Persistent facial pain in post-stroke patients, a hospital-based cohort study; experience from North India.

Background: Post-stroke pain is common after a stroke and might be underreported. We describe Persistent Facial Pain (PFP) developed in post-stroke patients. Method: ology: This was a prospective hospital-based cohort study of stroke patients, and patients were followed up. Out of 415 stroke patients, 26 developed PFP. Result: Out of all PFP patients, six patients had an ischemic stroke, and 20 had a hemorrhagic stroke. 57.7% of patients had hypertension, while 34.6 patients had diabetes. The stroke location was left-sided in 12 patients and right-sided in 14 patients. 46.15% of patients responded to venlafaxine, 30.77% responded to amitriptyline, and 23.08% responded to pregabalin. Conclusion: Persistent facial pain is a pain syndrome that might be missed in patients post-stroke. It might be more common in hemorrhagic stroke patients than in ischemic stroke patients. It responds adequately to antidepressants. A high index of suspicion is required to diagnose and appropriately manage these patients.

The effect of low dose thyroid replacement therapy in patients with episodic migraine and subclinical hypothyroidism: A randomised placebo-controlled trial.

INTRODUCTION: Migraine is a common headache syndrome associated with various other comorbidities. Thyroid replacement in migraine patients with hypothyroidism improves headaches; however, thyroid hormone replacement in subclinical hypothyroidism is debatable, and its efficacy is not known. OBJECTIVE AND METHODOLOGY: This prospective, single-centre, quasi-randomised interventional study was conducted on patients visiting the General Medicine and Neurology outpatient department at a tertiary centre to look at the efficacy of thyroxine in subclinical hypothyroidism. RESULTS: We assessed 87 patients for analysis; no patients were lost to follow-up. There was a decrease in all parameters evaluated (headache frequency, severity, duration, MIDAS score, MIDAS grade) at three months of follow-up in the treatment group compared to placebo group. There was a significant decrease in headache frequency and severity in the levothyroxine group compared to the placebo group at three months of follow-up. Also, the follow-up MIDAS score (mean ± SD: 6.30 ± 2.455 scores vs. 8.45 ± 5.757 scores) was significantly decreased by treatment at three months follow-up. CONCLUSION: Treatment of subclinical hypothyroidism effectively reduces migraine headaches, and it is logical to check thyroid function status in patients presenting with migraine headaches. However, a larger randomised controlled trial is required to prove the efficacy of levothyroxine in migraine with subclinical hypothyroidism.

Effect of persistent organic pollutants in patients with ischemic stroke and all stroke: A systematic review and meta-analysis.

The role of environmental contaminants and their association with stroke is still being determined. Association has been shown with air pollution, noise, and water pollution; however, the results are inconsistent across studies. A systematic review and meta-analysis of the effect of persistent organic pollutants (POP) in ischemic stroke patients were conducted; a comprehensive literature search was carried out until 30th June 2021 from different databases. The quality of all the articles which met our inclusion criteria was assessed using Newcastle-Ottawa scaling; five eligible studies were included in our systematic review. The most studied POP in ischemic stroke was polychlorinated biphenyls (PCBs), and they have shown a trend for association with ischemic stroke. The study also revealed that living near a source of POPs contamination constitutes a risk of exposure and an increased risk of ischemic stroke. Although our study provides a strong positive association of POPs with ischemic stroke, more extensive studies must be conducted to prove the association.

Platelet function suggests cardioembolic aetiology in cryptogenic stroke.

Platelet-monocyte (PMA) and platelet-neutrophil aggregations (PNA) play critical roles in the evolution of acute ischemic stroke (AIS). The present study investigates the mechanistic basis of platelet responsiveness in cryptogenic stroke compared with cardioembolic stroke. Platelet from 16 subjects, each from cryptogenic and cardioembolic stroke groups and 18 age-matched healthy controls were subjected to different investigations. Compared to healthy controls, platelet-monocyte and platelet-neutrophil interactions were significantly elevated in cryptogenic (2.7 and 2.1 times) and cardioembolic stroke (3.9 and 2.4 times). P-selectin expression on platelet surface was 1.89 and 2.59 times higher in cryptogenic and cardioembolic strokes, respectively, compared to healthy control. Cell population with [Ca2+i] in either stroke group was significantly outnumbered (by 83% and 72%, respectively, in cryptogenic and cardioembolic stroke) in comparison to healthy controls. Noteworthy, TEG experiment revealed that the cryptogenic stroke exhibited significant decline in Reaction Time (R) and amplitude of 20 mm (K) (by 32% and 33%, respectively) while thrombin burst (α-angle) was augmented by 12%, which reflected substantial boost in thrombus formation in cryptogenic stroke. Although TEG analysis reveals a state of hypercoagulability in patients with cryptogenic stroke. However, platelets from both stroke subtypes switch to a 'hyperactive' phenotype.

