Clinical Trial of Subcutaneous Steroid Injection in Patients with Migraine Disorder.

BACKGROUND: Neurologic literature on therapeutic effect of subcutaneous corticosteroids in patients with migrainous chronic daily headache is scarce. The aim of this research is to assess the therapeutic effects of this management in such patients. METHODS: Consecutive patients with migrainous chronic daily headache enrolled a prospective before-after therapeutic study during 2010-2013. Methylprednisolone 40 mg was divided into four subcutaneous injection doses. Two injections were administered in the right and left suboccipital area (exactly at retromastoid cervicocranial junction) and the other two injections in the lower medial frontal area (exactly at medial right and left eyebrows). A daily headache diary was filled out by the patients before and one month after the intervention. The severity of pain was classified based on a pain intensity instrument using numeric rating scale from 0-10 point scale. Paired t-test and Chi-square test were used for statistical analysis. RESULTS: 504 patients (378 females, 126 males) with migrainous chronic daily headache were enrolled in the study. Dramatic, significant, moderate, mild, or no improvements respectively constituted 28.6%, 33.3%, 23.8%, and 14.3% of the post treatment courses. Therapeutic effect of intervention on mean pain scores was significant; t=7.38, df=20, P=0.000. Two cases developed subcutaneous fat atrophy in frontal injection site and three cases experienced syncope during injection. CONCLUSION: Subcutaneous corticosteroids could be used as an adjunct therapy in patients with migrainous chronic daily headache.

Safety assessment of anticoagulation therapy in patients with hemorrhagic cerebral venous thrombosis.

BACKGROUND: Anticoagulation therapy is a routine treatment in patients with hemorrhagic cerebral venous thrombosis (CVT). However, fear of hemorrhagic complications and deterioration course following anticoagulation often disturbs the responsible physician. METHODS: This was a Prospective observational study on consecutive CVT patients with hemorrhagic venous infarction or subarachnoid hemorrhage (SAH) admitted in Ghaem Hospital, Mashhad, Iran, during 2006-2012. The diagnosis of CVT in suspected cases was confirmed by magnetic resonance imaging/magnetic resonance venography (MRI/MRV), and computerized tomography (CT) angiography following established diagnostic criteria. Demographic data, clinical manifestations from onset to end of the observation period, location of thrombus, location and size of infarction and hemorrhage, and clinical course during treatment were recorded. Choice of the treatment was left to the opinion of the treating physician. Clinical course during 1 week of treatment was assessed based on the baseline modified National Institute of Health Stroke Scale (NIHSS) score. Three or more points decrease or increase of modified NIHSS after 1 week of treatment was considered as improvement or deterioration courses, respectively. Other clinical courses were categorized as stabilization course. RESULTS: 102 hemorrhagic CVT patients (80 females, 22 males) with mean age of 38.6 ± 8 years were prospectively investigated. Of the 102 hemorrhagic CVT patients in the acute phase, 52 patients (50.9%) were anticoagulated with adjusted dose intravenous heparin infusion and 50 cases (49.1%) received subcutaneous enoxaparin 1mg/Kg twice daily. Decreased consciousness had a significant effect on the clinical course of the patients (X(2) = 9.493, df = 2, P = 0.009). Presence of SAH had no significant effect on the clinical course of our anticoagulated hemorrhagic CVT cases (X(2) = 0.304, df = 2, P = 0.914). Extension of Infarction in more than two thirds of a hemisphere had a significant influence on the distribution of clinical courses (X(2) = 5.867, df = 2, P = 0.044). Difference in distribution of clinical course among the two groups of our hemorrhagic CVT patients was not significant (X(2) = 8.14, df = 1, P = 0.87). CONCLUSION: Patients with hemorrhagic CVT without other contraindication for anticoagulation should be treated either with dose-adjusted intravenous heparin or body-weight-adjusted subcutaneous low molecular-weight heparin.

Randomized clinical trial of intravenous valproate (orifil) and dexamethasone in patients with migraine disorder.

BACKGROUND: Intravenous Valproate (IVVP) has been used in the treatment of migraine in some studies; however, it is far better known in the management of status epilepticus. METHODS: Consecutive patients with migraine in our Headache Clinic were enrolled in this prospective, randomized clinical trial in 2011. The patients were randomized into two therapeutic groups, one receiving 900 mg IVVP (Orifil) and the other 16 mg IV Dexamethasone (IVDEX) diluted in 150 CC normal saline and infused for 10 minutes. Worst severity of pain before treatment and least severity at 3 hours after the infusion using a 0-10 point numeric rating scale were recorded. An interview with the patient was performed 72 hours after treatment to detect a possible relapse of headache. RESULTS: Thirty-one migraine status patients, comprising 28 women and 3 men at a mean±SD age of 33.355±12.373 SD, were investigated. Differences in the therapeutic effects of IVVP (Orifil) and IVDEX on pain score were not significant between the two groups (t=0.933, df=29; P=0.358). Relapse of headache occurred in 68.42% of the IVVP (Orifil) group and 66.67% of the IVDEX group. Distribution of relapse was not significantly different between the two therapeutic groups of patients (P=0.870). CONCLUSION: IVVP (Orifil) was similar in efficacy to IVDEX as abortive therapy in patients with migraine status. IVVP (Orifil) appears to offer a safe and well-tolerated abortive treatment. TRIAL REGISTRATION NUMBER: IRCT13891146234N2.

