disease in a post-COVID-19 patient: did SARS-CoV-2 accelerate the neurodegeneration?

Background: Creutzfeldt-Jakob disease (CJD) is a rare, fatal neurodegenerative disorder, with few months as a usual duration from onset to death. Case presentation: In this case report, a patient of Sporadic CJD (sCJD) who presented one month after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The diagnosis of this case was established after confirming findings from clinical, neurophysiology, radiological, and laboratory features of this disease. Conclusion: Putting in mind all the updated data on the pathogenesis of CJD and the immune responses to SARS-CoV-2, we can suggest that COVID-19 can lead to accelerated pathogenesis and exaggerated manifestations of this fatal neurodegenerative disease.

A randomized pilot study of the efficacy and safety of loading ticagrelor in acute ischemic stroke.

BACKGROUND: Ticagrelor is one of the most recent antiplatelet drugs to be approved to treat ischemic heart disease. Its efficacy may exceed aspirin in improving clinical outcomes in patients with acute ischemic stroke who are ineligible for rt-PA. OBJECTIVES: We evaluated the safety regarding hemorrhagic complications (as a primary endpoint) and the efficacy (as a secondary endpoint) of a 180-mg loading dose of ticagrelor given within 9 h from the onset of the first-ever non-cardioembolic ischemic stroke. METHODS: We conducted our study on patients aged 18-75 years who presented with their first clinically manifested non-cardioembolic ischemic stroke and were recruited from the emergency department OF Kafr El-Sheik University Hospitals, Egypt. Eligible patients randomly received ticagrelor or aspirin loading and maintenance doses. Screening, randomization, and initiation of treatment all occurred within the first 9 h of stroke onset. RESULTS: Eighty-five patients received ticagrelor, and 84 received aspirin. Patients who received ticagrelor had a better clinical outcome in terms of NIHSS improvement at 2 days and 1 week of discharge and a favorable mRS score after 1 week of discharge and at 90-day follow-up. There was no significant difference between the two groups regarding hemorrhagic adverse effects. CONCLUSION: This pilot study found that ticagrelor had a better clinical outcome than aspirin based on NIHSS and mRS in acute ischemic stroke patients who received it within 9 h from symptom onset and had a shorter hospital stay duration. Ticagrelor was non-inferior to aspirin regarding hemorrhagic complications. TRIAL REGISTRATION: We registered our trial on ClinicalTrials.gov, named after "ticagrelor versus aspirin in ischemic stroke," and with a clinical trial number (NCT03884530)-March 21, 2019.

Post-COVID isolated subclavian artery dissection with multiple cerebral infarctions.

Background: Coronavirus disease 2019 (COVID-19) is a pandemic disease which predominantly affects the respiratory system with high critical care mortality and morbidity, yet it also causes multiple organs dysfunction in affected patients. There is a strong evidence that it increases the susceptibility of cerebrovascular strokes in such patients. Besides this prothrombotic complication, arterial dissection can be one of its mechanisms increasing the risks of stroke. Case presentation: Herein, we report a case of spontaneous isolated subclavian artery dissection in a COVID-19 patient. Sixty-one-year-old female presented with spontaneous isolated subclavian artery dissection without any traumatic events nor history of connective tissue disorders. She had left upper limb ischemia followed by cerebellar, thalamic and occipital infarctions. Whether this patient's subclavian artery dissection was triggered by exaggerated inflammatory response or arteriopathy secondary to COVID-19 remains speculative. Conclusions: Nonetheless, arterial dissection can be one of its complications, it is essential for treating physicians to be attentive for the diversity of COVID-19 clinical manifestations.

Sinus arrest following acute lateral medullary infarction.

Lateral medullary syndrome (LMS) is an ischemic stroke of the medulla oblongata that involves the territory of the posterior inferior cerebellar artery. LMS is often missed as the cause of autonomic dysregulation in patients with recent brain stem stroke. Due to the location of the nucleus tractus solitarius (NTS), the dorsal vagal nucleus, and the nucleus ambiguous in the lateral medulla oblongata, patients with LMS occasionally have autonomic dysregulation-associated clinical manifestations. We report a case of LMS-associated autonomic dysregulation. The case presented by recurrent syncope, requiring permanent pacemaker placement. This case shows the importance of recognizing LMS as a potential cause of life-threatening arrhythmias, heart block, and symptomatic bradycardia. Extended cardiac monitoring should be considered for patients with medullary strokes.

Lateralized readiness potentials can identify hemisphere of recovery in stroke patients.