Use of Ceftriaxone as a Predictor of Good Outcome in Stroke Patients: A Retrospective Chart Review.

Background: Whether ceftriaxone (CEFT) has any added advantage other than its antibiotics effect in stroke as a neuroprotective agent is not known, and this forms the base of this study. Purpose: We tried to assess the predictive role of the use of CEFT with respect to outcome in stroke patients. Methods: A retrospective chart review was conducted from a stroke registry over consecutive stroke patients admitted at a tertiary teaching institute from January 2017 to December 2018. Patients were categorized into three groups on the basis of antibiotics they received; patients without antibiotic treatment (NAB), piperacillin plus tazobactam treatment, and the CEFT treatment group. The outcome was assessed by the modified Rankin Scale at three months in good (0-3) and poor outcomes (4-6). Results: A total of 390 stroke patients were analyzed with ages ranging between 20 and 95 years and 151 of them were females. It was found that the severity at three months was significantly lower in those patients who were given CEFT antibiotic (P = 0.04; OR = 0.626; 95% CI [0.396, 0.990]). Conclusion: Stroke patients in CEFT-treated group have a better outcome compared to piperacillin-tazobactam therapy or without antibiotics use at three months. This study indicates the possibility of an additional neuroprotective effect of CEFT apart from its antibacterial property.

Raised Blood Urea Nitrogen-Creatinine Ratio as a Predictor of Mortality at 30 Days in Spontaneous Intracerebral Hemorrhage: An Experience from a Tertiary Care Center.

Background: Spontaneous intracerebral hemorrhage (SICH) accounts for 7.5%-30% of all strokes and carries higher morbidity and mortality. Raised blood urea nitrogen and creatinine ratio (BUNR) is a marker of dehydration and related to poor outcome in stroke patients. However, the ratio varies between 15 and 80 in different studies. The aim of the present study was to assess BUNR as an independent predictor of mortality and its sensitivity and specificity in predicting outcome in the SICH population. Materials and Methods: Patients above the age of 18 years with SICH who were admitted in the Department of Neurology at Sir Sunderlal Hospital, Banaras Hindu University between January 2018 and July 2020 were enrolled in the study and prospectively followed up. Demographic, clinical, radiological, and outcome parameters were recorded. Results: A total of 217 patients were included. Of these, 137 (63%) were males. Seventy-one patients died during the initial 30 days. Number of patients with intraventricular hemorrhage (IVH; P = 0.003), higher mean intracerebral hemorrhage (ICH) volume (P < 0.001) and midline shift (P = 0.021), and poor Glasgow Coma Scale (GCS) score (<9) (P = 0.040) was more in the group which did not survive. Mean level of urea was significantly lower among survivors than in those who died (P = 0.001). BUNR was also significantly higher in those who died than in those who survived (P = 0.001). BUNR with a cutoff value of 39.17 was significantly associated with mortality at 30 days with a sensitivity and specificity of 61.97% and 62.33%, respectively. On performing two different multivariable logistic studies, it was found that model B with BUNR ratio as a predictor of mortality out performed model A (without BUNR). Conclusions: The study showed that SICH was associated with significant mortality. Independent predictors of death at 30 days were lower GCS on admission, larger hematoma volume, and BUNR of more than 39.17.

Systematic Review and Meta-analysis of Environmental Toxic Metal Contaminants and the Risk of Ischemic Stroke.

Background: Stroke is the second largest cause of mortality (WHO 2014) and long-lasting disability worldwide. Many risk factors are associated with stroke, such as age, gender, chronic illnesses, cardiovascular disease, lifestyle, and smoking. With global industrialization, the roles of environmental contaminants and their association with stroke are still unclear and have attracted much more attention. Materials and Methods: We conducted a systematic review on the environmental toxic metal contaminants and the risk of ischemic stroke. A comprehensive literature search was carried out till June 30, 2021 from databases such as PubMed, Science Direct, Embase, and Scopus. The quality of all the articles which met our inclusion criteria was assessed using Newcastle-Ottawa scaling, and four eligible studies were included for our systematic review. Results: The serum and urine cadmium concentrations were positively associated with the risk of ischemic stroke. There was an inverse association of serum and urine concentrations of mercury (Hg), serum concentration of gold and cerium with ischemic stroke, and the serum and urine concentrations of lead (Pb) had no association with ischemic stroke risk. Conclusion: The study showed strong associations between heavy metals and ischemic stroke, but more studies are required to prove the associations.