Risk factors of short-term stroke recurrence in patients with minor ischemic cerebrovascular events.

BACKGROUND: Assessing the risk of recurrent ischemic events in patients with transient ischemic attack (TIA) and minor ischemic stroke (MIS) is of a great importance in clinical practice. METHODS: Consecutive patients with TIA or MIS who were visited in Ghaem Hospital, (Mashhad, Iran) were enrolled in a prospective cohort study during 2010 to 2011. Diagnosis of TIA or MIS was accomplished by a stroke neurologist. Only those who presented within 24 hours from the onset of symptoms were recruited. MIS was considered as an ischemic stroke with National Institutes of Health Stroke Scale (NIHSS) < 4. The endpoint of the study was a new ischemic cerebrovascular event or vascular death in 90 days and additionally in 3 days. The decision to admit and type of treatment in each case was left to the discretion of the stroke neurologist. The association between 20 potential factors with recurrent ischemic events in 3 and 90 days was investigated using univariate and multivariate analysis (MVA). RESULTS: 393 TIA patients (238 males and 155 females) and 118 MIS patients (77 males and 41 females) were enrolled in the study. Stroke occurred in 117 (23.2%) patients, TIA in 99 (19.6%), and there was 11 (2.2%) vascular deaths within 3 months in the total 511 patients with minor ischemic events. Crescendo TIAs and multiple TIAs were associated with greater risk of stroke in 3 days in a univariate analysis (OR = 5.12, P < 0.001) and (OR = 3.98, P = 0.003), respectively. Patients with index stroke had 11.5% lower risk of recurrent stroke in 3 days than patients with index TIA in multivariate analysis (OR = 0.115, P = 0.039). Diabetes was independently associated with 3 months stroke recurrence in the patients with minor ischemic events (OR = 2.65, P = 0.039). CONCLUSION: Multiple and crescendo TIAs are the main predictors of stroke recurrence, derived from the univariate analysis of the patients with minor ischemic events.

Assessment of ABCD² scale in patients with transient ischaemic attack or stroke.

BACKGROUND AND PURPOSE: Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in patients with transient ischaemic attack (TIA) or minor ischaemic stroke (MIS). MATERIAL AND METHODS: Consecutive patients with TIA or MIS referring to Ghaem Hospital, Mashhad presenting within 24 hours from the onset of symptoms were recruited to the prospective cohort study between 2010 and 2011. MIS was defined as an ischaemic stroke with National Institutes of Health Stroke Scale (NIHSS) score < 4. The end-point of the study was a new ischaemic cerebrovascular event or vascular death at 90 days and, additionally, at 3 days after the index TIA or MIS. The decision to admit and of method of treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD2 scoring system for recurrent stroke or TIA was quantified by the area under the curve (AUC), using the c-statistics. RESULTS: The study included 393 patients with TIA (238 males, 155 females) and 118 patients with MIS (77 males, 41 females). Among 511 patients with minor ischaemic events, 117 strokes (23.2%), 99 TIAs (19.6%), and 11 vascular deaths (2.2%) occurred within 3 months after the index event. The ABCD2 score had a weak predictive value for 3-month and 3-day recurrent stroke in patients with TIA (AUC = 0.599 and 0.591, respectively), but a high predictive value for 3-month and 3-day recurrent stroke in patients with MIS (AUC = 0.727 and 0.728, respectively). CONCLUSION: The ABCD2 score is highly predictive for short-term recurrent stroke in patients with MIS but not in patients with TIA, although it was originally designed for patients with TIA.

Comparative interrater reliability of Asian Stroke Disability Scale, modified Rankin Scale and Barthel Index in patients with brain infarction.

BACKGROUND: This study tried to develop an Asian Stroke Disability Scale (ASDS) and compared its interrater reliability with modified Rankin Scale (mRS) and Barthel Index (BI). METHODS: Three items including self-care, mobility, and daily activities were selected as variables for development of the ASDS. The variables were provisionally graded on a 2- to 4-point scale based on the importance of each item. Each of the variables was categorized into 3 categories. Afterward, 125 rater-patient assessments for each scale (mRS, BI, and ASDS) were performed on 25 stroke patients by 5 raters. For categorization of functional impairment as minor or major, the scores of mRS, BI and ASDS were categorized as ≤ 2 and > 2, < 90 and ≥ 90, and < 3 and ≥ 3, respectively.125 rater-patient assessments for each of the mRS, BI, and ASDS were performed on 25 stroke patients by five raters. RESULTS: The quantitative variability of BI, mRS, and ASDS scores was not significant (P = 0.379; P = 0.780; and P = 0.835, respectively). Interrater variability of mRS, BI, and ASDS scores based on qualitative categorization was not significant (P = 1.000; P = 0.978; and P = 0.901, respectively). Paired interrater variability of mRS, BI, and ASDS scores based on qualitative categorization was not significant (P > 0.05). CONCLUSION: The ASDS is easy to use, requires less than 1 minute to complete and is as valid as mRS and BI in assessment of functional impairment of patients with stroke.