BACKGROUND: Event related cortical potentials related to motor action are referred to as movement related cortical potentials. The late component of which is the readiness potential (RP) and its polarity is more negative in the hemisphere responsible for planning of motor action. This lateralized nature of RP during unilateral hand movement is studied as lateralized readiness potential (LRP) by calculating the contralateral-minus-ipsilateral difference wave for each hand. OBJECTIVE: The aim was to identify the hemisphere contributing to motor recovery in acute and chronic stroke patients through recording LRPs. METHODS: Twenty-nine cases with cerebrovascular stroke (15 acute and 14 chronic) were included in the study. EEG was recorded in response to self-cued button presses by the paretic side to obtain the averaged LRP amplitude. The hemisphere with greater negativity was considered the side of recovery. Functional recovery was assessed by Fugl Meyer test. RESULTS: In acute cases, recovery was more related to LRP activity in the contralesional hemisphere (73%), whereas lateralization was equal in chronic cases; 50% in either group. LRP amplitude was higher in the contralesional hemisphere (p = 0.02). Functional recovery assessed by the Fugl Meyer test (FM) was similar whether recovery was ipsi- or contralesional. CONCLUSIONS: Early after stroke, motor recovery is more likely to involve compensatory activity in the contralesional hemisphere, while in the chronic phase, the ipsilesional hemisphere may recover its function and become more active. Further research is needed to verify if the technique mentioned in our study could be used to guide customized NIBS protocols tailoring the optimal site and parameters for each patient.

A pilot study of the ticagrelor role in ischemic stroke secondary prevention.

INTRODUCTION: Ticagrelor is one of the most recent antiplatelet drugs used to treat ischemic heart disease. Its efficacy may equal or exceed aspirin in improving clinical outcomes in patients with acute ischemic stroke who are ineligible for rt-PA. AIM OF THE WORK: We aimed at evaluating the safety (as a primary endpoint) and efficacy (as a secondary endpoint) of a 180 mg loading dose of ticagrelor given within 9 h from the onset of first-ever ischemic stroke. METHODS: We conducted an open-label, randomized prospective controlled clinical trial between May 2019 and September 2020 on patients who presented with their first-ever ischemic stroke and were recruited from the emergency department, of Kafr el-sheik University Hospitals, Egypt. Eligible patients randomly received aspirin or ticagrelor loading and maintenance doses. Treatment began within 9 h of stroke onset. RESULTS: Aspirin was given to 84 patients; ticagrelor was given to 85. There was no significant difference between the 2 groups regarding the hemorrhagic and nonhemorrhagic complications. Patients who received ticagrelor had a better outcome regarding NIHSS improvement at 2 days and 1 week or discharge and a favorable mRS score after 1 week or discharge and at 90-day follow-up. CONCLUSION: Ticagrelor was noninferior to aspirin regarding safety profile. Compared with aspirin, ticagrelor had a better clinical outcome based on NIHSS and mRS in first-ever acute ischemic stroke patients who received it within 9 h from symptom onset, leading to a shorter hospital stay.

Rhino-orbito-cerebral mucormycosis during the COVID-19 third wave in 2021: an Egyptian preliminary report from a single tertiary hospital.

COVID-19 is a pandemic disease which predominantly affects the respiratory system with high critical care mortality and morbidity; however, it also causes multi-organ dysfunction in a subset of patients. Although causality between COVID-19 and mucormycosis remains unclear, many factors including glucocorticoids, worsening of blood glucose control, and viral-induced lymphopenia have been attributed to cause mucormycosis in patients with COVID-19. In COVID-19 patients, especially those who need oxygen support, inflammatory and cytokine storm or usage of steroids make the immune system weak. This may pave the way for opportunistic infections including mucormycosis. We report fourteen cases of COVID-19 infection, who developed rhino-orbito-cerebral mucormycosis, during treatment. Early recognition of this life-threatening infection is the key to allow for optimal treatment and improved outcomes.

Door to Needle Count Down: A 3-Years Experience in an Egyptian University Stroke Center.

BACKGROUND: The purpose of this study is to share our experience in changing hospital strategies to achieve rapid thrombolysis in acute ischemic stroke (AIS) patients in 2 university stroke centers. Rapid reperfusion by shortening door to needle time (DTN) reduces morbidity and mortality for patients with AIS. Our aim is to evaluate the effect of applying certain logistic strategies to reduce DTN for thrombolysis and its impact on clinical outcome. METHODS: In this retrospective registry-based observational study from the SITS-ISTR Dataset, we studied AIS patients admitted to 2 stroke centers in Ain Shams University over 3 successive years from 2016 till 2018. We analyzed change of DTN and outcome at 3 months by modified Rankin scale over these 3 years. RESULTS: By the end of the 3 year period there was a 6.1% increase in number of patients receiving thrombolysis. There was a significant decrease of median DTN by 41%, and increase in percentage of patients receiving recombinant tissue plasminogen activator within a shorter DTN. Also, the number of patients with a favorable outcome (modified Rankin scale≤2) increased by 23.3%. There was insignificant difference regarding mortality rate. CONCLUSION: Applying a goal-directed corrective strategy to improve quality of service can, in a short time, reduce DTN and improve patient outcome.