Impact of COVID-19 on Guillain-Barre Syndrome in India: A Multicenter Ambispective Cohort Study.

Introduction/Aims: Studies conducted during the coronavirus disease 2019 (COVID-19) pandemic have reported varied data regarding the incidence of Guillain-Barre syndrome (GBS). The present study investigated demographic and clinical features, management, and outcomes of patients with GBS during a specified period of the COVID-19 pandemic, and compared these features to those of GBS in the previous year. Methods: A multicenter, ambispective cohort study including 26 centers across India was conducted. Data from a pre-COVID-19 period (March 1 to August 31, 2019) were collected retrospectively and collected ambispectively for a specified COVID-19 period (March 1 to August 31, 2020). The study was registered with the Clinical Trial Registry India (CTRI/2020/11/029143). Results: Data from 555 patients were included for analysis: pre-COVID-19 (n = 334) and COVID-19 (n = 221). Males were more commonly affected during both periods (male:female, 2:1). Gastroenteritis was the most frequent antecedent event in 2019 (17.4%), whereas fever was the most common event in 2020 (10.7%). Paraparesis (21.3% versus [vs.] 9.3%, P = 0.001) and sensory involvement (51.1% vs. 41.3%; P = 0.023) were more common during COVID-19 in 2020, whereas back pain (26.3% vs. 18.4%; P = 0.032) and bowel symptoms (20.7% vs. 13.7%; P = 0.024) were more frequent in the pre-COVID period. There was no difference in clinical outcomes between the two groups in terms of GBS disability score at discharge and 3 months after discharge. Independent predictors of disability in the pre-COVID period included areflexia/hyporeflexia, the requirementfor intubation, and time to bulbar weakness; in the COVID-19 period, independent predictors included time from onset to admission, intubation, and intubation requirement. The mortality rate was 2.3% during the entire study period (13/555 cases). Discussion: Results of this study revealed an overall reduction in the frequency of GBS during the pandemic. The lockdown likely reduced the risk for antecedent infections due to social distancing and improved hygiene, which may have resulted in the reduction of the frequency of GBS.

The Bobath Concept (NDT) as rehabilitation in stroke patients: A systematic review.

BACKGROUND AND OBJECTIVES: The Bobath approach, also known as neurodevelopmental treatment (NDT), is a widely used concept in the rehabilitation of stroke patients with hemiparesis in many countries. This technique is being used since years all over the world; however, strong evidence of its usefulness is still not present. This review is aimed to find out its effectiveness based on the randomized controlled trials in the rehabilitation of stroke patients with motor disability and to compare it with other therapeutic techniques. MATERIALS AND METHODS: A systematic literature search on PubMed Central, Science-Direct, Cochrane, Scopus, Clinical Trial Database, and Indian Clinical Trial Registry in English till 31st July 2021 was undertaken. The review is published in Prospective Register of Systematic Reviews (PROSPERO) with registration number "CRD42019125400." Physiotherapy Evidence-based Database (PEDro) score has been used for the quality assessment of the studies. Randomized clinical trials that studied the comparative effect of the NDT/Bobath concept on motor activity outcomes and cognition/behavior in stroke patients in comparison with other rehabilitative techniques were included. RESULTS: No strong documentation describing the effectiveness of this neuro-developmental treatment or its supporting neuro-developmental treatment in comparison with other advanced neuro-physiotherapeutic techniques has been found so as to consider it as the recommended treatment for post-stroke hemiplegia/hemiparesis. Methodological aspects of selected studies for further research are suggested. INTERPRETATION AND CONCLUSIONS: This study is inconclusive in determining the effectiveness of the Bobath approach for the movement rehabilitation of stroke patients. These results are similar to the results of previous reviews done on the same topic.

Neurological manifestations of COVID-19: a systematic review and meta-analysis of proportions.