The ABCD(2) Score is Highly Predictive of Stroke in Minor Ischemic Stroke Patients.

Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in transient ischemic attack (TIA) and minor ischemic stroke (MIS) patients. Consecutive TIA or MIS patients referred to Ghaem Hospital, Mashhad were enrolled in a prospective cohort study during 2010-2011. Only TIA or MIS patients presenting within 24 h from the onset of symptoms were recruited. MIS was considered as ischemic stroke with NIHSS <4. The end point of the study was a new ischemic cerebrovascular event or vascular death at 90 days and additionally at 3 days. The decision to admit and treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD(2) scoring system for recurrent stroke or TIA was quantified by the area under the cure (AUC) using the c statistics. Three hundred ninety-three TIA patients (238 males, 155 females) and 118 MIS patients (77 males, 41 females) were enrolled in the study. One hundred seventeen strokes (23.2%), 99 TIA (19.6%), and 11 vascular death (2.2%) occurred within 3 months postevent in the whole of our 511 patients with minor ischemic events. The ABCD(2) score had a weak predictive value for 3 months and 3 days recurrent stroke in our TIA patients (AUC = 0.599, AUC = 0.591), but a high predictive value for 3 months and 3 days recurrent stroke in our MIS patients (AUC = 0.727, AUC = 0.728), respectively. The ABCD(2) score is highly predictive of short-term recurrent stroke in MIS patients but not TIA cases, despite its creation for TIA cohorts.

Interesting basis of vertebrobasilar arterial territory.

BACKGROUND: Vertebrobasilar arterial territory nourishes one-quarter of human brain. It constitutes some vital and strategic parts of the central nervous system. METHODS: A number of keywords (vertebral, basilar, artery, and territory) were searched in MEDLINE (Ovid and PubMed) as well as Google, ProQuest, Scopus, Cochrane Library, and Science Direct online databases. Only articles containing all keywords were included. We also reviewed archives of libraries in Mashhad University of Medical Sciences (Iran) for all anatomy, embryology, neurology, and neuroscience books and journals about vertebrobasilar arterial territories. RESULTS: The vertebrobasilar arterial (VA) system has a high incidence of variations, anomalies, and persistent fetal vessels. Two important anatomic facts explain why VA origin lesions seldom cause chronic hemodynamically significant low flow to the vertebrobasilar system. First, the VAs are paired vessels that unite to form a single basilar artery. Second, the extracranial VA gives off numerous muscular and other branches as it ascends in the neck. Thus, in the VA system, there is much more potential for development of adequate collateral circulation. Even when there is bilateral occlusion of the VAs at their origins, patients do not often develop posterior circulation infarcts. CONCLUSION: VA origin disease is more benign than ICA origin disease from hemodynamic aspect. This important point could make influence in therapeutic interventional decisions in asymptomatic VA origin stenosis.

Inter-rater reliability of modified Alberta Stroke program early computerized tomography score in patients with brain infarction.

BACKGROUND: The Alberta Stroke Program Early Computerized Tomography Score (ASPECTS) was used to detect significant early ischemic changes on brain CT of acute stroke patients. We designed the modified ASPECTS and compared it to the above system based on the inter-rater reliability. METHODS: A cross-sectional validation study was conducted based on the inter-rater reliability. The CT images were chosen from the stroke data bank of Ghaem hospital, Mashhad in 2010. The inclusion criteria were the presence of middle cerebral artery territory infarction and performance of CT within 6 hours after stroke onset. Axial CT scans were performed on a third-generation CT scanner (Siemens, ARTX, Germany). Section thickness above posterior fossa was 10 mm (130 kV, 150 mAs). Films were made at window level of 35 HU. The brain CTs were scored by four independent radiologists based on the ASPECTS and modified ASPECTS. The readers were blind to clinical information except symptom side. Cochrane Q and Kappa tests served for statistical analysis. RESULTS: 24 CT scans were available and of sufficient quality. Difference in distribution of dichotomized ≤7 and >7 ASPECT scores between four raters was significant (Q=13.071, df=3, p=0.04). Distribution of dichotomized <6 and ≥6 scores based on modified ASPECT system between 4 raters was not significantly different (Q=6.349, df=3, p=0.096). CONCLUSIONS: Modified ASPECT method is more reliable than ASPECTS in detecting major early ischemic changes in stroke patients candidated to tPA thrombolysis.