The Clinical Characteristics of Patients with Pre-Existing Leukoaraiosis Compared to Those Without Leukoaraiosis in Acute Ischemic Stroke.

BACKGROUND: Leukoaraiosis (LA) is a finding in the elderly, that might be asymptomatic or can impact their motor and cognitive functions. We studied the presence of LA in the MRI of patients with AIS and its impact on functional outcome at 3 months. METHODS: 500 consecutive patients diagnosed as AIS were enrolled. Medical history included pre-medication by antiplatelets or statins, and vascular risk factors were reported by history and laboratory investigations. Severity of stroke was assessed by NIHSS and stroke outcome was evaluated on discharge and at 3 months by modified Rankin scale (mRS). LA was diagnosed by MRI-FLAIR sequence and delineated from acute infarction by diffusion-weighted image. And accordingly, patients were divided into group A (absent LA) and group B (present LA). RESULTS: 460 patients completed the study, with 53% of patients on antiplatelet therapy and 11.7% on statins prior to stroke. The percentage of patients with LA was significantly more than those without LA. Patients with LA showed a significantly higher age, more frequent and longer duration of diabetes and hypertension, ischemic heart disease, previous stroke/TIA and antiplatelet intake. Microbleeds were more and mRS was worse in LA group. CONCLUSION: The presence of LA in the background MRI of AIS patients is accompanied by the presence of more risk factors, and unfavorable outcome. Pre-medication with antiplatelets did not prevent the incidence of a new stroke especially in LA group. This might necessitate the identification of some medication for secondary prevention in patients with small vessel disease.

Borderzone Infarction and Small Vessel Disease in a Sample of Egyptian Stroke Patients: Differences and Similarities.

BACKGROUND: The anatomical location of white matter hyperintense lesions in small vessel disease are apparently similar to those of borderzone infarction. The objective of this study is to find clinical and radiological points of differentiation between the two vascular disorders in a sample of Egyptian patients which might have an impact on primary and secondary prevention. METHODS: Ischemic stroke patients with white matter lesions were categorized into two groups: small vessel disease and borderzone infarctions. NIHSS was done on admission. Risk factor profile was reported, and investigations done including: HbA1C, lipid profile, CRP, ECG, echocardiography, carotid duplex, brain MRI, MRA and MR perfusion study. RESULTS: 46 patients completed the study, 29 with SVD and 17 with BZI. Smoking, hypertension and recurrent stroke were more common in borderzone infarctions, but only diabetes was significantly higher (p = 0.047). Limb shaking was more observed in borderzone infarctions (p = 0.049). Radiologically: lacunar pattern was observed more in small vessel disease, while rosary pattern was more in borderzone infarctions (p = 0.04). FLAIR symmetrical lesions and microbleeds were more significant in small vessel disease (p = <0.001; 0.048, respectively). Perfusion study time to peak denoted evidence of significant hypoperfusion in all regions of interest in borderzone infarctions. CONCLUSION: Limb shaking, retinal claudication or syncope, with MRI showing rosary pattern of white matter hyperintensity, few microbleeds and markedly impaired perfusion favor the diagnosis of borderzone infarctions. On the other hand, presence of lacunae, FLAIR showing symmetrical WMH and microbleeds with minimal or no perfusion deficit suggests the diagnosis of small vessel disease.

Pre-micro RNA polymorphism detection in small versus large vessel disease in stroke Egyptian patients.

Stroke is the main cause of adult disability and is responsible for around 11% of deaths all over the world. Ischemic stroke encompasses about 80-85% of total stroke cases. Several studies have shown the relation between microRNAs polymorphism and ischemic stroke. The aim of the study was to evaluate the influence of three common single nucleotide polymorphisms in pre-miRNAs (hsa-miR-146a/rs2910164, hsa-miR-196a2/rs11614913 and hsa-miR-499/rs3746444) on individual susceptibility to the risk of ischemic stroke subtypes in Egyptian population with 117 ischemic stroke patients. Results showed that hsa-miR-146a/rs2910164 was significantly associated with the risk of small vessel disease stroke in Egyptian population with no significant association between hsa-miR-196a2/rs11614913 and hsa-miR-499/rs3746444 with the risk of ischemic stroke. Therefore, it can be concluded that miR-146a/rs2910164 polymorphism is involved in the vulnerability to small vessel disease ischemic stroke risk in Egyptian population.