BACKGROUND: Coronaviruses mainly affect the respiratory system; however, there are reports of SARS-CoV and MERS-CoV causing neurological manifestations. We aimed at discussing the various neurological manifestations of SARS-CoV-2 infection and to estimate the prevalence of each of them. METHODS: We searched the following electronic databases; PubMed, MEDLINE, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, Cochrane Library, WHO database, and ClinicalTrials.gov . Relevant MeSH terms for COVID-19 and neurological manifestations were used. Randomized controlled trials, non-randomized controlled trials, case-control studies, cohort studies, cross-sectional studies, case series, and case reports were included in the study. To estimate the overall proportion of each neurological manifestations, the study employed meta-analysis of proportions using a random-effects model. RESULTS: Pooled prevalence of each neurological manifestations are, smell disturbances (35.8%; 95% CI 21.4-50.2), taste disturbances (38.5%; 95%CI 24.0-53.0), myalgia (19.3%; 95% CI 15.1-23.6), headache (14.7%; 95% CI 10.4-18.9), dizziness (6.1%; 95% CI 3.1-9.2), and syncope (1.8%; 95% CI 0.9-4.6). Pooled prevalence of acute cerebrovascular disease was (2.3%; 95%CI 1.0-3.6), of which majority were ischaemic stroke (2.1%; 95% CI 0.9-3.3), followed by haemorrhagic stroke (0.4%; 95% CI 0.2-0.6), and cerebral venous thrombosis (0.3%; 95% CI 0.1-0.6). CONCLUSIONS: Neurological symptoms are common in SARS-CoV-2 infection, and from the large number of cases reported from all over the world daily, the prevalence of neurological features might increase again. Identifying some neurological manifestations like smell and taste disturbances can be used to screen patients with COVID-19 so that early identification and isolation is possible.

Blood Biomarkers for the Differentiation of Cardiac Ischemic Stroke Subtypes: A Systematic Review.

BACKGROUND: Blood biomarkers are a cost-effective and valid method to diagnose ischemic stroke and differentiate its subtypes in countries with poor resources. OBJECTIVE: To perform a systematic review of published literature evaluating the diagnostic utility of blood-based biomarkers to diagnose and differentiate the etiology of ischemic stroke. METHODS: A comprehensive literature search was carried out till December 2017 in major scientific and medical databases including PubMed, Cochrane, OVID and Google Scholar. Modified Quality Assessment of Diagnostic Accuracy Studies questionnaire was used to assess the methodological quality of each study. RESULTS: Twenty-six studies were identified relevant to our systematic review. Various biomarkers have been studied, though only a few biomarkers such as a B-type natriuretic peptide (BNP) and Ddimer have proved their clinical utility. None of the other tested biomarkers appeared to have consistent results to diagnose ischemic stroke subtypes. Most of the studies had limitations in the classification of ischemic stroke, sample size, sample collection time, methods, biomarker selection and data analysis. CONCLUSION: Our systematic review does not recommend the use of any blood biomarker for clinical purposes based on the studies conducted to date. BNP and D-dimer may present optimal biomarker for diagnosis and differentiation of ischemic stroke. However, large well-designed clinical studies are required to validate utility of these biomarkers to differentiate subtypes of ischemic stroke.

A randomised control trial of short term efficacy of in-shoe foot orthoses compared with a wait and see policy for anterior knee pain and the role of foot mobility.

OBJECTIVES: To investigate the short-term clinical efficacy of in-shoe foot orthoses over a wait-and-see policy in the treatment of anterior knee pain (AKP) and evaluate the ability of foot posture measures to predict outcome. DESIGN: Single-blind, randomised control trial. PARTICIPANTS: Forty participants (18-40 years) with clinically diagnosed AKP of greater than 6-week duration, who had not been treated with orthoses in the previous 5 years. INTERVENTION: Prefabricated orthoses perceived as most comfortable from a selection of 3 different hardness values compared with a wait-and-see control group. OUTCOME MEASURES: Participant-perceived global improvement, Kujala Patellofemoral Score, usual and worst pain severity over the previous week and the Patient Specific Functional Scale measures at 6 weeks. RESULTS: Foot orthoses produced a significant global improvement compared with the control group (p = 0.008, relative risk reduction = 8.47%, numbers needed to treat = 2). Significant differences also occurred in measures of function (standardised mean difference = 0.71). Within the intervention group, individuals who exhibited a change in midfoot width from weight bearing to non-weight bearing of >11.25 mm were more likely to report a successful outcome (correct classification 77.8%). CONCLUSION: This is the first study to show orthoses provide greater improvements in AKP than a wait-and-see approach. Individuals with greater midfoot mobility are more likely to experience success from treatment. CLINICAL TRIAL REGISTRATION: ACTRN12611000492954.