Global Impact of COVID-19 on Stroke Care and IV Thrombolysis.

OBJECTIVE: To measure the global impact of COVID-19 pandemic on volumes of IV thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with 2 control 4-month periods. METHODS: We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. RESULTS: There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95% confidence interval [CI] -11.7 to -11.3, p < 0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95% CI -13.8 to -12.7, p < 0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95% CI -13.7 to -10.3, p = 0.001). Recovery of stroke hospitalization volume (9.5%, 95% CI 9.2-9.8, p < 0.0001) was noted over the 2 later (May, June) vs the 2 earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was noted in 3.3% (1,722/52,026) of all stroke admissions. CONCLUSIONS: The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID-19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months.

Vitamin D receptor gene polymorphism in patients with osteomalacic myopathy in Egypt.

INTRODUCTION: Vitamin D works by binding to vitamin D receptor (VDR). The muscle involvement in hypovitaminosis D was broadly named osteomalacic myopathy. METHODS: A case control study involved 20 female patients diagnosed with osteomalacic myopathy compared with 15 age-matched healthy female controls. We assessed both for VDR genotype single-nucleotide polymorphisms (SNP) at 3 sites (ApaI, BsmI, and FokI). RESULTS: ApaI and BsmI genotypes distribution in both groups showed non-significant difference unlike FokI genotypes in which we found significantly higher percentages of single allele mutation in patients vs. controls. CONCLUSION: The relation of VDR gene SNPs to muscle function was studied before but in healthy subjects. We tried to correlate if presence/absence of a certain mutation is responsible for the appearance of osteomalacic myopathy.

Factors related to time of stroke onset versus time of hospital arrival: A SITS registry-based study in an Egyptian stroke center.

BACKGROUND: High-quality data on time of stroke onset and time of hospital arrival is required for proper evaluation of points of delay that might hinder access to medical care after the onset of stroke symptoms. PURPOSE: Based on (SITS Dataset) in Egyptian stroke patients, we aimed to explore factors related to time of onset versus time of hospital arrival for acute ischemic stroke (AIS). MATERIAL AND METHODS: We included 1,450 AIS patients from two stroke centers of Ain Shams University, Cairo, Egypt. We divided the day to four quarters and evaluated relationship between different factors and time of stroke onset and time of hospital arrival. The factors included: age, sex, duration from stroke onset to hospital arrival, type of management, type of stroke (TOAST classification), National Institute of Health Stroke Scale (NIHSS) on admission and favorable outcome modified Rankin Scale (mRS ≤2). RESULTS: Pre-hospital: highest stroke incidence was in the first and fourth quarters. There was no significant difference in the mean age, sex, type of stroke in relation to time of onset. NIHSS was significantly less in onset in third quarter of the day. Percentage of patients who received thrombolytic therapy was higher with onset in the first 2 quarters of the day (p = <0.001). In-hospital: there was no difference in percentage of patients who received thrombolytic therapy nor in outcome across 4 quarters of arrival to hospital. CONCLUSION: Pre-hospital factors still need adjustment to improve percentage of thrombolysis, while in-hospital factors showed consistent performance.

Urban Versus Rural Egypt: Stroke Risk Factors and Clinical Profile: Cross-Sectional Observational Study.

BACKGROUND: Egypt is a densely populated country with living habits and health care services that differ from urban to rural regions. We aimed to study how characteristics of stroke vary among these regions. METHODS: This is a cross-sectional observational study of ischemic stroke, thus hemorrhagic and venous strokes were excluded. A total of 1475 ischemic stroke patients were recruited for analysis from a tertiary hospital in Cairo representing urban area and from a secondary care hospital in Suhag representing rural region. RESULTS: Analysis was done for 1143 ischemic stroke patients from urban and 332 from rural area. Onset to door was shorter in urban. Urban patients showed an older age and higher prevalence of hypertension and diabetes (65.9%, 48.6% respectively), while rural patients were characterized by female preponderance (51.5%), more dyslipidemia, smoking 44.6%, stroke in young 20.5%, atrial fibrillation 23.8% % and recurrent stroke 44.3%. Rural cases showed a severer deficit at onset and poorer outcome. CONCLUSION: Vascular risk factors, stroke type, and presentation tend to differ in Egypt according to the geographic distribution whether urban or rural. Studying patterns of such difference may aid in planning specific targeted preventive and therapeutic strategies for stroke in urban and rural Egypt.